The Clinical Problem Solvers

Reza and Rabih explore a case of pleuritic chest pain.

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Steph presents a case of pleuritic chest pain to Dan and Jack

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Malika presents a Human Dx case of pleuritic chest pain to Lindsey, Aaron, and Kelly

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Dr. Kelly Uelmen

Kelly is a second-year internal medicine resident at Mercy Health in Muskegon, MI.  I’m from Wisconsin and went to medical school at LMU-DCOM in Tennessee.  I am looking forward to a career in hospitalist medicine once I finish residency.  In my free time, I enjoy traveling (pre-COVID, anyway), cooking, reading fiction, and playing with my dog, Bubba. 

Dr. Aaron Sabal

Aaron is currently a PGY-3 at Mercy Health Muskegon aspiring for a career in hospital medicine. He was born and raised in Westland, MI (Detroit metro area) and went to Wayne State University for his undergraduate studies thinking he would be a physical therapist, massage therapist, and dietitian (yes, all three of those). However, one week prior to starting a massage therapy program, he had an epiphany and decided to go to medical school instead. He was fortunate to be accepted at MSUCOM and fell in love with Internal Medicine. His passions include all things medical. In particular, he is passionate about medical education, how best to help physicians learn, diagnostic reasoning, and creating an environment of learning where no one is afraid to express what they’re thinking. When he is not pursuing his love of learning, he is spending time with his wife and their boys (2 cats and a dog), playing with his animals, preparing to be a father to his soon-to-be-born son, crossfitting, doing DIY home-improvement projects, exploring national parks, or reading good nonmedical fiction with a cat or dog in his lap begging for his love and attention.

Malika Gill

Malika Gill is a 4th-year medical student at Virginia Commonwealth University pursuing internal medicine with interests in gastroenterology and medical education. She completed her undergraduate studies in biology and psychology at Virginia Commonwealth University. In her free time, she loves to read, try new restaurants, and spend time with friends and family. 

This is the second episode of a three-part series on understanding and dismantling race-based medicine. We invite Drs. Nwamaka Eneanya and Jennifer Tsai to discuss the limitations and harms of race-based medicine in clinical practice. Our guests explain how we can incorporate race-conscious medicine in clinical settings, medical education, and biomedical/epidemiological research to responsibly recognize and address the harms of racial inequality.

Learning Objectives

After listening to this episode learners will be able to…

• Explain how race-based medicine harms our ability to provide equitable care for all
• Understand the role of race in eGFR and other clinical calculators and the challenges of teasing out its role
• Describe what clinicians can do to identify race-based medicine and how they can adapt their practices to mitigate the potential harms of race-based medicine
• Explain the roles of medical education and biomedical/epidemiological research in accurately describing and justly addressing differences in clinical outcomes that stem from racial inequality
• Understand why race-conscious medicine–not colorblindness–is how we should move forward and beyond race-based medicine

Credits

• Written and produced by: Utibe R. Essien, MD, MPH, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Jazzmin Williams
• Hosts: Utibe R. Essien, MD, MPH, Rohan Khazanchi, and Jazzmin Williams
• Show Notes: Naomi Fields
• Infographic: Creative Edge Design
• Guests: Nwamaka Eneanya, MD, MPH, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania (@AmakaEMD) and Jennifer Tsai, MD, MEd, Yale Emergency Medicine Class of 2023 (@tsaiduck77)

Download Transcript Here

Episode 4 – Race-Based Medicine, Part 2: Clinical Perspectives

 Show Notes

Naomi F. Fields

Time Stamps

00:00    Mission, vision, and introductions of hosts

01:30    Background on three-episode series

02:26    Introductions of guests

04:16    How Dr. Eneanya has seen race-based medicine play out in clinical practice

07:19    How Dr. Tsai has seen race-based medicine play out in clinical practice

10:45    What role should race play in making clinical decisions?

13:16    Status of the current conversation on removing race from eGFR calculators: why is it so contentious?

19:05    Clarifying the “ethics vs science” argument and critiquing research techniques

22:00    Resurgence of race-based speculation in COVID-19-related research

25:57    Implantation of ideas about innate racial inferiority within medicine

28:32    Will removal of race from algorithms potentially harm our patients?

33:19    Danger of normalizing immutable, innate racial difference within clinical algorithms

38:10    What role should race hold as we move toward health equity?

45:50    Key takeaways for trainees

47:45    Key takeaways for faculty

49:17    Pointers to those interested in health equity research

50:17    One thing you can employ in your practice today

54:14    Bloopers!

Episode Takeaways:

Trainees

Asking thoughtful questions that challenge the “status quo” can prove an effective means of sparking discussions while minimizing the potential for negative retaliation. Dr. Tsai describes previously asking her attendings, “Why is there a race correction for adults in nephrology, but not for children? What happens at age 18 [to provoke the need for correction]?” Questions such as these can stimulate thoughtful inquiry and remind all of us of the responsibility to be critical practitioners.

Faculty

If you feel your cause is important, keep going — even when you are challenged by others. Attending physicians have tremendous power in dictating culture, and are so valuable in extending this work, especially given how the hierarchical nature of medicine can make it difficult for trainees to advocate firmly. Moreover, center patients not only in discussions about individual decision-making but in constructing and drawing meaning from the research. 

All

If you are interested in health equity, recognize that there is a breadth of research established in the fields of health equity, disparities, and structural racism. Be sure to do the work to educate yourself about the foundations of this work, and collaborate with those who have been studying and establishing it if you have the opportunity. 

Poet Marge Piercy has written, “The work of the world is as common as mud.” While there indubitably exists a need to advance scholarship and theory, we must also ground ourselves in the day-to-day actions that can bring comfort and kindness to our patients. Where can you give an extra inch to those for whom you are caring? 

Pearls

Role of Race in Clinical Reasoning

Harnessing the idea that “race is a social construct” to exclude consideration of race from medicine altogether does a disservice to our patients. Race, racism, and racial inequality have tangible impacts on people’s livelihoods, much less their experiences in the healthcare system. For instance, there is well-established research on how the stress of racism and racial inequality become “embodied” by modifying people’s cortisol levels to exert end-organ effects. Thinking about race is not racist in and of itself: It is the usage of race in the service of white supremacy or oppression that makes that transformation. Being race-conscious, or critically curious about the ways in which racism and racial inequality may affect our patients, can actually offer a starting point for advancing health justice. Much is akin to how naming the “battered child syndrome” catalyzed changes in our frameworks for addressing child abuse, critical curiosity in the space of racism can help us to develop thoughtful plans for tracking, discussing, and monitoring racism within in healthcare settings and beyond.

Race in eGFR Calculations — Why So Contentious?

eGFR equation-building is a complex science. Returning to the early literature that informs the equations reminds us that this research demonstrated racially stratified differences between Black and white cohorts. However, these studies did not account for many of the factors that can impact creatinine, the main biomarker used in eGFR calculations. These factors include a high-protein diet, muscle mass, creatinine generation, and certain medications. Many of the Black participants in the CKD epi study came from an African-American cohort (ASK trial) in which 50% of participants hadn’t graduated high school and over 50% made less than $50,000/year. These factors may have impacted their diet, physical activity, and medications, thus impacting their creatinine levels and the inputs that we use for GFR. This reminds us that using race as a catch-all can shroud other factors (ex. structural racism) that more rigorously account for differences observed between groups. And, as we think about revamping eGFR calculators, we must also ensure that there are standardized means of doing so across institutions.  

Ethics-Plus: Reforming our Approaches to Clinical Research 

Without question, there exists a strong ethical imperative to eradicate racism from biomedical science and to better use biomedical science in the service of health justice. There also exists an imperative to refine how we use race in research, given the scientific evidence that it is a social construct. Critiquing the cursory usage of race in studies illuminates the need to clearly define and standardize race as an operational variable, explain that to which racial differences are attributed, and describe how we interpolate meaning from these differences. Failing to do so may obfuscate the realities of social-structural racism, and obscure opportunities for improving understanding or intervention. Rigorous usage of race is not only ethically sound: it’s also better science.

In this vein, our researchers can take advantage of the technology that we have to ask more sophisticated questions that generate true accuracy, rather than those that simply accept race as a surrogate. We might critically think about why we might use race in a regression model, and proactively consider how we will interpret and responsibly discuss findings that may result. We might group people across socio-demographic categories (ex. education, income, number of previous hospitalizations) that also lead to clinical outcomes, not only race-based stratification. When racial differences are observed, we might further examine contributors to outcomes within a group. Our journals can help lead the charge by more diligently enforcing fastidious usage of race within papers they choose to publish. Rather than accepting racially-stratified differences in outcomes as inexorable and without further inquiry, we can seek to understand and address what underpins these phenomena. Consensus standards that guide authors on ethical use of race in scientific research exist. Our esteemed publications should ensure that investigations that utilize racial variables follow these guidelines before being published.

Addressing Potential Harms of Removal of Race from Clinical Calculators

Some have expressed fear that removing race from eGFR calculators will result in inaccurate therapeutic changes (ex. premature dialysis initiation, premature renal transplants, or inappropriate medication administration) that will primarily affect Black patients. However, the diagnostic approach used to determine changes in clinical management of renal disease (i.e. dialysis, transplant) is multifactorial; it is not based on eGFR alone. Additionally, research has shown that using symptom-prompted modifications to management, in the context of shared decision-making, can improve outcomes. Using the eGFR calculators as a sole determinant offers a limited metric with a ~30% margin of error. We can and should be incorporating other methods of evaluating kidney function (ex. 24-h Cr clearance, cystatin C) within a body of data. This can contribute to a more holistic understanding of disease progression and management.

How Bearing the Burden of Change Reinforces Racism

Some responses to the prospect of eliminating race corrections have asked proponents of these changes to prove that removing race corrections will not do harm to patients. In juxtaposition, research that established the corrections was not necessarily asked to prove that corrections are harmless. The additional evidence and surveillance needed to demonstrate the limited relevance of race belies a collective investment in the immutability of biological racial difference. However, race corrections do in fact cause both ideological and tangible harm in that they reify essential biological racial differences. Social psychology research demonstrates that when race is given this genetic basis, trainees display more apathy toward racial outgroups and a tendency to consider their physiology as innately dysfunctional. As a result, they demonstrate lower levels of accountability to creatively problem-solve for patients of color. It is also the case that many of these race corrections (eGFR, ASCVD, UTI, VBAC) about which people have been protective have not actually shown benefit to people of color.

Links

References discussed throughout episode

1. Tsai J. It’s Time to Talk about Racism in Medical Education. FIX19. https://feminem.org/2020/06/15/its-time-to-talk-about-racism-in-medical-education/
2. Tsai J. What Role Should Race Play in Medicine? Scientific American. September 12, 2018. https://blogs.scientificamerican.com/voices/what-role-should-race-play-in-medicine/ 
3. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med. 2016 Jul;91(7):916-20. doi: 10.1097/ACM.0000000000001232.
4. Tsai J. COVID-19’s Disparate Impacts Are Not a Story about Race. Scientific American. September 8, 2020. https://www.scientificamerican.com/article/covid-19s-disparate-impacts-are-not-a-story-about-race/
5. Tsai J, Cerdeña JP, Khazanchi R, Lindo EG, et al. There is no “African American physiology”: The fallacy of racial essentialism. J Intern Med. 2020;288(3):368-370. doi:10.1111/joim.13153
6. Eneanya ND, Yang W, Reese PP. Reconsidering the Consequences of Using Race to Estimate Kidney Function. JAMA. 2019;322(2):113-114. doi:10.1001/jama.2019.5774
7. Ahmed S, Nutt CT, Eneanya ND, et al. Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes. J Gen Intern Med. 2020. doi: 10.1007/s11606-020-06280-5.
8. Grubbs V. Precision in GFR Reporting: Let’s Stop Playing the Race Card. Clin J Am Soc Nephrol. Published online May 11, 2020. doi:10.2215/CJN.00690120
9. Powe NR. Black Kidney Function Matters: Use or Misuse of Race? JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.13378
10. National Kidney Foundation, American Society of Nephrology. Establishing a Task Force to Reassess the Inclusion of Race in Diagnosing Kidney Diseases. Published July 2, 2020.
11. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;0(0):null. doi:10.1056/NEJMms2004740
12. Braun L, Wolfgang M, Dickersin K. Defining race/ethnicity and explaining difference in research studies on lung function. Eur Respir J. 2013;41(6):1362-1370. doi:10.1183/09031936.00091612
13. Chadha N, Lim B, Kane M, Rowland B. “Toward the Abolition of Biological Race in Medicine.” Institute for Healing & Justice in Medicine; 2020. https://www.instituteforhealingandjustice.org/download-the-report-here

Additional references and papers as mentioned in the episode

1. Essien UR, Eneanya ND, Crews DC. Prioritizing Equity in a Time of Scarcity: The COVID-19 Pandemic. J Gen Intern Med. 2020;35(9):2760-2762. doi:10.1007/s11606-020-05976-y
2. Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59(5):350-355. doi:10.1136/jech.2004.024562
3. Gravlee CC. How race becomes biology: embodiment of social inequality. Am J Phys Anthropol. 2009 May;139(1):47-57. doi: 10.1002/ajpa.20983. PMID: 19226645.
4. Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI):
   1. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate [published correction appears in Ann Intern Med. 2011 Sep 20;155(6):408]. Ann Intern Med. 2009;150(9):604-612. doi:10.7326/0003-4819-150-9-200905050-00006
5. African American Study of Kidney Disease and Hypertension (AASK):
   1. AASK Clinical Trial in the NIDDK Repository: https://repository.niddk.nih.gov/studies/aask-trial/
   2. Lewis J, Agodoa L, Cheek D, et al. Comparison of cross-sectional renal function measurements in African Americans with hypertensive nephrosclerosis and of primary formulas to estimate glomerular filtration rate [published correction appears in Am J Kidney Dis 2002 Feb;39(2):444]. Am J Kidney Dis. 2001;38(4):744-753. doi:10.1053/ajkd.2001.27691
6. Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-619. doi:10.1056/NEJMoa1000552
7. Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology [published correction appears in J Am Coll Cardiol. 2019 Jun 25;73(24):3234]. J Am Coll Cardiol. 2019;73(24):3153-3167. doi:10.1016/j.jacc.2018.11.005
8. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 
9. Micheletti SJ, Bryc K, Ancona Esselmann SG, et al. Genetic Consequences of the Transatlantic Slave Trade in the Americas. Am J Hum Genet. 2020;107(2):265-277. doi:10.1016/j.ajhg.2020.06.012
10. Krieger N. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: an ecosocial perspective. Am J Public Health. 2003;93(2):194-199. doi:10.2105/ajph.93.2.194
11. Piercy M. To be of use. In: Circles on the Water: Selected Poems of Marge Piercy. Alfred A. Knopf; 1982.https://www.poetryfoundation.org/poems/57673/to-be-of-use

Disclosures

Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education, but the views presented herein represent his own and not necessarily those of the AMA or the Council. Dr. Eneanya is a member of the National Kidney Foundation and the American Society of Nephrology Task Force; the views herein represent her own and not necessarily those of the NKF or the Task Force. The hosts and guests report no other relevant financial disclosures. 

Citation

Eneanya A, Tsai J, Williams J, Essien UR, Paul D, Fields NF, Nolen L, Ogunwole M, Onuoha C, Khazanchi R. “Episode 4: Dismantling Race-Based Medicine, Part 2: Clinical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes December 17, 2020.

Reza, Rabih, Sharmin, and Arsalan break down meningoencephalitis in this bite sized schema episode, inspired by Dr. Kimberly Manning.

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Reza and Rabih tackle a second case of weakness

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Dhruv and Travis present a case of R sided weakness and numbness to Kiara, Tahir, and Aaron, as we continue our campaign to end neurophobia! 

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Dhruv Srinivasachar

Dhruv Srinivasachar is a 4th year medical student at Virginia Commonwealth University School of Medicine (the Medical College of Virginia for all the veteran attendings out there). Introduced to medicine through research, Dhruv has shifted his passions to empathetic clinical care and medical education, as a contributor to the CPSolvers (especially through VMR as a case presenter, discussant, and compiler of cases) and team member for the Not Just Little Adults podcast (CPedsSolvers, if you will). When he’s not interviewing for Med-Peds residency, he can be found biking around Richmond, VA, gardening, and cooking. 

Tahir Malik

Tahir Malik is a 4th-year medical student at Baylor College of Medicine interested in artificial intelligence, cardiology, and global health. He is interested in performing healthcare disparities research, in capacity-building in low-resource settings, and in understanding the role AI might play in global health solutions. In his free time, Tahir is an avid runner and biker and is trying to become a reasonable cook. 

Travis Smith

Dr. Smith is a student educator and community EM physician currently practicing in Jacksonville, Florida. He currently is an Associate Professor of Emergency Medicine, Assistant Dean of Clinical Education, and the Director of the Clinical Clerkship Curriculum for LECOM. He attended undergrad at FSU where he received his bachelor’s degree in Biological Science. He then attended Lake Erie College of Osteopathic Medicine in Bradenton for his medical degree and then completed his residency in emergency medicine at the University of Florida Jacksonville campus. He has been board-certified in emergency medicine through ABEM since 2013. In his free time, he serves as the lead section editor for the Human dx project as well as a frequent contributor to the Clinical Problem Solvers and is heavily involved in #Medtwitter running the @medtweetorials account as well as his own @RosenelliEM

Reza and Rabih tackle a case of weakness.

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In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we sit down with Ed Yong, an award-winning journalist and science writer with The Atlantic, to discuss the structural inequities amplified by COVID-19 as well as the social concerns associated with the impending/present second wave of the pandemic.

Learning Objectives

After listening to this episode listeners will be able to…

1. Understand the trajectory of the COVID-19 pandemic’s unique impact on communities of color in the United States and its tie to historical discrimination and structural inequities
2. Describe the racialized and politicized national response to COVID-19
3. Recognize the crucial role that social interventions can and could have played in decreasing the burden of COVID-19

Credits

• Written and produced by: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Naomi Fields, Chioma Onuoha, and Jazzmin Williams
• Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH
• Infographic: Creative Edge Design
• Guests: Ed Yong staff writer at The Atlantic (@edyong209)

Clinical Problem Solvers: Anti-Racism in Medicine

Show Notes – Episode 3: Structural Inequities and the Pandemic’s Winter Surge

December 3rd, 2020

By: Chioma Onuoha

Timestamps

00:00 Music/Intro

00:20 Mission and Vision

00:32 Introduction of Ed Yong

02:00 Disproportionate impact of COVID-19 on minority communities

04:00 Racism in the national/policy response to COVID-19

07:00 Health Care Worker Fatigue

09:30 Grief and the Unique Frustrations of Health Care Workers of Color

11:30 The “Chinese” Virus and the history of the pandemic

14:00 Administrative Blame Shifting

17:00 How Could This Have Been Prevented?

20:00 COVID-19 and indigenous populations

Takeaways

1. Social Interventions are Valuable

Currently in the COVID-19 pandemic, social interventions are the only interventions available to us. When it comes to pandemics more broadly, the role of non-pharmaceutical interventions, like mask wearing, social distancing, and stay at home orders, must be recognized for their robust potential to reduce disease spread and burden. (Reflection Question: How can I best communicate the importance of social interventions to my extended family, community, and patients?)

1. The Racial Disparities Exposed by COVID-19 are Not a Result of Biological Difference

It is dangerous to look at the racial and ethnic health disparities highlighted by COVID-19 and attribute them to biological differences*. Many of the populations who suffer from these disparities also suffer from structural inequity and historical discrimination which impact their quality of life and health outcomes. Marginalized communities have historically received the brunt of the blame when it comes to widespread pandemics without recognition of the role that structural factors play in creating and maintaining health inequity.

*To learn more about the danger of biological explanations for health disparities see the CPS Anti-Racism in Medicine three-part episode series Dismantling Race-Based Medicine. Part 1: Historical & Ethical Perspectives featuring Professor Edwin Lindo is available now.

1. Health Policy Must Target Structural Inequities

Inequities worsen if they are not specifically addressed in policy. Without intentional effort put into addressing the root cause of structural inequities, it is possible that interventions will cause more harm than good. (Reflection Question: How should the concept of equity vs. equity be applied in creation of health policy?)

Pearls

The disparities amplified by COVID-19 are not new or unsurprising

The narrative of COVID-19 being a “ great equalizer” is largely untrue. If anything, COVID-19 has removed “the veil” and made the extent of the inequities in this country very clear. Marginalized communities are especially vulnerable to COVID-19 due to structural factors like segregation, lack of access to clean water, poor air quality, and limited availability of health care.  These structural inequities are longstanding and will require long-lasting and intentional rectification.

Frontline Workers Pushed to their Limits

Touching accounts from frontline workers, in particular, nurses, who are uniquely positioned to face the devastating impacts of the disease, have clarified the toll that COVID-19 has placed on care workers. The emotional and physical fatigue associated with such immense loss of human life is leading to burnout among the very group that is required to address this disease. For many health care workers of color, their struggles are compounded by personal grief and increased expectations to lead anti-racism efforts within institutional walls.

Blame shifting

During COVID-19, we have seen marginalized communities be positioned as scapegoats to explain the prevalence and persistence of the disease. This is not a new phenomenon. Ed Yong cites anti-Blackness during the Ebola outbreak; homophobia, transphobia, and condemnation of sex workers and people who use drugs during the HIV epidemic; and current anti-asian rhetoric during COVID-19 and the original SARS as examples. Blame is deflected to populations on the outskirts of society and used as justification to delay or fail to provide aid. Throughout the duration of the pandemic, we have seen the nature of this blame evolve. While it started with accusations that Black people and POC do not take the virus seriously and/or have chronic diseases and unhealthy habits, most presently it manifests through discourse around black people’s weariness of taking the forthcoming COVID-19 vaccine. Rather than placing blame on marginalized populations, it is crucial that we first analyze history and external influences that may explain the behaviors and outcomes being observed.

Overreliance on Biomedical Measures

“[Rudolf Virchow] specifically writes ‘Medicine is a social science’ and we have lost that understanding” – Ed Yong

For much of the COVID-19 pandemic, rhetoric in the United States has centered around waiting for biochemical and pharmaceutical interventions to be developed rather than fully taking advantage of the social interventions currently available. Social interventions are powerful, and as we can see from the COVID-19 responses of countries like South Korea and Taiwan, they are effective at managing this disease. This reality highlights the importance of sociological and anthropological expertise in medicine and the need to expand interdisciplinary exchange in health care more broadly.

References Discussed in Episode

01:30

Yong, E. (2020, September 20). How Pandemic Defeated America. The Atlantic. https://www.theatlantic.com/magazine/archive/2020/09/coronavirus-american-failure/614191/

04:00

Serwer, A. (2020, May 8). The Coronavirus Was an Emergency Until Trump Found Out Who Was Dying, The Atlantic. https://www.theatlantic.com/ideas/archive/2020/05/americas-racial-contract-showing/611389/

Kendi, I. X. (2020, April 6). What the Racial Data Show. The Atlantic. https://www.theatlantic.com/ideas/archive/2020/04/coronavirus-exposing-our-racial-divides/609526/

05:50

APM Research Lab Staff. (2020, November 12). The Color of the Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S. APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race

07:00

Yong, E. (2020, November 13). No One Is Listening to US. The Atlantic. https://www.theatlantic.com/health/archive/2020/11/third-surge-breaking-healthcare-workers/617091/

Yong, E. (2020, November 20). Hospitals Know What’s Coming. The Atlantic.

https://www.theatlantic.com/health/archive/2020/11/americas-best-prepared-hospital-nearly-overwhelmed/617156/

Yong, E. (2020, July 7). The Pandemic Experts Are Not Okay. The Atlantic. https://www.theatlantic.com/health/archive/2020/07/pandemic-experts-are-not-okay/613879/

10:30

Dr. Uche Blackstock (@uche_blackstock)

Dr. Esther Choo (@choo_ek)

19:00

Rashawn, R. (2020, April 9). Why are Blacks dying at higher rates from COVID-19?. Brookings. https://www.brookings.edu/blog/fixgov/2020/04/09/why-are-blacks-dying-at-higher-rates-from-covid-19/

Hernandez, E. (2020, April 23). Inequities in COVID-19 are tragic but preventable. The Hill. https://thehill.com/blogs/congress-blog/healthcare/494251-inequities-in-covid-19-are-tragic-but-preventable#bottom-story-socials

20:00

McFarling, U.L. (2020, November 17). ‘They’ve been following the science’: How the Covid-19 pandemic has been curtailed in the Cherokee Nation. STAT. https://www.statnews.com/2020/11/17/how-covid19-has-been-curtailed-in-cherokee-nation/

Additional References

1. Essien, U. R., & Venkataramani, A. (2020, April 28). Data and Policy Solutions to Address Racial and Ethnic Disparities in the COVID-19 Pandemic. JAMA Health Forum. https://jamanetwork.com/channels/health-forum/fullarticle/2765498
2. Gold, J. (2020, June 12). ‘I Am Tired’: What Black Doctors Need You To Know Right Now. Forbes. https://www.forbes.com/sites/jessicagold/2020/06/12/i-am-tired-what-black-doctors-need-you-to-know-right-now/?sh=29a644254ad7
3. Gross, C. P., Essien, U. R., Pasha, S., Gross, J. R., Wang, S., & Nunez-Smith, M. (2020). Racial and Ethnic Disparities in Population-Level Covid-19 Mortality. Journal of General Internal Medicine, 35(10), 3097–3099. https://doi.org/10.1007/s11606-020-06081-w
4. Jones, CP (2020, April 7). Coronavirus Disease Discriminates. Our Health Care Doesn’t Have To | Opinion. Newsweek. https://www.newsweek.com/2020/04/24/coronavirus-disease-discriminates-our-health-care-doesnt-have-opinion-1496405.html
5. Kendi, I. X. (2020, June 16). Black People Are Not to Blame for Dying of COVID-19. The Atlantic. https://www.theatlantic.com/ideas/archive/2020/04/race-and-blame/609946/
6. Krishnan, L., Ogunwole, S. M., & Cooper, L. A. (2020). Historical Insights on Coronavirus Disease 2019 (COVID-19), the 1918 Influenza Pandemic, and Racial Disparities: Illuminating a Path Forward. Annals of Internal Medicine, 173(6), 474–481. https://www.acpjournals.org/doi/full/10.7326/M20-2223
7. Tavernise, S., & Oppel, R. A. (2020, June 2). Spit On, Yelled At, Attacked: Chinese-Americans Fear for Their Safety. The New York Times. https://www.nytimes.com/2020/03/23/us/chinese-coronavirus-racist-attacks.html
8. Williams DR, Cooper LA. (2020). COVID-19 and Health Equity-A New Kind of “Herd Immunity”. JAMA.323(24):2478-2480. doi:10.1001/jama.2020.8051
9. Williams, V. (2020, March 27). A poll finds African Americans and Latinos are more worried about the coronavirus; a public health expert explains why. The Washington Post. https://www.washingtonpost.com/nation/2020/03/27/poll-finds-african-americans-latinos-more-worried-about-covid-19-doctor-explains-why/?arc404=true
10. Yong, E. (2020, August 19). We Live in a Patchwork Pandemic Now. The Atlantic.https://www.theatlantic.com/health/archive/2020/05/patchwork-pandemic-states-reopening-inequalities/611866/
11. Yong, E. (2020, September 14). America Is Trapped in a Pandemic Spiral. The Atlantic. https://www.theatlantic.com/health/archive/2020/09/pandemic-intuition-nightmare-spiral-winter/616204/

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

Yong E,  Essien UR, Nolen L, Khazanchi, R, Ogunwole M, Fields N, Onuoha C, Williams J, , Paul D. “Episode 4: Structural Inequalities and a Second Wave.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. December 3, 2020.

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Reza and Rabih tackle a case of fever at Baystate.

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Kushal presents a Human Dx unknown to Jack, Kushal, Gabe, and Jake.

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Kushal Vaishani

Kushal is a hospitalist and contributing editor for the Adult Medicine section at Human Dx. After finishing his medical school in India, he completed his residency training at Brandon Regional Hospital and LSUHSC – University Hospital and Clinics. His academic interests include clinical reasoning, medical education, high-value care, and infectious diseases.

Gabe Siegel

Gabe Siegel is currently a PGY-1 Emergency Medicine Resident at Denver Health. Gabe completed medical school at Rush Medical College in Chicago, IL. When not working, he is busy enjoying the outdoors in Colorado and hunting for good food in Denver. His academic interests include health policy, critical care, and social EM.

Jake Hershey

Jake is currently a PGY-1 in the IM hospital training track at the University of Colorado and graduated from Rush Medical College alongside his friend and co-discussant Gabe. His passions in medicine include medical education, clinical reasoning, and after-work commiseration with his co-residents. In his free time, he loves exploring the Colorado wilderness to experience the amazing hiking, kayaking, and snowboarding that the state has to offer.

Dr. John Alexander presents a Human Dx unknown to Dr. Courtney Wagner, Dr. Ryan Goetz, and Dan

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Courtney Wagner

Courtney Wagner is PGY-2 in Internal Medicine resident at the University of Alabama at Birmingham. She is a Florida native and grew up in and around the water either swimming competitively, SCUBA diving, or fishing. She initially graduated from the University of Central Florida with a biological sciences degree and taught high school science before going back to school for nursing at the University of South Florida.  After gaining experience at the bedside as an ICU nurse, she pursued a career in medicine by returning to UCF for medical school. Currently interested in academic medicine with a heart for hospice and palliative and the geriatric population. She loves cooking, hiking, and triathlons, having completed over 60 races, including Ironman Cozumel. 

John Alexander

John Alexander is a PGY-2 internal medicine resident at the University of Tennessee Health Science Center in Memphis. He got his undergraduate degree in history from Rhodes College and graduated from William Carey University College of Osteopathic Medicine. His research interests include clinical and diagnostic reasoning and cardiology. He hopes to pursue a career in academic medicine. Outside of the hospital he enjoys playing tennis, traveling, and spending time with family and friends. 

Ryan Goetz

Ryan Goetz is a second-year internal medicine resident at the University of Alabama Birmingham. He attended medical school at the Medical College of Georgia. He wants to pursue a career in pulmonary/critical care medicine after completing his residency. His clinical/research interests include ventilator physiology/teaching, clinical reasoning, bronchiectasis, and ARDS. In his spare time, Ryan enjoys Orange Theory Fitness workouts, craft beer, and history podcasts.

Sharmin, Lindsey, and Alex discuss a clinical unknown with Dr. Natasha Chida from Johns Hopkins

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Dr. Natasha Chida

Dr. Chida is an Assistant Professor in the Division of Infectious Diseases at Johns Hopkins University School of Medicine. She serves as the Associate Program Director for the infectious diseases fellowship training program. She is also the Co-director of the Osler and Bayview Internal Medicine Residency Programs Medical Education Pathway, and firm faculty in the Osler Program, where she serves as a resident coach. Her research interests include career development for early-career professionals, women in medicine, and HIV education for fellows.

This is the first episode of a three-part series on understanding and dismantling race-based medicine by unearthing its origin and exposing the paucity of rigorous evidence in support of it. In this episode, we invite Critical Race Theory scholar Edwin Lindo, JD to discuss the invention of race, how its definition has changed over time, and how the fields of science and medicine contributed to its legitimacy as a tool for political and social oppression. 

Episode Learning Objectives

After listening to this episode learners will be able to…

1. Define race and what is meant by “race is a social construct”
2. Describe the influential role of science and medicine in creating race 
3. Understand why race is a poor proxy for genetics or ancestry

Credits

• Written and produced by: Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Naomi Fields, Chioma Onuoha, Jazzmin Williams, Dereck Paul, MS, and Utibe R. Essien, MD, MPH 
• Show Notes: Jazzmin Williams
• Hosts: Dereck Paul, MS, Rohan Khazanchi, LaShyra Nolen
• Infographic: Creative Edge Design
• Guests: Prof. Edwin Lindo, Assistant Dean for Social & Health Justice, University of Washington School of Medicine (@EdwinLindo) 

  Time Stamps

  00:00 ​Music/intro
  00:11 ​Our mission and vision
  00:38 ​Introduction to the Antiracism in Medicine team
  02:08​ ​Introduction of this episode and the Dismantling Race-Based Medicine series 02:49 ​Introduction of Prof. Edwin Lindo
  03:28 ​What is race? How is race a social construct? Why was it constructed in the first place?
  16:10​ Why color-blindness is not a solution to dismantling race-based medicine
  20:00 ​How has medicine played a key role in defining race throughout history? 37:50​ Race vs. ancestry vs genetics–implications for research and clinical practice 52:02 ​What can we start doing tomorrow?
  57:35 ​Conclusion and outro

  Episode Takeaways:

1. History matters​. Medicine has never been an apolitical field, and understanding the specific ways the medical field contributed to socio-political definitions of race through practices rooted in medical racism can help us avoid repeating the same harms of the past (e.g. racial essentialism). This education needs to span the whole MedEd continuum.

2. Definitions matter​. In research, clinical practice, and MedEd, we need to be explicit in our understanding and discussion of race vs. ethnicity vs. ancestry, and how each of these categorizations does or does not impact biological or genetic traits.

3. Bias is everywhere​. Objectivity is a top priority in medicine and research; however, history shows us how initial assumptions have tainted both study design and interpretation of results.

Conversation Starters and Reflection Questions for Trainees​ & ​Faculty

What teachings lie at the root of your belief that race has a biological basis?
– Dismantling race-based medicine starts at home by asking yourself, colleagues, and

classmates this question. Much of the data promoting biological difference amongst races comes from poorly-designed studies where race as a variable is ill-defined or confounding variables are inadequately controlled. This reflexive acceptance that race is rooted in biology comes from stereotypes created by Carl Linnaeus and other racial taxonomists.

How is racism causing the outcomes that I am seeing in my patient?
– Recognizing that racism, not race, is the root cause of racial health disparities is the first step to improving health outcomes for Black, Indigenouls People of Color (BIPOC) patients. Acknowledging this truth highlights the necessity of mitigating the harms of racism as part of any comprehensive treatment plan. This is done on an individual level, by offering existing support and resources, as well as on a systemic level through advocacy.

Pearls

Defining Race

Race is a socio-politically constructed taxonomy that was invented based on factors such as perceived skin color and culture, not science or biology. The concept of race emerged for the purpose of allocating and/or extracting resources. In the United States, the concept of race was key to extracting resources from Black and Indigenous peoples during the formation and expansion of the country.

The Role of Science and Medicine in Defining Race and Racism

Scientists and physicians legitimized race as a category by positing “objective” proof that white persons were biologically superior to other races. In 1735, Carl Linnaeus, often known as the the “father of taxonomy,” classified four “varieties” of human species and ascribed stereotypical characteristics to each race: “Native Americans as reddish, stubborn, and easily angered; Africans as Black, relaxed, and negligent; Asians as sallow, avaricious, and easily distracted; while Europeans were depicted as white, gentle, and inventive.”

In 1839, Dr. Samuel Morton asserted that White people were the most intelligent of all races and Black people were the least so based on head circumference and cranial capacity. In an 1850 report commissioned by the Louisiana legislature, Dr. Samuel Cartwright argued that Black people were lazier, less intelligent, and more susceptible to infectious diseases than White people because they had less lung capacity. Cartwright’s study influenced the equations that medical professionals still use to calculate the impact of various diseases on lung function. This baseless race correction impacts treatment decisions, which contributes to racial health inequities. In the early 1900s, eugenicists and social anthropologists claimed that Black people were predisposed to violent crime, which justified institutionalization and sterilization of Black people. Despite their claims being based on unproven assumptions, their research was praised for scientific rigor and used to justify subjugation based on race.

“The scientific method is only as strong as the variables you input into it and if you are not critical of the questions you are asking, who you are researching, how you are doing that research then the biases, the history, the legacy, they seep in.” – Edwin Lindo, JD

Why is color-blindness not a solution to dismantling race-based medicine?

Ignoring race and racism does not negate the profound impact that race and racism have on our BIPOC patients’ health. Colorblindness inflicts harm through erasure. Instead, researchers and clinicians must be aware of the impact of racism in order to explore ways of mitigating its damage. For more on this concept, stay tuned for the next episode!

Is race a good proxy for ancestry? For genetics?

Since race is a socio-political construct, its definition has changed over time and space. For example, racial categories in the US Census have changed numerous times, with new categories being created and others disappearing or returning depending on the political atmosphere at the time. In another example, a person who is considered Latinx in the US could be considered Mulatto in Brazil or Coloured in South Africa. Given that there is no standard definition of race, its imprecision does not meet the standards of clinical medicine. As Prof. Lindo states, “our eyes see race” when we study disease disparities, but the true risk factor may actually be racism, geographic ancestry, or a specific genetic variant. However, assuming a genetic difference based on a perceived association with race is poor science.

Links

References discussed throughout episode

1. “The Praxis” Podcast: ​https://clime.washington.edu/praxis

2. Boyd RW, Lindo EG, Weeks LD, McLemore MR. On Racism: A New Standard For

   Publishing On Racial Health Inequities. ​Health Aff Blog​. Published online July 2, 2020.

   https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/

3. Marya R, Lindo E. Healing the Nation’s “Broken and Scattered” Hoop. ​Common Dreams. Published online June 19, 2020.https://www.commondreams.org/views/2020/06/19/healing-nations-broken-and-scattered -hoop

4. Tsai J, Cerdeña JP, Khazanchi R, Lindo E, et al. There is no “African American physiology”: The fallacy of racial essentialism. ​J Intern Med.​ 2020;288(3):368-370. doi:10.1111/joim.13153

5. Chadha N, Lim B, Kane M, Rowland B. “Toward the Abolition of Biological Race in Medicine.” ​Institute for Healing & Justice in Medicine​; 2020. https://www.instituteforhealingandjustice.org/download-the-report-here

6. Wilkerson, I. (2020). Caste: The Origins of Our Discontents. Random House.

Additional references and papers as mentioned in episode

1. Roberts, D. (2012). Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century (50852nd ed.). The New Press.

2. Braun, L. (2014). Breathing Race into the Machine: The Surprising Career of the Spirometer from Plantation to Genetics (1st ed.). Univ Of Minnesota Press.

3. Harris, C. (1993). Whiteness as Property. Harvard Law Review, 106(8), 1707-1791. doi:10.2307/1341787

4. Williams DR. Miles to go before we sleep: racial inequities in health. J Health Soc Behav. 2012 Sep;53(3):279-95. doi: 10.1177/0022146512455804.

Disclosures

Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education, but the views presented herein represent his own and not necessarily those of the AMA or the Council. The hosts and guests report no other relevant financial disclosures.

Citation

Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 140: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” ​The Clinical Problem Solvers Podcast.​ ​https://clinicalproblemsolving.com/episodes​ November 17, 2020.

Show Transcript

1. Music

2. Introduction

3. Introduction to the Antiracism in Medicine team

4. Introduction of this episode and the Dismantling Race-Based Medicine series

5. Introduction of Prof. Edwin Lindo

6. What is race? How is race a social construct? Why was it constructed in the first place?

7. Why color-blindness is not a solution to dismantling race-based medicine

8. How has medicine played a key role in defining race throughout history?

9. Race vs. ancestry vs genetics–implications for research and clinical practice

10. What can we start doing tomorrow?

11. Conclusion and outro

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Reza and Rabih tackle a case of hematuria.

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Reza, Rabih, Sharmin, and Arsalan share their approach to CNS and lung lesions.

Lung Nodule Schema

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Reza and Rabih discuss an unknown case presented by Drs. Ramesh and Moriates at Dell Medical School

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Dr. Jan Ramesh

Jan Ramesh is the Hospital Medicine Fellow in Quality and Safety at Dell Medical School at The University of Texas at Austin.  Outside of the hospital, she enjoys writing poetry, drawing, and spending time with her husband and her two cats. 

Dr. Chris Moriates

Chris Moriates is a practicing hospitalist, Assistant Dean for Healthcare Value, and Associate Chair for Quality and Safety at Dell Medical School at The University of Texas at Austin, where he also directs the Distinction Track in Care Transformation for internal medicine residents and the Hospital Medicine fellowship. When not in the hospital, he most enjoys running around the lakes in Austin accompanied by his 9-year-old son on his bike, or hanging out with his 5-year-old daughter. 

Reza and Rabih tackle a case of pruritus.

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Reza and Rabih tackle a case of renal injury.

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Dr. Steph Le shares a story of gender discrimination and Emma and Annette discuss gender biases and stereotypes with UCSF’s Department of Surgery Chair, Dr. Julie Ann Sosa 

Dr. Julie Ann Sosa

Julie Ann Sosa, MD MA FACS is the Leon Goldman MD Distinguished Professor of Surgery and Chair of the Department of Surgery at the University of California San Francisco (UCSF), where she is also a Professor in the Department of Medicine and affiliated faculty for the Philip R. Lee Institute for Health Policy Studies. Dr Sosa came to UCSF in 2018 from Duke. Her clinical interest is in endocrine surgery, with a focus in thyroid cancer. She is an NIH-funded investigator and author of more than 325 peer-reviewed publications and 78 book chapters and reviews, all largely focused on outcomes research, health care delivery, hyperparathyroidism, and thyroid cancer, with a focus on clinical trials. She has authored or edited 7 books. Dr Sosa is Treasurer of the American Thyroid Association (ATA) and serves on the Board of Directors/Executive Council of the ATA and International Thyroid Oncology Group, as well as practice guidelines committees for the ATA, NCCN, and the American Association of Endocrine Surgeons; for the ATA, she is chairing the committee responsible for writing the next iteration of differentiated thyroid cancer guidelines. She is the Editor-in-Chief of the World Journal of Surgery and is an editor of Greenfield’s Surgery: Scientific Principles and Practice. She has mentored more than 90 students, residents, and fellows, for which she was recognized with induction as a full member to the American College of Surgeons Academy of Master Educators in 2020, and with the Lewis E. Braverman Distinguished Lectureship Award from the ATA in 2017. Dr Sosa was born in Montreal and raised in upstate New York. She received her AB at Princeton, MA at Oxford, and MD at Johns Hopkins, where she completed the Halsted residency and a fellowship.

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Description: Gizem Reyhanoglu presents a Human Dx unknown to Arsalan, Dr. Tranchito, & Dr. Kramer

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Gizem Reyhanoglu

Gizem Reyhanoglu is a 4th-year medical student at LECOM-Bradenton, applying to Internal Medicine this application cycle. She completed her undergraduate degree in biology at the University of Florida and completed a Master’s degree in Medical Sciences at the University of South Florida. In her spare time, Gizem enjoys watching The Office, training for half-marathon races, baking for her family/friends, and playing with her puppy, Leo. 

Lily Tranchito

Lily Tranchito is a PGY-3 at Case Western Reserve University/University Hospitals Internal Medicine program. She was born and raised in Cleveland, Ohio, earned her undergraduate degree from The Ohio State University, and graduated from Ohio University Heritage College of Osteopathic Medicine. She has a passion for medical education, cooking, gardening, daily walks around her neighborhood, and spending time with her family and friends. 

Patrick Kramer

Patrick Kramer is a PGY-3 in Internal Medicine at the Case Western Reserve University / University Hospitals Internal Medicine Residency Program in Cleveland, Ohio. Although he is originally just a kid from Akron, he took his talents to the University of Notre Dame and Loyola University Chicago – Stritch School of Medicine for his education. Career interests include pulmonary and critical care medicine as well as diagnostic reasoning and medical education. Outside of the hospital, Patrick has recently taken up disc golf in addition to his passions for coffee brewing, photography, and watching classic movies.

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Dr. David Jessee presents a Human Dx unknown to Sharmin, David & Antoinette

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David Jessee

David Jessee is an assistant professor of medicine and academic hospitalist at Virginia Commonwealth University School of Medicine.  He was born and raised in Southwest Virginia and completed his premedical and undergraduate education at the University of Virginia.  After graduating from VCU School of Medicine, he remained in Richmond to complete his internal medicine residency training and subsequently joined the faculty in the division of hospital medicine.  His interests include medical student and resident education with a focus on diagnostic reasoning and simulation-based experiences and assessment.  Additionally, he is involved in efforts which recognize early signs of clinical decline and enhance inpatient emergency and code response.  Outside the hospital, he enjoys running with his dog, biking, playing racquetball, watching UVA sports, and traveling to state and national parks.

Antionette Pusaterri

Antoinette Pusateri is a PGY-3 in Internal Medicine at The Ohio State University Medical Center. Born and raised in Columbus, Ohio she attended the University of Notre Dame for undergraduate majoring in Biology & Theology then returned to Columbus for medical school and Internal Medicine Residency at The Ohio State University College of Medicine and Wexner Medical Center.  She is currently interviewing for Gastroenterology & Transplant Hepatology Fellowship and has a passion for research and quality improvement, medical education and community engagement. She is also a strong advocate for trainee wellness, and herself finds wellness in CrossFit and horseback riding.

David Deng

David Deng is a PGY-3 in Internal Medicine at The Ohio State University Medical Center. He spent most of his life around Atlanta, GA, went to medical school at Medical College of Georgia, but is feels right at home in the Midwest. He’s currently pursuing a career in academic hospital medicine and is passionate about clinical reasoning and medical education. In his spare time, he loves cheering on Liverpool FC, trying hole-in-the-wall restaurants, and staying active lifting weights and running. 

The CPSolvers share a case of lactic acidosis – let’s practice those schemas together!

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Dr. Rencic and Colin presents a clinical unknown on Virtual Morning Report to CPSolvers, Rabih and Reza.

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Zari Zahra, Mel Fellay, Lindsey, Emma, and Sharmin discuss gender biases through stories.

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Melanie Fellay

Melanie Fellay is the CEO and Co-Founder of Spekit, the leading in-app learning and digital enablement companion that helps employees learn their tools and navigate process changes by accessing training resources in real-time, everywhere they work. Founded in 2018, Melanie and co-founder and former colleague, Zari Zahra, created Spekit to address the pain points they felt around driving adoption and continuous training that many Enablement and Operations leaders feel as well by bringing the sophistication of a modern digital adoption platform with the simplicity of a contextual knowledge base.

She’s a Salesforce and BizOps enthusiast with expertise in leading operations and success teams, thinking at scale and architecting Salesforce solutions. In her role, Melanie oversees the sales, marketing, customer success, and corporate development teams at Spekit. Melanie graduated from the University of Colorado, Boulder with a degree in Accounting & Finance. In her free time, Mel enjoys seeing Odesza at Red Rocks, exploring less-traveled corners of the earth and escaping it all through meditation.

Zari Zahra

Zari is a Pakistani-American Harvard MBA, an experienced Product Manager and builder of web and mobile apps for Pandora, SquareTrade, RealtyShares and Rakuten. Today, she is the Chief Product and Technology Officer and Co-founder of Spekit, the leading Salesforce adoption and contextual learning platform for growing orgs. Zari oversees all product and engineering departments, including a team office located in Karachi, Pakistan. 

In her free time, Zari spends time listening to audio books and spending time with her husband and mini-goldendoodle Rumi.

Dr. Varun Phadke presents a human dx case to Arsalan, Francesca Siegel, and Alec Yu.

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Francesca Siegel

Francesca Siegel is a third year medical student at The Ohio State University College of Medicine. She received her masters in Nutritional Sciences from the University of Cincinnati. She’s passionate about preventive medicine, effective science communion, public health, and serving her community. Outside of her school work, she enjoys volunteering with Clinica Latina, OSU’s Hispanic free clinic, running with her husband, travel, and cooking.

Alec Yu

Alec is medical student at the University of British Columbia in Vancouver, Canada. Prior to med school, he’s worked as an innovation officer at one of Vancouver’s tertiary care hospitals, and has served as a director and co-founder of a non-profit organization supporting youth engagement with humanitarian issues. A passionate problem-solver, Alec loves combining his interests with his lived experiences to start grassroots initiatives in his community. His current projects include investigating improvements to medical respite care for patients facing homelessness, and designing solid waste reduction strategies for improved hospital sustainability. On his down time, he loves cooking, running, and trying not to kill his plants.

Varun Phadke

Varun Phadke is an Assistant Professor in the Division of Infectious Diseases at the Emory University School of Medicine. He is involved in microbiology and infectious diseases education for medical students, residents, and fellows, and his scholarly interests include subspecialty clinical reasoning and diagnostic error. He loves cooking, reading mystery novels, and spending time with his wife and son.

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Dr. Joshua Inglis presents a Human Dx case to Sharmin, Vivek Nair and Joshua Morris.

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Joshua Morris

Josh is a proud cat dad to four kitties and a fourth year student at Dell Medical School applying Medicine-Pediatrics. He spent his third year doing an MA in design that cemented his passion for using creativity and innovation to better deliver care and information to patients and providers. In his spare time, he is active on MedTwitter (#MP4L), loves to run and be outside, and is obsessed with podcasts and audiobooks.

Vivek Nair

Vivek Nair is a second-year medical student at the University of Chicago Pritzker School of Medicine. He spent his undergraduate years at the University of Michigan. He is an avid runner and has been recently practicing his culinary skills (just in case medicine doesn’t work out).

Joshua Inglis

Dr Josh Inglis is an aspiring General Physician training at the Royal Adelaide Hospital. He obtained his medical degree from the University of Adelaide and is studying towards a Masters of Clinical Education. His academic interests include clinical reasoning, drug allergy and the electronic health record. Outside of work he enjoys playing tennis, brewing specialty coffee and walking his golden retriever.

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Reza and Rabih tackle a case of Vulvar Pain.

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Dr. Steph Sherman, Lindsey, Emma, and Sharmin tackle a case presented by Anna

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Dr. Steph Sherman

Dr. Stephanie Sherman is a hospitalist and residency associate program director at Baylor College of Medicine (BCM) who rounds at Ben Taub General Hospital and Houston’s VA hospital. She went to medical school at the University of Michigan and did internal medicine residency at Massachusetts General Hospital. She spends her free time with her husband, fellow clinical problem solver Zaven Sargsyan, and their ever-more-mobile 8-month-old son.

Associated Schema

Problem Representation
A 35-year-old man with advanced HIV/AIDS complicated by a recent diagnosis of Pneumocystis pneumonia and cytomegalovirus esophagitis presented with progressive fevers, dyspnea, and worsening pulmonary infiltrates in the weeks after starting antiretroviral therapy. 

Schemas
The CPSolvers’ schema for dyspnea highlights the relative importance of the pulmonary and cardiovascular systems before considering other etiologies.

Diagnosis
The patient was found to have extensive bilateral consolidations on computed tomography of the chest. Laboratory evaluation demonstrated an elevated alkaline phosphatase, an increase in his CD4 count from 22 to 43 per cubic millimeter, and a reduction in his HIV viral load from > 1 million to 3000 copies. Ultimately, a respiratory culture from his prior admission grew Mycobacterium avium complex, raising the question of whether direct infection with this pathogen or an inflammatory reaction to it in the setting of immune reconstitution could account for his clinical deterioration.

Teaching points

• Mycobacterium avium complex (MAC) is the most common of the nontuberculous mycobacteria (NTM) that acts as a human pathogen. Clinical manifestations are varied, most typically presenting as a chronic pulmonary infection in immunocompetent individuals and either localized (e.g., affecting the lymph nodes or other focal sites) or disseminated infection in immunocompromised patients (especially those with HIV infection). In the early HIV epidemic, disseminated MAC was the most common bacterial opportunistic infection and conferred significant morbidity and mortality even with treatment.
• The immune reconstitution inflammatory syndrome (IRIS) is a potential complication of antiretroviral therapy (ART), wherein patients with advanced immunosuppression related to HIV develop an inflammatory response (generally to microbial antigens) as their immune system recovers. The two main types of IRIS are (1) paradoxical IRIS, in which a patient with a known opportunistic infection on appropriate therapy appears to deteriorate clinically after starting ART, and (2) unmasking IRIS, in which a previously silent opportunistic infection becomes clinically apparent due to the newly present immune response. IRIS to MAC most commonly presents with peripheral lymphadenitis, pulmonary-thoracic manifestations, or intra-abdominal findings.
• Female physicians face many challenges in the clinical environment. Among the most frequently experienced microaggressions is “role misidentification,” or incorrect identification of an individual’s contribution to the health care team (e.g., assuming a female physician is a nurse). It has been suggested that frequent role misidentification (both on the part of patients as well as other healthcare team members) can lead to anxiety and a loss of sense of professional credibility among female trainees.
  • A pilot study recently demonstrated that distribution of new staff badges with the occupational title prominently displayed (i.e., reading “Doctor”) led to a significant improvement in role identification.
  • Additionally, others have suggested that a more deliberate use of professional titles (i.e., introducing female physicians as “Dr. X”) may also serve to combat stereotype threat and role misidentification. 

We invite scholars and antiracism activists, Drs. Rhea Boyd and Rachel Hardeman, to discuss the meaning of structural racism, the health impacts of police violence, the “say her name” movement, and the ways we can ensure our country’s current antiracist movement grows beyond a moment.

Learning Objectives

After listening to this episode learners will be able to…

• Define structural racism
• Understand how police violence is a social determinant of health
• Explore the relationship between policing and healthcare
• Explore and employ strategies to dismantle structural racism in clinical practice 

Credits

• Written and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Utibe R. Essien, MD, MPH 
• Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Michelle Ogunwole, MD
• Show notes: LaShyra Nolen
• Written & Produced By: Michelle Ogunwole, MD, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MS, and Utibe R. Essien, MD, MPH
• Infographic: Creative Edge Design
• Guests: Rachel Hardeman PhD, MPH (@RRHDr) and Rhea Boyd MD, MPH (@RheaBoyd)

Download Transcript Here

CPS-Anti-Racism Show Notes Episode 1

August 26, 2020

By LaShyra Nolen

Time Stamps

00:00 Music/intro 

01:00 Our mission and vision

01:50 Introduction to the Antiracism in Medicine team 

02:55 Introduction of Dr. Boyd and Dr. Hardeman

04:30 Defining structural racism 

10:30 Dr. Boyd’s Lancet piece on the history of police violence

12:00 Police violence, communities, and health outcomes

15:00 Dr. Hardeman on police brutality and a public health agenda

24:00 Understanding this moment (COVID-19 and George Floyd) 

29:00 The #SayHerName campaign and police brutality’s effects on women 

33:00 Emmett and Mamie Till 

44:00 Policing in healthcare settings

54:00 What can we start doing tomorrow? 

56:00 Conclusion and outro 

Episode Takeaways

“First do no harm and while you’re doing no harm, learn as much as you can.” -Dr. Rhea Boyd. 

Practitioners who benefit from the racist power structures existent in America must examine the ways they benefit from or ignore racism in their workspaces and beyond. Then we must all commit to dismantling racism with tangible policy change.

Trainees

We encourage trainees to reflect on the ways they have been socialized to learn and think about racism in our country. Trainees may use this foundation to question how this might impact their medical education and think about this educational legacy may be reformed through curricular and structural changes at their institutions. 

Faculty

Regardless of specialty or field, it is important all educators and clinicians do the work of understanding how racism is pervasive within their respective areas of expertise. This starts with self-education and a commitment to speak up when blatant examples of racism come up in the work space and beyond. 

Pearls 

Defining Structural Racism

Structural racism is a term that acknowledges that racism is perpetuated beyond individual interactions and interpersonal racism, but is present in the systems and policies that govern our everyday lives. These policies and decisions are often rooted in a historical legacy of white supremacy that have led to the systematic disadvantage of racial minorities in our society. Public health advocate, leader, and scholar, Dr. Camara Phyllis Jones, is credited for creating the framework many healthcare professionals and researchers use to think about systemic racism’s impacts on Black health. Her definition centers the idea that Black individuals did not inherit the diseases they disparately suffer from, but they inherited a disadvantaged system that creates the stark health disparities we see today. It is important to understand this unequal system negatively impacts everyone and every aspect of our society. 

Policing and health outcomes  

Evidence has shown that excessive policing not only impacts the individual health of Black and brown people who’ve interacted with the police, but it also impacts the health of their communities at large. Heightened police presence in communities of color can be perceived as a threat by community members which can result in sustained increases in stress and cortisol levels. This pathologic process can lead to adverse health outcomes affecting the cardiovascular, neurological, and endocrine systems.

Police brutality 

Police brutality should be thought of as the ways state-sanctioned violence leads to the physical, psychological, and emotional harm of its victims. It is important to understand that police brutality not only impacts individuals with direct relationships to those afflicted by this violence but also has widespread effects on the entire Black community. It impacts the health of our colleagues who constantly have to witness this injustice play on television, often without consequence. It also leads to decreased productivity in Black communities as they deal with the aftermath and ongoing challenges of police brutality. 

#SayHerName Campaign 

As we continue conversations around police brutality, antiracism, and health equity, we must remember to not exclude women, children, the LGBTQ community, and the disabled community, among other communities of intersecting marginalized identities who continue to be impacted by police brutality. Social media and public response to police brutality traditionally center cis-gendered men, but people like Breonna Taylor, Tony McDade, and Tamir Rice, along with so many others, need our voices too. 

Policing in Schools and Hospitals 

Health care systems must actively advocate and protect their patients and that means we have to also reevaluate the presence of police in our spaces. This includes thinking about our roles as mandated reporters and police presence in emergency departments. Police presence in medical spaces can add to Black patients’ feelings of not having a “safe space” and we must consider our roles in potentially perpetuating violence in this way. 

Links

References discussed throughout episode 

Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: An antidote to structural racism. Birth. 2020;47(1):3-7. doi:10.1111/birt.12462

Boyd RW. Police violence and the built harm of structural racism. Lancet. 2018;392(10144):258-259. doi:10.1016/S0140-6736(18)31374-6

Alang S, McAlpine D, McCreedy E, Hardeman R. Police Brutality and Black Health: Setting the Agenda for Public Health Scholars. Am J Public Health. 2017;107(5):662-665. doi:10.2105/AJPH.2017.303691

Hardeman RR, Medina EM, Kozhimannil KB. Structural Racism and Supporting Black Lives – The Role of Health Professionals. N Engl J Med. 2016;375(22):2113-2115. doi:10.1056/NEJMp1609535

Alyasah Ali Sewell, Justin M. Feldman, Rashawn Ray, Keon L. Gilbert, Kevin A. Jefferson & Hedwig Lee (2020) Illness spillovers of lethal police violence: the significance of gendered marginalization. Ethnic and Racial Studies. 2020. doiI: 10.1080/01419870.2020.1781913

Britton BV, Nagarajan N, Zogg CK, et al. US Surgeons’ Perceptions of Racial/Ethnic Disparities in Health Care: A Cross-sectional Study. JAMA Surg. 2016;151(6):582–584. doi:10.1001/jamasurg.2015.4901

Hardeman RR, Medina EM, Boyd RW. Stolen Breaths. N Engl J Med 2020; 383:197-199. doi: 10.1056/NEJMp2021072 

Bor J, Venkataramani AS, Williams DR, Tsai AC, Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. Lancet. 2018. doi: 10.1016/S0140-6736(18)31130-9. 

Additional references and papers as mentioned in episode 

Link to the work of Dr. Rupa Marya as mentioned by Dr. Boyd: https://medium.com/@radiorupa/health-and-justice-the-path-of-liberation-through-medicine-86c4c1252fb9

Link to African-American Policy Forum #SayHerName Campaign: https://aapf.org/sayhername

Link to latest work of Dr. Rachel Hardeman: Physician-patient racial concordance and disparities in birthing mortality for newborns. Brad N. Greenwood, Rachel R. Hardeman, Laura Huang, Aaron Sojourner. Proceedings of the National Academy of Sciences Aug 2020, 201913405; DOI: 10.1073/pnas.1913405117 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Episode Citation

Boyd R, Hardeman R, Ogunwole M, Fields N, Khazanachi R, Nolen L, Onuoha C, Paul D, Essien UR. “#120 Racism, Police Violence, and Health.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes/ August 26, 2020.

Dr. Krishan Sharma presents a Human Dx case to Sharmin & Baylor residents – Drs. Iqbal and Rana.

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Cyrus Iqbal

Cyrus is a PGY-3 internal medicine resident at Baylor College of Medicine. He loves sports, hip-hop, exploring new restaurants and coffee shops, and writing. He’s an aspiring hematologist/oncologist with a passion for medical education.

Ruchit Rana

Ruchit Rana is currently a third-year internal medicine resident at Baylor College of Medicine. Ruchit completed medical school at Baylor College of Medicine. He has a passion for practicing and improving medical education at all levels. In his free time, he enjoys cooking and baking dishes across all ethnicities and maintaining his multiple freshwater aquariums at home. He is a proud co-founder of the Schema Squad alongside his co-resident, Cyrus Iqbal.

Krishan Sharma

Krishan Sharma is currently an internal medicine resident at Massachusetts General Hospital. He earned his medical degree at Harvard Medical School, where he also pursued a Masters in Medical Sciences in medical education. His academic interests include cardiology, critical care, and clinical reasoning. His hobbies include basketball, drumming, and entering spice eating competitions.

Dr. Meredith Lash Dardia presents a Human Dx case to Arsalan & Wake Forest residents – Drs. Maus and Brooks.

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Human Dx Case

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Dr. Meredith Lash Dardia

Dr. Meredith Lash-Dardia is an internist at Weill Cornell Medical Associates in NYC. She graduated with a BA from Rutgers University and an MD from Rutgers Medical School (formerly UMDNJ). She did her training at Mount Sinai in NYC. Her areas of interest include preventative wellness, medical student teaching, as well as quality and patient safety initiatives. In her spare time, she works on local political campaigns and is involved in grassroots activism

Dr. Taylor Brooks

Taylor Brooks is in his third year of residency at Wake Forest School of Medicine’s Internal Medicine Residency (let’s go Deacs!). Originally from Ohio, Taylor spent his college years at The Ohio State University (let’s go Bucks!). He then completed medical school at the University of Cincinnati College of Medicine (let’s go Bearcats!). Aside from loving all of his alma maters equally, Taylor’s professional goals are to become a physician scientist, researching blood cancers and treating the patients who have them. He also hopes to one day teach the joys of academic hematology to internal medicine residents. In his free time, Taylor enjoys traveling the world with his amazing wife Cassandra, and throwing a ball around with his awesome Bernedoodle, Winston

Dr. Sarah Maus

Sarah Maus is currently a third year Internal Medicine resident at Wake Forest School of Medicine. She grew up in Springfield, IL before heading to Lexington, KY to complete undergraduate and medical school. She will be staying at Wake Forest next year as a Chief Resident, and hopes to pursue Hematology Oncology fellowship after her chief year. Outside of medicine, Sarah enjoys hiking in the mountains of North Carolina, playing tennis with friends, and spending quality time with family and her dog, Mila.

The CPSolvers share a case of abdominal pain and jaundice – let’s practice those schemas together!

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Schemas: abdominal pain, jaundice

Thought Train: abdominal pain

Episode description

Reza and Rabih tackle a case of Ascites.

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Ascites Schema

Episode Summary

An elderly woman with a history of progressive weakness, falls, and recently diagnosed ascites presented with weight loss and functional decline. Her workup was notable for ascites with a low serum-ascites albumin gradient (SAAG), thrombocytosis, and imaging evidence of peritoneal enhancement with omental nodularity and multiple pancreatic lesions. Biopsies of the peritoneal nodules were initially unrevealing for infections or solid malignancies. Ultimately, further tissue examination revealed primary peritoneal mesothelioma. The patient was not started on treatment and passed away one month later. 

 Teaching Points

The most common causes of low SAAG ascites include malignancy and infection. Malignancy can cause low SAAG ascites via peritoneal carcinomatosis (seen most commonly ovarian, bladder, or gastric cancer) as well as peritoneal mesothelioma. Tuberculosis is an important and difficult to diagnose infectious cause of low SAAG ascites. Ascitic fluid often reveals a lymphocytic predominance with elevated protein. Additionally, an elevated ascitic adenosine deaminase level (ADA) can suggest peritoneal tuberculosis

Asbestos exposure can lead to an array of benign and malignant diseases. Manifestations within the pulmonary parenchyma include asbestosis (a form of diffuse pulmonary fibrosis resulting in interstitial lung disease) and lung cancer (both small cell and non-small cell lung cancers). Pleural complications of asbestos exposure can include pleural effusions, pleural plaques, and malignant mesothelioma. Rarely, asbestos-related complications can occur in extra-pulmonary sites and present as peritoneal mesothelioma, with diffuse peritoneal nodules and low-SAAG ascites. 

Dr. Rezigh presents a clinical unknown on Virtual Morning Report to CPSolvers, Rabih and Reza.

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Schema

Whiteboard

Episode Summary

A 75-year-old-woman with multiple chronic medical problems presented with right arm pain, anorexia, and diffuse erythematous nodular plaques. Her work up was notable for an elevated serum lactate and S1Q3T3 pattern on ECG. Computed tomography of the chest, abdomen, and pelvis demonstrated a right pleural effusion as well as nodular soft tissue thickening surrounding the right atrium extending to the interatrial septum with local mass effect and narrowing of the superior vena cava. Biopsy of her rash revealed abnormal lymphoid proliferation. Further studies led to a diagnosis of diffuse large B-cell lymphoma (DLBCL) with prominent cutaneous manifestations.

Teaching Point

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin’s lymphoma and can have a diverse range of manifestations. Most often, patients present with a rapidly enlarging mass and/or systemic “B-symptoms” (e.g., fever, night sweats, weight loss). Laboratory abnormalities classically include elevated lactate dehydrogenase levels, which occur in >50% of patients. In a minority of patients (about 40%), DLBCL presents in extramedullary and extranodal locations, including the soft tissues, lung, endocrine organs, and central nervous system. Diagnosis requires histologic examination and immunophenotyping (flow cytometry, immunohistochemical staining). 

Episode Description

Emma, Lindsey and Sharmin tackle a case presented by Sarah.

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Blog post– by Smitha

Dr. Hastie presents a Human Dx case to Sharmin & Cleveland Clinic residents – Drs. Almaaitah and Montane.

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Schema #1

Human Dx Case

Dr. Bryce Montane

Bryce Montane is a Floridian born and raised! He went to University of South Florida as part of the 7-year medical program for undergraduate and medical school. He is now a PGY-3 Internal Medicine resident at the Cleveland Clinic. He is part of the inaugural Clinician Educator Track. He will be staying at the Cleveland Clinic next year as a Chief Resident and will then be pursuing a career in academic medicine.

Dr. Saja Almaaitah

Saja Almaaitah was born and raised in Jordan and graduated from the University of Jordan school of medicine. She then moved to the United States and joined Cleveland clinic for her internal medicine residency. During which, she was part of the clinical research scholar track. She has recently graduated residency and joined the rheumatology department at Cleveland Clinic. She hopes to pursue a career in academic medicine and research. In her free time, she enjoys hiking, reading and cooking.

Dr. Elizabeth Hastie

Elizabeth (Lizzy) Hastie is currently a third year internal medicine resident at UCSD. She completed her undergraduate education at the University of Colorado Boulder, and she attended Emory University for medical school. Lizzy is a member of the Resident as Clinician Educator (RACE) track at UCSD and will be a Chief Medical Resident for the 2021-2022 academic year. She is interested in pursuing an infectious disease fellowship following her chief year.

Dr. Alexandra Rojek presents a Human Dx unknown to Arsalan and Duke residents – Drs. Stacy Bagrova & Micah Schub.

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Schema #1

Schema #2

Human Dx Case

Dr. Alexandra Rojek

Alexandra Rojek is currently an internal medicine resident at the University of Chicago, interested in pursuing hematology/oncology with an interest in translational research. She attended Harvard University for her undergraduate education in chemical and physical biology, and then medical school at UCSF. During medical school, she developed an interest in medical education, particularly in her research on implicit bias in medical student evaluations. She has always had an interest in diagnostic reasoning and loves being a contributing editor at the Human Dx Project, and is excited to work with CPSolvers on sharing this case!

Dr. Micah Schub

Micah Schub is a third year internal medicine resident at Duke. He grew up in Los Angeles, CA and got his undergraduate degree in (slapping the) Double bass performance at the Juilliard School and a masters at the Manhattan school of music. He returned to LA to play in Cirque du Soleil’s “Iris” for a couple years before making a sharp turn and attending University of Pittsburgh School of Medicine. He is interested in nephrology, clinical reasoning and medical education. Outside of work, you can find him playing sweet tunes with his residency Weezer cover band “Wheezer.”

Dr. Stacy Bagrova

Stacy grew up in Donetsk, Ukraine and was lucky enough to move to the US just in time for college. She completed medical school at the University of Florida (Go Gators!).  Currently, she is trying to learn as much as possible and provide lots of (mostly unsolicited) teaching to junior learners as a third-year medicine resident at Duke University Medical Center. Her ideal career combines clinical rheumatology and medical education focused on diagnostic reasoning. In her free time, she loves to get lost in a good mystery novel, cook or bake while tuning in to one of her favorite podcasts, or go for a run, listening to a 70s-80s classic rock mix.

Episode description

Reza and Rabih tackle a case of hypotension.

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Dr. Costello presents a clinical unknown to Dr. Dhaliwal.

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Dr. Anna Costello

Anna Costello is a Pediatric Hospitalist at the Children’s Hospital of Philadelphia, where she completed her residency and chief residency. Her interests within Medical Education include clinical reasoning and linguistically and culturally competent care. Outside of the hospital, she is an avid reader, painter, and soccer player. 

Dr. Gurpreet Dhaliwal

Dr. Dhaliwal is a clinician-educator and Professor of Medicine at the University of California, San Francisco. He is the site director of the internal medicine clerkship at the San Francisco VA Medical Center, where he teaches medical students and residents in the emergency department, urgent care clinic, inpatient wards, outpatient clinic, and morning report. His academic interests are the cognitive processes underlying diagnostic reasoning and clinical problem-solving and the study of diagnostic expertise. Dr. Dhaliwal enjoys playing pickup basketball with his two sons … even though both can handily defeat him

Episode description

Reza and Rabih tackle a case of abdominal pain.

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Dr. Ryan Haran presents a Human Dx unknown to Arsalan and NYU residents – Drs. Jenny Whealdon and Greg Rubinfeld.

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Human Dx case

Dr. Jenny Whealdon

Jenny was born and raised on Bainbridge Island in Seattle, Washington. She attended Haverford College where she studied religion and theoretical chemistry; ultimately staying in the Philadelphia area to attend the University of Pennsylvania School of Medicine. There, she developed an interest in behavioral economics and decision making, particularly in the critical care setting. She completed her internal medicine training at NYU and is staying on as a Chief Resident.

Dr. Greg Rubinfeld

Greg is currently a chief resident at NYU Grossman School of Medicine.He aspires towards a career in academic cardiology where he hopes to find a marriage of his interests in thrombosis and coronary artery disease.When he is not in the hospital or at home with his wife and son, you might find him scuba diving wrecks along the east coast, nose deep in classic literature, or playing pick-up street hockey and collecting more bruises than he cares to admit.

Dr. Ryan Haran

Ryan grew up in Oregon and after attending Oregon State University went to medical school at Virginia Commonwealth University in Richmond, Virginia.He completed an internal medicine internship then spent a year as a radiology resident at Northwestern University in Chicago, Illinois before deciding that while radiology is cool and all he had learned too much medicine to just go and forget everything. As such, he decided to return to medicine and has now completed an internal medicine residency at his home institution of VCU where he will be staying on faculty as a hospitalist.

Case Recap

A 55-year-old previously healthy woman presented with subacute abdominal distension and acute emesis. On examination, she was found to be hypotensive and hypoxemic with evidence of ascites. Laboratory evaluation was notable for severe transaminase elevation (AST 2500, ALT 1300), leukocytosis to 53,000 per cubic millimeter, hemoglobin of 20 mg/dL, and a mildly elevated erythropoietin level. Imaging demonstrated an acute portal vein thrombus as well as a right-to-left intracardiac shunt. A bone marrow biopsy revealed trilineage hypercellularity with an erythroid predominance and JAK-2 positivity. The ultimate diagnosis was polycythemia vera with a secondary EPO-dependent polycythemia (likely secondary to her intracardiac shunt).

Teaching points

An absolute erythrocytosis refers to elevation in the red blood cell (RBC) mass and can be due to primary bone marrow, secondary (e.g., hypoxia, erythropoietin secreting tumors), and congenital etiologies. A key branch point is evaluation of the erythropoietin level (the primary stimulus for RBC synthesis), with normal/suppressed levels suggesting the presence of a primary or congenital disorder. Polycythemia vera (PV) is the most common primary erythrocytosis and lies on the spectrum of myeloproliferative neoplasms. Thrombosis and bleeding are life-threatening complications.

Dr. Leela Chockalingam presents a Human Dx unknown to Sharmin and BMC resident – Dr. Amir Gilad and Brigham resident  – Dr. Hannah Chen.

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Human Dx case

Abdominal pain schema

Dyspnea schema

Altered mental status schema

Amir Gilad

Amir Gilad is a PGY-1 (very soon to be PGY-2!) at Boston Medical Center. Born and raised in Toronto, he attended Boston University for medical school and loved it so much that he stayed on for his internal medicine residency. He’s an aspiring cardiologist who is passionate about medical education. Outside of medicine he enjoys cheering on his beloved Toronto sport teams, jogging along the Charles River, and exploring the beautiful city of Boston. 

Hannah Chen

Hannah Chen is a second year internal medicine resident at the Brigham & Women’s Hospital. She graduated from the University of North Carolina School of Medicine.  She has an interest in hospital medicine, nephrology, and health equity.  In her spare time, she enjoys eating/cooking and hiking.  

Leela Chockalingam

Leela Chockalingam grew up in Rochester, NY. She studied Chemistry at Carnegie Mellon University and then attended medical school at the Icahn School of Medicine at Mount Sinai in New York City. During medical school, she spent a year in Vietnam doing tobacco use treatment research. She is currently an Internal Medicine resident at the University of Colorado in Denver, CO. She is interested in pursuing pulmonary critical care fellowship, and would ultimately love to be a clinician educator focused on clinical reasoning and evidence based medicine. Her hobbies include reading fiction, being outside, and cooking for family and friends. 

Case recap

A 47-year-old man with alcohol and meth use presented with acute dyspnea, abdominal pain, and encephalopathy, and was found to be in acute congestive heart failure with atrial fibrillation and rapid ventricular rate. While in the emergency department, his oxygen requirement rapidly increased and he required intubation for hypoxemia and airway protection. Further evaluation revealed a suppressed thyroid stimulating hormone with an elevated free T3 and free T4, confirming a diagnosis of thyrotoxicosis meeting criteria for thyroid storm.

Teaching points

Hyperthyroidism refers to increased synthesis and release of thyroid hormones from the thyroid gland, whereas the term “thyrotoxicosis” represents the clinical syndrome produced by excess circulating thyroid hormone. The most common causes of hyperthyroidism include Grave’s disease, toxic nodular goiter/adenoma, and drug induced thyroid dysfunction. Thyrotoxic states can also occur when thyroid hormones are released from an injured thyroid gland in thyroiditis (autoimmune, viral, suppurative) or ingestion of exogenous thyroid hormone.

The clinical manifestations of hyperthyroidism can result from the thyrotoxic state itself (e.g., palpitations, fatigue, tremor, weight loss) or be related to the underlying cause of hyperthyroidism (e.g., grave’s ophthalmopathy, globus sensation/dysphagia from enlarged goiter). Complications of thyrotoxicosis include atrial fibrillation (with possible heart failure), thyrotoxic periodic paralysis, osteoporosis, and reproductive issues. Thyroid storm represents life-threatening thyrotoxicosis and its diagnosis is supported by the Burch & Wartofsky Score, which takes into account temperature, central nervous system effects, gastrointestinal/hepatic dysfunction, cardiovascular dysfunction, and the presence/absence of a precipitating trigger.

Dr. Kimberly Manning and her father, Mr. William Draper, commemorate Juneteenth, the holiday that celebrates the day when all remaining enslaved Black Americas were freed in Galveston Texas, on June 19th, 1865, with this hour-long storytelling event. 

Click here to watch the video on the CPSolvers Virtual Morning Report platform

Steph, Sharmin, Arsalan and Dan share a case of syncope and splenomegaly – let’s practice those schemas together!

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Splenomegaly Schema

Syncope Schema

Episode description

Reza and Rabih tackle a case of acute liver injury.

One RLR episode will be freely available each month but the remainder will be uploaded on Patreon only.

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More about the RLR series here.

You can find the article referenced in the episode Here

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Dr. Julia Burns presents a Human Dx unknown to Sharmin and Mercy residents  – Drs. Brady Alling and Aaron Sabal.

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Human Dx case

Dr. Brady Alling

Brady is a PGY 3 at Mercy Health in Muskegon, MI. Next year, he will be doing a fellowship in pulmonary & critical care in Colorado. His favorite thing about internal medicine is is the profound sense of accomplishment he feels when replacing electrolytes that are just slightly below the normal range.

Dr. Aaron Sabal

Aaron was born and raised in Westland, MI (Detroit metro area). He went to Wayne State University for my undergraduate studies thinking he would be a physical therapist, massage therapist, and dietitian (yes, all three of those). However, about one week prior to starting my massage therapy program, he had an epiphany and decided to go to medical school instead. He was fortunate to be accepted to MSUCOM and fell in love with Internal Medicine. His passions include all things medical. In particular, he is passionate about medical education, how best to help physicians learn, diagnostic reasoning, and creating an environment of learning where no one is afraid to express what they’re thinking. When he is not pursuing his love of learning, He is spending time with his wife and their boys (2 cats and a dog), playing with his animals, doing DIY home-improvement projects, exploring national parks, or reading a good non-medical book with a cat or dog in his lap begging for his love and attention.

Dr. Julia Burns

Julia is currently a geriatrics fellow at Mount Sinai Hospital in Manhattan. She earned her undergraduate degree from Fairfield University. She then went on to obtain a master of science in biomedical sciences from New York Medical College followed by her medical degree at Albany Medical College. She completed her internal medicine residency at NYU Winthrop Hospital on Long Island. Her academic interests include medical student and resident education.

Dr. Kavea Panneerselvam presents a Human Dx unknown to Arsalan and Utah residents  – Drs. Marja Anton and Guinn Dunn.

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Human Dx case

Dr. Marja Anton

Marja is a chief medical resident at the University of Utah. She is originally from
Chicago, IL and received her undergraduate degree from the University of
Wisconsin-Madison (go Badgers!). She then moved back to Chicago for medical
school at Loyola University Stritch School of Medicine. In her free time, you can find her traveling with her husband in their camper van, rock climbing with friends, tending to her garden or listening to the Clinical Problem Solvers! Next year she is excited to stay on at the University of Utah as an academic hospitalist.

Dr. Guinn Dunn

Guinn is a first year Internal Medicine resident at the University of Utah. She was
born and raised in Salt Lake City, received her undergraduate degree at the
University of Puget Sound, then headed back to Utah for medical school and
residency. She is interested in academic hospital medicine and quality improvement. She enjoys skiing, backpacking, and is looking forward to the birth of her first kiddo in a few weeks.

Dr. Kavea Panneerselvam

Kavea Panneerselvam is about to complete her intern year at Baylor College of medicine in Houston, TX. She grew up in the Houston area and completed her undergraduate at the University of Texas at Austin and is a proud Longhorn, and obtained her medical degree at UT Houston. After residency she hopes to pursue a career in gastroenterology. Specifically, she has an interest in IBD. In her free time she enjoys playing board games, discovering new movies, and making art for her friends and family.


Episode description

Reza and Rabih tackle a case of dyspnea & lightheadedness.

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More about the RLR series here.