The Clinical Problem Solvers

 https://clinicalproblemsolving.com/wp-content/uploads/2023/04/4.13.23-Neuro-VMR-RTP.mp3We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Dr. Ravi Singh presents a case of right arm weakness to Yazmin and Sridhara.Neurology DDx Schema Yazmin Heredia @minherediaYazmin is a Mexican Graduate from the Universidad Autonoma de Yucatan. During her medical training, she developed a strong interest in Public Health, Medical Education, and Health Equity and is looking forward to pursuing a career in Internal Medicine. When she is not volunteering on a project, she likes taking care of her plants, developing her skills in the fine arts, or learning a new language. Sridhara Yaddanapudi@syaddana_neuro Sridhara is a board-certified internist, neurologist, vascular neurologist, and hypertension specialist. Currently, he holds the position of Clinical Assistant Professor at Thomas Jefferson University Hospital and serves as the Director of Neurology for Jefferson New Jersey.As a medical professional, he is passionate about case-based learning, clinical reasoning, and teaching decision-making while avoiding the pitfalls of heuristics. His goal is to bridge the ever-growing gap between neurology and internal medicine, an area in which he has a keen interest. Ravi Singh@rav7ks Ravi (Ravitej) Singh is originally from Greenwich, London U.K where he grew up playing soccer and rugby. He attended medical school at University of Debrecen, Hungary and completed residency at Medstar Harbor Hospital in Baltimore. Currently he is an associate program director for Sinai Hospital IM residency program in Baltimore as well as a Hospitalist on the teaching service. He is a faculty member at the Johns Hopkins School of Medicine and takes time out of his schedule to run a series of case-based teaching sessions as well as medical simulation with all of the medical students that rotate at Sinai throughout the year. He is also a co-chair of the ACP Maryland IMG committee where he advocates for IMG issues Jo and highlights their contributions to the healthcare system Download CPSolvers App hereRLRCPSOLVERS  

https://clinicalproblemsolving.com/wp-content/uploads/2023/04/ARM-Ep20-Medical-Racism-and-Indigenous-Peoples.mp3CPSolvers: Anti-Racism in Medicine SeriesEpisode 20 – Medical Racism and Indigenous PeoplesShow Notes by Sudarshan (“Sud”) KrishnamurthyApril 4, 2023Summary: This episode highlights the checkered past of medicine and the advancements in the field that have occurred at the expense of the humanity of Indigenous peoples. During this episode, we hear from Dr. Nav Persaud, a staff physician in the Department of Family and Community Medicine at St. Michael’s Hospital in Unity Health Toronto, and Dr. Alika Lafontaine, the current President of the Canadian Medical Association. Together, our guests explain how Indigenous knowledge systems are the foundation of modern medicine and also share strategies to promote truth and reconciliation with Indigenous Peoples in North America. This discussion is hosted by Alec Calac and Gillette Pierce.Episode Learning ObjectivesAfter listening to this episode, learners will be able to…Explain how the dark legacy of discrimination and deliberate oppression of Indigenous Peoples has led to present-day disparities across the worldDescribe how medicine has held some white men to high esteem, even when they harbored significant racist and sexist notionsIdentify the role of Indigenous knowledge systems in shaping much of modern medicine today, yet experiencing erasure from the mainstream CreditsWritten and produced by: Alec J. Calac, Gillette Pierce, Sudarshan Krishnamurthy, Rohan Khazanchi, MD, MPH,  Dereck Paul, MD, Jazzmin Williams, Victor A. Lopez-Carmen MPH, Ashley Cooper, Naomi F. Fields, LaShyra Nolen, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins, Michelle Ogunwole MD, Utibe R. Essien MD, MPHHosts: Alec J. Calac and Gillette PierceInfographic: Creative Edge DesignAudio Edits: Caroline CaoShow Notes: Sudarshan (“Sud”) KrishnamurthyGuests: Dr. Nav Persaud and Dr. Alika LafontaineTime Stamps0:00 Introduction0:45 Episode Introduction1:10 Guest Introductions3:30 Existing global disparities among Indigenous Peoples6:00 How access to medications are impacted among Indigenous Peoples in Canada8:30 Framing around the Design of Structures in Canada to suppress Indigenous voices13:30 Legacy of Osler and the importance of rediscovering forgotten dark histories16:20 Dehumanization of individuals belonging to marginalized groups by the healthcare system27:50 Modern medicine and its roots in Indigenous knowledge systems31:30 Provision of healthcare to Indigenous Peoples in Canada34:50 Alec’s own advocacy around renaming a campus parking garage36:55 Weaponization of professionalism 45:00 Clinical takeaways and practical tools for clinician listenersEpisode TakeawaysIndigenous communities around the world experience significant disparities in life expectancy, burden of disease, and socioeconomic status, due to deliberate exclusion of Indigenous Peoples from the mainstream and suppression of their voices in the design of the system.Within medicine, we tend to hold white men from history books in high esteem, often without recognizing the dark legacy that accompanied their lives. William Osler is one such example who, along with numerous other sexist and racist misconducts, took remains of Indigenous people with him as a gift to his mentor in Germany, that is still held by a German museum who refuses to return it.The dehumanization of individuals of color at the margins of society by the healthcare system is not simply a thing of the past, and is certainly a persistent phenomenon. Cindy Gladue, Brian Sinclair, and Joyce Echaquan are three Indigenous individuals who suffered immense harm at the hands of the healthcare system.There is strength in reconciling Indigenous history, and we must prevent further erasure of Indigenous knowledge systems. The solutions to these issues do not fall upon one community’s shoulders, but instead on the shoulders of all of us along with the oppressive systems that have led us here.PearlsAlec begins by contextualizing this episode with the fact that although Indigenous people make up 6% of the global population, they compose 15% of the global population experiencing extreme poverty. Additionally, Indigenous communities experience lower life expectancy,  higher burden of disease, and lower socioeconomic status compared to non-Indigenous Peoples. These disparities are likely attributable, in part, to the disruption of Indigenous knowledge systems, inadequate infrastructure, and poor identification of health data among these groups, rather than individual behavior.  [Supplementary Resource for Listeners: CPSolvers Episode 12: Addressing Anti-Indigenous Racism in Medicine with team members Alec Calac and Victor Anthony Lopez-Carmen]Nav discusses that despite publicly funded healthcare systems in Canada and federal protections in place for certain Indigenous groups, Indigenous populations and other groups facing discrimination and historic oppression are much more likely to report not being able to take medications due to cost. Although healthcare services are publicly funded, access to medications depends on private or public insurance and is linked with employment. While some have the impression that there is a safety net in Canada for life-saving medications, Nav still sees patients in his practice who are harmed by the system and not able to afford life-saving medications, many of them Indigenous, and this is a violation of their right to access essential medicines.Alika expands on Nav’s framing by highlighting the three broad demographics in Canada: the Inuit, the Métis, and the First Nations. In contrast to settlers in the United States where “conquering” through deception was a priority, the spread of settlers was more so through the signing of agreements that were never lived up to. Indigenous peoples in Canada have deliberately been left out of the mainstream to ensure their voices were suppressed in the design of the system. Alika elaborates on the history of Indigenous populations in Canada and how they would conduct X-Rays on the Inuit children, and ship these kids away for 3 to 10 years if they found tuberculosis in the lungs, without even allowing the children to say goodbye to their parents. Alika recalls stories of individuals in Ottawa who were on the same floor for several years, only to realize that they were members of the same family after being placed in these TB sanatoriums and crossing paths there.Nav begins to discuss how Osler is still revered as one of the most prominent historical physicians in Canada and the United States. A colleague brought information to Nav that Osler had brought remains of Indigenous people as a gift to one of his mentors in Germany. This led him to look into Osler’s history a little further, and Nav found it easy to find other instances of racist and sexist misconduct by William Osler. These remains are still in a museum in Germany, with no plan of return to Indigenous communities. [Supplementary Resource for Listeners: Read Dr. Persaud’s initial article on Osler here] Osler lived in the time of Numbered Treaties and the North-West Rebellion under Louis Riel, when Indigenous rights were front and center. It is ridiculous to consider that a physician brought Indigenous remains with him as a gift during this period in history, when Osler knew Indigenous people were fighting for their rights and lives. So, we must rethink the esteem that we hold white men like Osler in, and rediscover the forgotten history that accompanies them. [Supplementary Resource for Listeners: You can read more about the North-West Rebellion here]Alika discusses the dehumanization of individuals of color and other identities who exist at the margins within the healthcare system and emphasizes that these are not phenomena of the past. He highlights the hostility within the healthcare system and how healthcare must be a service that is available equally to everybody, and not treated as a favor being done to individuals. He narrates the stories of Cindy Gladue, Brian Sinclair, and Joyce Echaquan, all of whom suffered immense harm at the hands of the healthcare system as Indigenous individuals. [Supplementary Resource for Listeners: You can read about Cindy Gladue, Brian Sinclair, and Joyce Echaquan here] Nav expands on this aspect of dehumanization of Indigenous peoples and speaks about how the Indigenous remains are being treated in Germany today. Although there is guidance that they must be returned, they have decided to retain them. In addition, there is writing within these skulls with numbers written on the inside, as if to catalog them. The museum has also added multiple barriers for those who wish to rightfully receive these remains, and has placed the onus on these communities for these remains to be returned.Alec importantly highlights that while these harms might seem historical and like things of the past, they have taken place within one or two generations and even today. He discusses his experiences as an Indigenous person in California who attends a medical school that begrudgingly decided to return Indigenous remains, from one of the largest collections in the world.Alika talks about strength in knowing his history. He discusses the medical knowledge of settlers in Canada believing in four humors and the practice of bloodletting to relieve sickness. At that time, Indigenous Peoples were harvesting plants at their peak potency and concentrating these plants in teas, and delivering medications through oral and transdermal routes. He talks about how Atropine, a commonly used drug by anesthesiologists like Alika, is derived from Belladonna and how folks practicing traditional medicine use Belladonna.Alika also delves deeper into the provision of healthcare to Indigenous peoples in Canada. He mentions that healthcare was provided to Indigenous peoples rooted in a charitable effort, rather than as a basic human right. It is important to move beyond being nice to each other, and begin to think about the requirements and obligations we have to each other as human beings.Alec goes on to highlight that as much as we have gained, we have much more to fight for. In episode 12, we discussed how the American Indian and Alaskan Native life expectancy as of 2021 was equivalent to that of the American public in the 1940s. The solution to these issues shouldn’t fall upon one or a few of our shoulders, but instead upon the shoulders of all of us along with the systems that have the resources and infrastructures to inform change.Alec used Nav’s article to advocate for the renaming of a parking garage on campus that was named after William Osler. Our spaces reflect our values, so the question he asked was why they had a parking garage named after an individual who has no relation to the local community in San Diego? We think about the legacy in medicine, but forget about the community we are in. [Supplementary Resource for Listeners: Read Alec’s Editorial about his advocacy related to renaming a street and parking structure in his medical school campus here.]Nav describes professionalism as a vague concept that is often used to oppress individuals from racialized and marginalized backgrounds. Professionalism is often antithetical to a rights-based approach to medicine, where every member of a team feels comfortable to speak up when everything is not right with a patient’s care and professionalism can scare people from speaking out when needed.Alika expands on this explanation of professionalism in terms of what is acceptable, decided by whoever is in control. It can be used to amplify what leaders think is important and suppress what leaders do not like, demonstrating the importance of leadership from diverse backgrounds and varied lived experiences. Retaliation can be severe to violations of professionalism, and it’s hard to know the effects of retaliation unless one has experienced these themselves. [Supplementary Resource for Listeners: Read about the experience Dr. Lafontaine describes regarding his own experience with reporting unprofessional and unacceptable conduct here]Nav states that it is important for us to reflect on what has happened and recollect all of the work people have done to chronicle anti-Indigenous racism. Racism is not new, and there have been numerous reports that document racism and anti-Indigenous discrimination over decades and centuries. We must respect what has happened, and recognize as non-Indigenous people that we benefit from advocacy and efforts of Indigenous peoples for Indigenous rights over generations.Alika emphasizes that the point of this conversation is not to make anyone feel like they are a bad person, but instead to help them acknowledge that in this healthcare system we provide both health and harm. Providing our patients with more space and ensuring our patients feel human again is a great first step. It is also important to remember that in the course of restructuring power, there are winners and losers and we may not all have the same voice around the table that we did before. We entered medicine to help people, and sometimes the best way to help people is by getting out of the way and allowing for others to step forward.ReferencesPersaud N, Butts H, Berger P. William Osler: saint in a “White man’s dominion”. CMAJ. 2020;192(45):E1414-E1416. doi:10.1503/cmaj.201567Reid P, Cormack D, Paine SJ. Colonial histories, racism and health-The experience of Māori and Indigenous peoples. Public Health. 2019;172:119-124. doi:10.1016/j.puhe.2019.03.027Redvers N, Blondin B. Traditional Indigenous medicine in North America: A scoping review. PLoS One. 2020;15(8):e0237531. Published 2020 Aug 13. doi:10.1371/journal.pone.0237531Fredericks CF. Mapping the Sustainable Development Goals onto Indian Nations. In: Miller RJ, Jorgensen M, Stewart D, eds. Creating Private Sector Economies in Native America: Sustainable Development through Entrepreneurship. Cambridge: Cambridge University Press; 2019:185-194. doi:10.1017/9781108646208.011Browne AJ, Lavoie JG, McCallum MJL, Canoe CB. Addressing anti-Indigenous racism in Canadian health systems: multi-tiered approaches are required. Can J Public Health. 2022;113(2):222-226. doi:10.17269/s41997-021-00598-1Persaud N, Ally M, Woods H, et al. Racialised people in clinical guideline panels. Lancet. 2022;399(10320):139-140. doi:10.1016/S0140-6736(21)02759-8Lafontaine AT, Lafontaine CJ. A retrospective on reconciliation by design. Healthc Manage Forum. 2019;32(1):15-19. doi:10.1177/0840470418794702Lafontaine A. Indigenous health disparities: a challenge and an opportunity. Can J Surg. 2018;61(5):300-301. doi:10.1503/cjs.013917Durand-Moreau Q, Lafontaine J, Ward J. Work and health challenges of Indigenous people in Canada. Lancet Glob Health. 2022;10(8):e1189-e1197. doi:10.1016/S2214-109X(22)00203-0Okpalauwaekwe U, Ballantyne C, Tunison S, Ramsden VR. Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review. BMC Public Health. 2022;22(1):1630. Published 2022 Aug 29. doi:10.1186/s12889-022-14047-2Berger P. Canadian Physicians’ Breach of Duty to Patients and Communities from the Acquisition of Indigenous Skulls in the 19th Century to the Abandonment of People with AIDS in the 20th Century. J Biocommun. 2021;45(1):E13. Published 2021 Aug 15. doi:10.5210/jbc.v45i1.10849Calac AJ. Opinion: William Osler desecrated Indigenous remains. His name should be removed from UCSD. The San Diego Union Tribune. https://www.sandiegouniontribune.com/opinion/commentary/story/2021-08-24/sir-william-osler-uc-san-diego-indigenous-skulls-racistCanadian Press. Alberta surgeon handed 4-month suspension for hanging noose on operating-room door. Haida Gwaii Observer. https://www.haidagwaiiobserver.com/news/alberta-surgeon-handed-4-month-suspension-for-hanging-noose-on-operating-room-door/Disclosures The hosts and guests report no relevant financial disclosures.CitationPersaud N, Lafontaine A, Calac A, Pierce G, Krishnamurthy S, Essien UR, Fields NF, Lopez-Carmen VA, Cooper A, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 20: Advancing Medicine at the Expense of Indigenous Humanity” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. April 4, 2023Transcript Download CPSolvers App hereRLRCPSOLVERS

https://clinicalproblemsolving.com/wp-content/uploads/2023/03/3.23.23-TCQ-RTP.mp3Dr. Vipul Kumar presents a fascinating case of pancytopenia and rash to guest discussant, Dr. Anand Patel.   Dr. Vipul Kumar MD PhD is a hematology-oncology fellow at UCSF. He is currently in his second year of fellowship and has a clinical interest in oncology of all forms as well as a passion for teaching.   Dr. Anand Patel is an assistant professor of medicine at University of Chicago where he treats patients with leukemia and myeloid malignancies. He also serves as medical director of the inpatient leukemia service. His research focuses on the development of clinical trials to help improve the standard of care for patients with high risk leukemias and myeloid malignancies.Twitter: @Anand_88_Patel Download CPSolvers App hereRLRCPSOLVERS 

https://clinicalproblemsolving.com/wp-content/uploads/2023/03/Promo-episode.mp3Aaron presents a mystery in reverse to RR Student discounthttps://www.rlrcpsolvers.com/student-discounts/IMG discountUse coupon code RLRIMG at check out  https://rlrcpsolvers.com/annual-planGlassHealth sponsorshiphttps://twitter.com/GlassHealthHQhttps://glass.health/cpsolversUse promo code CPSOLVERS for one month free! 

https://clinicalproblemsolving.com/wp-content/uploads/2023/03/SLS-03.09.22-RTP.mp3Simone and Moses review their approach to chronic lower extremity weakness in a patient with new-onset jaundice, as Vale presents them a case with a neuro flavor to it. Download CPSolvers App hereRLRCPSOLVERS

The hosts discuss a perplexing medical case involving lower extremity edema, tachycardia, and later pharyngitis. They explore the evaluation and differential diagnosis of sinus tachycardia and lower extremity edema, interpretation of lab findings in thyroid toxicosis, diagnosis and treatment of pharyngitis, differential diagnosis of leukopenia and neutropenia, and engage in a complex case discussion with some mustache jokes.

https://clinicalproblemsolving.com/wp-content/uploads/2023/02/RLR-for-podcast_RTP.mp3Reza takes us through the journey of the last RLR with a reflective lens. Student discounthttps://www.rlrcpsolvers.com/student-discounts/ IMG discountUse coupon code RLRIMG at check out  https://rlrcpsolvers.com/annual-plan  GlassHealth sponsorshiphttps://twitter.com/GlassHealthHQhttps://glass.health/cpsolversUse promo code CPSOLVERS for one month free! 

 https://clinicalproblemsolving.com/wp-content/uploads/2023/02/12.16.23-Neuro-VMR-RTP.mp3We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Yazmin presents a case of lethargy and myoclonus to Kiara and Maria.Neurology DDx Schema Maria Jimena Aleman @MariaMjalemanMaría Jimena Alemán was born and raised in Guatemala where she currently works in community and rural health care. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Ella Fitzgerald. Outside of medicine, she enjoys modern art, 21st century literature, and having hour-long conversations over a nice hot cup of coffee or tequila. Kiara Camacho@kiaracamacho96 Kiara Camacho-Caballero was born in Lima, Perú and she is a medical doctor at Universidad Científica del Sur. She is passionate about Internal Medicine, Cardiology, and medical education. Her research interests are cardiology, neurology, and, geriatrics. Her plans are to apply for Internal Medicine residency in the US this year. Outside medicine, she is a past triathlete and her dream is to perform an IRONMAN 70.3 someday. Kiara enjoys running, and spending time with her dog named Zack and her favorite food is turkey legs. Yazmin Heredia @minherediaYazmin is a Mexican Graduate from the Universidad Autonoma de Yucatan. During her medical training, she developed a strong interest in Public Health, Medical Education, and Health Equity and is looking forward to pursuing a career in Internal Medicine. When she is not volunteering on a project, she likes taking care of her plants, developing her skills in the fine arts, or learning a new language.Download CPSolvers App hereRLRCPSOLVERS

https://clinicalproblemsolving.com/wp-content/uploads/2023/02/02.09.23-ARM-Ep19-RTP.mp3CPSolvers: Anti-Racism in Medicine Series Episode 19 – Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm ReductionShow Notes by Alec CalacFebruary 9, 2022Summary: This episode highlights racialized disparities in addiction treatment. During this episode, we hear from Dr. Jessica Isom, a board-certified community psychiatrist and faculty leader in the Yale Department of Psychiatry’s Social Justice and Health Equity Curriculum, and Dr. Ayana Jordan, the endowed Barbara Wilson Associate Professor in the Department of Psychiatry, Addiction Psychiatrist and Associate Professor in the Department of Population Health at New York University (NYU) Grossman School of Medicine. Together, our guests explore and unpack how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care. There is a special emphasis on the use of public health models that prioritize harm reduction and person-centered care to prevent drug-related fatalities and curb the opioid epidemic along lines of race and class. This discussion is hosted by Ashley Cooper, Sudarshan Krishnamurthy, and new team member Gillette Pierce.Episode Learning Objectives:After listening to this episode, learners will be able to…Explain how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care.Describe how the media shapes public sentiment toward substance use and addiction treatment.Identify realistic solutions to drug policy reform that promote health equity among marginalized communities living in the United States.Credits:Written and produced by: Ashley Cooper, MPhil; Sudarshan Krishnamurthy; Gillette Pierce; Alec J. Calac; Michelle Ogunwole, MD, PhD; Ayana Watkins; Chioma Onuoha; Naomi F. Fields, MD; Victor A. Lopez-Carmen, MPH; Rohan Khazanchi, MPH; Sudarshan Krishnamurthy; Utibe R. Essien, MD, MPH;  Jazzmin Williams; LaShyra Nolen;  Jennifer Tsai MD, MEdHosts: Ashley Cooper, Sudarshan Krishnamurthy, and Gillette PierceInfographic: Creative Edge DesignAudio Edits: Caroline Cao and Ashley Cooper, MPhilShow Notes: Alec CalacGuests: Jessica Isom, MD, MPH and Ayana Jordan, MD, PhD Time Stamps:1:30                        Guest Introductions4:15                        Framing the Sociohistorical Context of the Opioid Epidemic10:47                     Racialization of Substance Use and Medicalization of the Human Experience14:28                     Changing “Faces of Addiction” and Impact on U.S. Drug Policy16:35                     United States, Chinese Laborers, and Anti-Chinese Sentiment (“Opium Fiends”)19:30                     “Moral Panic”23:00                     Separating Minoritized Individuals from the Majority23:40                     Cocaine Possession Sentencing Disparities26:50                     Shifting Social Attitudes Toward Substance Use and Addiction30:30                     (Mis)framing of Substance Use as a White Problem to Enact Change33:15                     Rectifying Racial Health Inequities in Opioid Addiction Treatment36:10                     Take-Home Methadone and a Less Clear Need for Methadone Clinics40:40                     Understanding Substance Use Disparities with Racially Disaggregated Data47:00                     Pushing Back Against “One Size Fits Most” 49:30                     Harm Reduction Practices53:00                     Narrowing the Empathy Gap and Connecting with Patients55:25                     Spirit of Sankofa: Looking Back to Move Forward59:15                     Reducing Harm and “Optimizing Safety”1:08:00                  Community-Centered Solutions1:10:20                  Drug Policy Reform1:15:42                  Episode TakeawaysEpisode Takeaways:Health care providers, especially physicians, cannot be equity-ignorant or egalitarian in our racialized society. They can use their training and privilege to advocate for meaningful policy reform.The opioid epidemic is more than a white problem. Demographic data in research and practice must always be disaggregated by race and ethnicity.Screening for substance use and offering connections to treatment and community-based services are important strategies that clinicians can implement in their own practice today. Pearls:In 2020, American Indian and Alaska Native (Indigenous) communities experienced the highest drug overdose mortality rate of any racial or ethnic group, also surpassing rates among the non-Hispanic white population. Between 2007 – 2019, Black individuals experienced a higher death rate for opioid overdose deaths than any other racial or ethnic group. [Supplementary Resource for Listeners: CPSolvers Episode 12: Addressing Anti-Indigenous Racism in Medicine with team members Alec Calac and Victor Anthony Lopez-Carmen]Dr. Jordan begins our episode by framing the racialization and criminalization of substance use in the larger history of the United States, emphasizing that American society has seen substance use as “criminal behavior” or a moral failing, rather than as a medical condition, which began towards the early 2000s. She mentions that academia, as well as the media, have contributed to this complex social phenomenon by tying together race, gender, and substance use, especially in the context of maternal health and neonatal abstinence syndrome. The foundational literature in this area has furthered stigma and bias, especially towards Black birthing persons. These narratives have vilified individuals who would benefit from comprehensive, person-centered substance use treatment, rather than incarceration and other adverse harms. Dr. Isom continues the conversation around the intentionality of these structural processes and the language that frames the racialization of substance use in the United States by lawmakers, media, and the healthcare profession. This parallels another process, which is the medicalization of human experiences, especially those relating to childbirth and pregnancy. A more Western perspective on health care emphasizes the role of physicians and health care providers and marginalizes the role and contributions of doulas and midwives. She then ties this back to Dr. Jordan’s conversation about the criminalization of substance use and how resources and infrastructure are dedicated to incarceration, rather than psychotherapy and related treatments. [Supplementary Resource for Listeners: Advancing Health Equity: A Guide to Language, Narrative and Concepts]Sudarshan goes further into the changing “faces of addiction” and asks our guests to describe its impact on drug policy in the United States. Dr. Isom first challenges our listeners to engage with anti-racist praxis and challenge dominant racial narratives about substance use, policing, and other encounters. She then goes into how the racialization of substance use drove positive public sentiment for the adoption of punitive outcomes for substance use. One example that is presented involves the complicated relationship between the United States and Chinese immigrants and farmworkers in California. Once the need for labor was largely met, anti-Chinese narratives (e.g., opium fiends) emerged around opium, gambling, and prostitution, which fits into this pattern or formula of associating specific racial and ethnic groups with substance use as a rhetorical threat to the “most valued demographic” in the United States (white women and children) to drive the adoption of punitive measures. This largely obscures the reality that substance use rates are similar among different racial and ethnic groups. [Supplementary Resource for Listeners: San Francisco Opium Ordinance described in Race and the Criminalization of Drugs – National Press Foundation | NPF featuring Dr. Jessica Isom and Dr. Helena Hansen]Dr. Jordan echoes these thoughts and posits that divergence from the “ideal” American identity (i.e., white, cisgender, heterosexual) makes it possible to other (verb) individuals and enact policies and laws that punish individuals with marginalized identities. She shared that rhetoric used by Nixon and the subsequent war on drugs has similarities to Trumpism and messaging associated with Make America Great Again (MAGA). This is then reaffirmed during the Reagan Administration and is later codified into sentencing structures, in which we see vastly different amounts of cocaine possession (100:1 crack versus powder cocaine possession offenses) amounting to similar sentences, with crack cocaine use most prevalent among minoritized individuals and powder cocaine use most prevalent among the white majority. Involvement with the carceral system further intersects with issues around employment, household income, and other related disparities. To our listeners, how might we begin redressing these harms and reinvest in minority communities adversely affected by the war on drugs?  [Supplementary Resource for Listeners: Cracks in the System: 20 Years of the Unjust Federal Crack Cocaine Law | American Civil Liberties Union]The conversation then shifts into changing social attitudes toward substance use and addiction. Dr. Isom breaks down media messaging and the varying tones and contexts used to describe substance use disparities and how that contributes to social stigma. She explains how different types of stigma intersect with media messaging to craft narratives that encourage sympathy or even a lack of sympathy towards certain racial and ethnic groups and health behaviors. Dr. Isom then discusses that policy reform and changing attitudes toward substance use and addiction are largely driven by the hurt and pain of those in the white majority with substance use disorder, further minimizing the experiences of marginalized communities.Dr. Jordan agrees with this characterization and goes more into the historical media coverage of substance use and the dehumanizing language that was (and is still) used to describe drug use among minority individuals. This segues into a conversation about the legacy of the war on drugs and today’s racial inequities in opioid addiction treatment. Ashley delineates that methadone has been disproportionately prescribed in predominantly Black communities, as a means to drive down crime, whereas white patients undergoing substance use treatment are more likely to receive buprenorphine. Dr. Jordan highlights the harm that these prescribing practices cause as they falsely associate race and substance use with criminal activity and neighborhood safety. She further goes into the stigma and stereotyping that continues to this day with the incessant and inhumane need to pick up prescription treatment once daily, submit “clean” urine samples under direct supervision, and submit to oral examinations. Dr. Jordan then questions the utility and continued operation of methadone clinics, especially as the United States largely moves on from the COVID-19 pandemic. She highlights actions taken by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) to expand access to take-home methadone doses, which promoted patient autonomy and had comparable adherences outcomes and no significant changes in potential adverse harms, such as overdose and diversion. Other actions include elimination of the United States Drug Enforcement Administration (DEA) X waiver which was needed to prescribe buprenorphine. Dr. Jordan concludes by thinking about incentive strategies that would encourage health care providers to change their prescribing practices and minimize racial inequities in opioid addiction treatment [Supplementary Resource for Listeners: Lessons from COVID 19: Are we finally ready to make opioid treatment accessible? – PMC]Dr. Isom highlights the differences in substance use disparities and infrastructure utilization from the national level moving into discrete communities. Using an equity lens, she shares her own experiences in Massachusetts examining treatment utilization and encourages health care providers to examine racially disaggregated data to make sure that services offering suboxone (buprenorphine and naloxone) are reaching and being used in the most impacted communities. She also discusses the importance of the patient-provider relationship and shared-decision making, which helps ensure that a full range of services are being offered to patients. Dr. Jordan and Dr. Isom both agree that simply offering treatment services and having an “open door” are not enough. Dr. Jordan discusses the importance of de-centering the majority and identifying the factors that are most relevant to minoritized individuals and communities. Oftentimes, researchers and practitioners working to implement addiction treatment programs and interventions are not from those same communities. Dr. Jordan pushes back on the notion that “one size fits most” is the optimal approach for treating substance use disorder and that the evidence we rely on for patients undergoing substance use treatment was largely informed by the experiences of white individuals. Therefore, traditional settings of addiction care may unintentionally cause harm to individuals with marginalized identities.Gillette moves the conversation into strategies addressing substance use disparities, particularly those that emphasize the importance of harm reduction. Dr. Isom begins by sharing her experiences in the clinic and how harm reduction approaches such as offering fentanyl test strips humanize substance use treatment and place individual and community health and well-being at the center of treatment. To her dismay, she also learned that her racially and linguistically diverse patient population was one of most affected by the opioid epidemic in the Commonwealth of Massachusetts. Reflecting on these health data and rethinking “traditional” addiction treatment strategies helped her connect with her patients and close a self-described empathy gap that she says patients accessing treatment often have with their health care provider. Dr. Jordan enters into the conversation and also shares how she best connects with her patients who often feel unheard and marginalized by the health care system. She discusses the strengths and limitations of harm reduction approaches and the continued need for a clinician-researcher workforce that reflects the diversity seen in communities experiencing hardship. An important part of her discussion includes the contributions of community health workers and a need not just to focus on harm reduction, but also to optimize safety among individuals using substances such as alcohol and opioids. This complementary approach has the potential to increase the positive impact that the harm reduction movement has made over time.The group briefly discusses Dr. Isom’s article Nothing About Us Without Us in Policy Creation and Implementation | Psychiatric Services (2021) which highlights the need for patients and communities to be included in the creation and implementation of drug policy. This approach has the potential to best direct resources to the most impacted communities and may be more impactful than traditional community engagement models. Dr. Jordan has also written about culturally-responsive programs benefiting Black communities affected by the opioid epidemic and has completed a pilot study providing addiction treatment in partnership with faith-based organizations. Both guests acknowledge that academics do not always have the right solutions and that practitioners have to listen openly to community knowledge holders.Towards the end of the episode, Dr. Jordan highlights opportunities for meaningful drug policy reform, including examining federal methadone regulations (e.g., dosing, availability), investing in harm reduction and safety optimization, and decreasing police involvement in mental health crisis response and police presence in substance use treatment settings.New Host! Kiersten TâLeigh (Ta-Lee) “Gillette” Gillette-Pierce (she/they) is currently a student at Johns Hopkins School of Public Health pursuing a Master of Science in Public Health with a double concentration in Maternal, Fetal, and Perinatal Health and Women, Sexual and Reproductive Health. As an academic researcher, they focus on transnational racial/ethnic and gender disparities in pregnancy-related, sexual, and reproductive health outcomes for all persons with gynecologic organs, with a specific interest in people of African descent. She is published in the Journal of Advanced Nursing and Medicine, Science, and Law. Gillette has also published work with Rewire News Group and the Center for American Progress focusing on sexual and reproductive health and rights policy, reproductive justice, and health outcomes for Black birthing persons. With almost ten years of experience in the global sexual and reproductive health, rights, and justice field, Gillette aims to improve sexual and reproductive health care and outcomes for disenfranchised communities and significantly improve pregnancy-related outcomes for people of African descent.  Speaker BiographiesDr. Jessica Isom, MD, MPH, is a board-certified community psychiatrist and faculty leader in the Yale Department of Psychiatry’s Social Justice and Health Equity Curriculum. She primarily works in Boston as an attending psychiatrist at Codman Square Health Center where she is leading a grant effort to infuse antiracism in Opioid Use Disorder (OUD) services. She is a nationally recognized expert on racial equity and justice in psychiatry with a focus on workforce development and organizational transformation. Her professional interests include working toward eradicating racial and ethnic mental health disparities, mitigating the impact of implicit racial bias on clinical care, and the use of a community-centered population health approach in psychiatric practice. She serves on multiple advisory boards and is a consultant, curriculum developer and presenter to a variety of organizations including Fortune 500 companies and medical societies through her company, Vision for Equity LLC. Dr. Isom received her MD from the University of North Carolina School of Medicine, and completed her residency at Yale University. Ayana Jordan, MD, PhD, is the Barbara Wilson Associate Professor in the Department of Psychiatry, Addiction Psychiatrist and Associate Professor in the Department of Population Health at New York University (NYU) Grossman School of Medicine. She also serves as Pillar Co-Lead for Community Engagement at NYU Langone’s Institute for Excellence in Health Equity. As Principal Investigator for the Jordan Wellness Collaborative (JWC), she leads a research, education, and clinical program that partners with community members to provide optimal access to evidence-based treatments for racial and ethnic minoritized patients with mental health disorders. Through her multifaceted work, she provides addiction treatment in faith settings, studies health outcomes for people with opioid use disorder in the carceral system, and trains addiction specialists to provide culturally-informed treatment. Dr. Jordan is dedicated to creating spaces and opportunities for more people of color, specifically Black women in academia who are vastly underrepresented. She has numerous peer-reviewed publications, has been featured at international conferences, and is the proud recipient of various clinical and research awards. The fundamental message of equity and inclusion has informed her research, clinical work, and leadership duties at NYU and beyond.ReferencesAhmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2022. Designed by LM Rossen, A Lipphardt, FB Ahmad, JM Keralis, and Y Chong: National Center for Health Statistics.American Medical Association; Manatt Health. National roadmap on state-level efforts to end the opioid epidemic: leading-edge practices and next steps. https://www.end-opioid-epidemic.org/wp-content/uploads/2019/09/AMA-Manatt-National-Roadmap-September-2019-FINAL.pdf. Published September 2019. Accessed October 17, 2022.Balasuriya, L., Isom, J., Cyrus, K., Ali, H., Sloan, A., Arnaout, B., Steinfeld, M., DeSouza, F., Jordan, A., Encandela, J., & Rohrbaugh, R. (2021). The Time Is Now: Teaching Psychiatry Residents to Understand and Respond to Oppression through the Development of the Human Experience Track. Academic Psychiatry, 45(1), 78–83. https://doi.org/10.1007/s40596-021-01399-xCastillo, E. G., Isom, J., DeBonis, K. L., Jordan, A., Braslow, J. T., & Rohrbaugh, R. (2020). Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education. Academic Medicine, 95(12), 1817–1822. https://doi.org/10.1097/ACM.0000000000003559DeSouza, F., Mathis, M., Lastra, N., & Isom, J. (2021). Navigating Race in the Psychotherapeutic Encounter: A Call for Supervision. Academic Psychiatry, 45(1), 132–133. https://doi.org/10.1007/s40596-020-01328-4Friedman, J. R., & Hansen, H. (2022). Evaluation of Increases in Drug Overdose Mortality Rates in the US by Race and Ethnicity Before and During the COVID-19 Pandemic. JAMA Psychiatry, 79(4), 379. https://doi.org/10.1001/jamapsychiatry.2022.0004Godkhindi P, Nussey L, O’Shea T. “They’re causing more harm than good”: a qualitative study exploring racism in harm reduction through the experiences of racialized people who use drugs. Harm Reduct J. 2022 Aug 25;19(1):96. doi: 10.1186/s12954-022-00672-y. PMID: 36008816; PMCID: PMC9406271.Goldman, M. L., Swartz, M. S., Norquist, G. S., Horvitz-Lennon, M., Balasuriya, L., Jorgensen, S., Greiner, M., Brinkley, A., Hayes, H., Isom, J., Dixon, L. B., & Druss, B. G. (2022). Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type. Psychiatric Services, 73(10), 1165–1168. https://doi.org/10.1176/appi.ps.202100428Hansen H, Jordan A, Plough A, Alegria M, Cunningham C, Ostrovsky A. Lessons for the Opioid Crisis-Integrating Social Determinants of Health Into Clinical Care. Am J Public Health. 2022 Apr;112(S2):S109-S111. doi: 10.2105/AJPH.2021.306651. PMID: 35349328; PMCID: PMC8965192.Hughes M, Suhail-Sindhu S, Namirembe S, Jordan A, Medlock M, Tookes HE, Turner J, Gonzalez-Zuniga P. The Crucial Role of Black, Latinx, and Indigenous Leadership in Harm Reduction and Addiction Treatment. Am J Public Health. 2022 Apr;112(S2):S136-S139. doi: 10.2105/AJPH.2022.306807. PMID: 35349317; PMCID: PMC8965189.Isom, J., & Balasuriya, L. (2021). Nothing About Us Without Us in Policy Creation and Implementation. Psychiatric Services, 72(2), 121–121. https://doi.org/10.1176/appi.ps.72202Isom, J., Jordan, A., Goodsmith, N., Medlock, M. M., DeSouza, F., Shadravan, S. M., Halbert, E., Hairston, D., Castillo, E., & Rohrbaugh, R. (2021). Equity in Progress: Development of Health Equity Curricula in Three Psychiatry Residency Programs. Academic Psychiatry, 45(1), 54–60. https://doi.org/10.1007/s40596-020-01390-yJames K, Jordan A. The Opioid Crisis in Black Communities. J Law Med Ethics. 2018 Jun;46(2):404-421. doi: 10.1177/1073110518782949. PMID: 30146996.Jordan, A., Mathis, M. L., & Isom, J. (2020). Achieving Mental Health Equity: Addictions. Psychiatric Clinics of North America, 43(3), 487–500. https://doi.org/10.1016/j.psc.2020.05.007Jordan A, Babuscio T, Nich C, Carroll KM. A feasibility study providing substance use treatment in the Black church. J Subst Abuse Treat. 2021 May;124:108218. doi: 10.1016/j.jsat.2020.108218. Epub 2020 Dec 3. PMID: 33771290.Kuehn, B. M. (2022). Black Individuals Are Hardest Hit by Drug Overdose Death Increases. JAMA, 328(8), 702. https://doi.org/10.1001/jama.2022.13702Lagisetty, P. A., Ross, R., Bohnert, A., Clay, M., & Maust, D. T. (2019). Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry, 76(9), 979. https://doi.org/10.1001/jamapsychiatry.2019.0876Naseem S. Miller. (2021, May 17). Racial disparities in opioid addiction treatment: Primer & research roundup. The Journalist’s Resource. https://journalistsresource.org/home/systemic-racism-opioid-addiction-treatment/Nweke, N., Isom, J., & Fashaw-Walters, S. (2022). Health Equity Tourism: Reckoning with Medical Mistrust. Journal of Medical Systems, 46(5), 27. https://doi.org/10.1007/s10916-022-01812-4Portnoy, G. A., Doran, J. M., Isom, J. E., Wilkins, K. M., DeViva, J. C., & Stacy, M. A. (2021). An evidence-based path forward for diversity training in medicine. The Lancet Psychiatry, 8(3), 181–182. https://doi.org/10.1016/S2215-0366(21)00024-9Race and the Criminalization of Drugs. (2021, April 22). National Press Foundation. https://nationalpress.org/topic/race-and-the-criminalization-of-drugs/Roxas, N., Ahuja, C., Isom, J., Wilkinson, S. T., & Capurso, N. (2021). A Potential Case of Acute Ketamine Withdrawal: Clinical Implications for the Treatment of Refractory Depression. American Journal of Psychiatry, 178(7), 588–591. https://doi.org/10.1176/appi.ajp.2020.20101480Townsend, T., Kline, D., Rivera-Aguirre, A., Bunting, A. M., Mauro, P. M., Marshall, B. D. L., Martins, S. S., & Cerdá, M. (2022). Racial/Ethnic and Geographic Trends in Combined Stimulant/Opioid Overdoses, 2007–2019. American Journal of Epidemiology, 191(4), 599–612. https://doi.org/10.1093/aje/kwab290Wyatt JP, Suen LW, Coe WH, Adams ZM, Gandhi M, Batchelor HM, Castellanos S, Joshi N, Satterwhite S, Pérez-Rodríguez R, Rodríguez-Guerra E, Albizu-Garcia CE, Knight KR, Jordan A. Federal and State Regulatory Changes to Methadone Take-Home Doses: Impact of Sociostructural Factors. Am J Public Health. 2022 Apr;112(S2):S143-S146. doi: 10.2105/AJPH.2022.306806. PMID: 35349318; PMCID: PMC8965186. Disclosures The hosts and guests report no relevant financial disclosures.CitationIsom J, Jordan A, Cooper A, Krishnamurthy S, Pierce G, Calac A, Watkins A, Onuoha C, Lopez-Carmen VA, Nolen L, Williams J, Tsai J, Ogunwole M, Khazanchi R, Fields NF. “Episode 19: Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm Reduction”. The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. February 9, 2022. Show TranscriptDownload CPSolvers App hereRLRCPSOLVERS

https://clinicalproblemsolving.com/wp-content/uploads/2023/02/02.07.2023-Schema-Episode-with-Dan-RTP.mp3 Sharmin, Dan, Ann Marie, and Jack discuss an interesting case of non-resolving pneumonia with some radiologic surprises! Schemas: CAP Pulmonary Disease and Eosinophilia Lung Nodules Lung Cavities Download CPSolvers App here RLRCPSOLVERS