The Clinical Problem Solvers

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The Spaced Learning Series discuss a fascinating new case of a patient found down. 

Featuring:
Anna Fretz
Priyanka Athavale
Kirtan Patolia

Schemas:
Hyperkalemia
Lactic Acidosis
Hypothermia
Hyperammonemia

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Débora and Noah bring back the Clinical Unknown Series!

To kick off the first episode, we host Alec and Austin, who discuss a case presented by Laure. Embark on this diagnostic journey with us! 

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In honor of Women’s History month in the United States, Sharmin, Kaylin, and Jane discuss the Matilda Effect, the current state of gender inequality, and reflect on some of the many incredible women scientists that came before us and helped pave the way for a better future.

For more on the topics discussed, check out:

Women Scientists Were Written Out of History. It’s Margaret Rossiter’s Lifelong Mission to Fix That What Rosalind Franklin truly contributed to the discovery of DNA’s structure Women are credited less in science than men The Diversity–Innovation Paradox in Science Her work paved the way for blockbuster obesity drugs. Now, she’s fighting for recognition Celebrating 10 women medical pioneers Curiosity by Dr Faith Fitzgerald  

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Episode description

Reza and Rabih discuss a case of a patient with whole body pain

 

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In this clinical reasoning Rafael Medina Subspecialty episode, Dr. Mark Heslin presents a case to Dr. Tony Breu of a man presenting with facial swelling. 

Session facilitator: Youssef Saklawi

The goal of this series is to expand access to subspecialty, primary care, and internal medicine-adjacent specialty education to learners around the world. If you would like to get involved as a case presenter or discussant (or nominate an attending/educator), fill out the form HERE.

Case Discussant: Anthony C. Breu, MD is the Director of Resident Education at the Veterans Affairs Boston Healthcare System and an Assistant Professor of Medicine at Harvard Medical School. He is also core faculty at the Center for Bioethics at Harvard Medical School. He completed his undergraduate degree in biomedical ethics at Brown University, where he also received his medical degree.

 

Case Presenter: Mark Heslin is a third-year internal medicine resident at the University of Pennsylvania. This summer, he will be starting his career as an academic hospitalist at Stanford. His clinical interests include medical education, clinical reasoning, diagnostic error, and the use of innovative technology to disseminate the teaching of clinical reasoning. 

 

 

To join us live and present a case, check out our virtual morning reports! 

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Sharmin, Jack, and Youssef discuss their approach to joint pain as they reason through a case presented by Maddy. 

Monoarticular Arthritis Framework

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Episode title: Episode 323: Neurology VMR – Visual hallucinations

Episode description: We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Valeria presents a case of visual hallucinations to Greg and Umbish.

Neurology DDx Schema

Valeria Roldan

@valeroldan23

Valeria Roldan was born and raised in Lima, Peru. She recently graduated medical school at Universidad Peruana Cayetano Heredia and is excited to pursue a career in Neurology. She is passionate about LGBTQ+ health, particularly advocating for trans rights, as well as medical education. She would describe herself as an optimist and outside of medicine you probably will find her running or talking about pop culture over a glass of wine

Gregory I. Atafo

Dr. Atafo is a general physician currently practicing in Accra, Ghana. He attended undergrad at the University of Benin, Nigeria where he received his degree as a Doctor of Optometry. He then attended the University of Ghana for his medical degree. He is currently applying for residency in the United States and has interests in Neuroscience, Internal Medicine and Global health.

In his free time, Greg loves to play soccer, volunteer at medical outreach programs and is passionate about sharing medical knowledge across borders.

Umbish Dino

@UmbishD

Umbish Dino, born in New York but raised in Pakistan, embodies a blend of cultures that enrich her perspective both personally and professionally. Having lived and worked in both the United States and Pakistan, she’s set to bring her diverse experiences back to the U.S. as she embarks on her journey into the 2024 internal medicine residency match. Outside the hospital, she is a devoted mom to her four-year-old son, Rayyan, and two cats, Drogo and Luna. She is a talented singer, and a culinary enthusiast who finds joy in cooking. Her passion for clinical reasoning has drawn her to the CP Solvers Academy, where she engages with complex medical cases, reflecting her commitment to excellence in patient care and her zeal for continuous learning.

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CPSolvers: Anti-Racism in Medicine Series

Episode 24 – Leveraging Narrative Medicine to Cultivate Antiracist Praxis

Show Notes by Sudarshan Krishnamurthy

February 13, 2024

Summary: This episode highlights the ways in which we might leverage stories, at the individual and structural levels, to reimagine medicine with a liberatory practice. During this episode, we hear from Zahra Khan, an educator and editor who has written extensively on abolition in medicine, and Dr. Sayantani DasGupta, a physician-educator, prolific children’s book author and faculty at the Center for the Study of Ethnicity and Race and the Institute for Comparative Literature and Society at Columbia University. Together, our guests offer context around how the medical and carceral systems are deeply intertwined and go hand-in-hand. Further, they expand on this to discuss how we might use stories in the form of visionary and speculative fiction to reimagine new landscapes of health care. This discussion is hosted by Sudarshan Krishnamurthy and Ashley Cooper. The show notes for this episode were written by Sudarshan Krishnamurthy.

Episode Learning Objectives

After listening to this episode, learners will be able to:

1. Illustrate the relationship between narrative medicine and healing relationships.
2. Explain the significance of abolition medicine, and the role of the medical system in upholding and perpetuating carceral logics.
3. Discuss how we might use narrative and stories to enact social change and reimagine medicine.

Credits

• Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, Team
• Hosts: Sudarshan Krishnamurthy and Ashley Cooper
• Infographic: Creative Edge Design
• Audio Edits: Ashley Cooper
• Show Notes: Sudarshan Krishnamurthy
• Guests: Dr. Sayantani DasGupta, Zahra Khan

Time Stamps

00:00 Opening

00:45 Introductions

01:03 Guest Introduction 1 – Zahra Khan

01:26 Guest Introduction 2 – Sayantani DasGupta

02:40 Background and Inspiration for Guests

13:45 Narrative Medicine in the Clinical Setting 

23:45 Role of Narrative in Abolition Medicine

37:10 How does storytelling impact your clinical work and vice-versa?

42:00 Abolitionist reimaginings of Health

55:05 Democratizing Narrative Medicine

1:03:05 Closing Remarks and Clinical Pearls

Speaker biographies (Abbreviated)

• Zahra Khan is an educator and editor whose work emerges at the intersection of narrative, healing and disability justice, and liberation pedagogy. Her research, writing, and community engagement focuses on shifting consciousness in medical education toward abolitionist possibilities. Zahra enjoys facilitating spaces that cultivate critical consciousness, earnest reflection, and collective care. Her work has appeared in publications such as the Lancet, Journal of Medical Ethics, and AMA Journal of Ethics. She currently works with Project NIA, a nonprofit dedicated to ending youth incarceration, and teaches in the graduate program in Narrative Medicine at Columbia University and at CUNY School of Medicine.
• Sayantani DasGupta is a faculty member in the Master’s Program in Narrative Medicine, the Center for the Study of Ethnicity and Race and the Institute for Comparative Literature and Society, all at Columbia University. Originally trained in pediatrics and public health, her work has appeared in journals including The Lancet, JAMA, Pediatrics, The Hastings Center Report, Literature and Medicine, Teaching and Learning in Medicine, and The Journal of Medical Humanities. She is an associate editor of the journal Literature and Medicine, and her current interests are in issues of narrative humility in medical education and practice, racial justice and health, diaspora studies, and science fiction/health futurities. She is also a New York Times bestselling children’s author. Learn more about her work at www.sayantanidasgupta.com.

Episode Takeaways

• Origin Stories – Zahra encountered abolition for the first time at the ‘Beyond the Bars’ Conference, where she encountered students and community members from all backgrounds who were dedicated to ending mass incarceration. Here, she encountered Angela Davis, where she was encouraged to reimagine and build frameworks that center justice and do not reproduce oppression. She started in the Narrative Medicine program at Columbia around Sayantani, and wanted to focus on incarceration as a healthcare issue, and has since engaged in work that attempts to decarcerate health care. Sayantani became a physician since she thought it was a concrete tool for social justice. She came from an activist family, with her mother being one of the first South Asian feminist activists in the country. She grew up among stories of activist struggle and decolonial movements, and discovered a lot around the frameworks in medicine as she navigated her medical education. She discovered narrative medicine, and to her, it was about finding and retelling individual and structural stories in antiracist ways. Now, she teaches undergraduates and graduate students at the intersections of stories, social justice, and health. Part of her journey has been imagining how abolition and medicine go together, thinking through the carceral logics that have built medicine, and reimagining a new form of medicine with a liberatory practice.
• Role of Narrative Medicine in the Clinical Setting – Narrative Medicine is often called different things in different places; it is called health humanities in some places, to decenter the physician in the health care team, and Sayantani is a fan of this terminology. What the term gestures towards is the centering of the ‘story’ in healing relationships. However, it is important to think about individual stories within the broader historical and sociocultural context; for instance, you cannot highlight stories in individual physician-patient dyads, without discussing mechanisms of racialized, historical, or sociocultural power and other larger structural forces. Listening to individual stories within the context of their structural stories is important. Stories are not inherently just. It is important to be critical of stories, and we must train individuals to recognize stories that dehumanize groups of people and transform them into more just stories that humanize everyone.
• For instance, Toni Morrison’s “Home” depicts scenes of a community of Black women nursing a woman who has been the victim of medical racism and violence. It helps us understand Morrison’s critiques of anti-Black racism in medicine, and better understand care, restoration, and safety too. This helps people think about how people tend to each others’ well-being in their communities as well. It also helps illustrate the power of witnessing and mutual recognition, where there is a narrative exchange between patient and provider, with a validation of patients’ suffering. Apart from this, this also helps practitioners in improving their capacity to develop empathy for their patients, to be more curious about, and appreciate the complex context of those they care for.
• Narrative in Abolition Medicine: Zahra explains that structural competency is a framework that Jonathan Metzl and Helena Hansen offer to understand structural factors and barriers to care that perpetuate worse health outcomes like housing, food, and water as upstream factors that lead to worse health. Sayantani and Zahra (along with Yoshiko Iwai) have written about policing to be another one of these upstream factors that affect health, and offer ‘abolition medicine’ as a framework. Medicine often has a role in caring for those impacted by police brutality, and it should also have a role in creating new visions for violence prevention and reenvisioning healthcare without relying on carceral logics. It involves understanding stories and their relationships to power and structural oppression. Narrative medicine can offer us an imaginative space to create change. “Practicing New Worlds”, a book by Andrea Ritchie, talks about visionary fiction to help us look towards abolitionist futures, and can even help us reimagine new possibilities for health care. Sayantani expands on this to discuss the class she teaches on the relevance of visionary medicine, speculative fiction, and imagining an antiracist health system. Abolition Medicine itself involves recognizing and dismantling the carceral logics baked into medicine, and looking outside of medicine to see how we might reimagine these structures to improve health.
• How does storytelling impact your clinical work, and how does clinical work impact storytelling? – As a pediatrician, Sayantani shares that physical health, corporeal health, intellectual health, and imaginative health can be thought of as a part of the same praxis. Childrens’ fiction has always been about imagination, and it creates paths forward and gives young people the ability to imagine acts of justice within the storyteller’s own stories. 
• Abolitionist reimaginings of health – Zahra talks about the piece she wrote with Yoshiko and Sayantani, and talks about how they wrote this piece in the backdrop of the American Medical Association recognizing systemic racism as a public health crisis, and acknowledging that police violence has severe health consequences. They realized that if policing and prisons are systems that require abolitionist reimaginings, health care does too. Ruth Wilson Gilmore, an abolitionist scholar and geographer, uses the term ‘organized abandonment’ to describe what happens when communities lose protections from the state through systems and structures that are involved in disinvestment from communities, leading to these communities being more vulnerable to increased criminalization and police presence, and resulting in these communities lacking safe and just infrastructure in the form of housing options, lack of access to clean and safe water, transportation, etc. For instance, the presence of police and ICE officials in health care settings, along with the use of restraints, are examples of the ways policing has permeated medicine as well. And we have examples of mutual aid networks and organizations that worked to improve care in the setting of organized abandonment; some of these include the Black Panther Party providing free healthcare in communities, and the Puerto Rican activist organization ‘The Young Lords’ ensuring their community receives tuberculosis screenings. There are also more contemporary organizations doing this work; Zahra works with Mental Health First, organized by the Anti Police-Terror Project, a multiracial, intergenerational, mobile, crisis-intervention team led by mental health officials to provide life-affirming treatment and deescalation assistance, without having to rely on law enforcement. This offers a framework for abolitionist and non-carceral solutions that can be implemented around the world.
• Sayantani shares that the medical system and carceral system work hand-in-hand and it is not possible to decarcerate medicine or practice antiracism in medicine without acknowledging the carceral logics that permeate medicine and that the medical industrial complex is a part of the carceral system. This is a prerequisite to dismantling oppressive systems within medicine.
• Democratizing Narrative Medicine – Zahra says that one of the loudest aspects of narrative medicine that is most powerful is using ‘story’, staying with narratives, and close reading and listening of story. Democratizing narrative medicine is also a matter of breaking open institutions to make knowledge and information more accessible to the public. Zahra also expresses hope around the spread of narrative medicine to the mainstream, and thinks that it might help more people organize around the story. However, institutions are only one place where actions happen, and actions within the institution often remain within the institution. So, it is important to consider how we might use narrative to advance social justice outside of institutions and in the world. Sayantani adds that there is a reason that certain voices are kept away from the fore, and that there are structural forces that are doing so intentionally. For instance, book bans around the country exist because states recognize the radical power of ‘story’  and it is the reason that they attempt to suppress the spread of these stories. Stories are imaginative playgrounds for social change. She even adds that she prescribes reading in a clinical setting, both for the parent to the child and by the child themselves. It is also important to recognize that teachers and librarians that attempt to get banned stories in the hands of their students are also engaged in this work of democratizing narrative medicine. 

Pearls

• Zahra says that there are so many resources that help us practice and imagine new futures now, and shares with listeners these resources. One of these include Interrupting Criminalization – Beyond Do No Harm is one network of U.S. based health practitioners, advocates, nurses, community members, educators, social workers, and others who are working across racial, gender, reproductive, migrant and disability justice, drug policy, sex worker, and anti-HIV criminalization movements. Another is an Interrupting Criminalization podcast called One Million Experiments, that shares projects that are happening all over the country that build transformative solutions to safety without relying on police and prisons. Another thing Zahra mentions is that we must all be cartographers in mapping out new possibilities of an antiracist health care that satisfies all of us. As Mariame Kaba says, this is an opportunity to shrink the space between our values and our actions, and this is a collaborative and collective project where she invites everyone to think about their role in advancing health and justice.
• Sayantani encourages listeners of this podcast not to feel overwhelmed. So many times, we take care of others’ needs better than our own, and there is a sense of exhaustion, frustration, and anger that many face from medical training. We must strive to change the violent carceral logics that medical training and education inculcates, and also remember that we do not have to do everything alone and that we are not alone in this work. Rather than viewing it as one more thing to do, it is easier to become learners again, where we view antiracism as a new philosophy of living, learning, and working, and just taking it one step at a time. 

References

Dasgupta, S. (n.d.). GU4340: Visionary Medicine: Racial Justice, Health and Speculative Fictions. Science and Society – Columbia University. https://scienceandsociety.columbia.edu/content/gu4340-visionary-medicine-racial-justice-health-and-speculative-fictions-s-dasgupta 

Iwai Y, Khan ZH, DasGupta S. Abolition medicine. Lancet. 2020 Jul 18;396(10245):158-159. doi: 10.1016/S0140-6736(20)31566-X. PMID: 32682471; PMCID: PMC7365639.

Narvaez, A. (1970, June 18). THE young lords seize x‐ray unit. The New York Times. https://www.nytimes.com/1970/06/18/archives/the-young-lords-seize-xray-unit-take-it-to-area-where-they-say-it.html 

Interrupting criminalization: Research in action. Interrupting Criminalization | Research In Action. (n.d.). https://www.interruptingcriminalization.com/  

Beyond the Bars Conference 2023: Seeding Justice. (n.d.). New York City. https://centerforjustice.columbia.edu/events/beyond-bars-conference-2023-seeding-justice 

Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014 Feb;103:126-133. doi: 10.1016/j.socscimed.2013.06.032. PMID: 24507917; PMCID: PMC4269606.

Khan Z, Iwai Y, DasGupta S. Military metaphors and pandemic propaganda: unmasking the betrayal of ‘Healthcare Heroes’. Journal of Medical Ethics. 2021;47:643-644.

Khan ZH, Iwai Y, DasGupta S. Abolitionist Reimaginings of Health. AMA J Ethics. 2022 Mar 1;24(3):E239-246. doi: 10.1001/amajethics.2022.239. PMID: 35325526.

Ritchie, Andrea J. Gumbs, Alexis Pauline. Brown, Adrienne Maree. (2023). Practicing new worlds: Abolition and emergent strategies. Consortium Book Sales & Dist.

DuBois, W. E. B. (1920). The Comet. http://zacharyrawe.com/sem_6_the_comet_dubois.pdf 

Nelson, A. (2013). Body and soul: The black panther party and the fight against medical discrimination. University of Minnesota Press.

Beyond do no harm – interrupting criminalization: Research in action. Interrupting Criminalization | Research In Action. (n.d.-a). https://www.interruptingcriminalization.com/beyond-do-no-harm 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Khan Z, DasGupta S, Krishnamurthy S, Cooper A, Siddiqui H, Calac A, Pitre A, Pierce G, Essien UR, Fields NF, Lopez-Carmen V, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Leveraging Narrative Medicine to Cultivate Antiracist Praxis.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. February 13, 2024.

Show Transcript

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https://clinicalproblemsolving.com/wp-content/uploads/2024/02/SLS-2_29_24-RTP_2.mp3 Episode description: SLS team members Priyanka, Kirtan and Anna discuss a case of progressive renal dysfunction in a patient with recent weight loss, peripheral eosinophilia and organomegaly Featuring: Anna FretzKirtan PatoliaPriyanka Athavale Schemas
AKI
Eosinophilia 

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Sharmin and Kaylin sit down with Dr. Denise Davis to discuss communication as a procedure, continuous and incremental improvement, and the interrelationship between social and health justice

 

Denise L. Davis is a general internist and Clinical Professor of Medicine at University of California San Francisco. She serves as Associate Director for Faculty Development for the SanFrancisco VA Center of Excellence in Primary Care Education. Dr.Davis teaches locally and nationally on a range of topics, including teaching and coaching students, trainees and physicians in communication skills that increase quality, safety and improve patient experience. She is on the Executive Committee of the Academy on Communication in Healthcare and serves as VP of Diversity, Equity and Inclusion. She is also a specialist for minority medical students at UCSF School of Medicine. Dr. Denise Davis is a recipient of many awards, includingthe prestigious Kaiser Foundation Award for Excellence in Teaching and she was elected to the UCSF Academy of Medical Educators in 2015.

 

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