The Clinical Problem Solvers

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Sharmin, Rabih, Reza, and Arsalan tackle a schema for glomerulonephritis 

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Dr. Amara Finch presents a case of abdominal pain at VMR to Maani, Maria, Anna and Smitha.

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Dr. Amara Finch

Originally from Atlanta, Georgia, Amara spent time in Massachusetts, Vermont, British Columbia, Connecticut and Colorado before returning to the vibrant ATL for medical school. She is now an intern in the Med-Peds program at the University of Arizona in Phoenix. She is passionate about better understanding the relationship between early life exposures and lifelong health as a means to improve preventive medicine for kiddos, re-imagine our approach to adult disease, and disrupt intergenerational cycles of health inequity. Outside of the hospital you can find her hiking, biking, writing, and working on her collection of fermented foods including kimchi and hot sauce.

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Steph presents a case of pleuritic chest pain to Dan and Jack

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Malika presents a Human Dx case of pleuritic chest pain to Lindsey, Aaron, and Kelly

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Dr. Kelly Uelmen

Kelly is a second-year internal medicine resident at Mercy Health in Muskegon, MI.  I’m from Wisconsin and went to medical school at LMU-DCOM in Tennessee.  I am looking forward to a career in hospitalist medicine once I finish residency.  In my free time, I enjoy traveling (pre-COVID, anyway), cooking, reading fiction, and playing with my dog, Bubba. 

Dr. Aaron Sabal

Aaron is currently a PGY-3 at Mercy Health Muskegon aspiring for a career in hospital medicine. He was born and raised in Westland, MI (Detroit metro area) and went to Wayne State University for his undergraduate studies thinking he would be a physical therapist, massage therapist, and dietitian (yes, all three of those). However, one week prior to starting a massage therapy program, he had an epiphany and decided to go to medical school instead. He was fortunate to be accepted at MSUCOM and fell in love with Internal Medicine. His passions include all things medical. In particular, he is passionate about medical education, how best to help physicians learn, diagnostic reasoning, and creating an environment of learning where no one is afraid to express what they’re thinking. When he is not pursuing his love of learning, he is spending time with his wife and their boys (2 cats and a dog), playing with his animals, preparing to be a father to his soon-to-be-born son, crossfitting, doing DIY home-improvement projects, exploring national parks, or reading good nonmedical fiction with a cat or dog in his lap begging for his love and attention.

Malika Gill

Malika Gill is a 4th-year medical student at Virginia Commonwealth University pursuing internal medicine with interests in gastroenterology and medical education. She completed her undergraduate studies in biology and psychology at Virginia Commonwealth University. In her free time, she loves to read, try new restaurants, and spend time with friends and family. 

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/ARM-EP4-Dismantling-Race-Based-Medicine-Part-2-Clinical-Perspectives.mp3

This is the second episode of a three-part series on understanding and dismantling race-based medicine. We invite Drs. Nwamaka Eneanya and Jennifer Tsai to discuss the limitations and harms of race-based medicine in clinical practice. Our guests explain how we can incorporate race-conscious medicine in clinical settings, medical education, and biomedical/epidemiological research to responsibly recognize and address the harms of racial inequality.

Learning Objectives

After listening to this episode learners will be able to…

• Explain how race-based medicine harms our ability to provide equitable care for all
• Understand the role of race in eGFR and other clinical calculators and the challenges of teasing out its role
• Describe what clinicians can do to identify race-based medicine and how they can adapt their practices to mitigate the potential harms of race-based medicine
• Explain the roles of medical education and biomedical/epidemiological research in accurately describing and justly addressing differences in clinical outcomes that stem from racial inequality
• Understand why race-conscious medicine–not colorblindness–is how we should move forward and beyond race-based medicine

 

Credits

• Written and produced by: Utibe R. Essien, MD, MPH, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Jazzmin Williams
• Hosts: Utibe R. Essien, MD, MPH, Rohan Khazanchi, and Jazzmin Williams
• Show Notes: Naomi Fields
• Infographic: Creative Edge Design
• Guests: Nwamaka Eneanya, MD, MPH, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania (@AmakaEMD) and Jennifer Tsai, MD, MEd, Yale Emergency Medicine Class of 2023 (@tsaiduck77)

 

Download Transcript Here

Episode 4 – Race-Based Medicine, Part 2: Clinical Perspectives

 Show Notes

Naomi F. Fields

Time Stamps

00:00    Mission, vision, and introductions of hosts

01:30    Background on three-episode series

02:26    Introductions of guests

04:16    How Dr. Eneanya has seen race-based medicine play out in clinical practice

07:19    How Dr. Tsai has seen race-based medicine play out in clinical practice

10:45    What role should race play in making clinical decisions?

13:16    Status of the current conversation on removing race from eGFR calculators: why is it so contentious?

19:05    Clarifying the “ethics vs science” argument and critiquing research techniques

22:00    Resurgence of race-based speculation in COVID-19-related research

25:57    Implantation of ideas about innate racial inferiority within medicine

28:32    Will removal of race from algorithms potentially harm our patients?

33:19    Danger of normalizing immutable, innate racial difference within clinical algorithms

38:10    What role should race hold as we move toward health equity?

45:50    Key takeaways for trainees

47:45    Key takeaways for faculty

49:17    Pointers to those interested in health equity research

50:17    One thing you can employ in your practice today

54:14    Bloopers!

Episode Takeaways:

Trainees

Asking thoughtful questions that challenge the “status quo” can prove an effective means of sparking discussions while minimizing the potential for negative retaliation. Dr. Tsai describes previously asking her attendings, “Why is there a race correction for adults in nephrology, but not for children? What happens at age 18 [to provoke the need for correction]?” Questions such as these can stimulate thoughtful inquiry and remind all of us of the responsibility to be critical practitioners.

Faculty

If you feel your cause is important, keep going — even when you are challenged by others. Attending physicians have tremendous power in dictating culture, and are so valuable in extending this work, especially given how the hierarchical nature of medicine can make it difficult for trainees to advocate firmly. Moreover, center patients not only in discussions about individual decision-making but in constructing and drawing meaning from the research. 

All

If you are interested in health equity, recognize that there is a breadth of research established in the fields of health equity, disparities, and structural racism. Be sure to do the work to educate yourself about the foundations of this work, and collaborate with those who have been studying and establishing it if you have the opportunity. 

Poet Marge Piercy has written, “The work of the world is as common as mud.” While there indubitably exists a need to advance scholarship and theory, we must also ground ourselves in the day-to-day actions that can bring comfort and kindness to our patients. Where can you give an extra inch to those for whom you are caring? 

Pearls

Role of Race in Clinical Reasoning

Harnessing the idea that “race is a social construct” to exclude consideration of race from medicine altogether does a disservice to our patients. Race, racism, and racial inequality have tangible impacts on people’s livelihoods, much less their experiences in the healthcare system. For instance, there is well-established research on how the stress of racism and racial inequality become “embodied” by modifying people’s cortisol levels to exert end-organ effects. Thinking about race is not racist in and of itself: It is the usage of race in the service of white supremacy or oppression that makes that transformation. Being race-conscious, or critically curious about the ways in which racism and racial inequality may affect our patients, can actually offer a starting point for advancing health justice. Much is akin to how naming the “battered child syndrome” catalyzed changes in our frameworks for addressing child abuse, critical curiosity in the space of racism can help us to develop thoughtful plans for tracking, discussing, and monitoring racism within in healthcare settings and beyond.

Race in eGFR Calculations — Why So Contentious?

eGFR equation-building is a complex science. Returning to the early literature that informs the equations reminds us that this research demonstrated racially stratified differences between Black and white cohorts. However, these studies did not account for many of the factors that can impact creatinine, the main biomarker used in eGFR calculations. These factors include a high-protein diet, muscle mass, creatinine generation, and certain medications. Many of the Black participants in the CKD epi study came from an African-American cohort (ASK trial) in which 50% of participants hadn’t graduated high school and over 50% made less than $50,000/year. These factors may have impacted their diet, physical activity, and medications, thus impacting their creatinine levels and the inputs that we use for GFR. This reminds us that using race as a catch-all can shroud other factors (ex. structural racism) that more rigorously account for differences observed between groups. And, as we think about revamping eGFR calculators, we must also ensure that there are standardized means of doing so across institutions.  

Ethics-Plus: Reforming our Approaches to Clinical Research 

Without question, there exists a strong ethical imperative to eradicate racism from biomedical science and to better use biomedical science in the service of health justice. There also exists an imperative to refine how we use race in research, given the scientific evidence that it is a social construct. Critiquing the cursory usage of race in studies illuminates the need to clearly define and standardize race as an operational variable, explain that to which racial differences are attributed, and describe how we interpolate meaning from these differences. Failing to do so may obfuscate the realities of social-structural racism, and obscure opportunities for improving understanding or intervention. Rigorous usage of race is not only ethically sound: it’s also better science.

In this vein, our researchers can take advantage of the technology that we have to ask more sophisticated questions that generate true accuracy, rather than those that simply accept race as a surrogate. We might critically think about why we might use race in a regression model, and proactively consider how we will interpret and responsibly discuss findings that may result. We might group people across socio-demographic categories (ex. education, income, number of previous hospitalizations) that also lead to clinical outcomes, not only race-based stratification. When racial differences are observed, we might further examine contributors to outcomes within a group. Our journals can help lead the charge by more diligently enforcing fastidious usage of race within papers they choose to publish. Rather than accepting racially-stratified differences in outcomes as inexorable and without further inquiry, we can seek to understand and address what underpins these phenomena. Consensus standards that guide authors on ethical use of race in scientific research exist. Our esteemed publications should ensure that investigations that utilize racial variables follow these guidelines before being published.

Addressing Potential Harms of Removal of Race from Clinical Calculators

Some have expressed fear that removing race from eGFR calculators will result in inaccurate therapeutic changes (ex. premature dialysis initiation, premature renal transplants, or inappropriate medication administration) that will primarily affect Black patients. However, the diagnostic approach used to determine changes in clinical management of renal disease (i.e. dialysis, transplant) is multifactorial; it is not based on eGFR alone. Additionally, research has shown that using symptom-prompted modifications to management, in the context of shared decision-making, can improve outcomes. Using the eGFR calculators as a sole determinant offers a limited metric with a ~30% margin of error. We can and should be incorporating other methods of evaluating kidney function (ex. 24-h Cr clearance, cystatin C) within a body of data. This can contribute to a more holistic understanding of disease progression and management.

How Bearing the Burden of Change Reinforces Racism

Some responses to the prospect of eliminating race corrections have asked proponents of these changes to prove that removing race corrections will not do harm to patients. In juxtaposition, research that established the corrections was not necessarily asked to prove that corrections are harmless. The additional evidence and surveillance needed to demonstrate the limited relevance of race belies a collective investment in the immutability of biological racial difference. However, race corrections do in fact cause both ideological and tangible harm in that they reify essential biological racial differences. Social psychology research demonstrates that when race is given this genetic basis, trainees display more apathy toward racial outgroups and a tendency to consider their physiology as innately dysfunctional. As a result, they demonstrate lower levels of accountability to creatively problem-solve for patients of color. It is also the case that many of these race corrections (eGFR, ASCVD, UTI, VBAC) about which people have been protective have not actually shown benefit to people of color.

Links

References discussed throughout episode

1. Tsai J. It’s Time to Talk about Racism in Medical Education. FIX19. https://feminem.org/2020/06/15/its-time-to-talk-about-racism-in-medical-education/
2. Tsai J. What Role Should Race Play in Medicine? Scientific American. September 12, 2018. https://blogs.scientificamerican.com/voices/what-role-should-race-play-in-medicine/ 
3. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med. 2016 Jul;91(7):916-20. doi: 10.1097/ACM.0000000000001232.
4. Tsai J. COVID-19’s Disparate Impacts Are Not a Story about Race. Scientific American. September 8, 2020. https://www.scientificamerican.com/article/covid-19s-disparate-impacts-are-not-a-story-about-race/
5. Tsai J, Cerdeña JP, Khazanchi R, Lindo EG, et al. There is no “African American physiology”: The fallacy of racial essentialism. J Intern Med. 2020;288(3):368-370. doi:10.1111/joim.13153
6. Eneanya ND, Yang W, Reese PP. Reconsidering the Consequences of Using Race to Estimate Kidney Function. JAMA. 2019;322(2):113-114. doi:10.1001/jama.2019.5774
7. Ahmed S, Nutt CT, Eneanya ND, et al. Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes. J Gen Intern Med. 2020. doi: 10.1007/s11606-020-06280-5.
8. Grubbs V. Precision in GFR Reporting: Let’s Stop Playing the Race Card. Clin J Am Soc Nephrol. Published online May 11, 2020. doi:10.2215/CJN.00690120
9. Powe NR. Black Kidney Function Matters: Use or Misuse of Race? JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.13378
10. National Kidney Foundation, American Society of Nephrology. Establishing a Task Force to Reassess the Inclusion of Race in Diagnosing Kidney Diseases. Published July 2, 2020.
11. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;0(0):null. doi:10.1056/NEJMms2004740
12. Braun L, Wolfgang M, Dickersin K. Defining race/ethnicity and explaining difference in research studies on lung function. Eur Respir J. 2013;41(6):1362-1370. doi:10.1183/09031936.00091612
13. Chadha N, Lim B, Kane M, Rowland B. “Toward the Abolition of Biological Race in Medicine.” Institute for Healing & Justice in Medicine; 2020. https://www.instituteforhealingandjustice.org/download-the-report-here

 

Additional references and papers as mentioned in the episode

1. Essien UR, Eneanya ND, Crews DC. Prioritizing Equity in a Time of Scarcity: The COVID-19 Pandemic. J Gen Intern Med. 2020;35(9):2760-2762. doi:10.1007/s11606-020-05976-y
2. Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59(5):350-355. doi:10.1136/jech.2004.024562
3. Gravlee CC. How race becomes biology: embodiment of social inequality. Am J Phys Anthropol. 2009 May;139(1):47-57. doi: 10.1002/ajpa.20983. PMID: 19226645.
4. Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI):
   1. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate [published correction appears in Ann Intern Med. 2011 Sep 20;155(6):408]. Ann Intern Med. 2009;150(9):604-612. doi:10.7326/0003-4819-150-9-200905050-00006
5. African American Study of Kidney Disease and Hypertension (AASK):
   1. AASK Clinical Trial in the NIDDK Repository: https://repository.niddk.nih.gov/studies/aask-trial/
   2. Lewis J, Agodoa L, Cheek D, et al. Comparison of cross-sectional renal function measurements in African Americans with hypertensive nephrosclerosis and of primary formulas to estimate glomerular filtration rate [published correction appears in Am J Kidney Dis 2002 Feb;39(2):444]. Am J Kidney Dis. 2001;38(4):744-753. doi:10.1053/ajkd.2001.27691
6. Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-619. doi:10.1056/NEJMoa1000552
7. Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology [published correction appears in J Am Coll Cardiol. 2019 Jun 25;73(24):3234]. J Am Coll Cardiol. 2019;73(24):3153-3167. doi:10.1016/j.jacc.2018.11.005
8. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 
9. Micheletti SJ, Bryc K, Ancona Esselmann SG, et al. Genetic Consequences of the Transatlantic Slave Trade in the Americas. Am J Hum Genet. 2020;107(2):265-277. doi:10.1016/j.ajhg.2020.06.012
10. Krieger N. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: an ecosocial perspective. Am J Public Health. 2003;93(2):194-199. doi:10.2105/ajph.93.2.194
11. Piercy M. To be of use. In: Circles on the Water: Selected Poems of Marge Piercy. Alfred A. Knopf; 1982.https://www.poetryfoundation.org/poems/57673/to-be-of-use

 

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. Dr. Eneanya is a member of the National Kidney Foundation and the American Society of Nephrology Task Force; the views herein represent her own and not necessarily those of the NKF or the Task Force. The hosts and guests report no other relevant financial disclosures. 

Citation

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.

 

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/Meningoencephalitis-Schema-BeaST-Mode-Edition_FINAL-online-audio-converter.com_.mp3

Reza, Rabih, Sharmin, and Arsalan break down meningoencephalitis in this bite sized schema episode, inspired by Dr. Kimberly Manning.

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Dhruv and Travis present a case of R sided weakness and numbness to Kiara, Tahir, and Aaron, as we continue our campaign to end neurophobia! 

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Dhruv Srinivasachar

Dhruv Srinivasachar is a 4th year medical student at 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 interviewing for Med-Peds residency, he can be found biking around Richmond, VA, gardening, and cooking. 

Tahir Malik

Tahir Malik is a 4th-year medical student at Baylor College of Medicine interested in artificial intelligence, cardiology, and global health. He is interested in performing healthcare disparities research, in capacity-building in low-resource settings, and in understanding the role AI might play in global health solutions. In his free time, Tahir is an avid runner and biker and is trying to become a reasonable cook. 

Travis Smith

Dr. Smith is a student educator and community EM physician currently practicing in Jacksonville, Florida. He currently is an Associate Professor of Emergency Medicine, Assistant Dean of Clinical Education, and the Director of the Clinical Clerkship Curriculum for LECOM. He attended undergrad at FSU where he received his bachelor’s degree in Biological Science. He then attended Lake Erie College of Osteopathic Medicine in Bradenton for his medical degree and then completed his residency in emergency medicine at the University of Florida Jacksonville campus. He has been board-certified in emergency medicine through ABEM since 2013. In his free time, he serves as the lead section editor for the Human dx project as well as a frequent contributor to the Clinical Problem Solvers and is heavily involved in #Medtwitter running the @medtweetorials account as well as his own @RosenelliEM

 

https://clinicalproblemsolving.com/wp-content/uploads/2020/12/ARM-EP-3-Structural-Inequities-and-the-Pandemics-Winter-Surge-1.mp3

In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we sit down with Ed Yong, an award-winning journalist and science writer with The Atlantic, to discuss the structural inequities amplified by COVID-19 as well as the social concerns associated with the impending/present second wave of the pandemic.

Learning Objectives

After listening to this episode listeners will be able to…

1. Understand the trajectory of the COVID-19 pandemic’s unique impact on communities of color in the United States and its tie to historical discrimination and structural inequities
2. Describe the racialized and politicized national response to COVID-19
3. Recognize the crucial role that social interventions can and could have played in decreasing the burden of COVID-19

Credits

• Written and produced by: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Naomi Fields, Chioma Onuoha, and Jazzmin Williams
• Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH
• Infographic: Creative Edge Design
• Guests: Ed Yong staff writer at The Atlantic (@edyong209)

Clinical Problem Solvers: Anti-Racism in Medicine

Show Notes – Episode 3: Structural Inequities and the Pandemic’s Winter Surge

December 3rd, 2020

By: Chioma Onuoha

Timestamps

00:00 Music/Intro

00:20 Mission and Vision

00:32 Introduction of Ed Yong

02:00 Disproportionate impact of COVID-19 on minority communities

04:00 Racism in the national/policy response to COVID-19

07:00 Health Care Worker Fatigue

09:30 Grief and the Unique Frustrations of Health Care Workers of Color

11:30 The “Chinese” Virus and the history of the pandemic

14:00 Administrative Blame Shifting

17:00 How Could This Have Been Prevented?

20:00 COVID-19 and indigenous populations

Takeaways

1. Social Interventions are Valuable

Currently in the COVID-19 pandemic, social interventions are the only interventions available to us. When it comes to pandemics more broadly, the role of non-pharmaceutical interventions, like mask wearing, social distancing, and stay at home orders, must be recognized for their robust potential to reduce disease spread and burden. (Reflection Question: How can I best communicate the importance of social interventions to my extended family, community, and patients?)

1. The Racial Disparities Exposed by COVID-19 are Not a Result of Biological Difference

It is dangerous to look at the racial and ethnic health disparities highlighted by COVID-19 and attribute them to biological differences*. Many of the populations who suffer from these disparities also suffer from structural inequity and historical discrimination which impact their quality of life and health outcomes. Marginalized communities have historically received the brunt of the blame when it comes to widespread pandemics without recognition of the role that structural factors play in creating and maintaining health inequity.

*To learn more about the danger of biological explanations for health disparities see the CPS Anti-Racism in Medicine three-part episode series Dismantling Race-Based Medicine. Part 1: Historical & Ethical Perspectives featuring Professor Edwin Lindo is available now.

1. Health Policy Must Target Structural Inequities

Inequities worsen if they are not specifically addressed in policy. Without intentional effort put into addressing the root cause of structural inequities, it is possible that interventions will cause more harm than good. (Reflection Question: How should the concept of equity vs. equity be applied in creation of health policy?)

Pearls

The disparities amplified by COVID-19 are not new or unsurprising

The narrative of COVID-19 being a “ great equalizer” is largely untrue. If anything, COVID-19 has removed “the veil” and made the extent of the inequities in this country very clear. Marginalized communities are especially vulnerable to COVID-19 due to structural factors like segregation, lack of access to clean water, poor air quality, and limited availability of health care.  These structural inequities are longstanding and will require long-lasting and intentional rectification.

Frontline Workers Pushed to their Limits

Touching accounts from frontline workers, in particular, nurses, who are uniquely positioned to face the devastating impacts of the disease, have clarified the toll that COVID-19 has placed on care workers. The emotional and physical fatigue associated with such immense loss of human life is leading to burnout among the very group that is required to address this disease. For many health care workers of color, their struggles are compounded by personal grief and increased expectations to lead anti-racism efforts within institutional walls.

Blame shifting

During COVID-19, we have seen marginalized communities be positioned as scapegoats to explain the prevalence and persistence of the disease. This is not a new phenomenon. Ed Yong cites anti-Blackness during the Ebola outbreak; homophobia, transphobia, and condemnation of sex workers and people who use drugs during the HIV epidemic; and current anti-asian rhetoric during COVID-19 and the original SARS as examples. Blame is deflected to populations on the outskirts of society and used as justification to delay or fail to provide aid. Throughout the duration of the pandemic, we have seen the nature of this blame evolve. While it started with accusations that Black people and POC do not take the virus seriously and/or have chronic diseases and unhealthy habits, most presently it manifests through discourse around black people’s weariness of taking the forthcoming COVID-19 vaccine. Rather than placing blame on marginalized populations, it is crucial that we first analyze history and external influences that may explain the behaviors and outcomes being observed.

Overreliance on Biomedical Measures

“[Rudolf Virchow] specifically writes ‘Medicine is a social science’ and we have lost that understanding” – Ed Yong

For much of the COVID-19 pandemic, rhetoric in the United States has centered around waiting for biochemical and pharmaceutical interventions to be developed rather than fully taking advantage of the social interventions currently available. Social interventions are powerful, and as we can see from the COVID-19 responses of countries like South Korea and Taiwan, they are effective at managing this disease. This reality highlights the importance of sociological and anthropological expertise in medicine and the need to expand interdisciplinary exchange in health care more broadly.

References Discussed in Episode

01:30

Yong, E. (2020, September 20). How Pandemic Defeated America. The Atlantic. https://www.theatlantic.com/magazine/archive/2020/09/coronavirus-american-failure/614191/

04:00

Serwer, A. (2020, May 8). The Coronavirus Was an Emergency Until Trump Found Out Who Was Dying, The Atlantic. https://www.theatlantic.com/ideas/archive/2020/05/americas-racial-contract-showing/611389/

Kendi, I. X. (2020, April 6). What the Racial Data Show. The Atlantic. https://www.theatlantic.com/ideas/archive/2020/04/coronavirus-exposing-our-racial-divides/609526/

05:50

APM Research Lab Staff. (2020, November 12). The Color of the Coronavirus: COVID-19 Deaths by Race and Ethnicity in the U.S. APM Research Lab. https://www.apmresearchlab.org/covid/deaths-by-race

07:00

Yong, E. (2020, November 13). No One Is Listening to US. The Atlantic. https://www.theatlantic.com/health/archive/2020/11/third-surge-breaking-healthcare-workers/617091/

Yong, E. (2020, November 20). Hospitals Know What’s Coming. The Atlantic.

https://www.theatlantic.com/health/archive/2020/11/americas-best-prepared-hospital-nearly-overwhelmed/617156/

Yong, E. (2020, July 7). The Pandemic Experts Are Not Okay. The Atlantic. https://www.theatlantic.com/health/archive/2020/07/pandemic-experts-are-not-okay/613879/

10:30

Dr. Uche Blackstock (@uche_blackstock)

Dr. Esther Choo (@choo_ek)

19:00

Rashawn, R. (2020, April 9). Why are Blacks dying at higher rates from COVID-19?. Brookings. https://www.brookings.edu/blog/fixgov/2020/04/09/why-are-blacks-dying-at-higher-rates-from-covid-19/

Hernandez, E. (2020, April 23). Inequities in COVID-19 are tragic but preventable. The Hill. https://thehill.com/blogs/congress-blog/healthcare/494251-inequities-in-covid-19-are-tragic-but-preventable#bottom-story-socials

20:00

McFarling, U.L. (2020, November 17). ‘They’ve been following the science’: How the Covid-19 pandemic has been curtailed in the Cherokee Nation. STAT. https://www.statnews.com/2020/11/17/how-covid19-has-been-curtailed-in-cherokee-nation/

Additional References

1. Essien, U. R., & Venkataramani, A. (2020, April 28). Data and Policy Solutions to Address Racial and Ethnic Disparities in the COVID-19 Pandemic. JAMA Health Forum. https://jamanetwork.com/channels/health-forum/fullarticle/2765498
2. Gold, J. (2020, June 12). ‘I Am Tired’: What Black Doctors Need You To Know Right Now. Forbes. https://www.forbes.com/sites/jessicagold/2020/06/12/i-am-tired-what-black-doctors-need-you-to-know-right-now/?sh=29a644254ad7
3. Gross, C. P., Essien, U. R., Pasha, S., Gross, J. R., Wang, S., & Nunez-Smith, M. (2020). Racial and Ethnic Disparities in Population-Level Covid-19 Mortality. Journal of General Internal Medicine, 35(10), 3097–3099. https://doi.org/10.1007/s11606-020-06081-w
4. Jones, CP (2020, April 7). Coronavirus Disease Discriminates. Our Health Care Doesn’t Have To | Opinion. Newsweek. https://www.newsweek.com/2020/04/24/coronavirus-disease-discriminates-our-health-care-doesnt-have-opinion-1496405.html
5. Kendi, I. X. (2020, June 16). Black People Are Not to Blame for Dying of COVID-19. The Atlantic. https://www.theatlantic.com/ideas/archive/2020/04/race-and-blame/609946/
6. Krishnan, L., Ogunwole, S. M., & Cooper, L. A. (2020). Historical Insights on Coronavirus Disease 2019 (COVID-19), the 1918 Influenza Pandemic, and Racial Disparities: Illuminating a Path Forward. Annals of Internal Medicine, 173(6), 474–481. https://www.acpjournals.org/doi/full/10.7326/M20-2223
7. Tavernise, S., & Oppel, R. A. (2020, June 2). Spit On, Yelled At, Attacked: Chinese-Americans Fear for Their Safety. The New York Times. https://www.nytimes.com/2020/03/23/us/chinese-coronavirus-racist-attacks.html
8. Williams DR, Cooper LA. (2020). COVID-19 and Health Equity-A New Kind of “Herd Immunity”. JAMA.323(24):2478-2480. doi:10.1001/jama.2020.8051
9. Williams, V. (2020, March 27). A poll finds African Americans and Latinos are more worried about the coronavirus; a public health expert explains why. The Washington Post. https://www.washingtonpost.com/nation/2020/03/27/poll-finds-african-americans-latinos-more-worried-about-covid-19-doctor-explains-why/?arc404=true
10. Yong, E. (2020, August 19). We Live in a Patchwork Pandemic Now. The Atlantic.https://www.theatlantic.com/health/archive/2020/05/patchwork-pandemic-states-reopening-inequalities/611866/
11. Yong, E. (2020, September 14). America Is Trapped in a Pandemic Spiral. The Atlantic. https://www.theatlantic.com/health/archive/2020/09/pandemic-intuition-nightmare-spiral-winter/616204/

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

Yong E,  Essien UR, Nolen L, Khazanchi, R, Ogunwole M, Fields N, Onuoha C, Williams J, , Paul D. “Episode 4: Structural Inequalities and a Second Wave.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. December 3, 2020.

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https://clinicalproblemsolving.com/wp-content/uploads/2020/11/Nov-HDx-Case_FINALjkfdja-2.mp3

Kushal presents a Human Dx unknown to Jack, Kushal, Gabe, and Jake.

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Kushal Vaishani

Kushal is a hospitalist and contributing editor for the Adult Medicine section at Human Dx. After finishing his medical school in India, he completed his residency training at Brandon Regional Hospital and LSUHSC – University Hospital and Clinics. His academic interests include clinical reasoning, medical education, high-value care, and infectious diseases.

Gabe Siegel

Gabe Siegel is currently a PGY-1 Emergency Medicine Resident at Denver Health. Gabe completed medical school at Rush Medical College in Chicago, IL. When not working, he is busy enjoying the outdoors in Colorado and hunting for good food in Denver. His academic interests include health policy, critical care, and social EM.

Jake Hershey

Jake is currently a PGY-1 in the IM hospital training track at the University of Colorado and graduated from Rush Medical College alongside his friend and co-discussant Gabe. His passions in medicine include medical education, clinical reasoning, and after-work commiseration with his co-residents. In his free time, he loves exploring the Colorado wilderness to experience the amazing hiking, kayaking, and snowboarding that the state has to offer.

https://clinicalproblemsolving.com/wp-content/uploads/2020/11/HDx_DM_NOV_UAB_FINAL-2.mp3

Dr. John Alexander presents a Human Dx unknown to Dr. Courtney Wagner, Dr. Ryan Goetz, and Dan

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Courtney Wagner

Courtney Wagner is PGY-2 in Internal Medicine resident at the University of Alabama at Birmingham. She is a Florida native and grew up in and around the water either swimming competitively, SCUBA diving, or fishing. She initially graduated from the University of Central Florida with a biological sciences degree and taught high school science before going back to school for nursing at the University of South Florida.  After gaining experience at the bedside as an ICU nurse, she pursued a career in medicine by returning to UCF for medical school. Currently interested in academic medicine with a heart for hospice and palliative and the geriatric population. She loves cooking, hiking, and triathlons, having completed over 60 races, including Ironman Cozumel. 

John Alexander

John Alexander is a PGY-2 internal medicine resident at the University of Tennessee Health Science Center in Memphis. He got his undergraduate degree in history from Rhodes College and graduated from William Carey University College of Osteopathic Medicine. His research interests include clinical and diagnostic reasoning and cardiology. He hopes to pursue a career in academic medicine. Outside of the hospital he enjoys playing tennis, traveling, and spending time with family and friends. 

Ryan Goetz

Ryan Goetz is a second-year internal medicine resident at the University of Alabama Birmingham. He attended medical school at the Medical College of Georgia. He wants to pursue a career in pulmonary/critical care medicine after completing his residency. His clinical/research interests include ventilator physiology/teaching, clinical reasoning, bronchiectasis, and ARDS. In his spare time, Ryan enjoys Orange Theory Fitness workouts, craft beer, and history podcasts.