The Clinical Problem Solvers

In this episode, Dr. Elliot Tapper discusses a clinical unknown case presented by Dr. Jennifer Mundell

Jennifer Mundell 

Jennifer Mundell, MD FACP is the associate program director for Ascension St Vincent Internal Medicine Residency Program. She graduated from University of Louisville School of Medicine and completed IM residency at Ascension St. Vincent in 2016. The residents best know her for building differentials, baking cakes, and owning more cars than garage spaces. During her free time, she enjoys writing up interesting cases with residents, taking her family to a beach, and planning next year’s Halloween decorations.

Elliot Tapper

Elliot Tapper, MD is an Assistant Professor in the Division of Gastroenterology at the University of Michigan in 2016. His clinical activity and research efforts focus on the outcomes of patients with cirrhosis, particularly those with hepatic encephalopathy. He did his residency and was resident, chief resident, and a fellow in gastroenterology and transplant hepatology, at Beth Israel Deaconess Medical Center where he served as Director of Quality Improvement for the Liver Center. He is very active on twitter and tweets at @ebtapper

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Emma presents a case to Dr. Yao Heng, followed by a discussion about her experience as a woman in Internal Medicine procedural subspecialty. 

Dr. Yao Heng

Dr. Yao Heng was born in Bangkok, Thailand. She immigrated to the US in her 20’s. After graduating from the University of California, Berkeley with a Bachelor of Arts in Biochemistry, she received her medical degree at the University of California, San Francisco. She completed her residency in Internal Medicine at the University of California, San Francisco and specialty fellowship in Gastroenterology at the University of Washington. She went to University of Brugmann in Brussel, Belgium for special training in biliary tract disorders. She has been practicing gastroenterology and hepatology at Kaiser Permanente since 1992. She is currently in charge of the capsule endoscopy and balloon enteroscopy programs at San Francisco Kaiser. She has a strong interest in small bowel disorders, the microbiome and gut directed hypnotherapy. 

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RLR are back on the podcast with 4 fascinating cases.

Over the winter, they’ve been releasing a lot of cool content on Patreon.

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Doug presents an unknown case of vision loss to Dr. Cherayil, Lindsey and Dan. 

Dr. Neena Cherayil. Dr. Cherayil is an Assistant Professor of Neurology in the Departments of Neurology and Ophthalmology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. She completed her neurology residency followed by a neuro-ophthalmology fellowship at the University of Pennsylvania. She is currently associate clerkship director of the neurology clerkship at Feinberg as well as co-module leader for the MS2 Neurosciences course.  She enjoys leading morning report every week with the neurology residents and students and seeing the fascinating spectrum of afferent and efferent neuro-ophthalmic complaints in clinic. Her particular academic interests include diagnostic reasoning and curricular development with a focus on neuro-anatomic localization.  Her favorite cranial nerve is, of course, CN III – the oculomotor nerve.

CPSolvers team members Rafael Medina and Simone Vais take a moment to reflect on what is going on in the world of medicine focusing on vaccine uptake with two incredible experts on the matter about what their experiences have been.

Dr. Matifadza Hlatshwayo Davis.

Dr. Davis is the Director of Health for the City of St. Louis. Dr. Hlatshwayo Davis received her medical degree from Cleveland Clinic Lerner College of Medicine and a Master’s in Public Health Degree from Case Western Reserve University. She completed her internal medicine residency at University Hospitals Case Medical Center. She went on to complete her Infectious Diseases fellowship at the Washington University School of Medicine (WUSM), also completing a one year HIV fellowship and a Sexually Transmitted Infections (STI) fellowship. She has held many, many positions throughout her illustrious career in medicine. Dr. Hlatshwayo Davis is now a national and international medical contributor on COVID-19 with a particular focus on marginalized populations, as well as the Director of Health for the city of St. Louis (among much else). Her career passions include community engagement, the care of people living with HIV and the impact of COVID-19 infection in marginalized populations. 

Dr. Teresa Villela

Dr. Villela is a graduate of Tucson High School, Yale University, and the University of Connecticut School of Medicine. She currently serves as Chief of Family and Community Medicine at San Francisco General Hospital and is Professor and Vice Chair in the UCSF Department of Family and Community Medicine.

Her interests include chronic illness care, family medicine education, reproductive health, health of Latinxs in the U.S., and health care disparities.  Her clinical practice includes inpatient adult medicine, short-term nursing home care, and ambulatory family medicine. She lives with her partner in the Mission district of San Francisco; they have a daughter who is a junior in college. All three are vaccinated against COVID and 2 of 3 have had boosters.    

Sharmin presents a case of angioedema to Jack, Dan and Lindsey.

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CPSolvers: Anti-Racism in Medicine Series

Episode 13: Centering Asian Americans: Racism, Violence, and Health

Show Notes by Naomi F. Fields

December 21, 2021

Summary: This episode is about racism faced by Asian-Americans, why it often goes unrecognized, and how we can work to rectify these wrongs. This discussion is hosted by Jazzmin Williams, Rohan Khazanchi, MPH, and Jennifer Tsai MD, MEd, as they interview Thu Quach, PhD, an epidemiologist and galvanizing leader who has led the Asian Health Services (Oakland, CA) in addressing racial disparities in COVID-19, and Tung Nguyen, MD, a Professor of Medicine at the University of California, San Francisco, and a nationally-renowned health disparities researcher. Our inspiring guests help us to contextualize struggles faced by Asian-Americans even as they outline and energize within us a path forward – together.

Content Warning: This episode contains themes of violence, trauma-induced mental health concerns, and brief mentions of suicide. If you or someone you know is struggling with suicidal thoughts, please call the National Suicide Prevention Hotline at 800-273-8255, that’s 800-273-TALK.

Episode Learning Objectives:

After listening to this episode learners will be able to…

1. Define the myth of the “Model Minority” and explain how it impacts the racism experienced by Asian-Americans.
2. Describe how divisiveness amongst minoritized groups was and remains politically orchestrated, and how minority groups can work together in solidarity against White oppression.
3. Appreciate how intergenerational trauma may surface amongst Asian-Americans, and how these intergenerational relationships may also offer fertile ground for generating understanding. 
4. Highlight how structural racism against Asian-Americans surfaces in clinical settings, and describe means of counteracting such structures.
5. Understand how engaged community-based work, centered on trust and accountability, has supported the health of communities served by Oakland, CA’s Asian Health Service.
6. Reckon with the health disparities that exist amongst Asian-Americans, how such disparities are related (in part) to insufficient data-gathering, inequitable clinical settings, and violence, and how they were further exacerbated by the COVID-19 pandemic. 

Credits

• Written and produced by: Jazzmin Williams, Rohan Khazanchi, MPH, Jennifer Tsai MD, MEd, Alec Calac, Victor Lopez-Carmen, MPH, Utibe R. Essien, MD, MPH, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Ayana Watkins, and Michelle Ogunwole, MD
• Hosts: Jazzmin Williams, Rohan Khazanchi, MPH, and Jennifer Tsai MD, MEd 
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Naomi F. Fields
• Guests: Thu Quach, PhD, and Tung Nguyen, MD

Time Stamps

00:00 Introduction

04:00 How Dr. Thu Quach’s and Dr. Tung Nguyen’s journeys shape their work

11:40 Policy work as a way of mitigating burnout

12:55 Balancing individual and communal focus (include?)

14:12 Origin of Asian Health Services

16:35 Impact of the COVID-19 pandemic on Asian communities in Oakland 

17:40-17:50 Content Warning: Mention of suicide

22:25 Forms of Anti-Asian racism 

25:17 The danger of gaslighting Asian-Americans and of comparing oppressions

27:51 Explanation of the model minority myth and a deeper dive into comparative oppressions

30:03 Engaging with community members via validation, and operationalizing means of working against anti-Asian racism

33:58 Dr. Jennifer Tsai reflecting on her father’s experience 

37:10 Dr. Nguyen on pathways to intergenerational connection and combatting erasure

39:45 Dr. Quach on intergenerational trauma and reconciliation 

43:56 Rohan Khazanchi reflecting on Asian-American disparities in Nebraska and community strength

46:30 Data collection and disaggregation: strengths, challenges, and insufficiencies 

56:14 Structural anti-Asian racism in clinical settings

59:22 Clinical tools and takeaways

Episode Takeaways:

• Recognize that structural barriers can embed anti-Asian racism into clinical settings. 

Insufficient language services (i.e., provision in only English +/- Spanish), limitations of medical technology (i.e., difficulty of sending patient messages through the electronic medical record in languages other than English), limited healthcare literacy, and English-only signage on healthcare campuses are just a few of the structurally racist barriers faced by many Asian folks seeking healthcare. Dr. Nguyen encourages us to recognize how such barriers represent assumptions about people’s capabilities, how they can worsen people’s healthcare, and how they communicate exclusion to our Asian patients. 

• See the world through others’ eyes, and act.

Dr. Nguyen calls us to ask ourselves: “If [my] mother and father were like this person, how would they negotiate the system that I’m in? What can I do to either ameliorate those problems, or to fix those problems behind the scenes, so they don’t have to deal with them on a day to day basis?” This can help us reach the goal of taking care of patients in the ways that they want to be taken care of, by operationalizing the vision Dr. Quach shared for “letting lived experiences guide us.” 

• Create spaces to have conversations about the broader contexts affecting patients. 

Dr. Quach reminds us that environmental factors and the political landscape affect patients’ wellbeing everyday. Creating spaces where these experiences can be shared by patients as well as by practitioners can highlight the structural nature of seemingly individualized problems. By appreciating the impact of factors affecting entire communities, we can be better positioned to act upon them. 

• Remember that more deeply understanding your patients can provide meaning!

Seeking to more deeply understand your patients is not an additional burden: ultimately, it is an additional benefit. Dr. Nguyen describes that in his experience, striving for understanding deepens the patient-provider relationship over time and offers fulfillment to him as well as to his patients. 

Pearls

• Case study: Oakland, CA’s Asian Health Services’ origin, ethos, and lessons
  • Dr. Quach describes the community- and advocacy-based origins of Asian Health Services, a Federally Qualified Health Center in Oakland, CA. She also describes their role in detecting and relaying the double-bind of challenges (COVID-19 and racism) being faced by community members throughout the pandemic, and how her team generated solutions that signaled their ongoing responsibility to the communities they served.
• Asian-Americans face both apparent and enshrouded forms of racism, both of which have directly related health effects.
  • Dr. Nguyen goes on to expand on these forms. One form includes the eye-catching racist acts that explicitly manifest anti-Asian sentiments, such as violence toward elders, verbal abuse, and gun violence. In addition to the physical wrongs done to the victims, these acts function as community stressors that harm the mental, emotional, and physical wellbeing of so many others. 
  • Another more insidious form of racism is erasure. This often manifests in a glaring lack of recognition of many of the problems faced by many Asian Americans. In the healthcare space, it can also result in a lack of data collection to demonstrate and understand issues faced by these groups. As a result, there are often failures to address their unique needs. 
• The “Model Minority” myth engenders both the racist erasure of Asian-Americans and division amongst minority groups. 
  • Created in the 1960s by conservatives seeking to divide minority groups during the Civil Rights Movement, the model minority myth projects the relative success of some Asian-Americans onto all Asian-Americans; and subsequently casts  them as an “ideal” group unaffected by the problems and negative stereotypes that plague other minority groups. In so doing, the model minority myth obscures how White supremacy actually affects Asian-Americans, and perpetuates a zero-sum game which pits minority groups against each other rather than alongside each other in solidarity. 
• Data on the problems faced by Asian Americans is lacking. This perpetuates further erasure of Asian-American health disparities, and there are multiple needed interventions to redress this injustice disparity. 
  • Erasure often conceals the need for the collection of information that would spotlight challenges/inequities faced by Asian-Americans. For instance, Dr. Nguyen describes how the National Academy of Medicine and the Centers for Disease Control, amongst other major health organizations, issued valid and needed statements about the impact of COVID-19 on other minority groups, but did not mention the problems faced by Asian- Americans – nor the fact that the data was insufficient. The resulting message implied to the public was that no problems existed. 
  • Additionally, data collection practices often do not capture all experiences due to usage of inaccessible language, or neglecting to spotlight voices from the most marginalized community members. 
  • Data disaggregation, which seeks to spotlight specific ethnic groups within the Asian diaspora, can be a helpful step in better understanding the experiences unique to Asian-American communities we serve. It requires recognizing the diversity of experiences and gaining buy-in from community members. 
• “You don’t fight fire with fire, you fight fire with water.” – Fred Hampton
  • Dr. Nguyen mentioned this quote, and expounded upon it to say, “You don’t fight racism, with more racism you fight racism with solidarity and partnership and coalition building.” Although the Model Minority myth has generated divisiveness amongst minority groups, true power can come from folks turning away from gaslighting and the wrly named “Oppression Olympics” to recognize that we all need to work together against the real enemy: Oppression writ large by White supremacy. 
• Within Asian-American communities, intergenerational relationships can be a critical strength. 
  • Multiple members of this episode describe challenging experiences with bridging understanding of their elder family members that may mirror dynamics within Asian-American communities more broadly. 
  • On the one hand, these relationships convey the intergenerational traumas (of migration, of racism, and the like) that impact elders’ experiences, yet may differ from those of younger individuals. 
  • Simultaneously, these relationships present opportunities to connect interpersonally as “genuine human beings,” and to find solution-generating commonalities. 
  • Relatedly, our guests both describe experiences acting as “cultural brokers” to assist with healthcare needs of their elders that impacted their own journeys into medicine. These insights primed them to understand what challenges community members might be facing now. 

References

1. Asian Health Services. https://asianhealthservices.org 
2. Catch Me Up to Speed Podcast. “Episode #9: Asian-American history.” https://www.audible.com/pd/Episode-9-Asian-American-history-Podcast/B094JN9KMY?ref=a_pd_Catch-_c0_lAsin_0_1&pf_rd_p=1da7ab30-c785-4a0e-a160-4a7e7077b353&pf_rd_r=3QRHMQRNRTAS8S8BFX2Q 
3. Public Broadcasting Service. “Asian Americans: The history of identity, contributions, and challenges experienced by Asian Americans.” https://www.pbs.org/show/asian-americans/ 
4. Asian American Voices. “My language, my right.” https://www.asianamvoices.org/     
5. Chu JN, Stewart SL, Gildengorin G, et al. Effect of a media intervention on hepatitis B screening among Vietnamese Americans. Ethn Health. 2019;1-14. doi:10.1080/13557858.2019.1672862
6. Quach T, Von Behren J, Tsoh J, et al. Improving the knowledge and behavior of workplace chemical exposures in Vietnamese-American nail salon workers: a randomized controlled trial. Int Arch Occup Environ Health. 2018;91(8):1041-1050. doi:10.1007/s00420-018-1343-2
7. Yan BW, Hwang AL, Ng F, Chu JN, Tsoh JY, Nguyen TT. Death Toll of COVID-19 on Asian Americans: Disparities Revealed. J Gen Intern Med. 2021 Nov;36(11):3545-3549. doi: 10.1007/s11606-021-07003-0.
8. Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D,  Essien UR, Khazanchi, R. “Antiracism in Medicine – Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/antiracism-in-medicine/. January 19, 2021.
9. Los Angeles Times (2021). “Hate crimes against Asians jumped 107% in California in ‘an epidemic of hate’.” https://www.latimes.com/california/story/2021-06-30/california-attorney-general-hate-crimes 
10. California Department of Justice (2021). Anti-Asian hate crime events during the COVID-19 pandemic. https://oag.ca.gov/system/files/media/anti-asian-hc-report.pdf 
11.  The Practice (2019). “The Model Minority Myth.” Harvard Law School.  https://thepractice.law.harvard.edu/article/the-model-minority-myth/
12. Kawai, Yuko. (2005). Stereotyping Asian Americans: The Dialectic of the Model Minority and the Yellow Peril, Howard Journal of Communications, 16:2, 109-130, DOI: 10.1080/10646170590948974
13. Smith, Andrea. “Chapter Six: Heteropatriarchy and the Three Pillars of White Supremacy: Rethinking Women of Color Organizing”. Color of Violence: The INCITE! Anthology, edited by INCITE! Women of Color Against Violence, New York, USA: Duke University Press, 2016, pp. 66-73. https://doi.org/10.1515/9780822373445-008
14. Hampton, F. (1969). “Power anywhere where there’s people.” https://www.historyisaweapon.com/defcon1/fhamptonspeech.html 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Quach T, Nguyen T, Williams J, Tsai J, Fields NF, Calac A, Lopez-Carmen V, Krishnamurthy S, Nolen L, Onuoha C, Watkins A, Williams J, Essien UR, Ogunwole M, Khazanchi R. “Antiracism in Medicine – Episode 13: Centering Asian Americans: Racism, Violence, and Health.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/antiracism-in-medicine/. December 21, 2021.

Show Transcript

Rabih discusses the case with one key question: Do we use an AND or an Or or, Both?

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Maria presents a case of episodic transient loss of consciousness to Gabriel and Ravi.

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Maria Jimena Aleman

Maria Jimena Aleman was born and raised in Guatemala where she currently is a medical student in Universidad Francisco Marroquin. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She also 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 Louis Armstrong. Outside of medicine she enjoys modern art, 21st century literature and having hour long conversations over a nice hot cup of coffee or tequila.

Gabriel Talledo

Gabriel is a MS2 student from Cayetano Heredia University. When it comes to medicine, he enjoys dermatology, infectiology, and LGBTQ+ health. He fell in love with his career when he understood medicine not just as a concept of knowledge but a combination of knowledge and social justice pursuit. He loves cooking Peruvian cuisine (one of the best in the world), eating, jogging and watching TV series. Recently he is doing a transgender education program at his university and a volunteering of sexual education in Lima schools.

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Dr. Kushal, Dr. Saman, and Dr. Brandon discuss a case of worsening dyspnea and fever.

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Dr. Kushal Vaishnani

Dr. Kushal Vaishnani is a Hospitalist at Atrium Health. He finished his medical school at B.J. Medical College, Ahmedabad, India. He completed his transitional year at Brandon Regional Hospital and Internal Medicine residency at LSUHSC – University Hospital and Clinics in Lafayette. His academic interests include clinical reasoning, medical education, high value care, and infectious diseases.

Dr. Saman  Nematollahi

Saman is from Tucson, AZ. He graduated from the University of Arizona College of Medicine, finished internal medicine residency at Columbia, and his infectious diseases fellowship at Johns Hopkins. He is now working as a transplant ID physician at the University of Arizona. He is also completing his Master’s of Education in the Health Professions. He enjoys cooking with Reza and washing the dishes. In his spare time, he loves to watch PJ Masks with his wife and son, who was featured in Episode 42 as AstroBoy.

Dr. Brandon Pearce

Brandon Pearce is a third-year Internal Medicine resident at Ascension St. Vincent in Indianapolis.  His medical interests include pulmonary critical care and clinical education.  In his spare time, he enjoys basketball, hiking with his fat Labradors, and traveling.