The Clinical Problem Solvers

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Sue Ellen presents a clinical unknown to Nick, Jennifer, and Dan

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Nicholas Hornstein

Nicholas Hornstein is a PGY-3 at UCLA Ronald Reagan Medical Center. He was born and raised in Los Angeles, earned his undergraduate degree from Brandeis University, and graduated from Columbia University with an MD and a PhD in Computational Biology. He has a passion for climbing, cooking, furry animals, and the advancement of medical genomics/technology.  He will be furthering his education next year with a Fellowship in Hematology Oncology at MD Anderson Cancer Center and couldn’t be more excited.

Suellen Li

Suellen Li is a PGY-2 internal medicine resident at Massachusetts General Hospital. She grew up in Roanoke, VA and attended Duke University, where she studied Environmental Sciences & Policy and Global Health. She then moved to Chicago to complete medical school at the University of Chicago Pritzker School of Medicine. After finishing residency, she hopes to pursue a career in hospital medicine. In her free time, she enjoys reading, eating chips and being a cat mom.

Jennifer Plotkin

Jennifer Plotkin is a PGY2 in internal medicine at UCLA. She was born and raised in Los Angeles. She attended MIT for undergrad where she majored in Chemistry. She completed her medical school training at Johns Hopkins. She loves internal medicine for its problem solving and meaningful therapeutic relationships with patients. Her interests include primary care, endocrinology, and medical education, particularly in the veteran population. Outside of medicine, she enjoys running, rooting for the Lakers and Dodgers, and exploring restaurants.

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Summary

In this special episode of the Antiracism in Medicine Series, originally recorded for the 2021 Society of General Internal Medicine Annual Meeting, the CPSolvers Antiracism team discusses what must be done to make medical education more antiracist. The conversation spans stages of academic medical career progression, ranging from recruitment to training to retention. The ARM team draws upon their own research and personal experiences to provide listeners with recommendations and actionable next steps.   

Learning Objectives

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

1. Explore the common barriers to entering the medical profession that minoritized trainees face and discuss strategies that trainees and institutions can adopt to overcome them.
2. Recognize how racist ideologies are often perpetuated in medical education and ways that academic medical centers can revise their curricula to prepare a physician workforce that is invested in recognizing and addressing the root cause of health disparities.
3. Understand the “minority tax” that minoritized trainees and faculty experience in diversity, equity, and inclusion reform efforts; identify models to properly compensate individuals for their time and expertise.  

Credits

• Written and produced by: Dereck Paul, MD, MS; Chioma Onuoha, Utibe R. Essien, MD, MPH; Rohan Khazanchi, MPH; LaShyra Nolen; Naomi F. Fields; Michelle Ogunwole, MD; Jazzmin Williams; and Jennifer Tsai MD, M.Ed
• Host: Chioma Onuoha
• Infographic: Creative Edge Design
• Guests: Rohan Khazanchi, MPH; Naomi F. Fields; Michelle Ogunwole, MD; Utibe R. Essien, MD, MPH; Jazzmin Williams

Timestamps:

00:00 Introduction

02:15 Barriers to Entry in Medicine 

05:15 How to Identify an Uplifting Institutional Home 

11:40 Racism Ingrained in Medical Education

15:10 Imagining an Ideal Medical School Curriculum

17:40 A Roadmap to Engaging Hyperlocal Communities in Medical Education

20:30 Moving Beyond Ahistorical Conversations about Health Disparities 

27:05 Engaging All Learners as Stakeholders for Health Equity and Antiracism

33:40 Re-examining Who the Experts Are

42:40 Recognizing Privilege and Positionality 

45:25 Patient Safety Analogy and “Racism Saps the Strength of the Whole”

49:44 Where Do You Find Your Hope?

Takeaways:

1. Reimagining the learning environment: Creating a more antiracist learning environment will require institution-level commitments and broader reforms in the medical education regulatory environment (i.e. board examinations and mandated competencies). 
2. Valuing health equity work: antiracism and health equity work must be properly compensated at all levels of training. Such compensation could be monetary or come in the form of academic currency, like co-authorship of publications.
3. How to be a good ally and co-conspirator: Power and access are needed to sustain and amplify antiracist justice within medicine. Many times, granting this power and access will require that individuals with privileged identities historically possessing a disproportionate amount of power transfer that power to individuals from marginalized backgrounds. Rather than centering the importance of individual advancement, we can remember that whenever racism is operational, as Dr. Camara Jones says, it “saps the strength of the whole society.” Using justice to guide our distribution of power will improve everyone’s livelihood. 
4. Advancing beyond ahistorical teaching on racial health disparities: Health equity education must include racism as a driver of health inequities. As prior podcast episodes have highlighted, misleading theories of racialized biological differences cannot be presented as the cause of racial health disparities. 

Pearls:

Acculturation to Medical Education 

While the process of medical education is exciting, progressing through clinical training involves acculturation for all. This acculturation can differentially affect learners based on their own backgrounds and experiences. It is important for learners to reach out to mentors and peers who can offer insight into learning the ropes, and a safe place to land; it is also important for educators to recognize this and offer this to their learners. Additionally, it is important that institutions create environments where students have educators and faculty of similar backgrounds as theirs to learn from.

For trainees: What to consider when evaluating medical schools and residency programs

It can be challenging for students and residents  to decide if an institution is truly committed to antiracism, social justice and equity. While time and action are true measures of this commitment, some things to consider include:

• Is there diversity, which is more than skin deep, in the leadership?
• Does the institution involve community members in training?
• What is the relationship between community members and the academic medical center?
• How does the institution respond to issues of injustice that affect trainees?
• Is advocacy celebrated or at least respected and encouraged?
• Does the institution recognize past historical transgressions? What have they done to address a painful history if one exists?
• Does the curriculum equip learners with a vocabulary to discuss racism?
• Does the curriculum include historical context about the communities served by the academic medical center?

Engaging All Students as Stakeholders

Antiracism education can seem relegated to students with niche interests. Nevertheless, there are ways to engage all students as stakeholders. 

• Board exam writers can shape their learning objectives toward antiracism based on our evolving knowledge base and more accurate paradigms of racism-as-the-risk factor, given that board exams shape what educators include in their curricula. 
• On an institutional level, we can incentivize scientifically accurate, ethically responsible, justice-based means of representing and incorporating race, racism, and health equity within faculty members’ work. These are the people that learners often look up to and after whom they model their careers. 
• Finally, we might eschew the idea that learners are disinterested in these topics, and commit to deep education regarding race/racism in medicine. Learners are often intellectually curious with a heart to learn what is needed to provide the best care for their patients. 

Curricular Reforms to Operationalize Antiracism

Curricula seeking to address health inequities cannot be ahistorical. Health disparities are not created in a vacuum; thus, discussion of disparate outcomes should include conversations about the systemic and structural underpinnings of inequity.

Similarly, medical curricula must become comfortable reframing who the “experts” are on health disparities topics. In brief, community stakeholders are crucial experts on the lived experiences and health of their neighbors. Community engagement, as well as prioritization of hyperlocal issues impacting communities proximate to academic institutions, can and should be integrated in health equity curricula.

References:

1. Amutah C, Greenidge K, Mante A et al. Misrepresenting Race — The Role of Medical Schools in Propagating Physician Bias. New England Journal of Medicine. 2021;384(9):872-878. doi:10.1056/nejmms2025768
2. Nolen L. How Medical Education Is Missing the Bull’s-eye. New England Journal of Medicine. 2020;382(26):2489-2491. doi:10.1056/nejmp1915891
3. Sharma M, Pinto A, Kumagai A. Teaching the Social Determinants of Health. Academic Medicine. 2018;93(1):25-30. doi:10.1097/acm.0000000000001689
4. Phelan S, Burke S, Cunningham B et al. The Effects of Racism in Medical Education on Students’ Decisions to Practice in Underserved or Minority Communities. Academic Medicine. 2019;94(8):1178-1189. doi:10.1097/acm.0000000000002719
5. Khazanchi R, Keeler H, Marcelin J. Out of the Ivory Tower: Successes From a Community-Engaged Structural Competency Curriculum. Academic Medicine. 2021;96(4):482-482. doi:10.1097/acm.0000000000003927
6. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Academic Medicine. 2016;91(7):916-920. doi:10.1097/acm.0000000000001232
7. Jones C. Toward the Science and Practice of Antiracism: Launching a National Campaign Against Racism. Ethn Dis. 2018;28(Supp 1):231. doi:10.18865/ed.28.s1.231
8. Tsai J, Lindo E, Bridges K. Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education (MedCRT) to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short. Front Public Health. 2021. doi: 10.3389/fpubh.2021.653643

 

Transcript

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Disclosures

Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education, but the views presented herein represent his own and not necessarily those of the AMA or the Council. The hosts and guests report no other relevant financial disclosures.

Citation

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. https://clinicalproblemsolving.com/episodes. June 10, 2021.

 

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Rabih moderates as an interactive, international virtual morning report community discusses a case of fever

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Dr. Hernán Carrillo

Hernán Carrillo is Head of the Internal Medicine Department at Las Higueras Hospital in Talcahuano, Chile. He’s also an Assistant Professor at Concepción’s University. He is passionate about his work in public health care and is specially crazy about diagnostic process. Loves to play guitar and singing, and he’s learning a little bit of piano. Also enjoys photography. He is totally in love with his family!

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Description: We continue our campaign to #EndNeurophobia led by Aaron Berkowitz! This time, Doug presents a case of headache and blurry vision to Hannah and Dhruv.

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Dhruv Srinivasachar

Dhruv Srinivasachar is a soon-to-be 1st year Medicine-Pediatrics resident at Western Michigan University and a graduate of Virginia Commonwealth University School of Medicine (the Medical College of Virginia for all the veteran attendings out there). Introduced to medicine through research, Dhruv has shifted his passions to empathetic clinical care and medical education, as a contributor to the CPSolvers (especially through VMR as a case presenter, discussant, and compiler of cases) and team member for the Not Just Little Adults podcast (CPedsSolvers, if you will). When he’s not looking for apartments or stressing about intern year, he can be found biking, gardening, and cooking.

Hannah Roberts

Hannah is currently finishing medical school in Arizona with plans for emergency medicine. She graduated from the US Naval Academy and completed active duty before starting med school. Her interests in medicine include nuclear weapons safety, medical education, and clinical applications of evolutionary biology. Outside of medicine she is a dog person and loves being outside mountain biking, running, and camping.

Doug Pet

Doug Pet 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 Spike ball, and making custom wooden pens on his lathe.

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Sharmin, Rabih, Reza, and Arsalan tackle a schema for pulmonary disease with eosinophilia

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Dr. Katrina Armstrong and Dr. Vineet Arora join the #bosslady Wdx team to discuss navigating negotiations as women in medicine

Dr. Katrina Armstrong

Dr. Katrina Armstrong is the Jackson Professor of Clinical Medicine at Harvard Medical School, Chair of the Department of Medicine and Physician-in-Chief of Massachusetts General Hospital. She is an internationally recognized investigator in medical decision making, quality of care, and cancer prevention and outcomes, an award winning teacher, and a practicing primary care physician. She has served on multiple advisory panels for academic and federal organizations and has been elected to the American Society of Clinical Investigation and the Institute of Medicine. Prior to coming to Mass General, she was the Chief of the Division of General Internal Medicine of the Robert Wood Johnson Clinical Scholars Program at the University of Pennsylvania.

Dr. Vineet Arora

Vineet Arora, MD, MAPP is an academic hospitalist and Associate Chief Medical Officer for Clinical Learning Environment and Assistant Dean for Scholarship & Discovery at the University of Chicago. Through her role, she bridges educational and hospital leadership to engage frontline staff into the institutional quality, safety, and value mission. An accomplished researcher, she is PI of numerous NIH grants to evaluate novel interventions that combine systems change with learning theory to improve care which has resulted in publications that have been cited over 11,000 times.  She is an elected member of the National Academy of Medicine and the American Society of Clinical Investigation. As an advocate for women in medicine, she was featured in the New York Times for an editorial that called to end the gender pay gap in medicine. She is a founding member of the 501c3 Women of Impact dedicated to advancing women leaders in healthcare. She is on the leadership group of the National Academy of Science Engineering and Medicine’s Action Collaborative to End Sexual Harassment in Higher Education.

 

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“There’s nothing new under the sun, but there are new suns” – Octavia E. Butler

Summary: We invite social justice champion and acclaimed scholar of race, gender, and the law, Dorothy E. Roberts, JD, to discuss the history of race-based medicine and the movement for health equity and justice.

Episode Learning Objectives

After listening to this episode learners will be able to…

1. Understand race as a social construct and political invention
2. Explore the history of race as a proxy for genetics and ancestry
3. Explore the history of race-based pharmaceuticals
4. Explore the history of race-based clinical algorithms

 

Credits

• Written and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Jenny Tsai, MD, Jazzmin Williams, Dereck Paul, MS, and Utibe R. Essien, MD, MPH 
• Infographic: Creative Edge Design
• Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Michelle Ogunwole, MD
• Guest: Dorothy E. Roberts, JD (@DorothyERoberts)

 

Timestamps:

00:00 Introduction

03:40 Defining Race

13:40 Responses to Common Race Based Medicine Arguments

20:40 Race as a Proxy for Racism

31:00 BiDiL and Race Based Medicine Definition

42:00 Dr. Duana Fullwiley and the “African Gene”

49:30 Debunking Folklore Health Narratives

53:30 Slavery Hypertension Hypothesis

57:00 Importance of Intentional and Plausible Research Methods

1:00:00 Race in Medical Algorithms 

1:12:00 Moving Away from Relying on Simplistic Biological Concepts of Race

1:15:48 Advice for Listeners

1:21:00 Closing Remarks 

Takeaways:

1. Definition of Race: Race is not a biological category, instead it is a permeable, flexible, and unstable social construction and political invention that facilitates political and economic inequality. However it is important to remember that this political invention DOES affect biology because of the way that it creates social inequity.
2. Historical Context: Historically, laws such as interracial marriage bans have protected established structures of white supremacy and reinforced the social construct of race.
3. Race is a Poor Proxy for Genetics: Diseases with genetic or population associations are often evolutionary adaptations to specific geo-environments. Race, a social construction, groups people from large swaths of of global territory based on superficial phenotype is often a poor proxy for these genetic associations with disease. 
4. Race is a proxy for Racism: race was invented as a way to classify people into subordinate groups and support the political sanctioning of inequity.  The very function of race is thus to support and uphold racism. When we evaluate race in medicine we have to recall  this origin story and not rely on race as a placeholder for anything else except racism.
5. The Root of Inequities: Health inequities are overwhelmingly caused by differences in social status, living conditions, and experiences of discrimination. When we cling to race as the cause of  health inequities, we obscure and divert attention away from these social factors that need to be addressed.
6. Intersectionality: Race and racism intersect with socioeconomic status, education, geography, sexual orientation, religion, immigration status, gender and other identities with differential impact. 
7. Our responsibility in medicine: “What we have to do is include medicine in the political movement to bring down the structures of racism and white supremacy and the way in which medicine incorporates those and promotes those. And [this] HAS to be in conjunction with broader social movements…that are dedicated to radically transforming our world into one in which human beings are equally valued…”-Dorothy E. Roberts JD
8. For the patient I see tomorrow:  Beyond recognizing that race is not a proxy for biology, we can all ask ourselves “What way is structural racism affecting my patient and what can I do about it?” The answer to this question may not be easily answered and may not always be found in the clinical setting.

Pearls:

“Genetics is not the end all be all of understanding disease” – Dorothy E. Roberts JD

An Emphasis on Genetics is Not the Solution to Race-Based Medicine

Being antiracist in medicine does not mean being more precise in our understanding of genetics. Rather we need a deeper and broader understanding of the influence of the structural and political determinants of health inequities. Part of the problem with focusing on race in medicine is that it limits our perspectives and encourages research practices that lack the rigor required to identify root causes of racial health inequities. We should be focusing on root causes rather than proxies. It does not mean that we should stop exploring genetic causes of disease, but rather that we should not pretend that understanding genetics is the solution to addressing disparities. Dr. Roberts put it expertly: “to be anti-racist, it doesn’t mean, well, then let’s just be more precise in our genetics. It means being anti all the things that race and racism do.”

Medicine Must Move Beyond Othering Black People

All too often in medicine, Black people are singled out from all other human beings as having different bodies from the norm, aka whiteness. Examples of this include: BiDiL, the blood pressure drug marketed solely to black people; arguments for race-based medicine that cite sickle cell, a disease that is most common in Black people because of geographic varietion rather than innate difference; and the slavery hypertension hypothesis which posits that hypertension disparities observed in Black people are a result of the stress of slavery and the middle passage rather than the longitudinal impacts of structural racism. Rather than searching for obscure explanations for inequalities, we must instead recognize the ways that racism impedes health at both individual and structural levels. 

Race-based algorithms can produce inequity and there is a moral dilemma we must attend to

There is a persistent question about whether race-based clinical algorithms disadvantage patients and how we should think through use of them in clinical medicine. Professor Roberts offers some guidance: whenever you are stuck, go back to the origin story- what is race? Then you can ask yourself, how is race being used and does that use further inequity? 

Professor Roberts also offers a few scenarios.

1. Race-based algorithms: Race is being used as a biological construct AND it can produce harm. For example, GFR- race correction for Black patients. The use of race is  based on a false/biological concept of race AND many studies show that this can harm patients ( i.e. clinical resources are withheld based on results of algorithm). This is the rationale for NOT using these kinds of race-based algorithms.
2. Race “neutral” algorithms, which are used for allocation of resources for most fit patients. Race is not included in the algorithm, however because of the experiences of structural racism, certain groups will have worse scores. These worse scores may lead to the withholding of resources and ultimately further inequity. For example, the proposal of race neutral ventilator algorithms that were set up to allocate ventilators to the most fit patients during the COVID-19 pandemic. This race neutral algorithm could disadvantage Black patients, who because of structural racism may have lower fitness scores. This could worsen existing disparities in COVID-19 outcomes among Black patients. 

Moral dilemma: Including race as a biological construct in clinical algorithms can lead to inequity. However whenever structural racism isn’t included in clinical algorithms, we also risk denying a group who has experienced structural racism access to much needed resources. We have not thought about this enough in medicine and we don’t have a gold standard of how to include race as a proxy for structural racism in our clinical algorithms. As we move forward we must continue to think critically about the ethical and just way to include race or rather structural racism in clinical algorithms and ensure that our algorithms do not further inequity.

References:

1. Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 140: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. 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. https://clinicalproblemsolving.com/episodes. December 17, 2020.
3. Roberts D. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century. The New Press: 2012.
4. Roberts D. “The problem with race-based medicine.” TEDMED 2015. Link to talk.
5. Roberts DE. What’s Wrong with Race-Based Medicine?: Genes, Drugs, and Health Disparities. Minnesota Journal of Law, Science & Technology. 2011;12(1):1-21.
6. Yudell M, Roberts D, DeSalle R, Tishkoff S. NIH must confront the use of race in science. Science. 2020;369(6509):1313-1314. doi:10.1126/science.abd4842
7. Roberts DE. Is race-based medicine good for us?: African American approaches to race, biomedicine, and equality. J Law Med Ethics. 2008;36(3):537-545. doi:10.1111/j.1748-720X.2008.302.x
8. Taylor AL, Ziesche S, Yancy C, Carson P, D’Agostino R Jr, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN; African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med. 2004 Nov 11;351(20):2049-57. doi: 10.1056/NEJMoa042934. 
9. The Slavery Hypertension Hypothesis: Dissemination and Appeal of a Modern Race Theory. (2003). Epidemiology, 14(1), 111-118. Retrieved May 9, 2021, from http://www.jstor.org/stable/3703292
10. Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon Books, 1997.
11. Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020 Dec 17;383(25):2477-2478. doi: 10.1056/NEJMc2029240.
12. Hansen H, Netherland J. Is the Prescription Opioid Epidemic a White Problem?. Am J Public Health. 2016;106(12):2127-2129. doi:10.2105/AJPH.2016.303483
13. Bibbins-Domingo K, Fernandez A. BiDil for heart failure in black patients: implications of the U.S. Food and Drug Administration approval. Ann Intern Med. 2007 Jan 2;146(1):52-6. doi: 10.7326/0003-4819-146-1-200701020-00009. Erratum in: Ann Intern Med. 2007 Apr 17;146(8):616. PMID: 17200222.
14. Roberts DE. Abolish race correction. Lancet. 2021 Jan 2;397(10268):17-18. doi: 10.1016/S0140-6736(20)32716-1. PMID: 33388099.

Transcript

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Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

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. https://clinicalproblemsolving.com/episodes. May 10, 2021.

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Dan, Doug, and Lindsey are joined by expert neurologist Dr. Aaron Berkowitz to help break down a consult question about back pain and double vision 

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We continue our campaign to #EndNeurophobia, as Gabriela, Sherry, and Kaitlyn discuss a case with Dr. Aaron Berkowitz

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Kaitlyn Thomas

Kaitlyn Thomas is a 3rd year medical student at Lake Erie College of Osteopathic Medicine at their Seton Hill campus in Greensburg, Pennsylvania. She is interested in medical education, advocacy and assisting underserved populations. She has contributed to the CPSolvers on Virtual Morning Report on several occasions and produced a few videos for their illness scripts. In her free time, she enjoys hiking, spending time with family, and finding new recipes to cook.

Sherry Chao

Sherry Chao is a 4th year medical student at University of North Carolina at Chapel Hill. She is interested in medical education and is also an aspiring physician-scientist hoping to apply computational systems biology to understanding hematologic diseases. In her free time, she likes to travel and explore outdoors with her husband, try out new escape rooms, and play with her bearded dragon, Toothless.

Gabriela Pucci 

Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).

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Reza and Rabih work through a case of dyspnea and finger swelling, presented to them by Dr. Usha George.

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Dr. Usha George

Dr. Usha George, MBBS (MAHE India), MSc (Respiratory Medicine) Imperial College University of London, FRCP London, is at present attached to Sunway Medical Centre, Malaysia. It is a 650 bedded private tertiary hospital, also involved in training medical students. I practice as a Respiratory and General Medicine Physician. My special interest is in clinical and diagnostic reasoning.