The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2021/01/RTP_HDx_Sharmin_1.26.21_FINAL.mp3Dr. Sabal presents a case of bilateral wrist pain to Sharmin, Dr. Davey, and Dr. Singh. Download CPSolvers App herePatreon websiteWant to test your learning? Take our episode quiz hereDr. Sonya DaveySonya Davey attended medical school at the Perelman School of Medicine at the University of Pennsylvania and is currently an Internal Medicine PGY-1 at Brigham & Women’s Hospital. She loves to travel, read, and enjoy meals with family and friends.Dr. Nicky SinghNicky Singh attended medical school at the Perelman School of Medicine at the University of Pennsylvania and is a current PGY-3 resident at Massachusetts General Hospital. As a resident, he has been involved with several educational initiatives, including co-leading the Residents in Medical Education interest group and the Point of Care Ultrasound group and serving as an Education Council representative and Simulation Program Chief. He is interested in cardiology and medical education. Outside of medicine, he enjoys hiking, South Asian dance, exploring new recipes with his Instant Pot, and trying to up his Peloton numbers.Dr. Aaron SabalAaron 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.

https://clinicalproblemsolving.com/wp-content/uploads/2021/01/ARM-EP-5-Racism-Power-and-Policy.mp3In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we are joined by Aletha Maybank MD, MPH, the American Medical Association’s (AMA) inaugural Chief Health Equity Officer and director of the AMA’s Center for Health Equity, and Camara Jones MD, PhD, MPH, thought leader in the fields of health equity and public health and former president of the American Public Health Association (APHA). We discuss policy, professional organizations, and history as they relate to advancing health equity, and imagine what the anti-racist health system of the future looks like. Learning ObjectivesAfter listening to this episode listeners will be able to…Recognize that racism is both structural and interpersonal, and that both aspects must be addressed simultaneously.Appreciate the importance of acknowledging history and sustaining institutional memory in advancing anti-racism efforts and achieving structural change.Understand that collective action and a focus on community, rather than individualism, are most effective in combating racism and achieving health equity.CreditsWritten and produced by: Rohan Khazanchi, LaShyra Nolen, Naomi Fields, Dereck Paul, MS,  Utibe R. Essien, MD, MPH, Michelle Ogunwole, MD, Chioma Onuoha, Jazzmin Williams, and Jennifer Tsai MD, M.EdHosts: Rohan Khazanchi, LaShyra Nolen, Naomi FieldsInfographic: Creative Edge DesignShow Notes: Chioma Onuoha Guests: Aletha Maybank MD, MPH, (@DrAlethaMaybank) and Camara Jones MD, PhD, MPH (@camarajones)Download Transcript HereEpisode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the FutureShow NotesChioma OnuohaTimestamps00:00 Music/Intro01:14 Guest Introductions03:09 Framing Racism 05:15 Allegory: Cement Dust in Our Lungs 07:00 The AMA’s Declaration on Racism as a Public Health Threat 13:28 History and the AMA and APHA Movements 15:20 Barriers to Achieving Health Equity in Medicine 20:55 Documenting, Centering, and Institutionalizing “The Work” 23:30 The AMA’s Racist Past 31:00 How Do We Create Sustainable Work? 35:25 Creating and Maintaining Urgency 39:00 Racism Saps the Strength of the Whole Society 43:43 Building an Anti-Racism Health Care System from A Grassroots Level52:15 Building an Anti-Racism Health Care System from A Governmental Level 53:45 Health is Not Created with the Health Sector 56:53 Why Must All Health Workers Practice Anti-racism? 1:05:57 Outtakes TakeawaysName Racism for What It IsIf we don’t explicitly say the word racism, and identify its historical context,  then we are complicit in its denial.  Racism denial is deeply ingrained in our society and it needs to be called out and recognized as a system in order to be addressed. Though the field of medicine often fails to think systematically, it is imperative that all healthcare workers learn to recognize racism, actively practice anti-racism, and acknowledge the many systems that impact people and community’s health.Four Key Messages for Naming Racism: Racism ExistsRacism is a SystemRacism Saps the Strength of the Whole SocietyWe can Act to Dismantle RacismHistory and Documentation are Key Our country habitually denials racism by working to make its impacts invisible. Remembering history and collecting institutional memory avoids the danger of repeating work, wasting labor, and makes clear racism’s long standing effects. Part of this effort also includes learning the history of the organizations and institutions we are a part of. Focus on the Community While the health sector is where illness and ailments are often treated, a person’s health largely manifests outside of the health sector and is impacted by their community and environment. One of the biggest barriers to health equity is the narrow focus on the individual and a failure to see health as a widespread community issue. We must recognize that all policy is health policy and that which affects someone outside of the health sector may also affect their health. Our future should be grounded in our communities; our solutions cannot solely be declarative or institution-driven.Pearls Barriers to Achieving Health Equity Narrow focus on the individual – makes systems and structures invisible or irrelevantWe as a nation are ahistorical – we need to bring history into the fold Our endorsement of the myth of meritocracy – the uneven playing field White supremacist ideology To learn more, read about  Dr. Jones’ Seven Values Targets for Anti-Racism ActionInstitutionalizing Anti-Racism A movement can disappear as quickly as it arose if it is not institutionally ingrained. This means that anti-racism must be embedded into practice, performance standards and institutional culture. All policies, decisions, and behaviors should occur through the lens of anti-racism in order for its impact to be longstanding and effective. The Power of Collective Action “When we acknowledge each other’s work we acknowledge the power of collective action” – Dr. Camara Jones Addressing structural racism is a collective effort and is more effective when we shift from “what can I do” to “what can we do”. When we lift up our peers and validate/center the work of people on the margins, we recognize the power of collective action and ensure that efforts are not erased or lost. This includes recognizing the experts that have come before us and reaching out to younger generations.Addressing Structures and Values Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks. In order to address racism, we must address both the structures and the values. Structures include the ways that racism is institutionalized and systematically reinforced, and values include the way that racism manifests in our shared consciousness. Addressing values will require us to make clear that “racism saps the strength of the whole society” and to highlight the urgency of anti-racism efforts. Additionally, we should equip educators, parents, and those who will guide the next generations with the tools to operate within the framework of anti-racism. Because structural racism often operates through inaction and complacency, the work to combat it must be persistent and collective. Racism hurts all people and achieving anti-racism will require active “fellows in the struggle” not just feeling allies. References Mentioned01:55Jones, C. Camara Jones, Allegories on race and racism | Camara Jones | TEDxEmory. [Video]. YouTube. https://www.youtube.com/watch?v=GNhcY6fTyBM&ab_channel=TEDxTalks. Published June 10, 2014. Accessed January 11, 2021.03:55Jones, C. Camara Jones, APHA executive director citation award acceptance speech. [Video]. YouTube. https://youtu.be/BGmIXV859YQ. Published December 2, 2020. Accessed December 9, 2020.16:20Jones, CP. (2020). Seeing the Water: Seven Values Targets for Anti-Racism Action. Harvard Medical School Primary Care Blog. Retrieved from http://info.primarycare.hms.harvard.edu/blog/seven-values-targets-anti-racism-action 27:17Berney, B., & Friedman, R. (Producers), & Burnett, C., Loewenthal, D. (Directors). (2018). Power to Heal: Medicare and the Civil Rights Revolution. Retrieved from https://www.blbfilmproductions.com/ 28:55Baker, RB., et al. Creating a segregated medical profession: African American physicians and organized medicine, 1846-1910. J Natl Med Assoc. 2009 Jun;101(6):501-12. doi: 10.1016/s0027-9684(15)30935-4. PMID: 19585918.Washington, HA., et al. Segregation, civil rights, and health disparities: the legacy of African American physicians and organized medicine, 1910-1968. J Natl Med Assoc. 2009 Jun;101(6):513-27. doi: 10.1016/s0027-9684(15)30936-6. PMID: 19585919.Additional References Boyd RW, Krieger N, Jones CP. In the 2020 US election, we can choose a just future. Lancet. 2020;396(10260):1377-1380. doi:10.1016/S0140-6736(20)32140-1Crear-Perry J, Maybank A, Keeys M, Mitchell N, Godbolt D. Moving towards anti-racist praxis in medicine. Lancet. 2020;396(10249):451-453. doi:10.1016/S0140-6736(20)31543-9Ford CL, Airhihenbuwa CO. The public health critical race methodology: praxis for antiracism research. Soc Sci Med. 2010 Oct;71(8):1390-8. doi: 10.1016/j.socscimed.2010.07.030. Epub 2010 Aug 11. PMID: 20822840.Jaffe S. Aletha Maybank: AMA’s Chief Health Equity Officer. The Lancet. 2020;395(10242):1963. doi:10.1016/S0140-6736(20)31408-2Jones CP, Holden KB, Belton A. Strategies for Achieving Health Equity: Concern about the Whole Plus Concern about the Hole. Ethn Dis. 2019;29(Suppl 2):345-348. doi:10.18865/ed.29.S2.345Jones CP, Jones CY, Perry GS, Barclay G, Jones CA. Addressing the social determinants of children’s health: a cliff analogy. J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi:10.1353/hpu.0.0228Jones CP. Allegories on “Race,” Racism, and Antiracism. 2019. Accessed December 7, 2020. https://www.radcliffe.harvard.edu/video/allegories-race-racism-and-antiracism-camara-phyllis-jonesJones CP. Confronting Institutionalized Racism. Phylon 2003;50(1-2):7-22. Jones CP. Overcoming Helplessness, Overcoming Fear, Overcoming Inaction in the Face of Need. Am J Public Health. 2016;106(10):1717. doi:10.2105/AJPH.2016.303406Jones CP. Systems of Power, Axes of Inequity: Parallels, Intersections, Braiding the Strands. Medical Care. 2014;52:S71. doi:10.1097/MLR.0000000000000216Jones CP. Toward the Science and Practice of Anti-Racism: Launching a National Campaign Against Racism. Ethn Dis. 2018;28(Suppl 1):231-234. doi:10.18865/ed.28.S1.231Jones, C. Camara Jones, APHA executive director citation award acceptance speech. [Video]. YouTube. https://youtu.be/BGmIXV859YQ. Published December 2, 2020. Accessed December 9, 2020.Jones, CP [@CamaraJones]. (2020, Nov 28). My map with the 28 states (in red) with at least one city/county/state-level body declaring “Racism is a public health crisis.” Each state name is followed by the number of jurisdictions making these declarations. State name is in CAPS if there is a state-level declaration. [Tweet]. Twitter. https://twitter.com/CamaraJones/status/1332729107952627712?s=20Maybank A. A Historic Day For Black Women, A Historic Day For The American Medical Association. Essence. Published November 18, 2020. Accessed December 7, 2020. https://www.essence.com/lifestyle/health-wellness/black-women-american-medical-association-racism/Maybank A. The Pandemic’s Missing Data. The New York Times. https://www.nytimes.com/2020/04/07/opinion/coronavirus-blacks.html. Published April 7, 2020. Accessed December 7, 2020.Metzl 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.2020.9289O’Reilly KB. AMA: Racism is a threat to public health. American Medical Association. Published November 16, 2020. Accessed December 7, 2020. https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-healthPrioritizing Equity video series. American Medical Association. Accessed December 7, 2020. https://www.ama-assn.org/delivering-care/health-equity/prioritizing-equity-video-seriesDisclosuresDr. Maybank is the AMA’s Chief Health Equity Officer and director of the Center for Health Equity. Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education. The views presented herein represent their own and not necessarily those of the AMA. The hosts and guests report no other relevant financial disclosures.CitationJones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D,  Essien UR, Khazanchi, R. “Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. January 19, 2021.  

https://clinicalproblemsolving.com/wp-content/uploads/2021/01/Clinical-Unknown-Armitage_RTP.mp3Dr. Dayyan Adoor and Dr. Keith Albrektson present a clinical unknown case to Dr. ArmitageDownload CPSolvers App herePatreon websiteWant to test your learning? Take our episode quiz hereDr. Dayyan AdoorDayyan Adoor is a 2nd year internal medicine resident at Case Western Reserve/University Hospitals. Following residency, he hopes to pursue a fellowship in Gastroenterology! In his free time, he likes to spend his time outdoors, often exploring the beautiful parks in Cleveland, and lately, learning how to ski!  Dr. Keith ArmitageDr. Keith Armitage is a professor of medicine in the division of infectious diseases at the Case Western Reserve University School of medicine. He is also the program director for the internal medicine residency at the Case Western Reserve/University hospitals internal medicine residency program where he is currently serving his 29th year as program director. In his free time Dr Armitage enjoys cheering on his beloved Arsenal Football Club and spending time with his wife and three daughters.  Dr. Keith Albrektson Keith Albrektson is a current chief resident at the Case Western Reserve/University hospitals internal medicine residency where he completed his internship and residency in internal medicine. Following his chief year he will be continuing his training in pulmonary and critical care at the University of New Mexico Medical Center.  

https://clinicalproblemsolving.com/wp-content/uploads/2021/01/RTP_JanNeuroVMR.mp3Our campaign to #EndNeurophobia continues with a neuro VMR featuring one of our favorite chief complaints, AMS!Download CPSolvers App herePatreon websiteSchemaWant to test your learning? Take our Episode QuizKaitlyn ThomasKaitlyn Thomas is a 3rd year medical student at Lake Erie College of Osteopathic Medicine at their Seton Hill campus in Greensburg, Pennsylvania. She is interested in medical education, advocacy and assisting underserved populations. She has contributed to the CPSolvers on Virtual Morning Report on several occasions and produced a few videos for their illness scripts. In her free time, she enjoys hiking, spending time with family, and finding new recipes to cook.Ninad BhatNinad Bhat is a third-year medical student at UCSF. He has always been fascinated by communication and the brain, seeking to combine his interests by becoming a neurologist involved in medical education. In his free time, he writes poetry and works to keep his obligatory medical student plants alive. Andrew LevyAndrew Levy is a 4th-year medical student at the University of Colorado SOM applying to Family Medicine with interests in Primary Care, Global Health, and Population Health. After taking a year off to help implement a WHO educational community-based first aid response program, he is now pursuing further public health training through UCSF in Implementation Sciences. He has been a fan of CPSolvers since being turned onto it, as well as the general topic of diagnostic reasoning, through Juan Lessing, an IM attending at the University of Colorado Hospital. In his free time, he enjoys exploring the great outdoors with his wife, Emily a fourth-year medical student at RVU in Colorado, and their three dogs Layla, Jade, and Avalanche.

https://clinicalproblemsolving.com/wp-content/uploads/2021/01/RTP_-Glomerulonephritis-Schema-Epidose-online-audio-converter.com_.mp3Sharmin, Rabih, Reza, and Arsalan tackle a schema for glomerulonephritis Patreon websiteDownload CPSolvers App hereSchemaWant to test your learning? Take our Episode Quiz

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/RTP_WDx-6_VMR_FINAL.mp3Dr. Amara Finch presents a case of abdominal pain at VMR to Maani, Maria, Anna and Smitha.Want to learn more about Women in Diagnosis (WDx) series?Blog post– by SmithaDownload CPSolvers App here Patreon websiteSchemaWant to test your learning? Take our Episode QuizDr. Amara FinchOriginally from Atlanta, Georgia, Amara spent time in Massachusetts, Vermont, British Columbia, Connecticut and Colorado before returning to the vibrant ATL for medical school. She is now an intern in the Med-Peds program at the University of Arizona in Phoenix. She is passionate about better understanding the relationship between early life exposures and lifelong health as a means to improve preventive medicine for kiddos, re-imagine our approach to adult disease, and disrupt intergenerational cycles of health inequity. Outside of the hospital you can find her hiking, biking, writing, and working on her collection of fermented foods including kimchi and hot sauce.

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/SLS_Dec_Final.mp3Steph presents a case of pleuritic chest pain to Dan and JackDownload CPSolvers App herePatreon websiteSchemaWant to test your learning?Take our Episode Quiz here

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/DECHDXLSFINAL.mp3Malika presents a Human Dx case of pleuritic chest pain to Lindsey, Aaron, and KellyDownload CPSolvers App herePatreon websiteSchemaWant to test your learning?Take our Episode Quiz hereDr. Kelly UelmenKelly 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 SabalAaron 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 GillMalika 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. 

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/ARM-EP4-Dismantling-Race-Based-Medicine-Part-2-Clinical-Perspectives.mp3This 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 ObjectivesAfter listening to this episode learners will be able to…Explain how race-based medicine harms our ability to provide equitable care for allUnderstand the role of race in eGFR and other clinical calculators and the challenges of teasing out its roleDescribe what clinicians can do to identify race-based medicine and how they can adapt their practices to mitigate the potential harms of race-based medicineExplain the roles of medical education and biomedical/epidemiological research in accurately describing and justly addressing differences in clinical outcomes that stem from racial inequalityUnderstand why race-conscious medicine–not colorblindness–is how we should move forward and beyond race-based medicine CreditsWritten and produced by: Utibe R. Essien, MD, MPH, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Jazzmin WilliamsHosts: Utibe R. Essien, MD, MPH, Rohan Khazanchi, and Jazzmin WilliamsShow Notes: Naomi FieldsInfographic: Creative Edge DesignGuests: 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 HereEpisode 4 – Race-Based Medicine, Part 2: Clinical Perspectives  Show Notes Naomi F. FieldsTime Stamps00:00    Mission, vision, and introductions of hosts01:30    Background on three-episode series02:26    Introductions of guests04:16    How Dr. Eneanya has seen race-based medicine play out in clinical practice07:19    How Dr. Tsai has seen race-based medicine play out in clinical practice10:45    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 techniques22:00    Resurgence of race-based speculation in COVID-19-related research25:57    Implantation of ideas about innate racial inferiority within medicine28:32    Will removal of race from algorithms potentially harm our patients?33:19    Danger of normalizing immutable, innate racial difference within clinical algorithms38:10    What role should race hold as we move toward health equity?45:50    Key takeaways for trainees47:45    Key takeaways for faculty49:17    Pointers to those interested in health equity research50:17    One thing you can employ in your practice today54:14    Bloopers!Episode Takeaways:TraineesAsking 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.FacultyIf 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. AllIf 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 ReasoningHarnessing 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 CalculatorsSome 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.LinksReferences discussed throughout episode 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/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/ 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.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/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.13153Eneanya 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.2019.5774Ahmed 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.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.00690120Powe NR. Black Kidney Function Matters: Use or Misuse of Race? JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.13378National Kidney Foundation, American Society of Nephrology. Establishing a Task Force to Reassess the Inclusion of Race in Diagnosing Kidney Diseases. Published July 2, 2020.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/NEJMms2004740Braun 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:10.1183/09031936.00091612Chadha 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 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-yKrieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59(5):350-355. doi:10.1136/jech.2004.024562Gravlee 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.Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI):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:10.7326/0003-4819-150-9-200905050-00006African American Study of Kidney Disease and Hypertension (AASK):AASK Clinical Trial in the NIDDK Repository: https://repository.niddk.nih.gov/studies/aask-trial/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.2001.27691Cooper 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/NEJMoa1000552Lloyd-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.2018.11.005Hoffman 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 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.2020.06.012Krieger 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.93.2.194Piercy 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. CitationEneanya 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.

 https://clinicalproblemsolving.com/wp-content/uploads/2020/12/Meningoencephalitis-Schema-BeaST-Mode-Edition_FINAL-online-audio-converter.com_.mp3Reza, Rabih, Sharmin, and Arsalan break down meningoencephalitis in this bite sized schema episode, inspired by Dr. Kimberly Manning.Want to test your learning?Take our Episode Quiz herePatreon websiteDownload CPSolvers App here