The Clinical Problem Solvers

We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time,Valeria presents a case of headache and altered mental status to Joy and Mattia.

Neurology DDx Schema

Valeria Roldán

@valeroldan23

Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.

Joy Glanton

@joytibalan

 Joy is a neuro enthusiast who has completed her neuroscience undergrad and medical studies in the Philippines. She is passionate about neurology and believes “the brain is everything; it’s what makes us who we are.” She is hoping to match into Neurology in 2023, and is currently in NYC completing clinical externships/rotations in neurology. Post residency, she aspires to do translational/clinical research work or pursue a career in academic/general neurology. Joy enjoys running, swimming, literary art, debates in neuroscience, and listening to rock and roll and classical music.

Mattia Rosso

@MattiaRosso3

Mattia Rosso is a neurology resident at the Medical University of South Carolina (MUSC) in Charleston, South Carolina. He is interested in movement disorders, behavioral neurology, and autoimmune neurology. He is also passionate about the intersection between the humanities and medicine. He started a Neurohumanities group at MUSC, which meets monthly and features internal and guest speakers. This group focuses on the role of the Arts, Cinema, Literature, Philosophy, and Music in medicine and neurosciences. Outside work, he enjoys photography, cinema, and discovering new music. Since starting residency, the Clinical Problem Solvers have been an irreplaceable source of learning and inspiration.

Maani and Emily are joined by Dr. Rachael Lee for a clinical unknown.

Dr. Rachael Lee

@DoctorRachael

Dr. Lee joined the UAB Division of Infectious Diseases at UAB in 2016 and is currently an Associate Professor. She is the UAB Chief Healthcare Epidemiologist and in this role, she utilizes evidence based medicine to prevent the spread of healthcare-associated infections. Her research focuses on multi-drug resistant pathogens as they relate to infection prevention and control.

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Reza and Rabih discuss a fascinating case of AMS, infection and polyuria. 

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Moses presents a case of hypoglycemia to Vale and Simone. 

 Hypoglycemia Schema

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Ann Marie, Jack and Dan discuss and delve deeper into hypokalemia and hypophosphatemia schemas based on a case presented by Sharmin.

Schemas

• Hypokalemia
• Hypokalemia a practical approach
• Hypophosphatemia

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Reza and Rabih discuss a fascinating case of hypercalcemia. 

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, John presents a case of diplopia to Valeria and Madellena.

Neurology DDx Schema

John Acquaviva

@DrJAStrange

John Acquaviva is a fourth-year medical student attending Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania. He has a passion for both clinical and academic neurology and will be starting neurology residency in the summer of 2023. He has special interests in neurophysiology, autoimmune neurology, and neuroimmunology, but is excited about all neurological fields. In his free time, he enjoys hanging out with friends, long-boarding, running, and martial arts.

Valeria Roldán

@valeroldan23

Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.

Madellena Conte

@MadellenaC

Madellena Conte was born and raised in San Francisco, CA. She completed her undergraduate degree at Dartmouth College. After college, she worked at Collective Health, a healthcare insurance technology company, and then completed her Master’s of Science in Global Health at UCSF where her research focused on understanding preferences for HIV care among people experiencing unstable housing. She is a MS4 at the Zucker School of Medicine at Hofstra/Northwell in New York and is currently taking a research year in the Division of HIV, ID, and Global Medicine at UCSF. Outside of medicine, Madellena loves to travel, meet new people, run, figure skate and really do anything outdoors. She plans on applying into internal medicine residency.

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CPSolvers: Anti-Racism in Medicine Series 

Episode 18 – Remedying Health Inequities Driven by the Carceral System

Show Notes by Ayana Watkins

October 18, 2022

Summary: This episode highlights the history and roots of the carceral system, as well as its far-reaching impacts on the health of women and children today. During this episode, we gain insight from special guests Dr. Jennifer James—a qualitative researcher, a Black Feminist scholar, and an assistant professor in the Institute for Health and Aging, the Department of Social and Behavioral Sciences, and the Bioethics program at the University of California San Francisco—and Dr. Nia Heard-Garris—a pediatrician and researcher in the Department of Pediatrics at Feinberg School of Medicine at Northwestern University and in the Division of Academic General Pediatrics and Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. This discussion is hosted by Sudarshan Krishnamurthy, Ashley Cooper, and Alec J. Calac.

Episode Learning Objectives

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

1. Understand the history of mass incarceration and its effect on health

2. Recognize how cultures of punishment and control within carceral spaces and within clinical settings impact health

3. Learn how to best care for and support those experiencing violence at the hands of the carceral system

4. Consider how we enact carceral structures and act as agents of the state in our clinical practices

Credits

• Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, Alec J. Calac, Michelle Ogunwole MD, PhD, Ayana Watkins, Chioma Onuoha, Naomi F. Fields MD, Victor A. Lopez-Carmen MPH, Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH,  Jazzmin Williams, LaShyra Nolen,  Jennifer Tsai MD, MEd, Zahada (Kiersten) Gillette -Pierce

• Hosts: Sudarshan Krishnamurthy, Ashley Cooper, and Alec J. Calac

• Infographic: Creative Edge Design

• Audio Edits: Isabella Gau

• Show Notes: Ayana Watkins

• Guests: Dr. Nia Heard-Garris, MD, MSc and Dr. Jennifer James, PhD, MS, MSW

Time Stamps
00:00 Introduction of episode and guests
04:01 History of  mass incarceration and its relationship with health
11:38 Understanding healthcare decision-making in carceral spaces
22:27 Substance Use and Treatment/Diversion vs. Incarceration of BIPOC mothers
29:30 Health Impacts on Children and Young Adults with History of Parental Incarceration
35:24 Remedying Health of Women and Children Impacted by the Criminal Legal System
45:55 Key takeaways

 Episode Takeaways:

1. Prisons are not places of healing. Incarceration negatively affects the physical and mental health of people who are incarcerated as well as their family members and loved ones, and limits access to healthcare before, during, and after incarceration. 

2. All healthcare professionals will have patients who are directly or indirectly impacted by the carceral system. Our guests remind us to think critically about our role in the carceral system and in imposing systems of control and punishment within clinical settings. Additionally, our guests urge us to recognize the ways in which our patients are impacted by incarceration and to ask our patients about these impacts in order to better care for them.

3. The ways to remedy the negative impacts of incarceration are to incarcerate fewer people and to invest in communities. Providing communities with the resources they need to survive, such as educational opportunities, jobs, and quality healthcare, will eliminate the need for incarceration. Additionally, decarceration and abolition will remedy the far-reaching health effects of the criminal legal system.

Pearls

 “Prisons and jails are not healing spaces [. . .] They are not spaces designed for healing or care, they are designed for punishment and control.”

• Dr. James explains that the culture of punishment, control, and violence within jails and prisons impedes healthcare for people who are incarcerated. People who are incarcerated are dehumanized and feel they are treated as inmates, rather than as patients. Correctional officers act as gatekeepers, deciding who does and does not need medical care. This means that people who are incarcerated are often not believed when they say they need medical care. As a result of this dehumanization and mistreatment, people who are incarcerated may forgo seeking medical care because they do not trust that the system and healthcare professionals will do anything but harm them further.

• Dr. Heard-Garris draws parallels between the culture within the carceral system and that within hospitals and clinics. For clinicians who do not work within jails or prisons, it is important to recognize the presence of these same issues within other clinical spaces. Hospitals and clinics also have security, armed guards, and police whose roles are to impose control, and their presence can impact health outcomes for patients. 

• Dr. Heard-Garris also added that having a family member in the carceral system makes it more likely that a person will lose confidence in the medical system and will not seek care, so this mistrust in healthcare reverberates in generations post-incarceration.

Substance Use and Society’s focus on incarceration and punishment over treatment, diversion, and healing for BIPOC women

• Dr. Heard-Garris explained that systems such as capitalism, politics, and white supremacy are the reasons our society focuses on incarceration and punishment rather than on substance use treatment. She discusses how it’s easier to incarcerate people than it is to invest in treatment because investment requires time, money, and the dismantling of our current systems.

• Dr. James adds that reproductive justice and the rights to family, and having the resources and support to raise children have never existed for people of color and people experiencing poverty. Current-day familial structures reflect policies dating back to slavery, the forced displacement of Native Americans, and the way immigrant families have been treated. Today, the carceral system plays a pivotal role in modern-day eugenics and in reproductive and family control. 

Health Impacts on Children and Young Adults with History of Parental Incarceration & Juvenile Justice Involvement

• Dr. Heard-Garris explains that the health impacts that affect people who are incarcerated also impact children and adolescents with parents who have been incarcerated. This exposure to the carceral system negatively impacts the physical and mental health of these children and young adults and reduces their access to healthcare.

• She also reminds us that children with parents who are incarcerated are not doomed to poor outcomes. Many of these children and young adults are resilient and are still able to thrive. However, they should not have to undergo these adverse childhood experiences and traumas. The carceral system needs to be changed and these children need to be supported and have their healthcare and education needs met.

 Remedying the Health of Women and Children Impacted by the Criminal Legal System

• Both Dr. James and Dr. Heard-Garris agree that the best way to remedy the health impacts of the carceral system is to incarcerate fewer people.

• Dr. James discusses changes that can be made if we assume the current carceral system will remain. We need a system, such as a single-payer healthcare system, that provides people with consistent access to high-quality care before, during, and after incarceration. Additionally, we should provide people who are incarcerated with better ways to communicate with their families. For healthcare specifically, it is important to believe people when they say they need care and provide them with access to trauma-informed care.

• Dr. Heard-Garris adds that a good place to start is to decarcerate people and offer them support. Additionally, we need to prevent incarceration by investing in communities and providing communities with resources, education, jobs, healthcare, etc. The goal is to create a society in which prisons and jails aren’t necessary because every person has what they need to survive.

Practices Clinicians can Incorporate to Reduce the Impacts of Mass Incarceration on Patients

• Dr. James reminds us that no matter where we work or what specialty we work in, we will see people who are impacted by incarceration. As physicians and healthcare professionals, we should ask people about their histories of trauma and about the impact of incarceration on their lives. Additionally, we need to be cognizant of the ways we as providers enact a carceral state and think critically about the way these systems impact patient care.

• Dr. Heard-Garris encourages us to ask patients about their interactions with the carceral system. Asking these questions provides us with an opportunity to better care for our patients. It can allow us to offer more support systems to patients and to connect patients with resources that have worked for others. We also have to be aware of our power and privilege and recognize that we do not treat all our patients equitably in order to change and do better.

References

1. Black Feminist Bioethics: Centering Community to Ask Better Questions. Hastings Cent Rep. 2022 03; 52 Suppl 1:S21-S23. James JE. PMID: 35470879.

2. Race, Racism, and Bioethics: Are We Stuck? Am J Bioeth. 2022 03; 22(3):22-24. James JE. PMID: 35258424.

3. Heard-Garris N, Sacotte KA, Winkelman TNA, Cohen A, Ekwueme PO, Barnert E, Carnethon M, Davis MM. Association of Childhood History of Parental Incarceration and Juvenile Justice Involvement With Mental Health in Early Adulthood. JAMA Netw Open. 2019 Sep 4;2(9):e1910465. doi: 10.1001/jamanetworkopen.2019.10465. PMID: 31483468.

4. Heard-Garris N, Winkelman TNA, Choi H, Miller AK, Kan K, Shlafer R, Davis MM. Health Care Use and Health Behaviors Among Young Adults With History of Parental Incarceration. Pediatrics. 2018 Sep;142(3):e20174314. doi: 10.1542/peds.2017-4314. Epub 2018 Jul 9. Pediatrics. 2019 May;143(5): PMID: 29987170.

5. Heard-Garris N, Johnson TJ, Hardeman R. The Harmful Effects of Policing—From the Neighborhood to the Hospital. JAMA Pediatr. 2022;176(1):23–25. doi:10.1001/jamapediatrics.2021.2936

6. Heard-Garris, N., Boyd, R., Kan, K., Perez-Cardona, L., Heard, N. J., & Johnson, T. J. (2021). Structuring poverty: how racism shapes child poverty and child and adolescent health. Academic pediatrics, 21(8), S108-S116.

7. Kaba, Mariame, et al. No More Police: A Case for Abolition. The New Press, 2022.

8. Roberts, Dorothy. Torn Apart: How the Child Welfare System Destroys Black Families–and How Abolition Can Build a Safer World. Basic Books, 2022.

9. Wilkerson, Isabel. Caste (Oprah’s Book Club): The origins of our discontents. Random House, 2020.

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

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.

Show Transcript 

Reza discussed a mind-blowing case presented by Rabih

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In this WDx episode, Sharmin and Dr Lekshmi Santhosh delve into the world of written evaluations: why are they important, implicit biases they can contain and how to do a better job in both writing and interpreting evaluations. 

Dr. Lekshmi Santhosh

Dr. Lekshmi Santhosh is an associate professor of medicine at UCSF. She specializes in adult pulmonary and critical care medicine with a focus on medical education. She attends in the Medical ICU, the Neuro ICU, on the Internal Medicine teaching wards, and has clinic at the Pulmonary Outpatient Faculty Practice at UCSF-Parnassus. She is the founder and Medical Director of the multidisciplinary long-COVID/post-ICU OPTIMAL Clinic at UCSF Health.

She serves as the Associate Program Director for Curriculum for the Internal Medicine Residency and the Associate Program Director of the Pulmonary and Critical Care Medicine Fellowship. She also is the Director of the Department of Medicine Grand Rounds. She obtained her Master’s in Health Professions Education from UC-Berkeley. Her primary interests in medical education research are related to ICU transitions of care, women in leadership, clinical reasoning, and subspecialty career choice.

Resources:

Analysis of Narrative Text in Evaluations of Continuing Medical Education Faculty by Gender 

Differences in Narrative Language in Evaluations of Medical Students by Gender and Under-represented Minority Status

UCSF’s Equity in Assessment Guidelines and Checklist

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