DEIA Curriculum: Outpatient Adult Medicine

Suggested Rotations: Outpatient Pediatrics PGY-1, PGY-2, PGY-3

Objective 1A: Describe the impact of racism on health and health care.

Objective 1B: Define the concept of structural violence and apply it to US Health Care System. 

Resources:

• Race & Medicine website with interesting videos, narrative and webinars:
  • Focus on pages on Biology, Racism, and Structural Racism (links in top left) (30-minute activity)
  • Go to the Topics in Medicine tab (links in top right) for information about different health issues and how racism can affect them. (30-minute activity)
  • Chapter 10 … There are no accidents. The Paul Farmer Story | ANTH101
  • Allegories on race and racism | Camara Jones | TEDxEmory (20-minute video)

Applications and Questions:

• How can racism negatively affect a person’s health?
• What can an individual provider do to combat the effects of racism on their patients’ health?
• The article about Paul Farmer defines structural violence and applies it to Haiti and African countries. How have you witnessed structural violence in the US health system during your clinical rotations?

Suggested Rotation: Leadership; Orientation; Community Medicine; Inpatient PGY1, PGY2, PGY3; Outpatient PGY1, PGY2, PGY3; ER; General Surgery

Objective 1A: Describe the experiences of those subjected to microaggressions in medicine and some strategies to mitigate its effects.

Objective 1B: Identify potential responses to daily microaggressions

Resources:

• Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting. Read the article and then click on download under appendices A and C for Bystander Training handout and Response Framework Handout. (30-minute read)

Applications and Questions:

• How can you best support colleagues when you witness that they have been disrespected by patients? 
• What ways of responding to a microaggression “feel” the best to you (e.g. direct, distract, delegate, delay, or displaying discomfort)? How can you best flexibly implement these approaches to microaggressions? 
• What resources are available at your institution if you choose to “delegate” when confronted with a microaggression?
• How do you feel that you can best support a colleague when you witness a microaggression directed towards them?

Suggested Rotations: Community Medicine; Orientation; Outpatient Clinic PGY1,PGY2, PGY3

Objective 1A: Apply the concept of structural and social determinants of health to their own patients. 

Objective 1B: Identify resources to address patients’ needs based on social determinants of health

Resources for Patients:

• Advancing Health Equity by Addressing the Social Determinants of Health (14-minute read)
• Family Physicians are Using Neighborhood Navigator to Address Social Determinants of Health (2-minute read)
• Neighborhood Navigator: Search health care resources by zip code in the United States (5-minute activity)

Applications and questions:

• What are some social factors that could be preventing your patients from having equitable access to health care?
• How could Neighborhood Navigator assist you and your patients in providing community resources to address social needs related to health care access?

Suggested Rotations: Dermatology; Outpatient Clinic PGY1, PGY2, PGY3

Objective 1A: Identify common rashes in people of color: dermatosis papulosa nigra, pseudofolliculitis barbae, acne keloidalis nuchae, keloids. 

Objective 1B: Recognize the presentation of skin cancers in people of color.

Resources:

• Common Dermatologic Conditions in Skin of Color (13-minute read)
• Recognizing Skin Cancer in People of Color (4-minute read)

Review Resources Focused on Skin of Color:

• Resources for skin of color images - Journal of the American Academy of Dermatology: Visit each link in Table I to familiarize yourself with resources:(20-minute activity)
• Mind the Gap — Black & brown skin: Explore for different presentations of rashes in skin of color.
• Mind the Gap Handbook: Explore the free online handbook
  
  

Applications and Questions:

• Reflect on your own experience learning about dermatology. Were the images you were presented with representative of patients with diverse skin tones? If not, how might you learn about identifying rashes for different skin types?
• Did the results in the quiz on the Mind the Gap website surprise you?  
  

Objective 2: List skin concerns that commonly affect trans and nonbinary patients treated with hormone therapy for gender-affirming care.

Resources:

• Dermatology for LGBTQIA+ people: Review presentation A (45-minute activity)

Applications and Questions:

• How can you promote health equity for trans patients with dermatologic concerns?
• Some insurance companies cover services such as laser hair removal for trans-women. Look up what is covered by the more common insurers for patients in your clinic.

Suggested Rotations: Geriatrics; Outpatient Clinic PGY1, PGY2, PGY3

Objective 1A: Describe ways to provide high-quality multicultural geriatric care.

Objective 1B: Discuss the intersection of racism and ageism and the impact of these structures on health.

Objective 1C: Apply the age friendly 5M person-centered care model to promote equity in the care of older adults from racial/ethnic minority populations.

Resources:

• Achieving High-Quality Multicultural Geriatric Care (14-minute read)
• Exploring the Intersection of Structural Racism and Ageism in Healthcare (20-minute read)
• Geriatric Five M's for Primary Care Workshop: Mobility, Medications, Mind, Multicomplexity, Matters Most  Review presentations A-E
  (90-minute activity)

Applications and Questions:

• What can clinicians do to provide high-quality geriatric care for ethnic and racial minority (older adult) populations?
• Think of an older adult from an ethnic/racial minority to whom you have provided care. How did the intersection of racism and ageism affect their health? 
• How could you utilize the 5M model to care for this patient? How can use of a structured model of care such as the 5M model promote health equity?

Suggested Rotations: Hospice; Geriatrics; Outpatient Clinic PGY1, PGY2, PGY3; Inpatient Medicine PGY1, PGY2, PGY3

Objective 1A: Describe end of life practices in Chinese American and Russian American Communities.

Objective 1B: List ways to approach the topic of Hospice with African American patients.

Resources:

• Fact sheets about end-of-life care for Russian and Chinese American Patients 
  • End-of-Life Care: The Russian Culture (2-minute read)
  • What Matters Most at the End-of-Life for Chinese Americans?  (10-minute read)
• Black and African-American Outreach Guide for Hospice (19-minute read)

Applications and Questions:

• How can you show culturally sensitive end of life care to Russian and Chinese American patients?
• Can you describe the difference between cultural competency and cultural humility? Is cultural competency possible?
• What are some culturally humble ways to present options for Hospice with African American patients?
• Ask your institution to register for the Center to Advance Palliative Care in order to access their seminars and toolkits on addressing diversity, equity and racism in palliative care: Improving Health Equity for People with Serious Illness

Suggested Rotations: Outpatient Clinic PGY1, PGY2, PGY3; LGBQTIA+ Health Rotation; Endocrine Rotation

Objective 1A: Upon completion of this rotation residents will be able to list at least 3 features of a trans-affirming clinic. 

Objective 1B: Upon completion of this rotation residents will be able to define the following terms: cultural humility, cis-gender, trans-gender, agender, puberty suppression.

Objective 1C: Residents can explain the basics of estrogen-gender affirming hormonal therapy and testosterone-gender affirming hormonal therapy.

Resources:

• Creating Affirming Health Care Facilities for transgender patients (12-minute video)
• Documentary for parents whose children come out as LGBTQ (35-minute watch)
• Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know (18-minute read)
• Engaging Families of Transgender and Gender Diverse Youth Supporting families of transgender youth: start at PowerPoint slide 9 (10-minute read)
• UCSF Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

Applications and Questions:

• Is your clinic trans-affirming? How so? What are one or two things you could change to make your clinic more trans-affirming?
• What can physicians do to ensure equitable health care for LGBTQ+ youth and people of all ages?
• Does your clinic provide gender affirming hormone therapy? If so, reflect on your experience working with this population, what goes well, what could be better. If not, consider what barriers prevent this service from being provided. Why might it be important for patients to receive their care in their patient centered medical home as opposed to a specialty clinic? Are the steps your program might take to get closer to providing this resource?
• If your state does not permit gender-affirming hormone therapy, how can you best support your patients in seeking the care they need?

Suggested Rotations: Outpatient PGY1, PGY2, PGY3; Inpatient PGY1, PGY2, PGY3; Outpatient Pediatrics PGY1, PGY2, PGY3; Endocrine Rotation; General Surgery

Objective 1A: List ways to Improve communication skills with patients about weight-related health. 

Objective 1B: Describe the adverse consequences of weight stigma on patients’ emotional and physical health.

Resources:

• Weight Bias in Clinical Care: Improving Health Care for Patients with Overweight and Obesity (45-minute read)
• Obesity Bias Module (15-minute activity)

Applications and Questions:

• How can you approach issues of weight and health with patients in sensitive and effective ways? What words should you avoid to decrease weight stigma? What words can you use instead?
• How important is it for you to check a weight at each patient encounter? What are the pros and cons of doing so?
• How do you discuss weight status vs. lifestyle strategies for wellness in patient visits?

Objective 2A: Recognize the historical context of Body Mass Index (BMI) and its relationship to understanding health.

Objective 2B: Analyze the risks and benefits of using BMI as an indicator of health.

Objective 2C: Evaluate which metrics are important to track and prioritize in visits related to metabolic health.

Resources:

• "Belly of the Beast" Excerpt: The War on Drugs and The War on Obesity (10-min read)
• Family & Community Health (5-min read)
• AMA adopts new policy clarifying role of BMI as a measure in medicine  (1-min read)
• How and why weight stigma drives the obesity ‘epidemic’ and harms health (5-min read)
• The Racial Origins of Fat Phobia: Short Wave (14-min listen)

Applications and Questions:

• Reflect on how, when, or if you use BMI in patient care. Might some of the resources above change your approach?
• How can you know your patient's health goals?  How do we track metrics that are consistent with these goals?
• How does the diet industry influence the way we think about the relationship between health and weight? Who is making money off of the ‘war on obesity’? 
• How has systemic racism influenced the way we think about weight in healthcare?
• How might using BMI as a key indicator of health result in worse outcomes for people of color?

Suggested Rotations: Outpatient PGY1, PGY2, PGY3; Inpatient PGY1, PGY2, PGY3; Outpatient Pediatrics PGY1, PGY2, PGY3; General Surgery; ER

Objective 1: Define ableism and list at least 2 examples of ableist language to avoid.

Resources:

• How to Identify + Reconsider Ableist Language at Work | Career Contessa: Decreasing ableist language in the workplace (6-minute read)
• Ableism in Healthcare Part 1 (33-minute video)

Recognize your own potential biases:

• Take the implicit association test on disability 

Applications and Questions:

• Think about a patient that you have seen that has communication barriers (from history of a stroke, hearing loss, cerebral palsy, ALS, mutism, etc.) How can you adapt your communication to be sure that they participate actively in visits and decision making?
• Ease their way: ask your next patient with a disability what challenges the disability might cause in their access to health care. Does your clinic have resources that might help? For example, option in EMR for bigger text for visual impairment, getting RX’s setup in bubble packs, OT to help mobility, exam tables that lower, etc. 

Suggested Rotations: Outpatient PGY-1, PGY-2, PGY-3; Labor and Delivery PGY-1, PGY-2, PGY-3; Inpatient PGY-1, PGY-2 , PGY-3; General Surgery, Pediatrics PGY-1, PGY-2 , PGY-3

Objective 1A: Identify challenges that exist in accessing healthcare for patients with NELP.

Objective 1B: Describe how language barriers impact patient outcomes and satisfaction.

Resources:

• The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the US: A Scoping Review (15-minute read): This is a systematic review looking at health outcomes in NELP patients. 

Applications and Questions:

• Can you reflect on a time when language barriers caused an undesired outcome (large or small) for a patient? What was the situation? What might have improved the outcome?
• Have you ever personally experienced language barriers for yourself or your family in the healthcare setting? 

Objective 2A: List and identify best practices in working with interpreters.

Objective 2B: Identify when a professional interpreter is needed for safe communication in clinical care.

Resources:

• Incorporating Medical Interpretation Into Your Practice: This is a toolkit for medical educators to teach medical students and residents how to work with medical interpreters. It has sample cases.
• TRANSLATORS (21-min watch): A free access documentary about children translating for their families.
• Clinicians’ Obligations to Use Qualified Medical Interpreters When Caring for Patients with Limited English Proficiency (5-min read): This has a vignette with ethical analysis about interpreter use in medical education.
• Appropriate Use of Medical Interpreters (5-min read)
• CLAS Standards—Think Cultural Health (3-min read)
  This is a quick list of clinic standards to advance health equity. 3-min read. 
• Language Is Not A Barrier—It Is An Opportunity To Improve Health Equity Through Education (5-min read)

Applications and Questions:

• Think of a time you have had to use a medical interpreter. What were the challenges that you experienced in communicating this way? 
• Reflect: Why is it unethical to use an underage child as an interpreter? What might be ethical implications of using adult family members or friends as interpreters? If you were experiencing health care in a country where your language is not spoken, would you want your sibling or parent to interpret for you?

Suggested Rotations: Clinic PGY1, PGY2, PGY3; Inpatient Medicine PGY1, PGY2, PGY3; General Surgery; ER 

Objective 1A: List 5 clues to recognize low health literacy in patients.

Objective 1B: Demonstrate the teach back method for low health literacy patients.

Resources:

• Understanding effects of health literacy on patient care (23-minute video)
• Teach back: a technique for clear communication: An example of the teach back method (4-minute video)
• This app will tell you the grade level of your writing: The average American reading level is 6th grade. Analyze a few of your most recent After Visit Summaries for readability. 
• Every Day Words - Search | CDC: Check your language: what are simpler ways of saying common medical terminology such as gastroesophageal reflux, adverse, acute, prophylaxis, renal, detect, bacterial.

Applications and Questions:

• Think about your own patients. Can you think of someone who’s care was impacted by low health literacy? Consider if low health literacy might be a factor in patients who are “non-compliant” with recommendations or prescriptions. 
• Practice using the teach-back method at least once in your next clinical session. Did anything surprise you about this experience? 
• Practice/develop scripts in which you teach patients about common topics in primary care such as GERD, IUDs, asthma, etc. using drawings and simple language.

Suggested Rotations: Sports Medicine; Orthopedics; PMR; General Surgery 

Objective: Residents will apply the recognition of orthopedic care disparities to advocacy for their patients' needs.

Resources:

• Editor’s Spotlight/Take 5: Eligibility Criteria for Lower-Extremity Joint Replacement May Worsen Racial and Socioeconomic Disparities
  (10-minute read)
• Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review (10-minute read)
• Responding to Malignant Social structures - Structural Competency Working Group (20-minute video—watch from start to 20:00)

Applications and Questions:

• Reflect on the article about eligibility criteria for total joint replacement. Has this impacted your referral patterns or patients?
• Reflect/apply: People of color have many obstacles to orthopedic and rehab care including bias, financial, transportation, and work barriers, as well as trust. Consider the levels of intervention outlined in the video. How can you advocate for interventions to mitigate these obstacles for your patients on each of these levels? What other individuals or groups could play a role in these interventions? 

Suggested Rotations: Behavioral Health; Addiction Medicine; Outpatient Clinic PGY1, PGY2, PGY3; ER

Objective 1A: Use non-stigmatizing communication when discussing mental health and/or substance use.

Objective 1B: Explain factors that contribute to addictions, as well as factors that can contribute to recovery.

Objective 1C: Identify biases that may impact provider behaviors towards members of minority groups with mental health/substance use.

Objective 1D: Apply patient-centered approaches to discussing substance use (e.g. motivational interviewing).

Resources:

• Words Matter - Terms to Use and Avoid When Talking About Addiction (5 minute read)
• Everything https://www.youtube.com/watch?v=PY9DcIMGxMs (15-minute video) 
• Ineffective Motivational Interviewing Example https://www.youtube.com/watch?v=vVEA-JNg-v0 (4-minute video)
• Effective Motivational Interviewing Example https://www.youtube.com/watch?v=BWZHNcIryg8 (7-minute video)

Applications and Questions:

• What are some terms that are helpful to use when discussing individuals with substance use disorders? What terms should be avoided?
• How does using person-first language help maintain the integrity of individuals with substance use challenges? 
• Dr Gabor Maté, an addiction medicine expert and author, explains substance abuse as a response to individual human suffering. How may a childhood history of abuse/neglect and overall human suffering contribute to challenges with substance use? How can Dr Maté’s conceptualization of substance use help you empathize with patients with substance use disorders? 
• Why is it important to explore in a non-judgmental manner a patient’s thoughts about addressing their substance use challenges vs. using a more directive approach (e.g. explicitly “calling out” a patient about their substance use)? 

Suggested Rotations: Infectious Disease; Outpatient Clinic; PGY1, PGY2, PGY3; ER; Urgent Care

Objective 1A: Identify barriers to HIV prevention and treatment for marginalized groups.

Objective 1B: Identify which patients should be offered Pre-exposure prophylaxis (PREP) and Post-Exposure Prophylaxis (PEP).

Resources:

• To End HIV Epidemic, We Must Address Health Disparities (5-minute read)
• Preexposure Prophylaxis for the Prevention of HIV Infection: Recommendation Statement (10-minute read)

Applications and Questions:

• Do you consistently prescribe PREP/PEP to at-risk patients in your clinic? How do you identify who is at risk?
• How might you go about addressing HIV disparities in your patient population/community?
• What role might mental illness play in preventing access or adherence to treatment? What other obstacles might impact your patients?

Suggested Rotations: Behavioral Health: Addiction Medicine; Outpatient Clinic PGY1,PGY2, PGY3; ER

Objective 1: Residents will apply concepts of increased primary prevention to address life-expectancy disparities in their patients with severe persistent mental illness.

Resources:

• Improving life expectancy in people with serious mental illness: should we place more emphasis on primary prevention? (8-minute read)
• A Tale of Mental Illness—From the Inside: A patient narrative (15-minute video)
• Take the implicit bias test “mental illness IAT": Do you implicitly associate people with mental illness with danger? (15-minute activity)

Applications and Questions:

• Patients with severe mental illness have a 20-year decrease in life expectancy. Review the charts of three of your patients with schizophrenia, psychosis or bipolar disorder-have you maximized all strategies to prevent premature cardiovascular disease? Can medications be adjusted to decrease risk of metabolic disease? Have you addressed smoking cessation proactively? 
• What are some biases that you may have observed in your clinical training about individuals with mental health problems, including those with severe and persistent mental illness? 

Objective 2: Residents will explain the concepts of historical trauma and apply it to understanding the impact on mental health of their patients.

Resources:

• Historical Trauma: The Confluence of Mental Health and History in Native American Communities (8-minute read and 8-minute video)
• What Does It Mean to Heal From Historical Trauma? (7-minute read)

Applications and Questions:

• Reflect on the concept of historical trauma. The reference discussed Native Americans. What other groups might be impacted? How might you address historical trauma with your patients?

Objective 3: Residents will apply the concept of intersectionality to their patients with mental illness. 

Resources:

• My Collective Brave: Intersectional Stories—This Is My Brave: Watch the intersectionality introductory video (3-minute video) and then explore several storytellers' narratives.

Applications and Questions:

• Apply the framework of intersectionality to a patient with mental illness that you have found challenging. How might that framework impact your approach to supporting that patient?

Suggested Rotations: Community Medicine; Orientation; Leadership; Outpatient Clinic PGY1, PGY2, PGY3; ER

Objective 1: State one thing you will change or focus on about your approach to caring for the unhoused.

Resources:

• How Health and Homelessness are Connected—Medically (7-minute read) 

Applications and Questions:

• Describe how lack of housing can negatively affect a person’s health and life expectancy.

Suggested Rotations: Community Medicine; Orientation; Leadership; Outpatient Clinic PGY1,2,3; ER

Objective 1: Describe how food insecurity can affect a patient’s ability to promote their own health.

Resources:

• Patient Perspectives: Valuable Food Insecurity Interventions
  (6-minute read)

Applications and Questions:

• What is the link between food insecurity and obesity?
• How can inquiring about food insecurity contribute to improving your patient’s health? Does your clinic routinely screen for food insecurity? What resources does your clinic have for patients with food insecurity?

Suggested Rotations: Community Medicine Rotation, Emergency Medicine, Geriatrics; Outpatient Clinic PGY-1, PGY-2, PGY-3; Inpatient Medicine PGY-1, PGY-2, PGY-3, Social Medicine Elective Rotation, Unhoused Populations Elective Rotation

Objective 1: Evaluate the unique challenges that patients who are recently released from incarceration face in accessing health care and caring for their health. 

Resources:

• How to Talk With Patients About Incarceration and Health (11-minute read)
• Connecting Recently Released Prisoners to Healthcare- How to Leverage Medicaid (8-minute read)
• Public Health Considerations for Correctional Health (5-minute read)
• Healthy People 2030- Incarceration (5-minute read)
• This Book Club guide provides an excerpt from the book "The New Jim Crow" with discussion guides and insights.

Applications and Questions:

• Analyze how existing federal and state policies can affect access to care for the recently incarcerated, with specific consideration of the role of insurance coverage. 
• Evaluate how recent incarceration is associated with mental health and how specific issues such as substance use, infectious disease, and physical trauma are uniquely relevant for people who have been recently incarcerated. 
• Analyze the relationship between recent incarceration and other social determinants of health, including housing, transportation, food security, education, and social support systems.
• Create an evidence-based approach to introducing the topic of recent incarceration with patients and a plan for addressing their unique health care needs.