The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2020/08/post-aup-racism-police-violence-and-health.mp3We invite scholars and antiracism activists, Drs. Rhea Boyd and Rachel Hardeman, to discuss the meaning of structural racism, the health impacts of police violence, the “say her name” movement, and the ways we can ensure our country’s current antiracist movement grows beyond a moment.Learning ObjectivesAfter listening to this episode learners will be able to…Define structural racismUnderstand how police violence is a social determinant of healthExplore the relationship between policing and healthcareExplore and employ strategies to dismantle structural racism in clinical practice  CreditsWritten and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Utibe R. Essien, MD, MPH Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Michelle Ogunwole, MDShow notes: LaShyra NolenWritten & Produced By: Michelle Ogunwole, MD, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MS, and Utibe R. Essien, MD, MPHInfographic: Creative Edge DesignGuests: Rachel Hardeman PhD, MPH (@RRHDr) and Rhea Boyd MD, MPH (@RheaBoyd) Download Transcript Here CPS-Anti-Racism Show Notes Episode 1August 26, 2020By LaShyra Nolen Time Stamps 00:00 Music/intro 01:00 Our mission and vision01:50 Introduction to the Antiracism in Medicine team 02:55 Introduction of Dr. Boyd and Dr. Hardeman04:30 Defining structural racism 10:30 Dr. Boyd’s Lancet piece on the history of police violence12:00 Police violence, communities, and health outcomes15:00 Dr. Hardeman on police brutality and a public health agenda24:00 Understanding this moment (COVID-19 and George Floyd) 29:00 The #SayHerName campaign and police brutality’s effects on women 33:00 Emmett and Mamie Till 44:00 Policing in healthcare settings54:00 What can we start doing tomorrow? 56:00 Conclusion and outro  Episode Takeaways“First do no harm and while you’re doing no harm, learn as much as you can.” -Dr. Rhea Boyd. Practitioners who benefit from the racist power structures existent in America must examine the ways they benefit from or ignore racism in their workspaces and beyond. Then we must all commit to dismantling racism with tangible policy change.TraineesWe encourage trainees to reflect on the ways they have been socialized to learn and think about racism in our country. Trainees may use this foundation to question how this might impact their medical education and think about this educational legacy may be reformed through curricular and structural changes at their institutions. FacultyRegardless of specialty or field, it is important all educators and clinicians do the work of understanding how racism is pervasive within their respective areas of expertise. This starts with self-education and a commitment to speak up when blatant examples of racism come up in the work space and beyond. Pearls Defining Structural RacismStructural racism is a term that acknowledges that racism is perpetuated beyond individual interactions and interpersonal racism, but is present in the systems and policies that govern our everyday lives. These policies and decisions are often rooted in a historical legacy of white supremacy that have led to the systematic disadvantage of racial minorities in our society. Public health advocate, leader, and scholar, Dr. Camara Phyllis Jones, is credited for creating the framework many healthcare professionals and researchers use to think about systemic racism’s impacts on Black health. Her definition centers the idea that Black individuals did not inherit the diseases they disparately suffer from, but they inherited a disadvantaged system that creates the stark health disparities we see today. It is important to understand this unequal system negatively impacts everyone and every aspect of our society. Policing and health outcomes  Evidence has shown that excessive policing not only impacts the individual health of Black and brown people who’ve interacted with the police, but it also impacts the health of their communities at large. Heightened police presence in communities of color can be perceived as a threat by community members which can result in sustained increases in stress and cortisol levels. This pathologic process can lead to adverse health outcomes affecting the cardiovascular, neurological, and endocrine systems.Police brutality Police brutality should be thought of as the ways state-sanctioned violence leads to the physical, psychological, and emotional harm of its victims. It is important to understand that police brutality not only impacts individuals with direct relationships to those afflicted by this violence but also has widespread effects on the entire Black community. It impacts the health of our colleagues who constantly have to witness this injustice play on television, often without consequence. It also leads to decreased productivity in Black communities as they deal with the aftermath and ongoing challenges of police brutality. #SayHerName Campaign As we continue conversations around police brutality, antiracism, and health equity, we must remember to not exclude women, children, the LGBTQ community, and the disabled community, among other communities of intersecting marginalized identities who continue to be impacted by police brutality. Social media and public response to police brutality traditionally center cis-gendered men, but people like Breonna Taylor, Tony McDade, and Tamir Rice, along with so many others, need our voices too. Policing in Schools and Hospitals Health care systems must actively advocate and protect their patients and that means we have to also reevaluate the presence of police in our spaces. This includes thinking about our roles as mandated reporters and police presence in emergency departments. Police presence in medical spaces can add to Black patients’ feelings of not having a “safe space” and we must consider our roles in potentially perpetuating violence in this way. LinksReferences discussed throughout episode Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: An antidote to structural racism. Birth. 2020;47(1):3-7. doi:10.1111/birt.12462Boyd RW. Police violence and the built harm of structural racism. Lancet. 2018;392(10144):258-259. doi:10.1016/S0140-6736(18)31374-6Alang S, McAlpine D, McCreedy E, Hardeman R. Police Brutality and Black Health: Setting the Agenda for Public Health Scholars. Am J Public Health. 2017;107(5):662-665. doi:10.2105/AJPH.2017.303691Hardeman RR, Medina EM, Kozhimannil KB. Structural Racism and Supporting Black Lives – The Role of Health Professionals. N Engl J Med. 2016;375(22):2113-2115. doi:10.1056/NEJMp1609535Alyasah Ali Sewell, Justin M. Feldman, Rashawn Ray, Keon L. Gilbert, Kevin A. Jefferson & Hedwig Lee (2020) Illness spillovers of lethal police violence: the significance of gendered marginalization. Ethnic and Racial Studies. 2020. doiI: 10.1080/01419870.2020.1781913Britton BV, Nagarajan N, Zogg CK, et al. US Surgeons’ Perceptions of Racial/Ethnic Disparities in Health Care: A Cross-sectional Study. JAMA Surg. 2016;151(6):582–584. doi:10.1001/jamasurg.2015.4901Hardeman RR, Medina EM, Boyd RW. Stolen Breaths. N Engl J Med 2020; 383:197-199. doi: 10.1056/NEJMp2021072 Bor J, Venkataramani AS, Williams DR, Tsai AC, Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. Lancet. 2018. doi: 10.1016/S0140-6736(18)31130-9. Additional references and papers as mentioned in episode Link to the work of Dr. Rupa Marya as mentioned by Dr. Boyd: https://medium.com/@radiorupa/health-and-justice-the-path-of-liberation-through-medicine-86c4c1252fb9Link to African-American Policy Forum #SayHerName Campaign: https://aapf.org/sayhernameLink to latest work of Dr. Rachel Hardeman: Physician-patient racial concordance and disparities in birthing mortality for newborns. Brad N. Greenwood, Rachel R. Hardeman, Laura Huang, Aaron Sojourner. Proceedings of the National Academy of Sciences Aug 2020, 201913405; DOI: 10.1073/pnas.1913405117 Disclosures The hosts and guests report no relevant financial disclosures.Episode CitationBoyd R, Hardeman R, Ogunwole M, Fields N, Khazanachi R, Nolen L, Onuoha C, Paul D, Essien UR. “#120 Racism, Police Violence, and Health.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes/ August 26, 2020.

https://clinicalproblemsolving.com/wp-content/uploads/2020/08/HDx_SS_Baylor_FINAL.mp3Dr. Krishan Sharma presents a Human Dx case to Sharmin & Baylor residents – Drs. Iqbal and Rana.Download CPSolvers App hereTake our Episode Quiz here.Patreon websiteCyrus IqbalCyrus is a PGY-3 internal medicine resident at Baylor College of Medicine. He loves sports, hip-hop, exploring new restaurants and coffee shops, and writing. He’s an aspiring hematologist/oncologist with a passion for medical education.Ruchit RanaRuchit Rana is currently a third-year internal medicine resident at Baylor College of Medicine. Ruchit completed medical school at Baylor College of Medicine. He has a passion for practicing and improving medical education at all levels. In his free time, he enjoys cooking and baking dishes across all ethnicities and maintaining his multiple freshwater aquariums at home. He is a proud co-founder of the Schema Squad alongside his co-resident, Cyrus Iqbal.Krishan SharmaKrishan Sharma is currently an internal medicine resident at Massachusetts General Hospital. He earned his medical degree at Harvard Medical School, where he also pursued a Masters in Medical Sciences in medical education. His academic interests include cardiology, critical care, and clinical reasoning. His hobbies include basketball, drumming, and entering spice eating competitions.

https://clinicalproblemsolving.com/wp-content/uploads/2020/08/Wake-Forest-Human-Dx-FINAL__.m4aDr. Meredith Lash Dardia presents a Human Dx case to Arsalan & Wake Forest residents – Drs. Maus and Brooks.Download CPSolvers App herePatreon websiteHuman Dx CaseWant to test your learning?Take our Episode Quiz here.Dr. Meredith Lash DardiaDr. Meredith Lash-Dardia is an internist at Weill Cornell Medical Associates in NYC. She graduated with a BA from Rutgers University and an MD from Rutgers Medical School (formerly UMDNJ). She did her training at Mount Sinai in NYC. Her areas of interest include preventative wellness, medical student teaching, as well as quality and patient safety initiatives. In her spare time, she works on local political campaigns and is involved in grassroots activismDr. Taylor BrooksTaylor Brooks is in his third year of residency at Wake Forest School of Medicine’s Internal Medicine Residency (let’s go Deacs!). Originally from Ohio, Taylor spent his college years at The Ohio State University (let’s go Bucks!). He then completed medical school at the University of Cincinnati College of Medicine (let’s go Bearcats!). Aside from loving all of his alma maters equally, Taylor’s professional goals are to become a physician scientist, researching blood cancers and treating the patients who have them. He also hopes to one day teach the joys of academic hematology to internal medicine residents. In his free time, Taylor enjoys traveling the world with his amazing wife Cassandra, and throwing a ball around with his awesome Bernedoodle, WinstonDr. Sarah MausSarah Maus is currently a third year Internal Medicine resident at Wake Forest School of Medicine. She grew up in Springfield, IL before heading to Lexington, KY to complete undergraduate and medical school. She will be staying at Wake Forest next year as a Chief Resident, and hopes to pursue Hematology Oncology fellowship after her chief year. Outside of medicine, Sarah enjoys hiking in the mountains of North Carolina, playing tennis with friends, and spending quality time with family and her dog, Mila.

https://clinicalproblemsolving.com/wp-content/uploads/2020/08/SLS_Abdominal-Pain-and-Jaundice_Arsalan_FINAL.mp3The CPSolvers share a case of abdominal pain and jaundice – let’s practice those schemas together!Patreon websiteSchemas: abdominal pain, jaundiceThought Train: abdominal pain

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/RLR-15-Ascites-Patient-and-Tears-RR-.mp3Episode descriptionReza and Rabih tackle a case of Ascites.More about the RLR series here.Ascites SchemaEpisode SummaryAn elderly woman with a history of progressive weakness, falls, and recently diagnosed ascites presented with weight loss and functional decline. Her workup was notable for ascites with a low serum-ascites albumin gradient (SAAG), thrombocytosis, and imaging evidence of peritoneal enhancement with omental nodularity and multiple pancreatic lesions. Biopsies of the peritoneal nodules were initially unrevealing for infections or solid malignancies. Ultimately, further tissue examination revealed primary peritoneal mesothelioma. The patient was not started on treatment and passed away one month later.  Teaching Points The most common causes of low SAAG ascites include malignancy and infection. Malignancy can cause low SAAG ascites via peritoneal carcinomatosis (seen most commonly ovarian, bladder, or gastric cancer) as well as peritoneal mesothelioma. Tuberculosis is an important and difficult to diagnose infectious cause of low SAAG ascites. Ascitic fluid often reveals a lymphocytic predominance with elevated protein. Additionally, an elevated ascitic adenosine deaminase level (ADA) can suggest peritoneal tuberculosisAsbestos exposure can lead to an array of benign and malignant diseases. Manifestations within the pulmonary parenchyma include asbestosis (a form of diffuse pulmonary fibrosis resulting in interstitial lung disease) and lung cancer (both small cell and non-small cell lung cancers). Pleural complications of asbestos exposure can include pleural effusions, pleural plaques, and malignant mesothelioma. Rarely, asbestos-related complications can occur in extra-pulmonary sites and present as peritoneal mesothelioma, with diffuse peritoneal nodules and low-SAAG ascites. 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/VMR-100-7-25-20-10.25-AM-1-2.mp3Dr. Rezigh presents a clinical unknown on Virtual Morning Report to CPSolvers, Rabih and Reza.Download CPSolvers App herePatreon websiteSchemaWhiteboardEpisode Summary A 75-year-old-woman with multiple chronic medical problems presented with right arm pain, anorexia, and diffuse erythematous nodular plaques. Her work up was notable for an elevated serum lactate and S1Q3T3 pattern on ECG. Computed tomography of the chest, abdomen, and pelvis demonstrated a right pleural effusion as well as nodular soft tissue thickening surrounding the right atrium extending to the interatrial septum with local mass effect and narrowing of the superior vena cava. Biopsy of her rash revealed abnormal lymphoid proliferation. Further studies led to a diagnosis of diffuse large B-cell lymphoma (DLBCL) with prominent cutaneous manifestations.Teaching PointDiffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin’s lymphoma and can have a diverse range of manifestations. Most often, patients present with a rapidly enlarging mass and/or systemic “B-symptoms” (e.g., fever, night sweats, weight loss). Laboratory abnormalities classically include elevated lactate dehydrogenase levels, which occur in >50% of patients. In a minority of patients (about 40%), DLBCL presents in extramedullary and extranodal locations, including the soft tissues, lung, endocrine organs, and central nervous system. Diagnosis requires histologic examination and immunophenotyping (flow cytometry, immunohistochemical staining). 

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/WDx_Episode1_FINAL.mp3Episode DescriptionEmma, Lindsey and Sharmin tackle a case presented by Sarah.Want to learn more about Women in Diagnosis (WDx) series?Blog post– by Smitha

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/hdx-ss-clc-final.mp3Dr. Hastie presents a Human Dx case to Sharmin & Cleveland Clinic residents – Drs. Almaaitah and Montane.Download CPSolvers App herePatreon websiteSchema #1Human Dx CaseDr. Bryce MontaneBryce Montane is a Floridian born and raised! He went to University of South Florida as part of the 7-year medical program for undergraduate and medical school. He is now a PGY-3 Internal Medicine resident at the Cleveland Clinic. He is part of the inaugural Clinician Educator Track. He will be staying at the Cleveland Clinic next year as a Chief Resident and will then be pursuing a career in academic medicine.Dr. Saja AlmaaitahSaja Almaaitah was born and raised in Jordan and graduated from the University of Jordan school of medicine. She then moved to the United States and joined Cleveland clinic for her internal medicine residency. During which, she was part of the clinical research scholar track. She has recently graduated residency and joined the rheumatology department at Cleveland Clinic. She hopes to pursue a career in academic medicine and research. In her free time, she enjoys hiking, reading and cooking.Dr. Elizabeth HastieElizabeth (Lizzy) Hastie is currently a third year internal medicine resident at UCSD. She completed her undergraduate education at the University of Colorado Boulder, and she attended Emory University for medical school. Lizzy is a member of the Resident as Clinician Educator (RACE) track at UCSD and will be a Chief Medical Resident for the 2021-2022 academic year. She is interested in pursuing an infectious disease fellowship following her chief year.

https://clinicalproblemsolving.com/wp-content/uploads/2017/05/CPSolvers-Human-Dx-AD-Duke-FINAL-.m4aDr. Alexandra Rojek presents a Human Dx unknown to Arsalan and Duke residents – Drs. Stacy Bagrova & Micah Schub.Download CPSolvers App herePatreon websiteSchema #1Schema #2Human Dx CaseDr. Alexandra RojekAlexandra Rojek is currently an internal medicine resident at the University of Chicago, interested in pursuing hematology/oncology with an interest in translational research. She attended Harvard University for her undergraduate education in chemical and physical biology, and then medical school at UCSF. During medical school, she developed an interest in medical education, particularly in her research on implicit bias in medical student evaluations. She has always had an interest in diagnostic reasoning and loves being a contributing editor at the Human Dx Project, and is excited to work with CPSolvers on sharing this case!Dr. Micah SchubMicah Schub is a third year internal medicine resident at Duke. He grew up in Los Angeles, CA and got his undergraduate degree in (slapping the) Double bass performance at the Juilliard School and a masters at the Manhattan school of music. He returned to LA to play in Cirque du Soleil’s “Iris” for a couple years before making a sharp turn and attending University of Pittsburgh School of Medicine. He is interested in nephrology, clinical reasoning and medical education. Outside of work, you can find him playing sweet tunes with his residency Weezer cover band “Wheezer.”Dr. Stacy BagrovaStacy grew up in Donetsk, Ukraine and was lucky enough to move to the US just in time for college. She completed medical school at the University of Florida (Go Gators!).  Currently, she is trying to learn as much as possible and provide lots of (mostly unsolicited) teaching to junior learners as a third-year medicine resident at Duke University Medical Center. Her ideal career combines clinical rheumatology and medical education focused on diagnostic reasoning. In her free time, she loves to get lost in a good mystery novel, cook or bake while tuning in to one of her favorite podcasts, or go for a run, listening to a 70s-80s classic rock mix.

https://clinicalproblemsolving.com/wp-content/uploads/2020/07/RLR-10_Hypotension.mp3Episode descriptionReza and Rabih tackle a case of hypotension.More about the RLR series here.