The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2023/06/6.8.23-SLS-RTP.mp3Episode description: The spaced learning series team discusses a case of intermittent episodes of presyncope in a patient found to have hypoglycemia and polycythemia.   Featuring: Anna FretzKirtan PatoliaPriyanka Athavale Schemas:SyncopeHypoglycemiaPolycythemia 

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In this episode of WDx, Dr Rebecca Berger joins Kara, Jane, & Sharmin to discuss a clinical unknown. Presented by Kara, the case starts with a young woman presenting with chronic isolated thrombocytopenia.

 

Dr. Rebecca Berger

Rebecca is an academic hospitalist and assistant professor of medicine at Weil Cornell Medicine and New York Presbyterian Hospital. In addition to her clinical work, she serves as the Director of Patient Safety for Inpatient Services for the Department ofMedicine and teaches medical students and residents, including leading small groups with students on their medicine clerkships focused on clinical reasoning and diagnosis.Rebecca obtained her undergraduate degree from Stanford University in 2009, her medical degree from Columbia University Vagelos College of Physicians and Surgeons in 2013, and completed her internal medicine internship and residency training at Massachusetts General Hospital (MGH) in 2016. She served as a NEJM Editorial Fellow from 2016-2017 and worked as a hospitalist at MGH before moving to Cornell in 2018.

 

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RR dedicate this episode to our beloved Rafa Medina. 

Rafa’s GoFundMe page.

 

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Maddy Conte and Seyma Yildirim introduce a new series on the podcast: “The Rafael Medina Subspecialty Series,” which will always be in loving memory of our dear friend and CPSolvers family member, Dr. Rafael Medina. Rafa presents a nephrology clinical unknown to Drs. Ashita Tolwani and Mustafa Muhammad.

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, fill out this form here: https://forms.gle/RLbx6A2vELp6PTYp9

 

Case presenter and facilitator: Dr. Rafael Medina

Rafa was a Brazilian medical graduate who proudly shared on Twitter, “Son of a tailor and confectionary vendor born and raised in rural Brazil. And now incoming internal medicine resident at the University of Colorado. Never let anyone tell you that your dreams are too big for you!” He tragically passed away last week. He impacted the lives of so many and touched every corner of the CPSolvers community, and rippled far beyond. Rafa helped spearhead the subspecialty series; this series has been renamed after Rafa and will continue strong in his honor. Rafa, we love you.

 

 

 

Case discussants:
Dr. Ashita Tolwani, Professor of Medicine at the University of Alabama at Birmingham (UAB). She was the Nephrology Fellowship Training Program Director from 2004-2010 and is now the Associate Program Director. She is also the Director for ICU Nephrology at UAB. (Twitter: luck_urine)

 

 

 

 

 

 

Dr. Mustafa Noor Muhammad, nephrology fellow at the University of Alabama at Birmingham. 

 

 

 

 

 

 

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CPSolvers: Antiracism in Medicine Series

Episode 21 – Psychosocial and Cultural Considerations for Providing Healthcare to Immigrant and Refugee Populations

Show Notes by Kiersten T. “Gillette” Gillette-Pierce

May 2, 2023

Summary: This episode highlights the psychosocial and cultural considerations for providing healthcare to immigrant and refugee populations. During this episode, we hear from Dr. Altaf Saadi, a neurologist who focuses on neuropsychiatric health disparities and addressing the needs of displaced populations at Mass General Hospital and Harvard Medical School, and Dr. Naweed Hayat, a child and adolescent psychiatry fellow at the University of California San Diego, who applies his own lived experience of resettlement to his clinical practice. Together, our guests explain how trauma shows up in those who experience resettlement, and the role of trauma-informed and culturally-responsive care for refugee, asylee, and immigrant population in clinical practice.. This discussion is hosted by Sudarshan Krishnamurthy, Ashley Cooper, and LaShyra Nolen. 

Episode Learning Objectives

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

1. Explain how the current state at the border is informed by historical immigration injustices.
2. Describe how physiological and psychological trauma show up among immigrant and refugee populations as a result of the violence and injustices experienced during migration, at the border, during the resettlement  process and across the lifecourse thereafter. 
3. Identify the role of trauma-informed, culturally-responsive care for refugee, asylee, and immigrant populations and how it can be operationalized in clinical practice.

Credits

• Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, LaShyra Nolen, Kiersten Gillette-Pierce, Rohan Khazanchi, MD, MPH,  Dereck Paul, MD, Jazzmin Williams, Victor A. Lopez-Carmen MPH, Naomi F. Fields, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins, Michelle Ogunwole MD, Utibe R. Essien MD, MPH
• Hosts: Sudarshan Krishnamurthy; Ashley Cooper, and LaShyra Nolen
• Infographic: Creative Edge Design
• Audio Edits: Garrett Weskamp
• Show Notes: Gillette Pierce
• Guests: Dr. Altaf Saadi and Dr. Naweed Hayat

Time Stamps

0:28 Introduction

0:31 Episode introduction

1:15 Guest introductions

3:50 Origin stories

8:06 The current state of the border

18:13 Culturally competent and trauma-informed care 

24:50 ICE and policing

36:28 Application of teachings

Episode Takeaways

• Origin Stories — For Dr. Hayat and Dr. Saadi, the work that they do is deeply informed by their lived experiences as migrants themselves as well as in their professional roles as clinicians who serve immigrant and refugee populations. 

• State of the Border — Policies that happened under the Trump administration and now under the Biden administration have left people vulnerable to injustices in Mexico and other Central American nations. People are fleeing persecution, gang violence, and other violence such as sexual or other violent assaults and now they must also face the additional burden of the lack of access to basic necessities like food, water and shelter. A lot of compounding trauma occurs at the border that has potential downstream mental health implications for individuals and their families. 

• Culturally Competent and Trauma-Informed Care — Interpersonal components such as screening for trauma exposure and providing resources to families are an important aspect of trauma-informed care, and it should also include efforts at the organization level to create sanctuary or immigrant-friendly spaces and implement immigration-informed care, which builds on the concept of trauma-informed care by honing in on the unique factors associated with immigrant populations, e.g. protocols for broaching sensitive topics like immigration status and policies to ensure people are safe from immigration enforcement.

• ICE and Policing — Instances of immigration enforcement in healthcare settings are rare, and when they do happen they can look like patients being interrogated at the bedside or even being arrested as they step out of the hospital just after visiting someone. These instances contribute to immense fear that can act as a deterrent from seeking care or engaging with any other helping professional institutions in the future–this goes for the individual(s) directly impacted and the people within their communities. 

• Impact of Health Records — The impact of health records within the context of healthcare for immigrant populations is complex because migration status really should not be documented explicitly as it can open people up to harms such as stigma from providers or being turned over to law enforcement agencies who may cooperate with immigration enforcement. Many organizations, such as the American Medical Association Journal of Ethics, recommend against documenting immigration status in medical records.

• Application of teachings — It is advised to amplify the work that is already being done in communities and identify what areas at the systems level need to change as well as the key stakeholders. 

Pearls

• Dr. Hayat discusses the five major waves of migration in the last fifty years, resulting from the Soviet-Afghan War, the Afghan Civil War, the Fall of the Taliban, August 2021 US and western forces departure, and how he grew up during the 1990s right after the collapse of the government. He recounts street fights in Kabul as well as an overall theme of people going back to a focus on survival, or the need for food, shelter, water and safety. 

• Dr. Saadi discusses how her parents left Iraq under Saddam Hussein’s dictatorship, where he was targeting many Iraqis with Iranian ancestry and Shi’a Muslims–which included members of her family. She notes she was born in Iran and her family emigrated to Canada and then to the United States just a month before 9/11. She recounts this time as particularly tumultuous for not only Muslim Americans but also South Asian Americans, Sikh Americans, as well as Arab Americans who were not Muslims. 

• Dr. Saadi highlights that the majority of immigrants do not come through the US-Mexico border, even for undocumented folks. Additionally, in the case of folks who are undocumented, it is likely the case that they attained this status as a result of overstaying their previously valid visa. 

• Dr. Saadi discusses the Biden administration rule proposal that would essentially prohibit refugees from seeking asylum in the US, making them ineligible for asylee status. 

• Dr. Saadi highlights that there needs to be a greater focus on the continuum of experiences when we discuss patients who are immigrants or forcibly displaced because there is not often a clear pre-post distinction. Many people’s journeys can involve being in an encampment, being detained in immigration prisons, or stopping in multiple countries before reaching the final destination.

• Dr. Saadi also uplifts the fact that while we focus primarily on those we have clinical encounters with, it is always important to mention that there are many people that did not make it to clinic for an amalgam of reasons — many people lost their lives in the quest for better lives and freedom from persecution.

• Dr. Hayat stresses the difference that cultural psychiatry, cultural competency, and the biopsychosocial model make in building rapport and there is a lot that goes on in between pre- and post-resettlement and those experiences have to be taken into account, especially in cases where there are language and cultural barriers. He highlighted the DSM-5 Cultural Formulation Interviews.

• Dr. Saadi recommends avoiding documentation of immigration status in medical records, or having clear guidelines on what to do if immigration enforcement is present at the clinical setting. 

• Dr. Saadi notes that we must not see people as the sum of their traumas, they are so much more than that — especially in the case of forcibly displaced peoples and immigrants. We must not reduce people to their trauma exposure alone.   

• Dr. Hayat interestingly mentions that some organizations have been able to build relationships with law enforcement, educate them, and share different challenges to help realize a common goal. 

• Dr. Hayat notes that while organizations recommend against documenting immigration status in medical records, needs can still be met through partnerships with community organizations. Dr. Saadi adds that we can collect this data, and there is immense groundwork that must be done to develop protections for immigrant and refugee populations and ensure the data are protected. 

• Dr. Saadi mentioned a toolkit around policies and actions that can be implemented at an organizational level that is publicly available at www.doctorsforimmigrants.com. She also mentions additional organizational-level policies and actions that can take place beyond what is mentioned in the toolkit such as setting up a medical legal partnership where people can connect to attorneys that can help them with their immigration case or civic engagement promotion.  She also mentioned Dr. Mark Kuczewski’s sanctuary doctrine toolkit that focuses more on the individual level. Refer to Good Sanctuary Doctoring for Undocumented Patients for more information. Dr. Hayat mentioned his colleague, Dr. Olivia Shadid, who does work on mental health evaluations for asylum seekers, which can be found here.

References

1. Morris JE, Saadi A. The Biden administration’s unfulfilled promise of humane border policies. Lancet. 2022 May 28;399(10340):2013. doi: 10.1016/S0140-6736(22)00741-3. Erratum in: Lancet. 2022 Jun 2;: PMID: 35644152.
2. Saadi, A. Undark. Opinion: Covid-19 Shows Us Why We Should Keep ICE Out of Hospitals. https://undark.org/2020/03/25/covid-19-immigration-hospitals/ 
3. Saadi. A. Boston Globe. The invasion of Ukraine reminds me of growing up in Iran. The trauma is lasting. https://www.bostonglobe.com/2022/03/16/magazine/invasion-ukraine-reminds-me-growing-up-iran-trauma-is-lasting/?outputType=amp
4. Shi M, Stey A, Tatebe LC. Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees. Curr Trauma Rep. 2021;7(4):83-91. doi: 10.1007/s40719-021-00217-x. Epub 2021 Nov 13. PMID: 34804764; PMCID: PMC8590436.
5. Valtis Y, Okah E, Davila C, Krishnamurthy S, Essien UR, Calac A, Fields NF, Lopez-Carmen VA, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 16: Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. May 3, 2022
6. Berkman JM, Rosenthal JA, Saadi A. Carotid Physiology and Neck Restraints in Law Enforcement: Why Neurologists Need to Make Their Voices Heard. JAMA Neurol. 2021;78(3):267–268. doi:10.1001/jamaneurol.2020.4669
7. James J, Heard-Garris N, Krishnamurthy S, Cooper A, Calac A, Watkins A, Onuoha C, Lopez-Carmen VA, Krishnamurthy S, Calac A, Nolen L, Williams J, Tsai J, Ogunwole M, Khazanchi R, Fields NF, Gillette-Pierce K. “Episode 18: Remedying Health Inequities Driven by the Carceral System” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. October 18, 2022.
8. Chiesa V, Chiarenza A, Mosca D, Rechel B. Health records for migrants and refugees: A systematic review. Health Policy. 2019 Sep;123(9):888-900. doi: 10.1016/j.healthpol.2019.07.018. Epub 2019 Jul 30. PMID: 31439455.

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Saadi A, Hayat N, Krishnamurthy S, Cooper, A, Nolen L, Gillette-Pierce K, Calac A, Essien UR, Fields NF, Lopez-Carmen VA, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 21: Antiracist Healthcare for Immigrant and Refugee Populations ” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. April 25, 2023

Show Transcript 

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

Neurology DDx Schema

 

Yazmin Heredia

@minheredia

Yazmin is a Mexican Graduate from the Universidad Autonoma de Yucatan. During her medical training, she developed a strong interest in Public Health, Medical Education, and Health Equity and is looking forward to pursuing a career in Internal Medicine. When she is not volunteering on a project, she likes taking care of her plants, developing her skills in the fine arts, or learning a new language.

 

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.

 

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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CPSolvers: Anti-Racism in Medicine Series

Episode 20 – Medical Racism and Indigenous Peoples

Show Notes by Sudarshan (“Sud”) Krishnamurthy

April 4, 2023

Summary: This episode highlights the checkered past of medicine and the advancements in the field that have occurred at the expense of the humanity of Indigenous peoples. During this episode, we hear from Dr. Nav Persaud, a staff physician in the Department of Family and Community Medicine at St. Michael’s Hospital in Unity Health Toronto, and Dr. Alika Lafontaine, the current President of the Canadian Medical Association. Together, our guests explain how Indigenous knowledge systems are the foundation of modern medicine and also share strategies to promote truth and reconciliation with Indigenous Peoples in North America. This discussion is hosted by Alec Calac and Gillette Pierce.

Episode Learning Objectives

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

1. Explain how the dark legacy of discrimination and deliberate oppression of Indigenous Peoples has led to present-day disparities across the world
2. Describe how medicine has held some white men to high esteem, even when they harbored significant racist and sexist notions
3. Identify the role of Indigenous knowledge systems in shaping much of modern medicine today, yet experiencing erasure from the mainstream 

Credits

• Written and produced by: Alec J. Calac, Gillette Pierce, Sudarshan Krishnamurthy, Rohan Khazanchi, MD, MPH,  Dereck Paul, MD, Jazzmin Williams, Victor A. Lopez-Carmen MPH, Ashley Cooper, Naomi F. Fields, LaShyra Nolen, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins, Michelle Ogunwole MD, Utibe R. Essien MD, MPH
• Hosts: Alec J. Calac and Gillette Pierce
• Infographic: Creative Edge Design
• Audio Edits: Caroline Cao
• Show Notes: Sudarshan (“Sud”) Krishnamurthy
• Guests: Dr. Nav Persaud and Dr. Alika Lafontaine

Time Stamps

0:00 Introduction

0:45 Episode Introduction

1:10 Guest Introductions

3:30 Existing global disparities among Indigenous Peoples

6:00 How access to medications are impacted among Indigenous Peoples in Canada

8:30 Framing around the Design of Structures in Canada to suppress Indigenous voices

13:30 Legacy of Osler and the importance of rediscovering forgotten dark histories

16:20 Dehumanization of individuals belonging to marginalized groups by the healthcare system

27:50 Modern medicine and its roots in Indigenous knowledge systems

31:30 Provision of healthcare to Indigenous Peoples in Canada

34:50 Alec’s own advocacy around renaming a campus parking garage

36:55 Weaponization of professionalism 

45:00 Clinical takeaways and practical tools for clinician listeners

Episode Takeaways

• Indigenous communities around the world experience significant disparities in life expectancy, burden of disease, and socioeconomic status, due to deliberate exclusion of Indigenous Peoples from the mainstream and suppression of their voices in the design of the system.

• Within medicine, we tend to hold white men from history books in high esteem, often without recognizing the dark legacy that accompanied their lives. William Osler is one such example who, along with numerous other sexist and racist misconducts, took remains of Indigenous people with him as a gift to his mentor in Germany, that is still held by a German museum who refuses to return it.

• The dehumanization of individuals of color at the margins of society by the healthcare system is not simply a thing of the past, and is certainly a persistent phenomenon. Cindy Gladue, Brian Sinclair, and Joyce Echaquan are three Indigenous individuals who suffered immense harm at the hands of the healthcare system.

• There is strength in reconciling Indigenous history, and we must prevent further erasure of Indigenous knowledge systems. The solutions to these issues do not fall upon one community’s shoulders, but instead on the shoulders of all of us along with the oppressive systems that have led us here.

Pearls

• Alec begins by contextualizing this episode with the fact that although Indigenous people make up 6% of the global population, they compose 15% of the global population experiencing extreme poverty. Additionally, Indigenous communities experience lower life expectancy,  higher burden of disease, and lower socioeconomic status compared to non-Indigenous Peoples. These disparities are likely attributable, in part, to the disruption of Indigenous knowledge systems, inadequate infrastructure, and poor identification of health data among these groups, rather than individual behavior.  [Supplementary Resource for Listeners: CPSolvers Episode 12: Addressing Anti-Indigenous Racism in Medicine with team members Alec Calac and Victor Anthony Lopez-Carmen]

• Nav discusses that despite publicly funded healthcare systems in Canada and federal protections in place for certain Indigenous groups, Indigenous populations and other groups facing discrimination and historic oppression are much more likely to report not being able to take medications due to cost. Although healthcare services are publicly funded, access to medications depends on private or public insurance and is linked with employment. While some have the impression that there is a safety net in Canada for life-saving medications, Nav still sees patients in his practice who are harmed by the system and not able to afford life-saving medications, many of them Indigenous, and this is a violation of their right to access essential medicines.

• Alika expands on Nav’s framing by highlighting the three broad demographics in Canada: the Inuit, the Métis, and the First Nations. In contrast to settlers in the United States where “conquering” through deception was a priority, the spread of settlers was more so through the signing of agreements that were never lived up to. Indigenous peoples in Canada have deliberately been left out of the mainstream to ensure their voices were suppressed in the design of the system. 

• Alika elaborates on the history of Indigenous populations in Canada and how they would conduct X-Rays on the Inuit children, and ship these kids away for 3 to 10 years if they found tuberculosis in the lungs, without even allowing the children to say goodbye to their parents. Alika recalls stories of individuals in Ottawa who were on the same floor for several years, only to realize that they were members of the same family after being placed in these TB sanatoriums and crossing paths there.

• Nav begins to discuss how Osler is still revered as one of the most prominent historical physicians in Canada and the United States. A colleague brought information to Nav that Osler had brought remains of Indigenous people as a gift to one of his mentors in Germany. This led him to look into Osler’s history a little further, and Nav found it easy to find other instances of racist and sexist misconduct by William Osler. These remains are still in a museum in Germany, with no plan of return to Indigenous communities. [Supplementary Resource for Listeners: Read Dr. Persaud’s initial article on Osler here]

 

• Osler lived in the time of Numbered Treaties and the North-West Rebellion under Louis Riel, when Indigenous rights were front and center. It is ridiculous to consider that a physician brought Indigenous remains with him as a gift during this period in history, when Osler knew Indigenous people were fighting for their rights and lives. So, we must rethink the esteem that we hold white men like Osler in, and rediscover the forgotten history that accompanies them. [Supplementary Resource for Listeners: You can read more about the North-West Rebellion here]

• Alika discusses the dehumanization of individuals of color and other identities who exist at the margins within the healthcare system and emphasizes that these are not phenomena of the past. He highlights the hostility within the healthcare system and how healthcare must be a service that is available equally to everybody, and not treated as a favor being done to individuals. He narrates the stories of Cindy Gladue, Brian Sinclair, and Joyce Echaquan, all of whom suffered immense harm at the hands of the healthcare system as Indigenous individuals. [Supplementary Resource for Listeners: You can read about Cindy Gladue, Brian Sinclair, and Joyce Echaquan here] 

• Nav expands on this aspect of dehumanization of Indigenous peoples and speaks about how the Indigenous remains are being treated in Germany today. Although there is guidance that they must be returned, they have decided to retain them. In addition, there is writing within these skulls with numbers written on the inside, as if to catalog them. The museum has also added multiple barriers for those who wish to rightfully receive these remains, and has placed the onus on these communities for these remains to be returned.

• Alec importantly highlights that while these harms might seem historical and like things of the past, they have taken place within one or two generations and even today. He discusses his experiences as an Indigenous person in California who attends a medical school that begrudgingly decided to return Indigenous remains, from one of the largest collections in the world.

• Alika talks about strength in knowing his history. He discusses the medical knowledge of settlers in Canada believing in four humors and the practice of bloodletting to relieve sickness. At that time, Indigenous Peoples were harvesting plants at their peak potency and concentrating these plants in teas, and delivering medications through oral and transdermal routes. He talks about how Atropine, a commonly used drug by anesthesiologists like Alika, is derived from Belladonna and how folks practicing traditional medicine use Belladonna.

• Alika also delves deeper into the provision of healthcare to Indigenous peoples in Canada. He mentions that healthcare was provided to Indigenous peoples rooted in a charitable effort, rather than as a basic human right. It is important to move beyond being nice to each other, and begin to think about the requirements and obligations we have to each other as human beings.

• Alec goes on to highlight that as much as we have gained, we have much more to fight for. In episode 12, we discussed how the American Indian and Alaskan Native life expectancy as of 2021 was equivalent to that of the American public in the 1940s. The solution to these issues shouldn’t fall upon one or a few of our shoulders, but instead upon the shoulders of all of us along with the systems that have the resources and infrastructures to inform change.

• Alec used Nav’s article to advocate for the renaming of a parking garage on campus that was named after William Osler. Our spaces reflect our values, so the question he asked was why they had a parking garage named after an individual who has no relation to the local community in San Diego? We think about the legacy in medicine, but forget about the community we are in. [Supplementary Resource for Listeners: Read Alec’s Editorial about his advocacy related to renaming a street and parking structure in his medical school campus here.]

• Nav describes professionalism as a vague concept that is often used to oppress individuals from racialized and marginalized backgrounds. Professionalism is often antithetical to a rights-based approach to medicine, where every member of a team feels comfortable to speak up when everything is not right with a patient’s care and professionalism can scare people from speaking out when needed.

• Alika expands on this explanation of professionalism in terms of what is acceptable, decided by whoever is in control. It can be used to amplify what leaders think is important and suppress what leaders do not like, demonstrating the importance of leadership from diverse backgrounds and varied lived experiences. Retaliation can be severe to violations of professionalism, and it’s hard to know the effects of retaliation unless one has experienced these themselves. [Supplementary Resource for Listeners: Read about the experience Dr. Lafontaine describes regarding his own experience with reporting unprofessional and unacceptable conduct here]

• Nav states that it is important for us to reflect on what has happened and recollect all of the work people have done to chronicle anti-Indigenous racism. Racism is not new, and there have been numerous reports that document racism and anti-Indigenous discrimination over decades and centuries. We must respect what has happened, and recognize as non-Indigenous people that we benefit from advocacy and efforts of Indigenous peoples for Indigenous rights over generations.

• Alika emphasizes that the point of this conversation is not to make anyone feel like they are a bad person, but instead to help them acknowledge that in this healthcare system we provide both health and harm. Providing our patients with more space and ensuring our patients feel human again is a great first step. It is also important to remember that in the course of restructuring power, there are winners and losers and we may not all have the same voice around the table that we did before. We entered medicine to help people, and sometimes the best way to help people is by getting out of the way and allowing for others to step forward.

References

1. Persaud N, Butts H, Berger P. William Osler: saint in a “White man’s dominion”. CMAJ. 2020;192(45):E1414-E1416. doi:10.1503/cmaj.201567
2. Reid P, Cormack D, Paine SJ. Colonial histories, racism and health-The experience of Māori and Indigenous peoples. Public Health. 2019;172:119-124. doi:10.1016/j.puhe.2019.03.027
3. Redvers N, Blondin B. Traditional Indigenous medicine in North America: A scoping review. PLoS One. 2020;15(8):e0237531. Published 2020 Aug 13. doi:10.1371/journal.pone.0237531
4. Fredericks CF. Mapping the Sustainable Development Goals onto Indian Nations. In: Miller RJ, Jorgensen M, Stewart D, eds. Creating Private Sector Economies in Native America: Sustainable Development through Entrepreneurship. Cambridge: Cambridge University Press; 2019:185-194. doi:10.1017/9781108646208.011
5. Browne AJ, Lavoie JG, McCallum MJL, Canoe CB. Addressing anti-Indigenous racism in Canadian health systems: multi-tiered approaches are required. Can J Public Health. 2022;113(2):222-226. doi:10.17269/s41997-021-00598-1
6. Persaud N, Ally M, Woods H, et al. Racialised people in clinical guideline panels. Lancet. 2022;399(10320):139-140. doi:10.1016/S0140-6736(21)02759-8
7. Lafontaine AT, Lafontaine CJ. A retrospective on reconciliation by design. Healthc Manage Forum. 2019;32(1):15-19. doi:10.1177/0840470418794702
8. Lafontaine A. Indigenous health disparities: a challenge and an opportunity. Can J Surg. 2018;61(5):300-301. doi:10.1503/cjs.013917
9. Durand-Moreau Q, Lafontaine J, Ward J. Work and health challenges of Indigenous people in Canada. Lancet Glob Health. 2022;10(8):e1189-e1197. doi:10.1016/S2214-109X(22)00203-0
10. Okpalauwaekwe U, Ballantyne C, Tunison S, Ramsden VR. Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review. BMC Public Health. 2022;22(1):1630. Published 2022 Aug 29. doi:10.1186/s12889-022-14047-2
11. Berger P. Canadian Physicians’ Breach of Duty to Patients and Communities from the Acquisition of Indigenous Skulls in the 19th Century to the Abandonment of People with AIDS in the 20th Century. J Biocommun. 2021;45(1):E13. Published 2021 Aug 15. doi:10.5210/jbc.v45i1.10849
12. Calac AJ. Opinion: William Osler desecrated Indigenous remains. His name should be removed from UCSD. The San Diego Union Tribune. https://www.sandiegouniontribune.com/opinion/commentary/story/2021-08-24/sir-william-osler-uc-san-diego-indigenous-skulls-racist
13. Canadian Press. Alberta surgeon handed 4-month suspension for hanging noose on operating-room door. Haida Gwaii Observer. https://www.haidagwaiiobserver.com/news/alberta-surgeon-handed-4-month-suspension-for-hanging-noose-on-operating-room-door/

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Persaud N, Lafontaine A, Calac A, Pierce G, Krishnamurthy S, Essien UR, Fields NF, Lopez-Carmen VA, Cooper A, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 20: Advancing Medicine at the Expense of Indigenous Humanity” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. April 4, 2023

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https://clinicalproblemsolving.com/wp-content/uploads/2023/03/3.23.23-TCQ-RTP.mp3Dr. Vipul Kumar presents a fascinating case of pancytopenia and rash to guest discussant, Dr. Anand Patel.   Dr. Vipul Kumar MD PhD is a hematology-oncology fellow at UCSF. He is currently in his second year of fellowship and has a clinical interest in oncology of all forms as well as a passion for teaching.   Dr. Anand Patel is an assistant professor of medicine at University of Chicago where he treats patients with leukemia and myeloid malignancies. He also serves as medical director of the inpatient leukemia service. His research focuses on the development of clinical trials to help improve the standard of care for patients with high risk leukemias and myeloid malignancies.
Twitter: @Anand_88_Patel 

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