The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2021/05/ARM-EP-8-Towards-Justice-and-Race-Concious-Medicine-RTP.mp3“There’s nothing new under the sun, but there are new suns” – Octavia E. ButlerSummary: We invite social justice champion and acclaimed scholar of race, gender, and the law, Dorothy E. Roberts, JD, to discuss the history of race-based medicine and the movement for health equity and justice.Episode Learning ObjectivesAfter listening to this episode learners will be able to…Understand race as a social construct and political inventionExplore the history of race as a proxy for genetics and ancestryExplore the history of race-based pharmaceuticalsExplore the history of race-based clinical algorithms CreditsWritten and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Jenny Tsai, MD, Jazzmin Williams, Dereck Paul, MS, and Utibe R. Essien, MD, MPH Infographic: Creative Edge DesignHosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Michelle Ogunwole, MDGuest: Dorothy E. Roberts, JD (@DorothyERoberts) Timestamps:00:00 Introduction03:40 Defining Race13:40 Responses to Common Race Based Medicine Arguments20:40 Race as a Proxy for Racism31:00 BiDiL and Race Based Medicine Definition42:00 Dr. Duana Fullwiley and the “African Gene”49:30 Debunking Folklore Health Narratives53:30 Slavery Hypertension Hypothesis57:00 Importance of Intentional and Plausible Research Methods1:00:00 Race in Medical Algorithms 1:12:00 Moving Away from Relying on Simplistic Biological Concepts of Race1:15:48 Advice for Listeners1:21:00 Closing Remarks Takeaways:Definition of Race: Race is not a biological category, instead it is a permeable, flexible, and unstable social construction and political invention that facilitates political and economic inequality. However it is important to remember that this political invention DOES affect biology because of the way that it creates social inequity.Historical Context: Historically, laws such as interracial marriage bans have protected established structures of white supremacy and reinforced the social construct of race.Race is a Poor Proxy for Genetics: Diseases with genetic or population associations are often evolutionary adaptations to specific geo-environments. Race, a social construction, groups people from large swaths of of global territory based on superficial phenotype is often a poor proxy for these genetic associations with disease. Race is a proxy for Racism: race was invented as a way to classify people into subordinate groups and support the political sanctioning of inequity.  The very function of race is thus to support and uphold racism. When we evaluate race in medicine we have to recall  this origin story and not rely on race as a placeholder for anything else except racism.The Root of Inequities: Health inequities are overwhelmingly caused by differences in social status, living conditions, and experiences of discrimination. When we cling to race as the cause of  health inequities, we obscure and divert attention away from these social factors that need to be addressed.Intersectionality: Race and racism intersect with socioeconomic status, education, geography, sexual orientation, religion, immigration status, gender and other identities with differential impact. Our responsibility in medicine: “What we have to do is include medicine in the political movement to bring down the structures of racism and white supremacy and the way in which medicine incorporates those and promotes those. And [this] HAS to be in conjunction with broader social movements…that are dedicated to radically transforming our world into one in which human beings are equally valued…”-Dorothy E. Roberts JDFor the patient I see tomorrow:  Beyond recognizing that race is not a proxy for biology, we can all ask ourselves “What way is structural racism affecting my patient and what can I do about it?” The answer to this question may not be easily answered and may not always be found in the clinical setting.Pearls:“Genetics is not the end all be all of understanding disease” – Dorothy E. Roberts JDAn Emphasis on Genetics is Not the Solution to Race-Based MedicineBeing antiracist in medicine does not mean being more precise in our understanding of genetics. Rather we need a deeper and broader understanding of the influence of the structural and political determinants of health inequities. Part of the problem with focusing on race in medicine is that it limits our perspectives and encourages research practices that lack the rigor required to identify root causes of racial health inequities. We should be focusing on root causes rather than proxies. It does not mean that we should stop exploring genetic causes of disease, but rather that we should not pretend that understanding genetics is the solution to addressing disparities. Dr. Roberts put it expertly: “to be anti-racist, it doesn’t mean, well, then let’s just be more precise in our genetics. It means being anti all the things that race and racism do.”Medicine Must Move Beyond Othering Black PeopleAll too often in medicine, Black people are singled out from all other human beings as having different bodies from the norm, aka whiteness. Examples of this include: BiDiL, the blood pressure drug marketed solely to black people; arguments for race-based medicine that cite sickle cell, a disease that is most common in Black people because of geographic varietion rather than innate difference; and the slavery hypertension hypothesis which posits that hypertension disparities observed in Black people are a result of the stress of slavery and the middle passage rather than the longitudinal impacts of structural racism. Rather than searching for obscure explanations for inequalities, we must instead recognize the ways that racism impedes health at both individual and structural levels. Race-based algorithms can produce inequity and there is a moral dilemma we must attend toThere is a persistent question about whether race-based clinical algorithms disadvantage patients and how we should think through use of them in clinical medicine. Professor Roberts offers some guidance: whenever you are stuck, go back to the origin story- what is race? Then you can ask yourself, how is race being used and does that use further inequity? Professor Roberts also offers a few scenarios.Race-based algorithms: Race is being used as a biological construct AND it can produce harm. For example, GFR- race correction for Black patients. The use of race is  based on a false/biological concept of race AND many studies show that this can harm patients ( i.e. clinical resources are withheld based on results of algorithm). This is the rationale for NOT using these kinds of race-based algorithms.Race “neutral” algorithms, which are used for allocation of resources for most fit patients. Race is not included in the algorithm, however because of the experiences of structural racism, certain groups will have worse scores. These worse scores may lead to the withholding of resources and ultimately further inequity. For example, the proposal of race neutral ventilator algorithms that were set up to allocate ventilators to the most fit patients during the COVID-19 pandemic. This race neutral algorithm could disadvantage Black patients, who because of structural racism may have lower fitness scores. This could worsen existing disparities in COVID-19 outcomes among Black patients. Moral dilemma: Including race as a biological construct in clinical algorithms can lead to inequity. However whenever structural racism isn’t included in clinical algorithms, we also risk denying a group who has experienced structural racism access to much needed resources. We have not thought about this enough in medicine and we don’t have a gold standard of how to include race as a proxy for structural racism in our clinical algorithms. As we move forward we must continue to think critically about the ethical and just way to include race or rather structural racism in clinical algorithms and ensure that our algorithms do not further inequity.References: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.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.Roberts D. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century. The New Press: 2012.Roberts D. “The problem with race-based medicine.” TEDMED 2015. Link to talk.Roberts DE. What’s Wrong with Race-Based Medicine?: Genes, Drugs, and Health Disparities. Minnesota Journal of Law, Science & Technology. 2011;12(1):1-21.Yudell M, Roberts D, DeSalle R, Tishkoff S. NIH must confront the use of race in science. Science. 2020;369(6509):1313-1314. doi:10.1126/science.abd4842Roberts DE. Is race-based medicine good for us?: African American approaches to race, biomedicine, and equality. J Law Med Ethics. 2008;36(3):537-545. doi:10.1111/j.1748-720X.2008.302.xTaylor AL, Ziesche S, Yancy C, Carson P, D’Agostino R Jr, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN; African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med. 2004 Nov 11;351(20):2049-57. doi: 10.1056/NEJMoa042934. The Slavery Hypertension Hypothesis: Dissemination and Appeal of a Modern Race Theory. (2003). Epidemiology, 14(1), 111-118. Retrieved May 9, 2021, from http://www.jstor.org/stable/3703292Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon Books, 1997.Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020 Dec 17;383(25):2477-2478. doi: 10.1056/NEJMc2029240.Hansen H, Netherland J. Is the Prescription Opioid Epidemic a White Problem?. Am J Public Health. 2016;106(12):2127-2129. doi:10.2105/AJPH.2016.303483Bibbins-Domingo K, Fernandez A. BiDil for heart failure in black patients: implications of the U.S. Food and Drug Administration approval. Ann Intern Med. 2007 Jan 2;146(1):52-6. doi: 10.7326/0003-4819-146-1-200701020-00009. Erratum in: Ann Intern Med. 2007 Apr 17;146(8):616. PMID: 17200222.Roberts DE. Abolish race correction. Lancet. 2021 Jan 2;397(10268):17-18. doi: 10.1016/S0140-6736(20)32716-1. PMID: 33388099.TranscriptDownload transcript hereDisclosuresThe hosts and guests report no relevant financial disclosures.CitationRoberts, DE, Onuoha C, Khazanchi R, Nolen L, Fields N, Tsai J, Essien UR, Paul D, Ogunwole M,. “Episode 8: Dismantling Race Based Medicine Part 3: Towards Justice and Race-Conscious Medicine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. May 10, 2021.

https://clinicalproblemsolving.com/wp-content/uploads/2021/04/RTP_TheConsultQuestion_Episode2_Aaron_SurveyIncluded.m4aThank you for your continued support and please give us feedback here!Dan, Doug, and Lindsey are joined by expert neurologist Dr. Aaron Berkowitz to help break down a consult question about back pain and double vision SchemaDownload CPSolvers App herePatreon websiteEpisode Quiz

Dive into the world of neurology as speakers tackle the stigma of 'neurophobia' and emphasize the importance of integrating clinical and basic sciences. They explore the complexities of right-sided hemiparesis and the vital role of patient history in diagnosis. The discussion unfurls around a 29-year-old patient, connecting diverse symptoms to intriguing neurological conditions. Gain insights into the significance of MRI interpretations, the unique anatomy of the cavernous sinus, and the challenges in managing ischemic strokes and meningitis. It's a thrilling journey through intricate medical concepts!

https://clinicalproblemsolving.com/wp-content/uploads/2021/04/April-16-VMR-RTP.m4aReza and Rabih work through a case of dyspnea and finger swelling, presented to them by Dr. Usha George.Download CPSolvers App herePatreon websiteSchema Episode QuizDr. Usha GeorgeDr. Usha George, MBBS (MAHE India), MSc (Respiratory Medicine) Imperial College University of London, FRCP London, is at present attached to Sunway Medical Centre, Malaysia. It is a 650 bedded private tertiary hospital, also involved in training medical students. I practice as a Respiratory and General Medicine Physician. My special interest is in clinical and diagnostic reasoning.

https://clinicalproblemsolving.com/wp-content/uploads/2021/04/RTP_WDX_VMREpisode_4.15.21_FINAL.mp3During this WDx VMR series episode, Kiara presents a case of chest pain to Priyanka, Ana Clara, Elena, and Anna. Download CPSolvers App herePatreon websiteSchema Episode QuizAna ClaraAna Clara Miranda is a 4th-year medical student from Brazil. She grew up in Belo Horizonte and moved to Rio de Janeiro in 2017 to attend medical school. Her medical interests are Pediatrics and Infectious Diseases. Today, she intends to go to the United States for an international clinical experience as a visiting student and, in 2023, apply for a Residency Program. Outside medical environment, she loves going to the beach with friends, enjoying nature and baking cakes.Elena VastiElena Vasti is a second year resident at Stanford in the department of Internal Medicine. She attended UC Davis to study Human Development and Exercise Biology and went on to UCLA Fielding School of Public Health to complete an MPH in Epidemiology and Community Health Sciences. She decided to switch careers to pursue clinical medicine and matriculated at UCSF School of Medicine in 2015. She enjoys running every day, analyzing movie trailers and both listening to and joining the CPSolvers any chance she gets! She plans to pursue a career in academic cardiology.

https://clinicalproblemsolving.com/wp-content/uploads/2021/04/RTP_4.08.21-HDx-SS-Emory_Final-1.mp3Raha and Shub join #PrezSharmin to tackle a clinical unknown presented by CarlosDownload CPSolvers App herePatreon websiteWant to test your learning? Take our Episode Quiz Dr. AgrawalShub Agrawal is a PGY-2 at Emory’s J. Willis Hurst Internal Medicine Residency. She grew up in Athens, GA and attended New York University for undergraduate degrees in neuroscience and anthropology. She attended the AU UGA Medical Partnership for medical school where she first became passionate about medical education. She is currently doing medical education research about how to best use podcasts in UME and GME curriculum. She hopes to spend her career teaching and designing curriculum in academic medicine. Outside of medicine, she enjoys spending time with her family, friends and imagining all the trips she will take once it is safe to travel again! Dr. SadjadiRaha Sadjadi is a PGY2 internal medicine resident at Emory University School of Medicine. She grew up in the San Francisco Bay Area and attended UC Berkeley for undergrad. After spending her whole life in the Bay Area, she moved to Atlanta to complete medical school at Emory University. At Emory she pursued her passion for caring for underserved populations while rotating at Grady Hospital and she found wonderful mentors invested in her growth as a physician and human.  For these very reasons, she remained at Emory to complete her internal medicine residency. She is interested in transplant hepatology and in reducing healthcare disparities. Dr. RubianoCarlos Rubiano is an Inpatient Medicine chief at UNC Hospitals where he also completed his internal medicine residency training. Prior to moving to North Carolina with his wife with whom he couples matched with, he completed his medical school training at Florida State University and undergraduate training in Biology at Florida Gulf Coast University. In medicine, he has a particular interest in medical education and hopes to be a clinician-educator as a soon-to-be hospitalist and one day as an ID clinician. Outside of medicine he loves playing pickleball and invites everyone to try this booming sport. 

https://clinicalproblemsolving.com/wp-content/uploads/2021/04/April-HDx_RTP.mp3Eamonn and Ashley join Jack in tackling a clinical unknown presented by TravisTake our episode quiz hereEamonn MaherEamonn hails from Charleston, West Virginia. He attended Marshall University for medical school and is currently in his final year of Dermatology residency at SLU. He will complete a Complex Medical Dermatology fellowship at NYU next year and hopes to practice with a focus on cutaneous lymphomas, connective tissue diseases, and immunobullous disorders. Outside of work he enjoys jiu jitsu, playing soccer, and spending quality time with his wife. Ashley BoerrigterAshley Boerrigter is a third-year OBGYN resident at St. Louis University, where she will be Administrative Chief Resident for the 2021-2022 academic year. She attended medical school at the University of Kentucky and her academic interests include medically complex pregnancies and curriculum development. Hobbies include tennis, sailing, and alternating between beach sunning and mountain skiing. 

Guests Michelle Morse and Paul Farmer join the podcast to discuss global health equity amidst the COVID-19 response. They explore topics such as the US-centric approach to COVID-19, lessons from Haiti, addressing social supports, the impact of identity on anti-racism movements, decolonizing global health, and finding joy and hope in global solidarity.

Dr. Usha George, a Respiratory and General Medicine Physician, presents a complex case involving fever, cough, shortness of breath, swelling of lower limbs, and excessive thirst. The speakers discuss the investigation and diagnosis of Cushing Syndrome, reflect on lessons learned from challenging clinical cases, and analyze a case of excessive thirst and edemas.

Neurology expert Aaron Berkowitz joins the Clinical Problem Solvers team to discuss a case of unilateral sensory changes in a 19-year-old male. They explore possible causes, including changes after tick bites and discuss the diagnostic process for sensory loss and weakness.