The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2021/10/ARM-Ep-11-RTP.mp3CPSolvers: Anti-Racism in Medicine SeriesEpisode 11: Racism, Redlining, and the Path Towards ReconciliationShow Notes by Sud Krishnamurthy, Michelle Ogunwole, Chioma OnuohaOctober 12th, 2021Summary: This episode is part of a 3-part series on Race, Place, and Health. In this episode, we invite Mr. Richard Rothstein, distinguished Fellow of the Economic Policy Institute and acclaimed author of the book, The Color of Law: A Forgotten History of How Our Government Segregated America, and Professor Fernando De Maio, PhD director of research and data use at the AMA’s Center for Health Equity, professor of sociology at DePaul University, and co-editor of the recently published book, Unequal Cities: Structural Racism and the Death Gap in America’s Largest Cities, to share their expertise on structural racism, neighborhood segregation, and health inequities. Episode Learning Objectives: After listening to this episode learners will be able to…Explain the differences between de jure and de facto segregationExplore the historical and present-day implications of neighborhood redlining and housing segregation on health disparitiesExplain the importance of precise definitions when discussing structural racism  Explore short and long term remedies to segregation CreditsWritten and produced by: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin WilliamsHosts: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPHInfographic: Creative Edge DesignAudio edits: David HuShow notes: Sudarshan Krishnamurthy, Michelle Ogunwole, Chioma OnuohaGuests: Richard Rothstein, Fernando De Maio, PhD Time Stamps00:00               Introduction02:29               De Jure and De Facto Segregation: The Color of Law06:45               Health Inequities and Segregation: Unequal Cities 12:07               Defining Structural Racism18:05               Federal Policy and Suburbanization24:50               The Racial Wealth Gap and its Consequences30:27               The Role of Health Equity Promoting Policy32:00               Potential Remedies for Past Harms39:45               Segregation of Medical Care41:20               What Can Listeners Do Going Forward? Episode Takeaways:   1. Terminology and Definitions of de jure and de facto segregation: The myth that segregation in modern societies has to do with private activities (e.g individual bias or bigotry that leads to a failure to sell a home to a person of color)  and personal choices ( e.g. Black people prefer to live among other Black people) is referred to as de facto segregation. Adopting this worldview removes any obligation to remedy the consequences of segregation. In contrast, de jure segregation refers to the involvement of federal, state, and local governments in creating, structuring, designing, reinforcing, and perpetuating segregation. This reality of de jure segregation helps us understand that we have an obligation to remedy this constitutional violation.  2. Segregation relates to crucial public health outcomes that ultimately have an effect on life expectancy: The average life expectancy across the United States is 78.6 years; however, there exists a 10 year gap in life expectancy among the 30 largest cities in the US, from 72.9 years in Baltimore to 82.9 years in San Francisco and San Jose. Across the country, we see a 4 year gap in life expectancy between Black and White Americans; and this gap between and Black and White individuals ranges from 12 years in Washington DC, more than 8 years in Chicago, to no gap in El Paso. These gaps are not a product of lifestyle choices, biology or individual behaviors. They are a product of deep-rooted man-made policies that extend to many sectors (healthcare, education, criminal justice etc). These policies have systematically disadvantaged some groups, and have advantaged others. These policies are woven deeply into the fabric of the United States, and are intimately related to residential segregation, life expectancy, and mortality. 3. Unconstitutional housing policy in the mid-20th century led to the present day wealth gap and has implications for disparities: Discriminatory policies prohibited African Americans from being homeowners, while allowing White Americans to purchase homes and accumulate generational wealth. These policies established the wealth gap between Black and White Americans that persists today. Nationally, African Americans’ income is 60% of that of White Americans. Although one would think this leads to a 60% wealth gap as well, household wealth of African Americans is 5% (95% wealth gap)  of that of White Americans. This extreme disparity between the 60% income ratio and the 5% wealth ratio is attributable to consequences of federal housing policy practiced in the mid-20th century. You can draw a line from these discriminatory housing policies, to the wealth gap, to disparities in education, health, and police brutality.Pearls On the importance of considering place based inequities Variability of health inequities between communities in a single city or across different cities is critical to consider when discussing health inequity.“We tend to think of health inequities as big, monolithic, deeply entrenched patterns, and they are, but their variability is really important. It gives us a sense of how different things can be.”-Professor Fernando De MaioOn language and the use of the term ‘structural racism’Structural racism  is a word that is used often, however many people do not know what it really means. Professor DeMaio notes that confusion around terminology is not a reason to shy away from discussions around it. He declares that one of our greatest challenges, and also one of our obligations, is to address structural racism head on.“It’s our collective responsibility to explain it, to define it, to communicate it in effective ways to physicians, to healthcare systems, to the public at large and in detail, with data and with narratives, all the ways through which racism impacts our health.” -Professor Fernando De Maio  On Remedies to segregation Mr. Rothstein shares two examples of potential remedies to segregation. The first would specifically address the constitutional violation that prohibited African Americans from becoming homeowners. The remedy would be for  the government to buy up homes at market value in neighborhoods where African Americans were not allowed to buy homes, and sell them back to qualified African American buyers at deeply discounted rates. The second remedy would correct a policy– the low-income housing tax credit– that reinforces segregation. Currently, low-income housing tax credit is a federal program distributed to housing developers who build housing for low-income families. However, this program reinforces segregation as developers are more inclined to build low-income housing in low-income neighborhoods. This can be reversed by placing a priority on use of these tax credits in higher-opportunity communities and prohibiting the use of this credit for creating more segregated communities.      Mr. Rothstein notes that the challenge is not in thinking of ideas or potential remedies…“ We know what the policies are to create equality, a more equal society and a non-segregated society. What’s missing is not policy ideas. What’s missing is a new civil rights movement that’s going to create the political environment where those policies have to be implemented.”-Mr. Richard RothsteinOn being a citizen and the collective effort needed to change the status quoMr. Rothstein leaves us with these wise words to consider as we head back into our professional roles in medicine.“In addition to being a physician, you’re a citizen. And I think the most important thing you can do is align yourself with other citizens in whatever profession they are, because this is going to take a community effort” -Mr. Richard RothsteinReferencesRothstein, R. (2017). The Color of Law: A Forgotten History of How Our Government Segregated America.Benjamins MR, De Maio F. Unequal Cities: Structural Racism and the Death Gap in America’s 30 Largest Cities. Baltimore: Johns Hopkins University Press; 2021.De Maio F, Ansell D. “As Natural as the Air Around Us”: On the Origin and Development of the Concept of Structural Violence in Health Research. Int J Health Serv. 2018;48(4):749-759. doi:10.1177/0020731418792825Benjamins MR, Silva A, Saiyed NS, De Maio FG. Comparison of All-Cause Mortality Rates and Inequities Between Black and White Populations Across the 30 Most Populous US Cities. JAMA Netw Open. 2021;4(1):e2032086. doi:10.1001/jamanetworkopen.2020.32086Metzl JM, Maybank A, De Maio F. Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System. JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289Liao TF, De Maio F. Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties. JAMA Netw Open. 2021;4(1):e2034578. doi:10.1001/jamanetworkopen.2020.34578Krieger M, Boyd R, De Maio F, Maybank A. “Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism And Health, ” Health Affairs Blog, April 20, 2021. doi: 10.1377/hblog20210415.305480Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality. London: Routledge; 2005.Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133. doi:10.1016/j.socscimed.2013.06.032The “Redress Project,”, i.e. the New Movement to Redress Racial Segregation, will launch early next year. For anyone who wants to receive more information about the launch of the New Movement to Redress Racial Segregation, please click here NMRRS. For a brief 8 minute summary of talks about how segregation happened, see this: https://www.facebook.com/NowThisPolitics/videos/270363507375249/See the 17-minute animated film, “Segregated by Design” https://www.segregatedbydesign.com/ For a high school curriculum unit to teach this history: https://www.zinnedproject.org/materials/how-red-lines-built-white-wealth-color-of-law-lessonRothstein, R. (2020, February 3). Opinion | The Neighborhoods We Will Not Share. The New York Times. https://www.nytimes.com/2020/01/20/opinion/fair-housing-act-trump.htmlRothstein, R. (2020b, April 21). The Coronavirus Will Explode Achievement Gaps in Education. Shelterforce. https://shelterforce.org/2020/04/13/the-coronavirus-will-explode-achievement-gaps-in-education/Rothstein, R. (2020c, August 14). Opinion | The Black Lives Next Door. The New York Times. https://www.nytimes.com/2020/08/14/opinion/sunday/blm-residential-segregation.html Disclosures The hosts and guests report no relevant financial disclosures.CitationDe Maio F, Rothstein R, Khazanchi R, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR. “Episode 11: Racism, Redlining, and the Path Towards Reconciliation.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. October 12, 2021.Show  TranscriptARM Ep 11 TRANSCRIPT V1   

Dr. Aaron Berkowitz, known for his efforts to #EndNeurophobia, explores the intricate world of diplopia alongside medical students Gabriela Pucci, Gabriel Talledo, and Valeria Roldan. They dissect the causes and classifications of double vision, emphasizing the role of cranial nerves and brain structures. Interesting case studies illuminate diagnostic approaches and the significance of thorough clinical examinations. The group dives into cranial nerve six and third cranial nerve pathologies, unraveling complexities and sharing invaluable insights for future neurologists.

https://clinicalproblemsolving.com/wp-content/uploads/2021/09/HDX-9_23-RTP.mp3 Alec presents a case of abdominal pain and hematochezia to Laura, Stef, and Jack. Laura GeiszlerLaura Geiszler is a third-year Internal Medicine resident at Lankenau Medical Center in Wynnewood, Pennsylvania. Laura completed her medical school at Philadelphia College of Osteopathic Medicine.She has a passion for humanizing medicine and promoting health and wellness to prevent disease. Outside of work she is a proud cat mom, fitness lover, fiction book enthusiast, and fashion addict.  Stefanie Gallagher Stefanie is a PGY-3 internal medicine resident at Lankenau Medical Center, located in Wynnewood, PA. She earned her medical degree from the Philadelphia College of Osteopathic Medicine, with a dual-degree in Bioethics from the University of Pennsylvania. She is an aspiring gastroenterologist and has a passion for disorders of the gut-brain axis. Outside of medicine, she enjoys her English bulldog (Boomer), cycling, and reading non-fiction. Alec RezighAlec Rezigh is an academic hospitalist at Baylor College of Medicine in Houston, TX. He completed medical school at McGovern Medical School in Houston and his residency at The University ofColorado. His clinical interests include medical education and clinical reasoning. He loves all things basketball, CPSolvers, and playing with his human and doggy daughters.   Download CPSolvers App herePatreon website 

https://clinicalproblemsolving.com/wp-content/uploads/2021/09/9.16.21-WDx-RTP.mp3Dr. Titer, Dr. Williams, Maani and Lindsey discuss macro/microaggressions in the clinical setting. Dr. KeAndrea TiterDr. KeAndrea Titer is an Assistant Professor in the Division of General Internal Medicine at University of Alabama at Birmingham. She was born and raised in Tampa, Florida. She received her Bachelor of Science in Biology from Oakwood University in Huntsville, Alabama. She went on to earn her medical degree from Loma Linda University School of Medicine in Loma Linda, California. She completed her residency and chief residency at the University of Alabama at Birmingham Tinsley Harrison Internal Medicine Residency Program. Her academic interests include physical exam-focused medical education where she co-directs the Enhanced Clinical Skills Residency Track and serves as Investigator for the AMA Reimagining Residency Grant awarded to John Hopkins, Stanford, and UAB focused on studying clinical skills as it relates to resident wellness. She is also passionate about diversity, equity, and inclusion and serves as the Assistant Director of Diversity and Inclusion for the Tinsley Harrison Internal Medicine Residency Program where she works to design initiatives and curriculum focused on recruitment, education, and building community. Dr. Karla WilliamsDr. Karla Williams is an assistant professor in the Division of General Internal Medicine and Hospital Medicine at UAB in Birmingham, AL. She serves as an assistant program director and the director of diversity and inclusion for the Tinsley Harrison Internal Medicine Residency Program. She has a passion for advancing diversity, equity and inclusion in graduate medical education and care delivery and was recognized as a recipient of the 2020 Dean’s Excellence Award in Diversity. She has recently worked with colleagues to develop a formal curriculum, Supporting Trainees by Addressing Inappropriate Behaviors by Patients, to address microaggressions and other inappropriate behaviors in the medical environment. This initiative has created a platform to have safe and honest discussions about the presence and effect of bias, including racial and gender derogations, in the medical environment and has been presented and implemented at numerous academic institutions at the UME and GME levels. The ultimate goal is to bring awareness to our implicit and explicit biases in an effort to cultivated more inclusive learning and clinical environments for trainees, faculty and patients.Download CPSolvers App here Patreon website

Anna presents a case of metabolic acidosis, pulmonary nodules, and fevers. The hosts discuss approaching complex cases in patients with underlying chronic conditions. They explore elevated anion gap metabolic acidosis and diabetic ketoacidosis. They also discuss a complex case involving persistent fever and respiratory failure, and diagnose iodine-induced thyrotoxicosis as the cause of a patient's fever.

https://clinicalproblemsolving.com/wp-content/uploads/2021/08/Special-Announcement-RTP-_1_-1.mp3RLR are recording an episode with author of the New York Time Diagnosis column, Dr. Lisa SandersSubscribe to our Join Live tier to join us on Zoom in real time on Monday August 30 at 9:30 AM PST/12:30 PM PST.A few weeks later, we will release this episode to all our Patreon tiers. Link to our Patreon

https://clinicalproblemsolving.com/wp-content/uploads/2021/08/RLR-on-CPSolvers-RTP.mp3RLR are back on the podcast with a fascinating case. Over the summer, they’ve been releasing a lot of cool content on Patreon. Check it out here for much more RLR content. Schema OneSchema TwoMore about the RLR series here.

 Lindsey presents a case of polyuria to Dan, Jack, and Sharmin https://clinicalproblemsolving.com/wp-content/uploads/2021/08/Schema-8.19-RTP.mp3  Hypernatremia schema  Polyuria schema Download CPSolvers App herePatreon website

Kirtan Patolia, a final-year medical student from B.J. Medical College, and Maria Jimena Aleman, a med student at Universidad Francisco Marroquin, dive into the complex world of speech impairments. They discuss aphasia vs. dysarthria, detailing the neurological roots of these conditions. The duo highlights the challenges of diagnosing strokes, especially in younger patients, and the vital role of thorough clinical evaluations. Their insights on the importance of patient history and symptom examination are both engaging and enlightening.

https://clinicalproblemsolving.com/wp-content/uploads/2021/08/Clinical-Unknown-8.5.21-RTP.mp3Dr. Palmer presents a clinical unknown case to Dr. StanleySchemaDr. Marion StanleyDr. Marion Stanley is a hospitalist and an internal medicine residency associate program director at Northwestern Memorial Hospital. She completed medical school at University of Chicago, Pritzker School of Medicine and graduated from University of California, San Francisco for residency. She spends her clinical time on the general medicine teaching services as well as the general medicine and oncology hospitalist units. She enjoys spending time with her husband and two daughters, ages 4 and 1. Dr. Geralyn Palmer Dr. Geralyn Palmer is a first year internal medicine resident at the University of Wisconsin. She completed her undergraduate and medical education in her home state of South Dakota. After residency, Geralyn hopes to pursue a career in medical education, and is currently considering a broad specialty differential. In her free time she enjoys long walks outside (preferably with dogs), experimenting in the kitchen, and The Great British Bake Off.  Download CPSolvers App herePatreon website