The Clinical Problem Solvers

We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Vijay presents a case of left upper extremity weakness to Vale and John.  

Neurology DDx Schema

Valeria Roldan

@ValeRoldan23

Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue a 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.

John Acquaviva

@DrJAStrange

John Acquaviva is a third-year medical student attending Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania. He has a passion for both clinical and academic neurological concepts and plans to practice neurology after medical school. He has a special interest in autoimmune neurology and neuroimmunology, but is excited about all neurological clinical presentations. In his free time, he enjoys hanging out with friends, long-boarding, and running while listening to neurology podcasts.

Vijay Balaji

@VijayBramhan

Vijay is currently a third-year internal medicine resident at Ramaiah Medical College & Hospital, Bangalore, India, and has interests in medical education and clinical reasoning. Outside academics, his interests include playing basketball, cooking, and philosophy.

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Travis and Simone present a clinical unknown to Anand.

Schema:

Dyspnea

Splenomegaly

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Dr. Croglio presents a riveting diagnostic journey to RLR.

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RR discuss a fascinating cause of confusion and a tremor

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Cardionerds, Tommy and Dinu, present a case to Dr. Vaidya, Lindsey, and Dan.

Dr. Anjali Vaidya

Dr. Vaidya is a heart failure and transplant cardiologist at the Lewis Katz School ofMedicine at Temple University, where she serves as the co-director of the Pulmonary Hypertension, right heart failure, and CTEPH program, as well as APD for the cardiology fellowship program and residency advisor for the internal medicine residency.

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In this episode, Anna & Smitha review the schemas of Inflammation and Glomerulonephritis as they work through a case presented by Emma.

Glomerulonephritis

Inflammation – Overview

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CPSolvers: Anti-Racism in Medicine Series

Episode 14: Race, Place, and Health: Clinician and Community Perspectives

Show Notes by Alec Calac

February 15th, 2022

Summary: This episode highlights how racism manifests in the built environment, and how community and individual-level efforts can mitigate these inequities. This discussion is the second of three planned conversations around the connections between race, place, and health. Our latest episode welcomes first-time guests Dr. Eugenia South, a physician-scientist and Vice Chair for Inclusion, Diversity, and Equity in the Department of Emergency Medicine at the Perelman School of Medicine, and Noelle Warford, Executive Director of the grassroots organization Urban Tree Connection. Hosted by team members Naomi Fields and LaShyra Nolen,our guests present their community-based work in Pennsylvania and lay bare the connections between race, place, and health.

Episode Learning Objectives:

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

1. Understand the historical and present-day role of land dispossession and property rights in determining health along lines of race and place.
2. Learn how advancing individual agency and distributive justice can empower community organizers and initiatives.
3. Understand the factors that promote and inhibit long-term resiliency and sustainability of place-based initiatives.
4. Learn how we can reimagine health by decolonizing wealth and philanthropy in modern society.
    

Credits

• Written and produced by: Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Alec Calac, Victor Lopez Carmen, MPH, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Sudarshan Krishnamurthy, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
• Hosts: Naomi F. Fields, LaShyra Nolen
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Alec Calac
• Guests: Dr. Eugenia South, MD, MSPH, and Noelle Warford, MSW

Time Stamps

00:00 Introduction

05:40 Built environments and structural racism

11:18 Agricultural perspective, land rights, and settler colonialism

15:00 Responsible community engagement and catalyzing individual agency

21:58 Engaging communities outside of the ivory tower

27:00 Scaling up interventions to the community level

32:29 Intervention sustainability

37:18 Decolonizing philanthropy and place-based investments

42:40 Navigating trade-offs and mitigating ethical tensions

49:20 Key takeaways

Episode Takeaways

1. Your “why” has to be clear before you engage in community-based work.

Ms. Warford reminds us that we need strong, sound ideological positions and guiding principles before engaging with the communities around us. She asks to think about what we are doing today to make it easier for people to live in the future. Our ancestors considered our present to be impossible, so how can we use our ideas and experiences to effect positive change in our communities? These movements require action, not passivity.

2. Take time to learn from your patients. Be curious.

Clinicians are incredibly privileged individuals. Dr. South reminds us that it is our great honor to talk to people in an exam room. Our patients are not just a list of problems. They are individuals who interact with environments that affect their health. She encourages us to see beyond these problems, and ask patients about their lives, challenges, and successes. Everything is important. Unfortunately, medical practice does not always allow us to slow down and take this time to listen. But, finding ways to do so can prove illuminating as well as rewarding.

Pearls

Built Environment, Physical Health, and Mental Health

• Dr. South detailed that there are clear physical health benefits associated with place-based interventions, but unfortunately many lots and buildings sit vacant and destitute across the US. There’s also more. When interviewing community members in Philadelphia, she shared that longstanding disinvestments in their communities made them feel “unimportant” and “neglected” by society, which had effects on their mental health.
• The 2021 Build Back Better Act recognized the impact that the built environment has on health, calling for environmental improvements such as planting trees.
• Ms. Warford is the Executive Director of Urban Tree Connection, a grassroots organization in West Philadelphia that uses land-based strategies and urban agriculture as tools for fostering community leadership and power.  She presented a powerful argument that connected settler colonialism, Indigenous genocide, and chattel slavery with modern-day property rights and tax codes. By preventing Black and Brown people from developing relationships with the land and using it as a way of forming social connection, as well as communal sustenance, structural racism manifests along lines of race and place. 
• Lash echoed this and also reaffirmed points made by Dr. South that the built environment changes how individuals see themselves, limiting their ability to push back on the status quo.

Individual Agency and Redistribution of Resources

• Ms. Warford centered the conversation and reminded the audience that it is not just healthcare systems that are being pushed to the brink. Non-profit organizations are experiencing the same organizational stress.  Working with Dr. South and others, Urban Tree Connection is helping community members realize their inherent agency and leadership capacity.
• In the process of redesigning the Memorial Garden in West Philadelphia, Ms. Warford and Dr. South foregrounded the reality that spaces have to be rooted in people’s experiences. There is often a sentiment that “If you build it, they will come”; however, one should not make assumptions about what community members want. It is important to get their perspectives and figure out what the “little things” are. The vision for any community-informed project has to meet community members where they are. What are their priorities? What are their needs?
• Continuing this conversation, Dr. South shared that “solutions have to be solutions, not fantasies.” Approaching community problems with an academic approach will not necessarily have community interests in mind (or prioritize them). By moving outside of this academic mindset, organizers and facilitators can work to effect meaningful, long-lasting change in the community.

Sustainability

• Dr. South has studied a variety of place-based interventions including vacant lot greening, abandoned house remediation, tree planting, and structural repairs to homes. She was recently awarded a $10 million grant from the National Institutes of Health that will allow her and her team to conduct a randomized-controlled trial that combines many interventions instead of just one. A serious concern that she and many others have is the sustainability of interventions after grant funding ends. Funding structures, especially from government agencies, are not exactly permissive of this.
• To promote sustainability, Dr. South and Ms. Warford encouraged the audience to confront the ethical tension between place-based interventions and long-term sustainability after funding streams dry up. It is important to educate and engage key stakeholders such as policymakers who can work to address these limitations.
• Ms. Warford shared that funding priorities are not necessarily community priorities. In limited funding environments, non-profit organizations often apply for any and all available funding streams, which may gradually shift the organization’s priorities, a phenomenon often referred to as mission creep.

   

Decolonizing Wealth and Philanthropy

• Our panelists detailed how much wealth is generated from the labor of Black and Brown people. Unfortunately, it is difficult for that wealth to be reinvested in those very same communities. Ms. Warford encouraged our listeners to think about how we can decolonize wealth and philanthropy, noting that place-based investments have to be gradual and intentional. She shared that funding entities must recognize the labor of community members and provide funds for their work. “People power” is a resource that must be cultivated, respected, and valued.

Recognizing Your Role

• Naomi recapped much of the discussion and shared that it was clear that “there is no quick fix.” Much of the work involves education, finances, time, and people power. Dr. South shared that there are many ways to be a part of dismantling structural racism. Some people are more front-facing, while others work behind-the-scenes. All perspectives and skillsets are welcome in this process. Ms. Warford shared that it will take time to navigate away from capitalist structures and extractive economies. It is important to celebrate the small wins and strive for the greater vision. LaShyra shared some personal reflections to this effect. The goal for this work will always be liberation and agency. When you’re just trying to make it every day, you don’t always have the privilege to do anything else.

References

1. Urban Health Lab. Urban Health Lab. Accessed January 3, 2022. https://www.urbanhealthlab.org
2. Urban Tree Connection. Accessed January 3, 2022. http://www.urbantreeconnection.org/index.php
3. Meet the Board: Noelle Warford. NESAWG. Published August 19, 2020. Accessed January 3, 2022. https://nesawg.org/news/meet-board-noelle-warford
4. Noelle Warford, Everyday Genius. Da Vinci Art Alliance. Accessed January 3, 2022. https://davinciartalliance.org/everyday-genius-blog/noelle-warford
5. Eugenia C. South, MD, MSPH. Opinion | If Black lives really matter, we must invest in Black neighborhoods. Washington Post. Accessed January 3, 2022. https://www.washingtonpost.com/opinions/2021/03/16/black-neighborhoods-parks-safety/
6. De Maio F, Rothstein R, Khazanchi R, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR. “Episode 200: Antiracism in Medicine Series – Episode 11 – Racism, Redlining, and the Path Towards Reconciliation.” The Clinical Problem Solvers Podcast. Published October 11, 2021. Accessed January 3, 2022. https://clinicalproblemsolving.com/2021/10/11/episode-200-antiracism-in-medicine-series-episode-11-racism-redlining-and-the-path-towards-reconciliation/
7. Eugenia C. South, MD, MSPH. Opinion | To Combat Gun Violence, Clean Up the Neighborhood – The New York Times. Accessed January 3, 2022. https://www.nytimes.com/2021/10/08/opinion/gun-violence-biden-philadelphia.html
8. “A Randomized Controlled Trial of Concentrated Investment in Black Neighborhoods to Address Structural Racism as a Fundamental Cause of Poor Health.” National Institutes of Health RePORTER. Accessed January 2, 2022. https://reporter.nih.gov/project-details/10413510#description
9. “Penn Researchers to Study the Impact of Environmental and Economic Interventions on Reducing Health Disparities in Black Philadelphia Neighborhoods with Nearly $10M Grant.” Penn Medicine. Accessed January 2, 2022. https://www.pennmedicine.org/news/news-releases/2021/october/penn-researchers-to-study-the-impact-of-environmental-and-economic-interventions
10. “How a scientist in Philadelphia is addressing health inequity.” Matter of Fact with Soledad O’Brien. Published December 17, 2021. Accessed January 2, 2022. https://www.matteroffact.tv/how-a-scientist-in-philadelphia-is-addressing-health-inequity/
11. Urban Tree Connection 2021 Annual Report. Accessed January 2, 2022. http://www.urbantreeconnection.org/admin/resources/2021-utc-annual-reportcompressed.pdf
12. Gardner JR. “A Willfully Misunderstood Earmark Can Help Reduce Climate-Change Heat Deaths.” The New Yorker. Published November 29, 2021. Accessed February 8, 2022. https://www.newyorker.com/news/daily-comment/more-tree-canopy-can-stop-climate-change-from-killing-vulnerable-americans 
13. H.R.5376 – 117th Congress (2021-2022): Build Back Better Act. (2021, November 19). https://www.congress.gov/bill/117th-congress/house-bill/5376/text
14. VolunteerHub. “Nonprofit Mission Creep: What is It? How to Prevent It.” Accessed February 8, 2022. https://www.volunteerhub.com/blog/what-is-mission-creep/ 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

South E, Warford N, Fields NF, Nolen L, Calac A, Lopez-Carmen V, Tsai J, Krishnamurthy S, Ogunwole M, Onuoha C, Watkins A, Williams J, Paul D, Essien UR, Khazanchi R. “Episode 14: Race, Place, and Health: Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. February 15, 2022.

Show Transcript

RR discuss an important patient phone call
For more RLR episodes, consider subscribing to Patreon: The Clinical Problem Solvers is creating podcasts, videos, schemas, illness scripts and more | Patreon 

Lindsey presents a case of fever in a returning traveler to Sharmin, Jack, and Dan. 

Fever in a Returning Traveler Schema

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Maria presents a case of increased drowsiness to Dr. Mathieu Brunet and Dr. Mattia Rosso. 

Neurology DDx Schema

Maria Jimena Aleman

Maria Jimena Aleman 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. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. 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.

Mathieu Brunet

Mathieu Brunet is an emergency physician and trauma team leader at the Hôpital du Sacré-Coeur-de-Montréal and an assistant professor of emergency medicine at Université de Montréal in Canada. After his emergency medicine training, he completed a Fellowship in Resuscitation & Reanimation at Queen’s University in Canada and a Master of Traumatology with the University of Newcastle in Australia. Mathieu has been a regular listener of the podcast and the daily Virtual Morning Reports. He finds The Clinical Problem Solvers to be an invaluable resource to progress and maintain motivation on the lifelong journey toward clinical reasoning expertise.

Mattia Rosso 

Mattia Rosso is a neurology resident at the Medical University of South Carolina (MUSC) in Charleston. He is interested in movement disorders, behavioral neurology, and autoimmune neurology. He is also passionate about the intersection between the humanities and medicine, with a focus on the fields of medical history and bioethics. Outside work, he enjoys photography, cinema, and discovering new music. Since starting residency, Clinical Problem Solvers have been an irreplaceable source of learning and inspiration. 

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