The Clinical Problem Solvers

Dr. David Jessee presents a Human Dx unknown to Sharmin, David & Antoinette

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David Jessee

David Jessee is an assistant professor of medicine and academic hospitalist at Virginia Commonwealth University School of Medicine.  He was born and raised in Southwest Virginia and completed his premedical and undergraduate education at the University of Virginia.  After graduating from VCU School of Medicine, he remained in Richmond to complete his internal medicine residency training and subsequently joined the faculty in the division of hospital medicine.  His interests include medical student and resident education with a focus on diagnostic reasoning and simulation-based experiences and assessment.  Additionally, he is involved in efforts which recognize early signs of clinical decline and enhance inpatient emergency and code response.  Outside the hospital, he enjoys running with his dog, biking, playing racquetball, watching UVA sports, and traveling to state and national parks.

Antionette Pusaterri

Antoinette Pusateri is a PGY-3 in Internal Medicine at The Ohio State University Medical Center. Born and raised in Columbus, Ohio she attended the University of Notre Dame for undergraduate majoring in Biology & Theology then returned to Columbus for medical school and Internal Medicine Residency at The Ohio State University College of Medicine and Wexner Medical Center.  She is currently interviewing for Gastroenterology & Transplant Hepatology Fellowship and has a passion for research and quality improvement, medical education and community engagement. She is also a strong advocate for trainee wellness, and herself finds wellness in CrossFit and horseback riding.

David Deng

David Deng is a PGY-3 in Internal Medicine at The Ohio State University Medical Center. He spent most of his life around Atlanta, GA, went to medical school at Medical College of Georgia, but is feels right at home in the Midwest. He’s currently pursuing a career in academic hospital medicine and is passionate about clinical reasoning and medical education. In his spare time, he loves cheering on Liverpool FC, trying hole-in-the-wall restaurants, and staying active lifting weights and running. 

The CPSolvers share a case of lactic acidosis – let’s practice those schemas together!

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Episode Description

Dr. Rencic and Colin presents a clinical unknown on Virtual Morning Report to CPSolvers, Rabih and Reza.

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Zari Zahra, Mel Fellay, Lindsey, Emma, and Sharmin discuss gender biases through stories.

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Melanie Fellay

Melanie Fellay is the CEO and Co-Founder of Spekit, the leading in-app learning and digital enablement companion that helps employees learn their tools and navigate process changes by accessing training resources in real-time, everywhere they work. Founded in 2018, Melanie and co-founder and former colleague, Zari Zahra, created Spekit to address the pain points they felt around driving adoption and continuous training that many Enablement and Operations leaders feel as well by bringing the sophistication of a modern digital adoption platform with the simplicity of a contextual knowledge base.

She’s a Salesforce and BizOps enthusiast with expertise in leading operations and success teams, thinking at scale and architecting Salesforce solutions. In her role, Melanie oversees the sales, marketing, customer success, and corporate development teams at Spekit. Melanie graduated from the University of Colorado, Boulder with a degree in Accounting & Finance. In her free time, Mel enjoys seeing Odesza at Red Rocks, exploring less-traveled corners of the earth and escaping it all through meditation.

Zari Zahra

Zari is a Pakistani-American Harvard MBA, an experienced Product Manager and builder of web and mobile apps for Pandora, SquareTrade, RealtyShares and Rakuten. Today, she is the Chief Product and Technology Officer and Co-founder of Spekit, the leading Salesforce adoption and contextual learning platform for growing orgs. Zari oversees all product and engineering departments, including a team office located in Karachi, Pakistan. 

In her free time, Zari spends time listening to audio books and spending time with her husband and mini-goldendoodle Rumi.

Dr. Varun Phadke presents a human dx case to Arsalan, Francesca Siegel, and Alec Yu.

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Francesca Siegel

Francesca Siegel is a third year medical student at The Ohio State University College of Medicine. She received her masters in Nutritional Sciences from the University of Cincinnati. She’s passionate about preventive medicine, effective science communion, public health, and serving her community. Outside of her school work, she enjoys volunteering with Clinica Latina, OSU’s Hispanic free clinic, running with her husband, travel, and cooking.

Alec Yu

Alec is medical student at the University of British Columbia in Vancouver, Canada. Prior to med school, he’s worked as an innovation officer at one of Vancouver’s tertiary care hospitals, and has served as a director and co-founder of a non-profit organization supporting youth engagement with humanitarian issues. A passionate problem-solver, Alec loves combining his interests with his lived experiences to start grassroots initiatives in his community. His current projects include investigating improvements to medical respite care for patients facing homelessness, and designing solid waste reduction strategies for improved hospital sustainability. On his down time, he loves cooking, running, and trying not to kill his plants.

Varun Phadke

Varun Phadke is an Assistant Professor in the Division of Infectious Diseases at the Emory University School of Medicine. He is involved in microbiology and infectious diseases education for medical students, residents, and fellows, and his scholarly interests include subspecialty clinical reasoning and diagnostic error. He loves cooking, reading mystery novels, and spending time with his wife and son.

Episode Description

Dr. Joshua Inglis presents a Human Dx case to Sharmin, Vivek Nair and Joshua Morris.

Human Dx Case Link

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Joshua Morris

Josh is a proud cat dad to four kitties and a fourth year student at Dell Medical School applying Medicine-Pediatrics. He spent his third year doing an MA in design that cemented his passion for using creativity and innovation to better deliver care and information to patients and providers. In his spare time, he is active on MedTwitter (#MP4L), loves to run and be outside, and is obsessed with podcasts and audiobooks.

Vivek Nair

Vivek Nair is a second-year medical student at the University of Chicago Pritzker School of Medicine. He spent his undergraduate years at the University of Michigan. He is an avid runner and has been recently practicing his culinary skills (just in case medicine doesn’t work out).

Joshua Inglis

Dr Josh Inglis is an aspiring General Physician training at the Royal Adelaide Hospital. He obtained his medical degree from the University of Adelaide and is studying towards a Masters of Clinical Education. His academic interests include clinical reasoning, drug allergy and the electronic health record. Outside of work he enjoys playing tennis, brewing specialty coffee and walking his golden retriever.

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Reza and Rabih tackle a case of Vulvar Pain.

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Dr. Steph Sherman, Lindsey, Emma, and Sharmin tackle a case presented by Anna

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Dr. Steph Sherman

Dr. Stephanie Sherman is a hospitalist and residency associate program director at Baylor College of Medicine (BCM) who rounds at Ben Taub General Hospital and Houston’s VA hospital. She went to medical school at the University of Michigan and did internal medicine residency at Massachusetts General Hospital. She spends her free time with her husband, fellow clinical problem solver Zaven Sargsyan, and their ever-more-mobile 8-month-old son.

Associated Schema

Problem Representation
A 35-year-old man with advanced HIV/AIDS complicated by a recent diagnosis of Pneumocystis pneumonia and cytomegalovirus esophagitis presented with progressive fevers, dyspnea, and worsening pulmonary infiltrates in the weeks after starting antiretroviral therapy. 

Schemas
The CPSolvers’ schema for dyspnea highlights the relative importance of the pulmonary and cardiovascular systems before considering other etiologies.

Diagnosis
The patient was found to have extensive bilateral consolidations on computed tomography of the chest. Laboratory evaluation demonstrated an elevated alkaline phosphatase, an increase in his CD4 count from 22 to 43 per cubic millimeter, and a reduction in his HIV viral load from > 1 million to 3000 copies. Ultimately, a respiratory culture from his prior admission grew Mycobacterium avium complex, raising the question of whether direct infection with this pathogen or an inflammatory reaction to it in the setting of immune reconstitution could account for his clinical deterioration.

Teaching points

• Mycobacterium avium complex (MAC) is the most common of the nontuberculous mycobacteria (NTM) that acts as a human pathogen. Clinical manifestations are varied, most typically presenting as a chronic pulmonary infection in immunocompetent individuals and either localized (e.g., affecting the lymph nodes or other focal sites) or disseminated infection in immunocompromised patients (especially those with HIV infection). In the early HIV epidemic, disseminated MAC was the most common bacterial opportunistic infection and conferred significant morbidity and mortality even with treatment.
• The immune reconstitution inflammatory syndrome (IRIS) is a potential complication of antiretroviral therapy (ART), wherein patients with advanced immunosuppression related to HIV develop an inflammatory response (generally to microbial antigens) as their immune system recovers. The two main types of IRIS are (1) paradoxical IRIS, in which a patient with a known opportunistic infection on appropriate therapy appears to deteriorate clinically after starting ART, and (2) unmasking IRIS, in which a previously silent opportunistic infection becomes clinically apparent due to the newly present immune response. IRIS to MAC most commonly presents with peripheral lymphadenitis, pulmonary-thoracic manifestations, or intra-abdominal findings.
• Female physicians face many challenges in the clinical environment. Among the most frequently experienced microaggressions is “role misidentification,” or incorrect identification of an individual’s contribution to the health care team (e.g., assuming a female physician is a nurse). It has been suggested that frequent role misidentification (both on the part of patients as well as other healthcare team members) can lead to anxiety and a loss of sense of professional credibility among female trainees.
  • A pilot study recently demonstrated that distribution of new staff badges with the occupational title prominently displayed (i.e., reading “Doctor”) led to a significant improvement in role identification.
  • Additionally, others have suggested that a more deliberate use of professional titles (i.e., introducing female physicians as “Dr. X”) may also serve to combat stereotype threat and role misidentification. 

We invite scholars and antiracism activists, Drs. Rhea Boyd and Rachel Hardeman, to discuss the meaning of structural racism, the health impacts of police violence, the “say her name” movement, and the ways we can ensure our country’s current antiracist movement grows beyond a moment.

Learning Objectives

After listening to this episode learners will be able to…

• Define structural racism
• Understand how police violence is a social determinant of health
• Explore the relationship between policing and healthcare
• Explore and employ strategies to dismantle structural racism in clinical practice 

Credits

• Written and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Utibe R. Essien, MD, MPH 
• Hosts: Dereck Paul, MS, Utibe R. Essien, MD, MPH, Michelle Ogunwole, MD
• Show notes: LaShyra Nolen
• Written & Produced By: Michelle Ogunwole, MD, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MS, and Utibe R. Essien, MD, MPH
• Infographic: Creative Edge Design
• Guests: Rachel Hardeman PhD, MPH (@RRHDr) and Rhea Boyd MD, MPH (@RheaBoyd)

Download Transcript Here

CPS-Anti-Racism Show Notes Episode 1

August 26, 2020

By LaShyra Nolen

Time Stamps

00:00 Music/intro 

01:00 Our mission and vision

01:50 Introduction to the Antiracism in Medicine team 

02:55 Introduction of Dr. Boyd and Dr. Hardeman

04:30 Defining structural racism 

10:30 Dr. Boyd’s Lancet piece on the history of police violence

12:00 Police violence, communities, and health outcomes

15:00 Dr. Hardeman on police brutality and a public health agenda

24:00 Understanding this moment (COVID-19 and George Floyd) 

29:00 The #SayHerName campaign and police brutality’s effects on women 

33:00 Emmett and Mamie Till 

44:00 Policing in healthcare settings

54:00 What can we start doing tomorrow? 

56:00 Conclusion and outro 

Episode Takeaways

“First do no harm and while you’re doing no harm, learn as much as you can.” -Dr. Rhea Boyd. 

Practitioners who benefit from the racist power structures existent in America must examine the ways they benefit from or ignore racism in their workspaces and beyond. Then we must all commit to dismantling racism with tangible policy change.

Trainees

We encourage trainees to reflect on the ways they have been socialized to learn and think about racism in our country. Trainees may use this foundation to question how this might impact their medical education and think about this educational legacy may be reformed through curricular and structural changes at their institutions. 

Faculty

Regardless of specialty or field, it is important all educators and clinicians do the work of understanding how racism is pervasive within their respective areas of expertise. This starts with self-education and a commitment to speak up when blatant examples of racism come up in the work space and beyond. 

Pearls 

Defining Structural Racism

Structural racism is a term that acknowledges that racism is perpetuated beyond individual interactions and interpersonal racism, but is present in the systems and policies that govern our everyday lives. These policies and decisions are often rooted in a historical legacy of white supremacy that have led to the systematic disadvantage of racial minorities in our society. Public health advocate, leader, and scholar, Dr. Camara Phyllis Jones, is credited for creating the framework many healthcare professionals and researchers use to think about systemic racism’s impacts on Black health. Her definition centers the idea that Black individuals did not inherit the diseases they disparately suffer from, but they inherited a disadvantaged system that creates the stark health disparities we see today. It is important to understand this unequal system negatively impacts everyone and every aspect of our society. 

Policing and health outcomes  

Evidence has shown that excessive policing not only impacts the individual health of Black and brown people who’ve interacted with the police, but it also impacts the health of their communities at large. Heightened police presence in communities of color can be perceived as a threat by community members which can result in sustained increases in stress and cortisol levels. This pathologic process can lead to adverse health outcomes affecting the cardiovascular, neurological, and endocrine systems.

Police brutality 

Police brutality should be thought of as the ways state-sanctioned violence leads to the physical, psychological, and emotional harm of its victims. It is important to understand that police brutality not only impacts individuals with direct relationships to those afflicted by this violence but also has widespread effects on the entire Black community. It impacts the health of our colleagues who constantly have to witness this injustice play on television, often without consequence. It also leads to decreased productivity in Black communities as they deal with the aftermath and ongoing challenges of police brutality. 

#SayHerName Campaign 

As we continue conversations around police brutality, antiracism, and health equity, we must remember to not exclude women, children, the LGBTQ community, and the disabled community, among other communities of intersecting marginalized identities who continue to be impacted by police brutality. Social media and public response to police brutality traditionally center cis-gendered men, but people like Breonna Taylor, Tony McDade, and Tamir Rice, along with so many others, need our voices too. 

Policing in Schools and Hospitals 

Health care systems must actively advocate and protect their patients and that means we have to also reevaluate the presence of police in our spaces. This includes thinking about our roles as mandated reporters and police presence in emergency departments. Police presence in medical spaces can add to Black patients’ feelings of not having a “safe space” and we must consider our roles in potentially perpetuating violence in this way. 

Links

References discussed throughout episode 

Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: An antidote to structural racism. Birth. 2020;47(1):3-7. doi:10.1111/birt.12462

Boyd RW. Police violence and the built harm of structural racism. Lancet. 2018;392(10144):258-259. doi:10.1016/S0140-6736(18)31374-6

Alang S, McAlpine D, McCreedy E, Hardeman R. Police Brutality and Black Health: Setting the Agenda for Public Health Scholars. Am J Public Health. 2017;107(5):662-665. doi:10.2105/AJPH.2017.303691

Hardeman RR, Medina EM, Kozhimannil KB. Structural Racism and Supporting Black Lives – The Role of Health Professionals. N Engl J Med. 2016;375(22):2113-2115. doi:10.1056/NEJMp1609535

Alyasah Ali Sewell, Justin M. Feldman, Rashawn Ray, Keon L. Gilbert, Kevin A. Jefferson & Hedwig Lee (2020) Illness spillovers of lethal police violence: the significance of gendered marginalization. Ethnic and Racial Studies. 2020. doiI: 10.1080/01419870.2020.1781913

Britton BV, Nagarajan N, Zogg CK, et al. US Surgeons’ Perceptions of Racial/Ethnic Disparities in Health Care: A Cross-sectional Study. JAMA Surg. 2016;151(6):582–584. doi:10.1001/jamasurg.2015.4901

Hardeman RR, Medina EM, Boyd RW. Stolen Breaths. N Engl J Med 2020; 383:197-199. doi: 10.1056/NEJMp2021072 

Bor J, Venkataramani AS, Williams DR, Tsai AC, Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. Lancet. 2018. doi: 10.1016/S0140-6736(18)31130-9. 

Additional references and papers as mentioned in episode 

Link to the work of Dr. Rupa Marya as mentioned by Dr. Boyd: https://medium.com/@radiorupa/health-and-justice-the-path-of-liberation-through-medicine-86c4c1252fb9

Link to African-American Policy Forum #SayHerName Campaign: https://aapf.org/sayhername

Link to latest work of Dr. Rachel Hardeman: Physician-patient racial concordance and disparities in birthing mortality for newborns. Brad N. Greenwood, Rachel R. Hardeman, Laura Huang, Aaron Sojourner. Proceedings of the National Academy of Sciences Aug 2020, 201913405; DOI: 10.1073/pnas.1913405117 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Episode Citation

Boyd R, Hardeman R, Ogunwole M, Fields N, Khazanachi R, Nolen L, Onuoha C, Paul D, Essien UR. “#120 Racism, Police Violence, and Health.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes/ August 26, 2020.

Dr. Krishan Sharma presents a Human Dx case to Sharmin & Baylor residents – Drs. Iqbal and Rana.

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Cyrus Iqbal

Cyrus is a PGY-3 internal medicine resident at Baylor College of Medicine. He loves sports, hip-hop, exploring new restaurants and coffee shops, and writing. He’s an aspiring hematologist/oncologist with a passion for medical education.

Ruchit Rana

Ruchit Rana is currently a third-year internal medicine resident at Baylor College of Medicine. Ruchit completed medical school at Baylor College of Medicine. He has a passion for practicing and improving medical education at all levels. In his free time, he enjoys cooking and baking dishes across all ethnicities and maintaining his multiple freshwater aquariums at home. He is a proud co-founder of the Schema Squad alongside his co-resident, Cyrus Iqbal.

Krishan Sharma

Krishan Sharma is currently an internal medicine resident at Massachusetts General Hospital. He earned his medical degree at Harvard Medical School, where he also pursued a Masters in Medical Sciences in medical education. His academic interests include cardiology, critical care, and clinical reasoning. His hobbies include basketball, drumming, and entering spice eating competitions.