DEIA Curriculum: Inpatient Adult Medicine

Suggested Rotations: Inpatient PGY1, PGY2, PGY3, Outpatient PGY1, PGY2, PGY3, ICU

Objective: Explain the factors that go into GFR calculations and how that might impact the care of Black patients.

Resources:

• Association of the Estimated Glomerular Filtration Rate With vs Without a Coefficient for Race With Time to Eligibility for Kidney Transplant (8-minute read)
• A New Way to Estimate Kidney Function (3-minutes read) 
• The Problem With Race-based Medicine (14-minute video)

Applications and Questions:

• How might current GFR calculation methods adversely impact the care of Black patients?
• What might be a more accurate way to account for different body types in assessing renal function? 

Suggested Rotation: Inpatient PGY1, PGY2, PGY3; Outpatient PGY1, PGY2, PGY3; ICU

Objective: Increase awareness of bias in medical documentation and impact on care.

Resources:

• Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record (14-minute read)
• Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record. (18-minute read)

Applications and Questions:

• Review 3 medical notes that you have written for patients that you feel are “challenging”:
  • Do they include any language that may transmit bias?
  • How might you change your wording in the future?

Suggested Rotations: Inpatient PGY1, PGY2, PGY3; ICU; ER

Objective 1: Discuss the potential harm in labeling a discharge “Against Medical Advice”

Resources:

• Annals for Hospitalists Inpatient Notes - Challenging the Myths of the Against Medical Advice Discharge (10-minute read)

Applications and Questions:

• How can physicians avoid the AMA designation and promote shared decision making and harm reduction?
• Reflect on a patient that left AMA when you have been on the inpatient service. What factors might have contributed? In hindsight could the team have done anything to change that outcome?

Objective 2: Define “Hostage bargaining syndrome” in the hospitalized patient and its negative impact on quality of care.

Resources:

• Hostage Bargaining Syndrome (12-minute read) 

Applications and Questions:

• What leads some hospitalized patients to adopt behaviors associated with hostages?
• What could you do or say to empower patients and mitigate hostage bargaining behaviors?

Suggested Rotations: Inpatient PGY1, PGY2, PGY3; ICU; ER

Objective 1A: Residents will list ways in which the inpatient care of the incarcerated patient can differ and potentially compromise care.

Objective 1B: Resident will examine their institution’s policies and guidelines and evaluate balance between patient rights and correctional system safety mandates.

Resources:

• How to Talk With Patients About Incarceration and Health (11-minute read)
• Incarcerated Patients and Equitability (7-minute read)
  
  

Applications and Questions:

• Identify three ways in which the inpatient care of the incarcerated patient can differ from usual care in areas such as right to privacy, visitation, use of restraints, etc. 
• Look online or contact your institution’s Safety and Security Department for existing guidelines, policies and procedures on caring for incarcerated patients. 
• What policy elements  at your institution regarding the care of incarcerated persons could put them at risk of poorer health outcomes? How might this be remedied?
• Have you cared for an incarcerated patient in restraints in the hospital? How did you feel about it? Examine possible feelings of moral distress.

Suggested Rotations: Inpatient PGY1, PGY2, PGY3; Hospice; ICU

Objective: Discuss cultural differences in attitudes and beliefs regarding advance directives and end-of life care and identify types of questions that can elicit information about patient preferences.

Resources:

• Cultural humility vs cultural competence (8-minute read) 
• A Culturally Responsive Approach to Advance Care Planning: A REFLECTION (7-minute read)

Applications and Questions:

• State a general question you could use to elicit cultural preferences with regard to advance directives or end of life care.
• How can you incorporate your patients' cultural beliefs into their advance care planning?

Suggested Rotations: Inpatient PGY1, PGY2, PGY3; ICU; General Surgery

Objective 1A: Residents will list three approaches to care which support the autonomy of patients with disability.

Objective 1B: Residents will recognize the bias inherent in using disability as a criterion for care.

Resources:

• Three Things Clinicians Should Know About Disability (6-minute read)
• Personal reflection exercise: Brief Abled Privilege Checklist (12-minute read)
• One Man's COVID-19 Death Raises The Worst Fears of Many People With Disabilities (5-minute listen)

Applications and Questions:

• Whose decision should it be to withdraw life sustaining therapy for patients with disabilities?
• During your inpatient rotations, take note of the language used to describe patients with disabilities. Does it differ from that used to describe others?

Suggested Rotations: Inpatient PGY1, PGY2, PGY3; ICU; General Surgery

Objective: Describe the disparities in access to critical care services based on income, particularly in rural areas.

Resources:

• Focus on the Figures:
  Income Disparities in Access to Critical Care Services
   (8-minute read)

Applications and Questions:

• Reflect on your patients' experiences of transfers to the ICU: 
  • If you work in an urban setting, how does your ICU team discuss patients who are transferred from outside hospitals?
  • If you work in a rural hospital, what barriers exist when transferring patients to a higher level of care?

Suggested Rotations: Cardiology, Inpatient PGY1, PGY2, PGY3; ER; ICU; Outpatient Clinic PGY1, PGY2, PGY3

Objective 1A: Residents will critically analyze the use of race in the ASCVD calculator.

Resources:

• Hidden in Plain Sight—Reconsidering  Use of Race Correction in Clinical Algorithms  (13-minute read)
• Using Race With Caution in the ASCVD Calculator

Application and Questions:

• What are the pros and cons of using race in the ASCVD calculator?
• Would you adapt your approach to multiracial patients?

Objective 2: Explain how the use of race to inform hypertension treatment recommendations rather than sociocultural, behavioral, and environmental factors can impact care and contribute to health inequities.

Resources:

• Background reading: Race-Based Prescribing for Black People With High Blood Pressure Shows No Benefit (9-minute read)

Application and Questions:

• Should your treatment targets or medication choices be different for Black patients? 
• Do you need to avoid ACE-inhibitors in Black patients? What are the health equity implications of doing so?

Suggested Rotations: Cardiology, Inpatient PGY1, PGY2, PGY3; ER; ICU; Outpatient Clinic PGY1, PGY2, PGY3

Objective: Describe how a woman with an acute myocardial infarction (MI) might present differently than a man.

Resources:

• Cardiology’s Problem Women (3-minute read)

Applications and Questions:

• What do you think of the title of this article? Are women the problem? What would be a better title?
• Please reflect on both the content and how articles with titles like this might reflect bias and possibly contribute to health inequities.
• What other groups may have “atypical” presentations for myocardial infarctions?

Suggested Rotations: General Surgery, Orthopedics, Sports Medicine

Objective: List three contributors to racial disparities in access to and outcomes for elective surgeries.

Applications and Questions:

• How might the inclusion of race in risk calculators affect who has access to elective cardiac surgeries?

Suggested Rotations: General surgery; Inpatient Medicine PGY1, PGY2, PGY3; Outpatient Clinic PGY1, PGY2, PGY3

Objective 1A: Resident will explain the complex factors that contribute to racial inequities in cancer outcomes.

Objective 1B: Resident will describe LGBTQIA+ cancer disparities.

Resources:

• The State of Cancer Disparities in the United States
  Simple brief overview (5-minute read)
• AACR Cancer Disparities Progress Report
  Deeper dive on cancer disparities (45-minute read)
• When More People Qualify for Medicaid, More Survive Cancer
  (5-minute read)
• Editorial:Cancer prevention, treatment and survivorship in the LGBTQIA community
• Cancer Disparities American Cancer Society Research Highlights (4-minute video)

Applications and Questions:

• What can you do to improve cancer outcome equity in your own patient panel? 
• Provide an example of how quality improvement (QI) work can improve overall cancer outcomes, but simultaneously increase inequity? How might your QI efforts focus on minoritized groups?
• If you were advocating to your senator, what might you ask for that would improve cancer equity?

Objective 2: Resident will explain the complex factors that contribute to inequity in cancer outcomes. 

Suggested Rotations: Adult ER; Urgent care; Community Medicine; Outpatient clinic PGY1, PGY2, PGY3, Inpatient Pediatrics; Peds ER

Objective 1A: Identify health  risks from climate change and toxic exposures in your region and ways they might impact certain communities/special populations. i.e Southwest heat risks, Pacific Northwest wildfire risks, pollution, agriculture/ farm worker impact, labor trafficking etc.

Objective 1B: List ways to identify, treat, and counsel patients that are at high risk for negative health impact due to extreme weather events in your community. For example, supporting patients with lung disease in wildfire smoke, or thinking of plans for farm workers on high heat days, etc.

Objective 1C: Residents will access the environmental health data from their communities and analyze it with an equity lens.

Resources:

• Guide for health departments about the impact of climate change on health and how to prepare: It mentions at-risk groups and strategies to prevent emergencies. Skim through and pick topics most relevant to your region. (10-15 minute activity)
• Environmental Justice Screen Mapper: This allows you to see mapped out data for your region. You can see lead, air quality issues, health disparities, climate change data and more. (5-minute activity)

Applications and Questions:

Focus: impact of climate change on health equity 

• Think of a patient you have cared for who is at an increased risk of climate-related health risks. 
  • What are patient factors (diagnoses, demographic factors) that increase their risk? 
  • What are ways that their health risks could be mitigated?
• Look at the Environmental Justice Screen tool for your community. Think about how it might impact your patient counseling. What are the major environmental health hazards for your area? Do you notice differences in exposures for more or less affluent communities in your region?

Suggested Rotations: Adult ER; General Surgery; ICU; Inpatient PGY1, PGY2, PGY3

Objective: Identify racial/ethnic disparities in emergency/acute pain control.

Resources:

• Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites (14-minute read)
• How doctors' racial biases can harm black patients (3-minute read)
• A Thousand Cuts: Racial and Ethnic Disparities in Emergency Medicine (4-minute read)

Applications and Questions:

• Summarize the evidence that implicit bias is one of the causes of racial disparities in the treatment of pain.
• What are some systemic or structural ways that providers and healthcare systems can prevent individual biases from impacting patients with acute pain?

Suggested Rotations: Inpatient Psychiatry; Behavioral Medicine; Community Medicine; ER; Behavioral Medicine

Objective 1: Identify disparities in emergency mental health care 

Resources:

• Assessing racial/ethnic disparities in treatment across episodes of mental health care (17-minute read)
• Racial disparities in emergency mental healthcare utilization among birthing people with preterm infants (12-minute read)

Application and Questions:

• If you were designing an equitable system to respond to people in mental health crisis, what would you propose?
• Describe biases you observed in mental health crises. 
• What steps might you take to avoid bias in interactions with patients experiencing a mental health crisis?

Objective 2: List three downsides to police-based emergency responses to mental health crises and consider some alternatives. 

Resources:

• Alternative strategies for mental health crisis responses: Join the campaign! – Portland Street Response (3-minute read)
• Discussion of police response to mental health crises: Why Are Police the Wrong Response to Mental Health Crises? (30-minute listen)

Objective 3: Role play or model de-escalation techniques for agitated patients.

Resources:

• Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup (33-minute read)

Application and Questions:

• Reflect on a time security was called for a patient with mental illness. What went well and what didn’t? How could de-escalation techniques be employed effectively in this situation?

Suggested Rotations: Inpatient Psychiatry; ER; Orientation; Community Medicine

Objective 1: Describe approaches/skills to appropriately care for people exposed to multiple forms of trauma utilizing trauma-informed care (TIC).

Resources:

• Human Trafficking in the Emergency Department: Improving Our Response to a Vulnerable Population (15-minute read)
• A guide for practicing trauma-informed care for patients with chronic pelvic pain: Practical tips and examples on how to do trauma-informed visits and physical exams. This resources has a chronic GYN pain focus, but is widely applicable. (7-minute video) 

Applications and Questions:

• Reflect on an interaction that you’ve had with a patient who had experienced trauma that could have gone better. How could you use TIC to improve your communication with them?
• What are one to two changes you might make in your approach to a trauma-informed pelvic exam after watching the video?