The Clinical Problem Solvers

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Sharmin, Ann Marie, and Jack discuss a fascinating case of back pain and granulomas presented by Dan.

Schemas:

Low Back Pain Overview

Bony Back Pain Overview

Granuloma on Histopath

Bone Lesions

Antibiotic Failure

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RLR discussed an intriguing case of a chronic consolidation

Thank you to our dear friend and colleague Dr. Kelley Chuang for her help with the production of this episode. (You are a legend, Kelley!)  @kelleychuang

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 We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time Dr. Doug Pet presents a case of slurred speech to Angelita and Diane. 

Neurology DDx Schema

Doug Pet

@doug_pet

Doug is a resident in neurology at UCSF. He grew up surrounded by cow farms and crab-apple trees in New Milford, CT. He completed a dual-degree program at Tufts and the New England Conservatory studying medical anthropology, community health, and jazz saxophone. He later worked for a non-profit in Berkeley, CA on bioethical and social justice issues related to genetic and reproductive technologies. Doug attended Vanderbilt University School of Medicine, after which he returned to the Bay Area for neurology residency at UCSF. He loves Brazilian music, playing Spikeball, and making custom wooden pens on his lathe.

Angelita Pusparani

@pusparani10

 Angelita Pusparani is a junior doctor (2ndY+) working in a small town in Indonesia. She is interested in discussing any cases (from neonate to geriatric), all patients inspire her. In her free time, Angelita is a basketball and marvel fan. She can also be found making a coffee or fried rice.

 

Diane Lebrun

Diane is an Internal Medicine Physician from Haiti. Her interest in Neurology started when she was a PGY-3 resident at Hopital Universitaire de Mirebalais (HUM), during her rotation in the Neurology Clinic. She has a special interest for Neuro-ICU, clinical reasoning, and medical education. In her free time, she enjoys spending quality time with family and friends, listening to faith-based music or podcasts, and dancing.

 

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CPSolvers: Anti-Racism in Medicine Series

Episode 16 – Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting

Show Notes by Sudarshan Krishnamurthy

May 3, 2022

Summary: This episode was recorded in front of a live audience at the Society of General Internal Medicine’s 2022 Annual Meeting in Orlando, FL. In this episode, we gain insights from three antiracism scholars, Drs. Yannis Valtis, Ebi Okah, and Carine Davila, about research in their respective fields. Dr. Valtis is a 4th year Med-Peds Resident at Brigham & Women’s Hospital and Boston Children’s Hospital, and his research focuses on race and the utilization of security responses in the inpatient hospital setting. Dr. Okah is a family medicine clinician and NRSA research fellow at the University of North Carolina School of Medicine, and she studies the association between the use of race in medical decision-making and beliefs regarding the etiology of disparities in health outcomes. Dr. Davila is a palliative care physician at Massachusetts General Hospital and her work examines racial and ethnic inequities in patient-clinician communication. This episode was led by Rohan Khazanchi, and was hosted by Sudarshan Krishnamurthy and Utibe R. Essien.

Episode Learning Objectives

After listening to this episode learners will be able to:

1. Understand the association of race with the utilization of security responses in hospital settings
2. Understand the association between the use of race in medical decision-making and beliefs regarding the etiology of racial differences in health outcomes
3. Understand racial/ethnic inequities in trust-building healthcare experiences and describe the importance of improving trust in the healthcare system through trust-building experiences with historically marginalized communities

Credits

• Written and produced by: Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH,  Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen MPH, Naomi F. Fields, LaShyra Nolen, Michelle Ogunwole MD, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
• Hosts: Sudarshan Krishnamurthy and Utibe R. Essien MD, MPH
• Infographic: Creative Edge Design
• Audio Edits: David Hu
• Show Notes: Sudarshan Krishnamurthy
• Guests: Drs. Yannis Valtis, Ebi Okah, and Carine Davila

 

Time Stamps

0:00 Introduction

4:20 Context and background of Yannis’ project

7:40 Framing of Ebi’s research

11:25 Inspiration for Carine’s work

14:50 Yannis’ explanation of his findings and potential next steps to intervene

25:45 Results from Ebi’s research

33:55 Carine’s findings from her work

40:00 Audience Questions

Episode Takeaways

• Our Black patients are nearly twice as likely to experience a security utilization as our White patients.

Along with previous literature demonstrating a higher use of restraints in our Black patients in the emergency department setting, Yannis’ work shows a higher use of security responses in Black patients compared to White patients. Simulation-based training interventions are currently being studied to help combat these inequities.

• Individuals who believe that genetic differences explain racial differences in health outcomes are more likely to practice race-based medicine.

Ebi’s research found that those physicians who possessed the belief that the etiology of racial differences in health outcomes was rooted in genetic differences were more likely to practice race-based medicine. On the other hand, those who believed that differences in social conditions explain racial differences in health outcomes were less likely to practice race-based medicine.

• Our Black and Hispanic patients are less likely to have had trust-building experiences and more likely to have had trust-eroding experiences with the healthcare system.

Carine’s research illustrated the presence of trust-building experiences and trust-eroding experiences at every touchpoint with the health care system. Further, her research shows that Black and Hispanic patients are less likely to have had positive experiences and more likely to have had negative experiences. In addition to a need for culturally competent interpersonal communication, health systems and structures must actively work to build trust with historically marginalized communities.

Pearls 

• “When we heard the Code Gray bell go off in the hospital, all of us knew that there was a very high likelihood that we would be entering the room a Black patient.”

In the landscape of the murder of George Floyd, Yannis described how his team began to ask questions about how they could better protect their Black patients from police brutality. Although they began with a large focus on police brutality as a whole, they realized that the presence of police within the hospital had not been sufficiently examined. Although it had not been objectively measured, their clinical and personal experiences indicated that security responses were more often utilized for minoritized patients in the hospital.

• “It did not make sense that an innate risk for poor health was attributed to Blackness, instead of thinking about how society assigns privileges and benefits by race that results in varying health outcomes.”

Ebi discussed the context behind what inspired her project, explaining that her journey began in medical school when students challenged race-based medical curricula and the use of race as a risk factor for disease. While starting residency, she was exposed to the use of race in clinical risk calculators and was confused by the rhetoric around the innate risk conferred by Blackness, instead of the influences of racism and inequitably distributed social determinants on health outcomes.

• “There are known inequities in patient-clinician communication in historically marginalized populations that have immediate and downstream effects on health outcomes for these patients.”

Carine talked about her expertise in empathically communicating with patients as a palliative care physician. As she embarked on her project, she realized that improving serious illness care would require improving serious illness communication. She explained that the willingness for patients to engage in communication is rooted in how much they have been listened to in the past. Importantly, there is literature demonstrating inequities in patient-clinician communication with impacts on immediate outcomes, such as patient satisfaction and trust-building, along with downstream health outcomes 

• “… we found that the chance of having security called on our Black patients was nearly double that of our White patients.”

Yannis described previous studies demonstrating that Black patients have a higher likelihood of being restrained than White patients in the emergency department and  psychiatric settings. However, there seemed to be a lack of literature exploring this in the inpatient hospital setting, where patient clinical presentations are more varied and management depends more on clinician behaviors. His team found that 1.5% of White patients had a security response called, in comparison to almost twice as many (2.8%)  Black patients. Yannis posited that this difference was due to explicit and implicit biases rooted in racism in our broader societal context. When thinking about an intervention to combat these inequities, Yannis described a project at the Brigham leveraging simulation-based training on  interacting with agitated patients followed by a debrief session to have clinicians reflect on their actions towards patients and the role of race.

• “… we found that the belief in genetic differences explaining racial differences in health outcomes is associated with the practice of race-based medicine.”

Ebi’s work focused on how physicians think about race and how they engage in race-based medicine. Her project asks three main questions: 1) To what extent do racial differences in genetics explain racial differences in health outcomes? 2) How do values related to diet, exercise, and other cultural differences between racial groups explain racial differences in health outcomes? and 3) How do differences in social conditions, such as the environment and socioeconomic status, influence racial differences in health outcomes? Ebi found that the belief in genetic differences as an explanation for racial health disparities was associated with use of race-based clinical practices. Additionally, the belief that social inequalities explained racial health disparities was not associated with race-based practice. 

• “Our Black and Hispanic patients are less likely to have had positive experiences and more likely to have had negative experiences with the healthcare system.”

People engage in positive trust-building and negative trust-eroding experiences at every touch point or every interaction with someone in the healthcare system. Carine explains that this forms the framework for how experiences within the healthcare system can be evaluated. Unsurprisingly,  it was found that Black and Hispanic patients were less likely to have had trust-building experiences and more likely to have had trust-eroding experiences with the healthcare system. Trust in the healthcare system is dependent on so many factors, and boils down to what the system has done to demonstrate that they are trustworthy. The onus is on us as a system to build and earn the trust of our patients through trustworthy behaviors, especially when the system has historically not done that. An important way of improving trust in the system within historically marginalized communities includes the recruitment of clinicians to the healthcare system from within these communities, to increase representation and better reflect the diversity of our patient population. The presence of these diverse clinicians also changes the inherent nature of the space that healthcare occupies. 

References

1. Valtis YK, Stevenson K, Murphy E, Hong J, Ali M, Shah S, Taylor AD, Sivashanker K, Shannon E. Race and the Utilization of Security Responses in a Hospital Setting. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
2. Okah E, Cronholm P, Crow B, Persaud A, Westby A, Bonham V. The use of race in medical decision-making is associated with beliefs regarding the etiology of racial differences in health outcomes. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
3. Davila C, Ravicz M, Jaramillo C, Wilson E, Chan S, Arenas Z, Kavanagh J, Feltz B, McCarthy B, Gosline A. Talking the Talk: Examining racial and ethnic inequities in patient-clinician communication. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
4. Okah E, Thomas J, Westby A, Cunningham B. Colorblind Racial Ideology and Physician Use of Race in Medical Decision-Making. J Racial Ethn Health Disparities. 2021 Sep 7:10.1007/s40615-021-01141-1. doi: 10.1007/s40615-021-01141-1.
5. Ogunwole SM. Without Sanctuary. N Engl J Med. 2021 Mar 4;384(9):791-793. doi: 10.1056/NEJMp2030623.
6. Corbie-Smith G, Henderson G, Blumenthal C, Dorrance J, Estroff S. Conceptualizing race in research. J Natl Med Assoc. 2008 Oct;100(10):1235-43. doi: 10.1016/s0027-9684(15)31470-x.
7. Nash KA, Tolliver DG, Taylor RA, Calhoun AJ, Auerbach MA, Venkatesh AK, Wong AH. Racial and Ethnic Disparities in Physical Restraint Use for Pediatric Patients in the Emergency Department. JAMA Pediatr. 2021 Dec 1;175(12):1283-1285. doi: 10.1001/jamapediatrics.2021.3348.
8. Carreras Tartak JA, Brisbon N, Wilkie S, Sequist TD, Aisiku IP, Raja A, Macias-Konstantopoulos WL. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med. 2021 Sep;28(9):957-965. doi: 10.1111/acem.14327.

 

Previous Episodes Discussed:

1. Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 2: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2020/11/17/episode-141-antiracism-in-medicine-series-episode-1-dismantling-race-based-medicine-part-1-historical-and-ethical-perspectives-with-edwin-lindo/ November 17, 2020.
2. Eneanya A, Tsai J, Williams J, Essien UR, Paul D, Fields NF, Nolen L, Ogunwole M, Onuoha C, Khazanchi R. “Episode 4: Dismantling Race-Based Medicine, Part 2: Clinical Perspectives.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2020/12/16/episode-148-antiracism-in-medicine-series-episode-4-dismantling-raced-based-medicine-clinical-perspectives/. December 17, 2020.
3. Manning KD, Corbie-Smith G, Khazanchi R, Nolen L, Fields N, Ogunwole M, Onuoha C, Tsai J, Paul D,  Essien UR. “Episode 6: Racism, Trustworthiness, and the COVID-19 Vaccine.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2021/02/25/episode-162-antiracism-in-medicine-series-episode-6-racism-trustworthiness-and-the-covid-19-vaccine/. February 23, 2021.
4. Roberts, DE, Onuoha C, Khazanchi R, Nolen L, Fields N, Tsai J, Essien UR, Paul D, Ogunwole M,. “Episode 8: Dismantling Race Based Medicine Part 3: Towards Justice and Race-Conscious Medicine.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2021/05/10/episode-176-antiracism-in-medicine-series-episode-8-towards-justice-and-race-conscious-medicine/. May 10, 2021.
5. Onuoha C, Khazanchi R, Fields N, Ogunwole M, Williams J, Essien UR, Tsai J,  Nolen L, Paul D. “Episode 9: Moving Towards Antiracism in Medical Education.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2021/06/10/episode-181-antiracism-in-medicine-series-episode-9-moving-towards-antiracism-in-medical-education/. June 10, 2021.

 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

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

Show Transcript

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Reza discussed a case that begins with dysuria, but ends in a way you will not believe.

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Dr. Blythe Butler presents a case to Dr. Alexandra “Jay” Teng, followed by a discussion about her experience as a woman in an Internal Medicine procedural subspecialty.

Alexandra “Jay” Teng

Alexandra “Jay” Teng hails from Berkeley and graduated from Harvard with a bachelor’s degree in history and science. After college, she worked at UCSF as a clinical research coordinator and patient navigator for women newly diagnosed with breast cancer, helping them prepare questions for their doctor and accompanying them to appointments. That experience helped convince her to pursue medicine. Dr. Teng earned her medical degree from UCSF, then completed internal medicine residency at UCLA. A competitive skier, she was originally interested in orthopedics, but she had a dramatic pivot at the end of her first year of medical school. “On the morning of my last final, I went into cardiac arrest and was admitted to Moffitt Hospital,” she said. The hospital team did an extensive workup, eventually diagnosing her with a rare condition called congenital long QT syndrome and implanting a cardiac defibrillator to prevent future life-threatening complications. “I was incredibly lucky, and feel a very personal connecting to cardiology,” she said. “I feel fortunate to train in the place and with the people who saved my life.”She completed Cardiology and Interventional Cardiology subspecialty fellowship at UCSF. She now works at Kaiser.

Blythe Butler

Blythe Butler is a first-year internal medicine resident at the University of California, San Francisco. She grew up in Spokane, Washington and attended Dartmouth College where she studied chemistry and mathematics. She went on to pursue a career in education and spent four years teaching general and AP chemistry as a high school teacher in San Jose, CA. She decided to switch careers to pursue medicine and completed medical school at UCSF. She enjoys running through Golden Gate Park, hiking and backpacking, and baking. Her career interests include medical education, communication in medicine, and health equity.

 

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In this case, Anna and Moses work through the schemas of dyspnea, AMS, HIV & infection, and lymphocytic pleocytosis as they discuss a case presented by Simone.

Schema: 

DyspneaAMS 2.0HIV & infectionLymphocytic pleocytosis  

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CPSolvers: Anti-Racism in Medicine Series

Episode 15: Housing is Health: Racism and Homelessness – Clinician + Community Perspectives 

 

Show Notes by: Victor Anthony Lopez-Carmen, MPH

April 5, 2022

 

Summary: This episode highlights homelessness’ impact on health, the structural and racialized nature of homelessness, and practical interventions to address housing inequities. This is the last of three episodes interrogating the relationships between race, place, housing, and health. During this episode, we gained insight from special guests Dr. Margot Kushel and Mr. Bobby Watts about what brought them into their fields, how their work reaches the most marginalized, and what can be done at the community and structural level to address homelessness. Dr. Margot Kushel is a Professor of Medicine and Division Chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center and Director of the UCSF Center for Vulnerable Populations and UCSF Benioff Homelessness and Housing Initiative. Mr. Bobby Watts is the chief executive officer of the National Health Care for the Homeless Council. This episode was hosted by Sudarshan Krishnamurthy, Jazzmin Williams, and Alec Calac.

 

Episode Learning Objectives:

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

1. Learn about non-stigmatizing language for healthcare providers when talking about individuals experiencing homelessness
2. Understand how systemic racism, including injust housing policies and over-policing, are at the root of homelessness and its disproportionate impact on Black and Brown communities
3. Understand the systemic factors that have increasingly led to the aging population experiencing homelessness today
4. Learn how homelessness contributes to adverse health outcomes, especially in the context of the COVID-19 pandemic
5. Describe  the utility of medical respite care when working with patients experiencing homelessness

 

Credits

• Written and produced by: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen, MPH, Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
• Hosts: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Victor Anthony Lopez-Carmen, MPH
• Guests: Dr. Margot Kushel and Mr. Bobby Watts

 

Time Stamps

00:00 Introduction

04:31 Guest career paths

11:58 Non-stigmatizing language around homelessness

19: 30 Structural racism and homelessness

33:09 Increasingly older population experiencing homelessness

42:01 Medical respite care

48:30 Criminalizing and over-policing homelessness

53:19 Key takeaways

 

Episode Takeaways

1. We must know the housing status of our patients, and how to ask about it.

Our guests remind us to ask our patients about their housing status using non-judgmental and non-stigmatizing language. If we do not know the housing status of our patients, then we do not know one of the most fundamental things that is going to affect their health and wellbeing. 

 

2. Know your community resources.

Our guests emphasize that physicians must be familiar with community resources. Do you have a medical respite center? Do you have a coordinated entry system (CES) in your community? Can you refer your patient there? 

 

3. If we are not part of the solution, we are complicit in structural injustice. 

Dr. Kushel and Mr. Watts remind healthcare providers to speak out about the structural causes of homelessness. Push back against individual narratives that blame individuals for systemic injustice. Push back against dehumanizing language. Push back against discussions that homelessness is caused by substance use or mental health problems. 

4. Disaggregated data on homelessness is vital. 

Missing racial and ethnic data on homelessness is an example of structural racism. We must know who we are serving to truly be able to tackle the systemic injustices that cause disproportionate rates of homelessness in America.

 

Pearls

Formative Career Moments:  

• Dr. Kushel explained how discharging patients experiencing homelessness only for them to come back a few days later in worse shape was unacceptable. This pattern led Dr. Kushel towards work on solving the systemic failures causing “catastrophic” health outcomes in populations experiencing homelessness. 
• Mr. Watts added a tangible example where people experiencing homelessness would be dropped off by ambulances in front of the center for homelessness where he worked, which was not equipped to deal with their medical circumstances. They would eventually end up back at where the hospitals they came from. Experiences like this made him want to contribute to solutions in the community.

 

Speaking about Homelessness: 

• Dr. Kushel encouraged people to go past the textbooks and learn from people on the frontlines of homelessness. This humanizes the crisis and also centers the lived experiences of persons experiencing homelessness as the experts who can teach us more than any textbook. 
• Dr. Kushel emphasized that we should use person-first language because homelessness is an experience and there is no such thing as an inherently homeless person. Some people also prefer  to use unhoused instead of homeless.
• Mr. Watts encouraged use of the term neighbor, such as “neighbors without homes, unhoused neighbors, or neighbors experiencing homelessness. Another term he uses is “people with the lived expertise of homelessness,” which centers them as experts in solution-making. 
• Dr. Kushel detailed how the use of dehumanizing language equates to complicity in a narrative that systemically harms our neighbors with lived expertise in homelessness.
• Dr. Kushel emphasized that we must speak to the structural racism at the root of disproportionate rates of homelessness in communities of color, instead of just focusing on mental health and substance use. 

 

Restrictive Housing Policy and Homelessness Today: 

• Mr. Watts described how property tax laws give more public funding to school districts in higher socioeconomic neighborhoods than poorer neighborhoods, leading to worse educational outcomes and thus higher rates homelessness in low-income neighborhoods. 
• Dr. Kushel and Mr. Watts remarked that housing, especially expensive house ownership, is massively subsidized in comparison to apartment renting, meaning populations who are less likely to own houses receive less financial support from state and federal housing programs.
• Dr. Kushel described how the wealth gap created by discriminatory housing policies also means that more racial minorities are renting properties, making them more vulnerable to gentrification and eviction, contributing further to the housing crisis.
• Mr. Watts explained that predatory home or apartment lending targets Black and Brown people, leading to higher rates of poverty and homelessness in those communities. He also described how other policies like redlining and racist policing practices contribute to the mass incarceration of Black and Brown people, increasing homelessness in those communities. 

 

Aging Compositions of the Population Experiencing homelessness across the US: 

• Dr. Kushel explained that in the early ’90s in San Francisco, 11% of those experiencing homelessness were 50 and older. By 2003, 37% were 50 and older. Now, among single adults experiencing homelessness, the median age is much closer to 50, meaning about half are under 50 and half are over 50. 44% had never once been homeless before the age of 50. So, the population experiencing homelessness is increasingly older. 
• Mr. Watts noted that the aging population experiencing homelessness came of age during mass incarceration, over policing, and thus many of them had histories with the prison system. Most were due to drug-related non-violent crimes that haunted them and limited employment opportunities throughout their lives. 
• Dr. Kushel also noted that housing became less and less affordable, adding on to the vulnerability of those in this generation who could not obtain well-paying jobs due to non-violent criminal histories. 
• Mr. Watts described how life expectancy among those experiencing homelessness is 20-30 years shorter than those with stable housing. This means they don’t benefit from social security because they are dying before they can receive it.

 

Health and Homelessness: 

• Dr. Kushel emphasized that people experiencing homelessness have elevated hospitalization rates and longer stays due to more comorbidities, and are more likely to be re-hospitalized.
• Mr. Watts described how care for people experiencing homelessness needs to take into account the realities of being without a house, such as having medications stolen or going bad because of lack of refrigeration (e.g. insulin), greater decompensation after discharge because of a lack of a place to rest, and other factors that lead to poorer health outcomes. 
• Our guests explained that inpatient and outpatient treatment plans need to prioritize knowing the patients’ housing status, shared decision-making, and creating plans that take homelessness into account so treatment regimens are effective. 
• Dr. Kushel commented that in order to create systemic changes that will decrease rates of homelessness and improve the health outcomes of those experiencing homelessness we need disaggregated data to fully understand which groups in society are most impacted and why.

 

Medical Respite Care: 

• Mr. Watts advocated for medical respite, a safe place to heal and “short circuit” the street-emergency room-street-emergency room cycle as a way to treat people experiencing homelessness who are not sick enough for inpatient service, but too sick to send back out to the streets, only for their sickness to worsen. Because of less hospitalization return rates, Dr. Kushel emphasized that medical respite programs also save taxpayer money. 
• Dr. Kushel and Mr. Watts emphasized that respite medical care needs to be integrated into the continuum of care and homeless response systems.  
• Dr. Kushel explained that medical respite care via the National Institute for Medical Respite Care was very successful during the COVID-19 pandemic and is inspiring more and more communities to integrate respite care into their practices. 

 

Policing: 

• Mr. Watts noted how the crack cocaine epidemic shifted the race demographics of homelessness in NYC from largely older, white drinkers to “50/50 young African American and Latinx”, with many cycling in and out of the carceral system due to over-policing and mass incarceration, which only made the crisis worse.
• Mr. Watts emphasized that to this day, you are still more likely to be arrested for drug charges if you are Black or Brown, even though rates of drug use are equal across races. This is due to over policing of Black and Brown communities, which leads to higher rates of homelessness in those populations.
• Mr. Watts and Dr. Kushel described how criminalizing homelessness is counter-productive and increases stigma, especially when the media focuses on one’s homelessness in the context of a crime. He states that people who are experiencing homelessness are actually more vulnerable to crimes happening to them, so they deserve more protection and service from the criminal justice system. Mr. Watts highlighted a program called CAHOOTS (Crisis Assistance Helping Out On The Streets) as a great, evidence-based mobile response model for addressing urgent needs among those experiencing homelessness.

 

References

1. Margot Kushel, M.D. UCSF Profiles. https://profiles.ucsf.edu/margot.kushel
2. G. Robert (Bobby) Watts, M.P.H., M.S., National Healthcare for the Homeless Council, Who We Are. https://nhchc.org/who-we-are/staff/ceo/
3. Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. BRIEF REPORT: the aging of the homeless population: fourteen-year trends in San Francisco. J Gen Intern Med. 2006;21(7):775-778. doi:10.1111/j.1525-1497.2006.00493.x
4. Semere W, Kaplan L, Valle K, Guzman D, Ramsey C, Garcia C, Kushel M. Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study. J Gen Intern Med. 2022 Feb 15:1–9. doi:10.1007/s11606-022-07438-z
5. Studying Homelessness: Using Research to Impact Social Determinants of Health by Margot Kushel, MD. https://www.youtube.com/watch?v=O4LMVx1WiKs
6. Caring for Homeless People During COVID-19 Pandemic. An Interview with Bobby Watts. AMA Journal of Ethics. https://www.youtube.com/watch?v=E7Z80jADnrg&t=495s
7. Homeless community in San Diego resists police terror and demands safe housing – Liberation News
8. Lopez, M., Rothstein, R. Segregated by Design. Silkworm Studio. Published April 5, 2019. Accessed April 3, 2022. https://vimeo.com/328684375
9. Swift, C. Crisis Assistance Helping Out On the Streets. Community Access. January 18, 2019. Accessed April 3, 2022. https://www.communityaccess.org/storage/images/Miscellaneous/Community_Feedback_Forum_2019/3_Crisis_Assistance_Helping_Out_on_the_Streets_CAHOOTS_presentation.pdf
10. Kushel M. Older homeless adults: can we do more?. J Gen Intern Med. 2012;27(1):5-6. doi:10.1007/s11606-011-1925-0

Disclosures 

The hosts and guests report no relevant financial disclosures.

 

Citation

Watts B, Kushel M, Krishnamurthy S, Williams J, Calac AJ, Lopez-Carmen VA, Fields NF, Nolen L, Tsai J, Ogunwole SM, Onuoha C, Watkins A, Essien UR, Khazanchi R. “Episode 15: Housing is Health: Racism and Homelessness – Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. April 5, 2022.

 

Show Transcript

https://clinicalproblemsolving.com/wp-content/uploads/2022/03/RTP-Schema-3.31.mp3

Ann Marie, Jack, and Dan talk through the hemoptysis and pulmonary-renal syndromes schemas based on a case presented by Sharmin

 

Schemas:

Hemoptysis

Pulmonary Renal Syndrome

 

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https://clinicalproblemsolving.com/wp-content/uploads/2022/03/RLR-83_RTP-1.mp3

Dr. Rehman presents an unsolved Dx mystery from Pakistan!

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