The Clinical Problem Solvers

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Episode 299: Neurology VMR – Clumsiness

Episode description: We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, María presents a case of clumsiness to Andrea and Sridhara.

Neurology DDx Schema

Andrea Mendez Colmenares

@andreamendez92

Andrea is a Venezuelan medical doctor and cognitive neuroscientist specializing in advanced white matter imaging. She recently completed a Ph.D. in Cognitive Neuroscience from Colorado State University, USA, and is currently a postdoctoral researcher at the BRAiN Lab in Colorado. Andrea is also actively involved in initiatives supporting neurology applicants (e.g., @NMatch2024) and research career development for international medical graduates. In her free time, she is usually playing guitar or climbing a mountain!

Sridhara Yaddanapudi

@syaddana_neuro

Sridhara is a board-certified internist, neurologist, vascular neurologist, and hypertension specialist. Currently, he holds the position of Clinical Assistant Professor at Thomas Jefferson University Hospital and serves as the Director of Neurology for Jefferson New Jersey.As a medical professional, he is passionate about case-based learning, clinical reasoning, and teaching decision-making while avoiding the pitfalls of heuristics. His goal is to bridge the ever-growing gap between neurology and internal medicine, an area in which he has a keen interest.

  Maria Jimena Aleman

@MariaMjaleman

María Jimena Alemán was born and raised in Guatemala where she currently works in community and rural health care. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Her life probably has a soundtrack of a mix between Shakira and Ella Fitzgerald. Outside of medicine, she enjoys modern art, 21st century literature, and having hour-long conversations over a nice hot cup of coffee or tequila.

 

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https://clinicalproblemsolving.com/wp-content/uploads/2023/08/8.10.23-SLS-RTP.mp3Episode description: The spaced learning series team discusses a case of nausea, vomiting and right upper quadrant pain in a pregnant patient. Featuring: Simone Vais
Moses Murdock
Valeria Roldan Schemas
Nausea & VomitingAbdominal Pain
Severe Acute Liver Injury 

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In this episode of WDx, Dr Casey Albin joins Kiara, Jane, & Sharmin to discuss a clinical unknown. Presented by Kiara, the case starts with the chief concern of difficulty recognizing family members.

 

Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/Partners Neurology before completing a fellowship in Neurocritical Care at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, EMCrit, and podcasts.

 

 

 

 

 

 

 

 

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Episode description

RR discuss a grounding case of chest pain

 

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In this Infectious Disease Rafael Medina Subspecialty episode, Dr. Jorge Salazar presents a case to Dr. Monica Gandhi of a transgender woman with a recent diagnosis of HIV presenting with fatigue and weight loss. 

Session facilitator: Maddy Conte

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: Monica Gandhi MD, MPH is Professor of Medicine and Associate Division Chief of the Division ofHIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital. She also serves as the medical director of the HIV Clinic at SFGH (“Ward 86”).

Case presenter:  Jorge Salazar is an Infectious Disease Fellow at the University of California, San Francisco. He also serves as an AIDS Research Institute Clinical Fellow and provides integrated HIV care for patients at Ward 86.

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Maddy presents a case to Jack, Sharmin, and Ann Marie of a patient who is found to have a mediastinal mass on imaging.

Mediastinal Mass Schema

 

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CPSolvers: Anti-Racism in Medicine Series

Episode 22 – Live from SGIM 2023: Best of Antiracism Research at the Society of General Internal Medicine’s 2023 Annual Meeting

Show Notes by Alec J. Calac

June 22, 2023

 

Summary: This episode highlights a selection of antiracism research presentations at a live recording of the podcast at the 2023 SGIM Annual Meeting. This year’s episode, our third conducted at SGIM, is focused on the importance of language in medicine and the role it can play in perpetuating stigma and bias. During this episode, we hear from Dr. Som Saha, an internist whose research focuses broadly on the influence of race and racism in the doctor-patient relationship among other research subjects, Dr. Mary Catherine Beach, whose work has been targeted towards improving healthcare quality for patients who face systemic disadvantage especially  in the setting of HIV/AIDS and sickle cell disease, and Dr. Pooja Lagisetty, whose work is focused on  understanding how stigma impacts access to care for people living with chronic pain and opioid use disorder. This episode is hosted by Sudarshan (Sud) Krishnamurthy and Ashley Cooper. The show notes for this episode were written by Alec Calac.

 

Episode Learning Objectives

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

1. Differentiate between stigma and bias in health care and the electronic health record using provided examples.
2. Describe difficulties and examples of how to measure unconscious race bias in medical practice.
3. Identify strategies to mitigate bias and stigma in the electronic health record as a trainee and medical practitioner.

    

Credits

• Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, Team
• Hosts: Sudarshan Krishnamurthy, Ashley Cooper
• Infographic: Creative Edge Design
• Audio Edits: Madellena Conte 
• Show Notes: Alec J. Calac
• Guests: Dr. Som Saha, Dr. Mary Catherine Beach, Dr. Pooja Lagisetty

 

Time Stamps

0:00 Opening

00:23 Introductions

01:50 Guest Introduction 1

02:43 Guest Introduction 2

04:05 Guest Introduction 3

05:25 Guest Career Paths and SGIM Research

07:20 Anti-Racist Praxis and Sickle Cell Clinical Research/Scale Development

10:00 Unconscious Race Bias

16:30 Positive, Negative, Neutral Language in the Electronic Health Record

19:54 Use Language to Personalize and Humanize Notes

21:22 Considerations for Alternative Language

25:20 “Disbelief of Pain” and Scare-Quotes

26:45 Interrupt Transmission of Stigma in the Electronic Health Record

29:20 Beginning of Audience Questions and “Euphemism Treadmill”

35:00 Reorienting Language

38:00 “Value” in the Electronic Health Record

40:00 Question about “Positive Language” as a Tool

42:00 Language and Intended Audiences, Context

45:50 Question on Multi-Level and/or System-Level Interventions

48:00 Becoming Conscious about the Unconscious

49:35 “Thinking Fast and Slow”

50:30 Question on Person-First Language and Artificial Intelligence

53:50 Pearls and “Ending with Hope”

 

Speaker Biographies (Abbreviated)

• Dr. Som Saha received his medical degree and post-graduate training in internal medicine from the University of California, San Francisco, and completed post-doctoral training in the Robert Wood Johnson Clinical Scholars Program (RWJ) at the University of Washington, where he obtained a master’s degree in public health. He subsequently worked at OHSU and the Portland VA for 2 decades before moving to Johns Hopkins University. Dr. Saha’s research focuses broadly on the influence of race and racism in the doctor-patient relationship, its relation to disparities in the quality of health care, and its implications for diversity in the healthcare workforce. He has also served as a Council member and Secretary of SGIM. He has been a research advisor or mentor for over 50 students, fellows, and junior faculty, over a third of whom have been from racial/ethnic groups underrepresented in medicine.

   

• Dr. Mary Catherine Beach is a professor in the School of Medicine, with appointments in the Center for Health Equity and the Berman Institute of Bioethics, at Johns Hopkins University. Dr. Beach’s research focuses on humanizing healthcare by promoting respect for patients as well as improved patient-clinician communication. Much of her work has been targeted toward improving healthcare quality for patients who face systemic disadvantage and in the setting of HIV/AIDS and sickle cell disease (SCD). Her research has been funded by the National Institutes of Health, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, and the Greenwall Foundation. Dr. Beach has won numerous awards for her scholarship and mentorship, including the David Levine Mentoring Award from the Johns Hopkins School of Medicine in 2015. She also is the 2017 recipient of the George L. Engel Award for outstanding research contributions to the theory, practice, and teaching of effective healthcare communication and related skills. In 2022, Dr. Beach was elected as a Hastings Center Fellow; and in 2023 was awarded the Excellence in Ethics Award from the Society of General Internal Medicine.

   

• Dr. Pooja Lagisetty received her medical degree from the Johns Hopkins School of Medicine and completed her internal medicine residency at Massachusetts General Hospital.  Following residency, she was a Robert Wood Johnson Clinical Scholar and received health services research methodology training.  She is currently an Assistant Professor of Medicine in the Division of General Internal Medicine at the University of Michigan and also a research investigator at the Center for Clinical Management and Research at the Ann Arbor VA. Clinically, she is boarded in both Internal Medicine and Addiction Medicine and practices as a primary care physician and teaching hospitalist.  Her research focuses on understanding how stigma impacts access to care for people living with chronic pain and opioid use disorder.  She is also interested in designing multidisciplinary care models for people with comorbid pain and substance use disorders in the general medical setting.  

Episode Takeaways

• • Stigma in Healthcare: Sud begins by asking our guests what led them to their current career paths and what work they are presenting at SGIM. Many of them share intersecting interests in stigma and other factors, such as chronic pain management, language (“drug-seeking” in the electronic health record), and the patient-provider relationship. Clinician-researchers are increasingly interested in developing novel scales and measures that can quantify stigma in healthcare. As noted by our guests, it is difficult to measure invisible factors such as unconscious race bias, because it is impossible to directly measure these factors. Instead, proxy factors, and other types of experimental inquiry (e.g., qualitative methods) have to be used to describe the impact that factors like bias have in health care. Importantly, there is a lot of nuance around language. It may be difficult to discern the impact that stereotypical language can have in health care because language is very contextual and means different things to different groups.

     

• Stigma (Adverse Impact) vs. Bias (Personal Characteristic): Important to make a distinction between these two concepts. Society stigmatizes certain behaviors, such as drug injection and alcohol use. When a health care provider uses such language (e.g., a person who injects drugs), they may not have any bias against the patient, but they are using language that ascribes stigma to the patient based on societal norms. Another example of phrasing, such as “delightful” and “pleasant” may convey positive bias for one group of patients over another, depending on their racial and/or social identities, but may not be examples of stigma. It is not always clear what is an example of stigma and/or bias in the electronic health record. Learn more here: Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record | Health Affairs

   

• Use Language for Good: Think about what people will remember when they access a patient’s electronic health record. Language can be a powerful tool for good, especially in the backdrop of the opioid epidemic.

   

• Opioid Epidemic and Stigma: Providers generally have a fear or discomfort using opioid agents as treatment for individuals with substance use disorders. Coupled with stigma, bias, and language used to describe these patients in the electronic health record, this perfect storm of factors can work against efforts to help patients in need of safe, comprehensive healthcare services.

   

• Active Use of the Electronic Health Record: Be mindful of the use of “scare-quoting” and other phrasing that could be misinterpreted. Consider taking on an active role in interrupting the continued communication of language that is outdated and no longer relevant to the care of the patient. As mentioned earlier, humanizing the electronic health record can have a significant impact down the line.

   

• “Euphemism Treadmill”: This describes the process of replacing words that have taken on a stigmatizing, pejorative, or derogatory connotation with new words that are more humanizing, and how this is an iterative (unlearning-learning) process. An interesting conversation followed that included discussions about the DSM in psychiatry and psychology (personal failing vs. medical disorder) and how this language-shifting process is likely multi-generational in scale.

Pearls

• “Do no harm” through language. Be conscious about the words and phrases used in the clinical encounter and electronic health record. Preserve the dignity of the patient. Small changes can have a large impact.

   

• Include personalizing and humanistic details in the electronic health record. The work begins with educating our learners, while incorporating these lessons into our clinical practice simultaneously.

 

References

 

Beach MC, Park J, Han D, Evans C, Moore RD, Saha S. Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length. Ann Fam Med. 2021 Nov-Dec;19(6):515-520. doi: 10.1370/afm.2740. PMID: 34750126; PMCID: PMC8575526.

 

Park J, Saha S, Chee B, Taylor J, Beach MC. Physician Use of Stigmatizing Language in Patient Medical Records. JAMA Netw Open. 2021 Jul 1;4(7):e2117052. doi: 10.1001/jamanetworkopen.2021.17052. PMID: 34259849; PMCID: PMC8281008.

 

Beach MC, Saha S. Quoting Patients in Clinical Notes: First, Do No Harm. Ann Intern Med. 2021 Oct;174(10):1454-1455. doi: 10.7326/M21-2449. Epub 2021 Aug 17. PMID: 34399061.

 

Beach MC, Saha S, Park J, Taylor J, Drew P, Plank E, Cooper LA, Chee B. Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women. J Gen Intern Med. 2021 Jun;36(6):1708-1714. doi: 10.1007/s11606-021-06682-z. Epub 2021 Mar 22. PMID: 33754318; PMCID: PMC8175470.

 

Kosakowski S, Benintendi A, Lagisetty P, Larochelle MR, Bohnert ASB, Bazzi AR. Patient Perspectives on Improving Patient-Provider Relationships and Provider Communication During Opioid Tapering. J Gen Intern Med. 2022 May;37(7):1722-1728. doi: 10.1007/s11606-021-07210-9. Epub 2022 Jan 6. PMID: 34993861; PMCID: PMC9130417.

 

Benintendi A, Kosakowski S, Lagisetty P, Larochelle M, Bohnert ASB, Bazzi AR. “I felt like I had a scarlet letter”: Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain. Drug Alcohol Depend. 2021 May 1;222:108664. doi: 10.1016/j.drugalcdep.2021.108664. Epub 2021 Mar 18. PMID: 33757709; PMCID: PMC8058315.

 

Disclosures 

The hosts and guests report no relevant financial disclosures.

 

Citation

Saha, S, Beach, M, Lagisetty, P, Cooper A, Krishnamurthy S, Calac A, Pierce G, Essien UR, Fields NF, Lopez-Carmen V, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 22: Live from SGIM 2023: Best of Antiracism Research at the Society of General Internal Medicine’s 2023 Annual Meeting” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. June 25, 2023.

 

Show Transcript 

 

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Episode description

RR discuss a grounding case of chest pain

 

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Dr. Kimberly Manning and her father, Mr. William Draper, commemorate Juneteenth, the holiday that celebrates the day when all remaining enslaved Black Americas were freed in Galveston Texas, on June 19th, 1865, with this hour-long storytelling event. 

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Dr. Gabriela Pucci presents a case of right arm weakness to Promise and Ravi. 

Promise Lee @promiseflee

Promise Lee is currently a 3rd year medical student at Loyola University Chicago Stritch School of Medicine. She is an aspiring internal medicine physician with interests in GI, obesity medicine, public health, and clinical reasoning. Outside of medicine, Promise is a food and fitness enthusiast who loves enjoying the outdoors, spending time with family and friends, and experimenting with new recipes.

 

Gabriela Figueiredo Pucci @gabifpucci

Gabriela Figueiredo Pucci, MD, is a Neurology PGY 1 at University of Pittsburgh Medical Center. Originally from Brazil, she graduated from Unicamp and completed her first Neurology residency at UNESP. She is enthusiastic about breaking down complex Neurology topics into infographics on her website (www.Neudrawlogy.com). She is passionate about Clinical Reasoning and loves to be part of the CPSolvers. On her free time, she likes to travel, cook, bake, and watch competitive cooking and baking reality shows.

Ravi Singh @rav7ks

Ravi (Ravitej) Singh is originally from Greenwich, London U.K where he grew up playing soccer and rugby. He attended medical school at University of Debrecen, Hungary and completed residency at Medstar Harbor Hospital in Baltimore. Currently he is an associate program director for Sinai Hospital IM residency program in Baltimore as well as a Hospitalist on the teaching service. He is a faculty member at the Johns Hopkins School of Medicine and takes time out of his schedule to run a series of case-based teaching sessions as well as medical simulation with all of the medical students that rotate at Sinai throughout the year. He is also a co-chair of the ACP Maryland IMG committee where he advocates for IMG issues Jo and highlights their contributions to the healthcare system

 

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