Category Archives: Health Equity

Addressing unequal and unjust health outcomes across different populations.

Violence

1) Pre-class reading

  • Raja, S.  Trauma Informed Care In Medicine: Current Knowledge and Future Research Directions.  Family and Community Health 38(3):216-26. July 2015
    • Context: Exposure to trauma is nearly universal, and yet differential incidence and impact of trauma are a large source of health disparities.  Trauma informed care uses an understanding of the prevalence and impact of trauma to provide care that is responsive, safe and empowering for providers and survivors.  Through universal and trauma specific practices, this approach serves to reduce health disparities.
    • Goal: Describe the components of a trauma informed clinical practice.
    • Reflect: Which of these practices have you seen implemented in your primary care practicum?  Have you participated in patient encounters that, in retrospect, may have benefitted from this approach?  How do you think implementation of trauma informed practices benefits providers?

2) Pre-class Module

  • Aquifer Trauma-Informed Care Course, Module 1: Understand the Nature and Prevalence of Trauma: Understand how simple and complex trauma may present in a diverse patient population, Cases 1-4  https://owhtic-re.meduapp.com
    • Instructions: Students will create an account using their UW email address.  After completing each case, click on “case summary download.”  This will provide you with a pdf of the instructional content.  Keep these completed pdfs for your own use and reference.
    • Context: These four clinical cases demonstrate a range of ways in which trauma may affect health and the clinical encounter.  Through the cases the concepts of trauma, the epidemiology of IPV and child abuse, and screening are reviewed.  Trauma informed care is introduced including universal trauma precautions and trauma specific interventions.  
    • Goal: Appreciate the prevalence and impact of trauma on patients’ health and interaction with the healthcare system.  Acquire skills for applying trauma informed care principles to the clinical encounter.
    • Reflect: Which patients from PCP do these cases remind you of?  What is one patient you might approach differently after working through these cases?
    • Further reading: interested students may complete other modules from this Aquifer course.

Optional Reading

  • Amnesty International Maze of Injustice: Sexual Violence Against Indigenous Women in the USA.(chapters 1,2,4)
    • 4 in 5 American Indian and Alaska Native women have experienced violence.  1 in 2 have experienced sexual violence.  Alaska Native women have 10 x risk of IPV compared to the general US population.  On some reservations indigenous women are murdered at more than 10x national average, many by non-indigenous men.  This report explores the complex etiologies and impact of this violence.
    • Goal: Explore the ways historical, political and sociocultural issues intersect with social determinants to affect the incidence and impact of violence.
    • Reflect: Why does violence disproportionally affect marginalized individuals and communities.  How does this knowledge improve our ability to serve patients responsively?
  • Violence Is a Public Health Problem, American Public Health Association Policy Statement Nov 2018
    • This 2018 policy statement looks at the rationale for viewing violence as a public health problem.  Risk factors for and differential impacts of violence are reviewed.  Successful public-health based intervention programs are discussed, and recommendations for physician practice, collaboration and advocacy are made.
    • This statement by the American Public Health Association reviews the epidemiology of violence, the differential impact on traditionally marginalized communities, the similarities to other types of epidemics and chronic health problems, the evidence available for physicians’ role in primary and secondary prevention and a call for further action in approaching violence through a public health lens.
    • Goal: Describe the scope of interpersonal violence and its impact on health.     Recognize structural factors that contribute to disparities in frequency and impact of violence in different populations.  Describe the potential role of physicians in responding to and preventing violence.  Understand the role of interprofessional and community partnerships in preventing and responding to violence.
    • Reflect:  What factors contribute to the resistance of the political and medical community to viewing violence through a public health lens?  What is one idea from this reading that you hope to take with you into your clinical work as a medical student?
  • Seattle: King County Violence Prevention Resources
    • Hosted by King County Public Health, this website has excellent general information on prevention of and resources for domestic violence, gun violence, trafficking and suicide.  Most resources are general or national, although some are King County specific.

Optional Videos

  • Futures without Violence video resource library: universal screening, education and referral
    • https://www.futureswithoutviolence.org/health-training-vignettes/
  • Violence Against American Indian and Alaska Native Women and Men, National Indigenous Women’s Resource Center.
    • http://www.niwrc.org/resource-topic/videos
    • This video describes the findings of a National Institute of Justice (NIJ) supported study on the prevalence of violence against American Indian and Alaska Native women and men, and briefly examines the impact of violence int that community.
    • Interested students can read about the some of the complex factors involved in the optional reading below, “Maze of Injustice, an Amnesty International report.”
    • Goal: Explore the ways historical, political and sociocultural issues intersect with social determinants to affect the incidence and impact of violence.
    • Reflect: Why does violence disproportionally affect marginalized individuals and communities.  How does this knowledge improve our ability to serve patients responsively

Additional Resources

  1. PEARR tool: Dignity Health Tool universal education and screening approach https://www.dignityhealth.org/hello-humankindness/human-trafficking/victim-centered-and-trauma-informed/using-the-pearr-tool
  2. Excellent Education and Safety Planning worksheets in multiple languages. (some of the worksheets include California specific resources, but all include general resources as well.   https://www.leapsf.org/html/safety_plan.shtml
  3. Futures without Violence training videos on implementing universal education using wallet cards –  https://www.futureswithoutviolence.org/health-training-vignettes/
  4. Futures without violence wallet card pdfs (link to wordpress IPV site resource)“Is Your Relationship Affecting Your Health” safety card
  5. Link to MyPlanApp website https://www.myplanapp.org/home
  6. State-by-State reporting requirements for violence towards adults Information on rules/requirements for mandatory reporting by state
  7. Hotlines: If it is safe for you to do so, consider programming these hotlines into your own phone.

Structural Competency Cases

These three readings explore the complexities of identity and power in the clinical setting from the patient and physician perspectives.

  1. Manning, Kimberly D. “The nod.” JAMA 312.2 (2014): 133-134.
  2. Gridley, Samantha. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Third Place Gauze and Guns.” Academic Medicine 90.10 (2015): 1356-1357.
  3. Lynch, Katrina. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Second Place The Doctor Will See You Now.” Academic Medicine 90.11 (2015): 1530-1531.

Optional readings for students who want to explore more:

Justice in Healthcare: Difficult Encounters

This lecture discusses an approach called “DEAR” to responding to difficult encounters.  This will be used to form responses to cases.

  • Describe: “I notice…”
  • Express: “I feel/think…”
  • Assert: “I want…” or “I plan to…”
  • Reinforce: (“This will work out well for you because…”)

Optional Resources:

Introduction to Health Equity

1. Read:  Read the first 3.5 pages of this article “The Many Roads Towards Achieving Health Equity

GOAL: Introduce key terms and reviews the history of health equity briefly

This article helps to build a broad overview of health equity, it’s evolution, and pertinent terms that will be discussed in class.  The remainder of the article references areas of further reading for interested students.

 

 

Justice in Healthcare: Bedside Rationing

Justice in healthcare is a substantial part of ethics in medicine, here we will cover some of the distinctive aspects of justice-based concerns and some basic ethics language to help wade through these interesting ethical issues.

READ: this short piece by Dr. Jonsen and Dr. Edwards goes into some detail about resource allocation in the medical setting.

GOAL: Familiarize yourself with some of the basics of resource allocation in the medical setting.

REVIEW THIS CASE: (full article is not required and only linked for reference) from Satel and Aronson (2008) “Transplant Tourism: Treating Patients when They Return to the U.S.” American Medical Association Journal of Ethics 10(5):271-277.

Now start to apply what you’ve learned. This reading provides some preliminary perspectives on a case of transplant tourism. This is just one among many forms of distributive justice where we see the ethical tensions in rationing at the bedside.  As you read consider:

  • What does bedside rationing mean in this case?
  • What is the central ethical question the physician faces in this case?
  • What do you think should be done?

Mr. Lawrence, a 50-year-old man with diabetes, is on dialysis for chronic renal failure and on the waiting list for a kidney transplant. Because he is in relatively good health, he is low on the list. His physicians advise him that he could be on the list for up to 3 years and that his health during that time would not be jeopardized, aside from the risks and inconveniences associated with long-term dialysis. Mr. Lawrence is divorced and on bad terms with his ex-wife; he has no children and has contacted his sister and her family to see if any of them could be a living donor. His sister is obese, at risk for diabetes, and is not a suitable donor candidate; no other family members or friends are willing to consider donating a kidney to Mr. Lawrence.

Unable to find a living donor and dismayed at the thought of remaining on dialysis for years, Mr. Lawrence decided to use his financial resources to purchase a kidney and undergo a transplant in China. He spent 2 months in China after the surgery, where he was cared for by a local transplant team that provided postoperative care, including monitoring his renal function and managing his immunosuppressant medications. The surgery occurred without any significant complications, and Mr. Lawrence’s recovery was excellent.

A month after his return to the United States, Mr. Lawrence ran out of the medications that his doctors in China had prescribed, including his immunosuppressants. He knew that failing to take the medication could cause graft rejection, so he made an appointment with Dr. Roberts, a nephrologist at a local academic center who specialized in care of renal transplant patients… Dr. Roberts understood how difficult it was to secure an organ, but didn’t want to be perceived as condoning Mr. Lawrence’s actions.

WATCH: When thinking about justice, it is important to explore the perspectives of all stakeholders and consider the systems through which they interact. In the case of transplant tourism, this means knowing where organs can come from as well as who seeks them out. This is a problem of global justice, which means that ALL governments and ALL healthcare systems are implicated in our ethical reasoning.  See this short video from BBC News that portrays one family’s experience.

GOAL: See one example of the complexities of different stakeholders perspectives on the trade of organs across countries

This is a very short clip, but delves into the emotions and sense of responsibility that pervade the distribution of organs as a very scarce resources across the world.

 

WATCH: Now that you’ve thought about the case on your own, see the perspectives of some experts from different professional backgrounds.

https://mediasite.hs.washington.edu/Mediasite/Play/4cb3214702c1459d90e52d85e4187b491d

GOAL: familiarize yourself with different professional backgrounds and different forms of expertise on ethics in a challenging clinical context.

 

READ: in preparation for the discussion of a different case where injustice appears at the bedside, review this OpEd by Dr. Ofri “The Insulin Wars”. This essay provides a robust perspective regarding what it can feel like to face societal injustices that obstruct one’s ability to provide optimal care.


For further reading (not required)…

There are several impressive documentaries on transplant tourism, here is one from the UK that is slightly older (2004) but provides extensive insight into the perspectives of various stakeholders including patients, families, and transplant surgeons on multiple sides of the debate: The Transplant Trade. There is another newer documentary that investigates China’s illegal organ trade called Human Harvest, which can be accessed through the library here.

There are a number of recent articles in the news regarding the insulin cost crisis in the US. See this OpEd by Maris Kreizman “Why Am I Stockpiling Insulin in my Fridge?” Or, watch this video: https://nyti.ms/2RcVv5u.

 

The Medical Safety Net with Health Policy

1. READ: The “Executive Summary” for Community Health Centers: Recent Growth and the Role of the ACA

  • NOTE: the longer “Issue Brief” contains additional details but is NOT required reading
  • GOAL: Provide additional data regarding community health centers, populations served, and funding received.
  • INSTRUCTIONS: Read the following summary for basic introductory information regarding community health centers. Pay particular attention to the mechanisms for funding and access.

 

Optional Video

 

Optional additional references

Adverse childhood experiences and biology of stress

Activities:

  1. WATCH: Nadine Burke Harris’s TED talk that introduces key concepts about Adverse Childhood Experiences and how they impact health.

GOAL: Define the scope and frequency of adverse childhood experiences (ACE) and toxic stress, the connection to illness across the lifespan, and opportunities for clinician intervention.

Dr. Nadine Burke Harris explains how incorporating an understanding of the frequency and effects of adverse childhood experiences (ACES) can impact medical practice.

Reflect: How can a physician’s understanding of ACEs impact their clinical practice and outcomes?

 

2. READ: Original ACEs study: Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine. 1998;14(4):245–258. doi:10.1016/s0749-3797(98)00017-8. 

GOAL: Define and provide examples of Adverse Childhood Experiences.  Review the relationship between various forms of trauma/violence/ACEs and health status or health care outcomes throughout the life course.

This massive prospective study is the original research that described the prevalence of certain “adverse childhood events” in a managed care population and provided evidence for the strong correlation with morbidity and mortality later in life. Please note: A caveat that some language in this original paper (“family dysfunction”) would not be used in the trauma informed care environment that this work ultimately produced.

REFLECT: How does this information change the way you think about chronic diseases such as diabetes?  In what way does the study population (white, employed, insured, middle class) affect your reading of this article?

OPTIONAL PRE-CLASS READING

1. READ (OPTIONAL): NYT article on WA state resilient community success story

GOAL: Apply concepts of resilience to responding to and preventing ACEs.

WA state was a leader in community level interventions to reduce ACEs and mitigate their outcomes.  Ready about some of these projects and outcomes.

REFLECT: How might physicians be involved in such projects?

2. READ (OPTIONAL): The Lifelong Effects of Early Childhood Adversity and Toxic Stress, Shonkoff et al, Pediatrics Jan 2012, 129 (1) , focusing on pages e235-238, and figure 2 on page e23

GOAL: Describe the proposed pathophysiologic mechanisms of toxic stress’ effect on health across the lifespan and the mediating effect of known resilience factors.

In this Pediatrics article, Shonkoff et al, delve into the science of toxic stress on the developing brain and the moderating effect of resilience factors.  Based on this science, they propose an “ecobiodevelopmental framework” from which the clinicians of the future should approach primary care.

REFLECT: What potential roles can clinicians take in responding to and preventing toxic stress?

3. READ (OPTIONAL): American Family Physician Curbside Consultation: Providing Trauma-Informed Care, Ravi A, Little, V.  May 2017https://www.aafp.org/afp/2017/0515/p655.html

GOAL: With deepened understanding of the prevalence and effects of childhood trauma, describe universal concrete actions that can be taken during the interview and exam to maximize emotional safety for patients.

This article was also provided in Immersion; it is provided here for clinical correlation.  Ravi and Little discuss trauma-informed care as a “…universal precaution to optimally address patient’s health care needs while decreasing the risk of traumatization.”

REFLECT: Have you seen these precautions taken in your clinical settings?

Additional Resources:

Confronting institutionalized inequity in medicine

Activities

  1. Read: Taylor, A. (2004). Combination of Isosorbide Dinitrate and Hydralazine in Blacks with Heart Failure. NEJM, 351(20), 2049-2057.
    • Do not worry about details of biological mechanism, focus on big picture: what was studied, in whom, what were results and what’s the clinical application?
  2. Read: “The art of medicine. The short life of a race drug” by Sheldon Krimsky
    • Understand how and why BIDIL was able to be marketed as a race-specific treatment.
  3. Optional – Watch: Dorothy Roberts, The problem with race-based medicine (TEDMED 2015)

 

White Fragility

Activities 1-3

  1. Read pages 54-58 (stop before the section Factors that Inculcate White Fragility) in the article White Fragility, by Robin DiAngelo
    • Discussions about race and racism can be inherently uncomfortable. Acts of racism can take all forms and it is important to consider intent versus impact when racist behavior is exhibited. Much of this is driven by societal norms and socialization.
  2. Review In-class handout: The Art of Mindful Inquiry and Health Ways to Communicate
    • In order to have a deeper discussion please review recommendations for inquiring about difficult topics and look over the discussion points that will be discussed.
  3. Watch the video clip Just Be American from the film Color of Fear.
    • This video in an excerpt from the 1994 film The Color of Fear. Eight men of different backgrounds, races and ethnicities were gathered by director Lee Mun Wah, for a dialog about the state of race relations in America as seen through their eyes. This is a response by David C. after hearing about experienced racism from other members of the group.

Your goal for each activity

  1. Create a personal definition of white fragility.
  2. Understand how societal norms can lead to power differentials that exist between racial groups.
  3. Create a framework for discussions that may be difficult or challenging.
  4. Create a framework for understanding why talking about racism may be more difficult for some than others.