The Silent Saboteur: Teaching the Clinical Implications of Occult Hypoxemia & Social Determinants of Health via a Pulmonary Embolism Case.

Abstract

Audience: Medical students on required fourth-year emergency medicine clerkship.

Introduction: Social determinants of health are the nonmedical factors that influence health outcomes.1 As part of the AMA Accelerating Change in Medical Education Consortium's third pillar of medical education, health systems science, social determinants of health are recognized as critical components to medical student education.2 The push for institutions to address health inequities has led medical schools to emphasize social determinants of health.3 Medical students have stepped up to advocate for change and are demanding concrete action, including the development of antiracist curriculum and learning environments.4 The current and next generations of physicians need to be prepared to be responsive to the public health and societal needs of everyone.5 Emergency departments are a window into a community and its challenges, reflecting the most critical social determinants of health (SDH) of the population they serve; as such, they are the ideal setting in which to learn about SDH.6 Core emergency medicine (EM) clerkships typically focus on disease management for the acutely ill and injured, with limited emphasis on the holistic care that addresses a patient's SDH-a missed educational opportunity.7 We present an oral (or white) board case that highlights the basic approach to pulmonary embolism while emphasizing consideration of both social determinants of health and racial considerations.

Educational objectives: By the end of this oral board case, learners will be able to: 1) obtain appropriate history of present illness (HPI) and physical exam elements for the undifferentiated chest pain patient, 2) identify elements of history and physical exam that are compatible with pulmonary embolism, 3) formulate a differential diagnosis for chest pain and perform the appropriate work-up to narrow this differential diagnosis, 4) appropriately manage pulmonary embolism, 5) review and discuss the diversity, equity and inclusion (DEI) elements of the case, and 6) review and discuss the importance of social determinants of health (SDH) in disposition decisions and patient outcomes.

Educational methods: This case is meant to be used as an oral board or white board case for medical students and interns.

Research methods: Educational content was assessed via three questions related to occult hypoxemia and Glomerular Filtration Rate (GFR) reporting by race at the end of clerkship exam. The results of learners who were present for the case were compared to those who were not present. Results were stratified to compare whether the student was applying for an Emergency Medicine residency or another specialty.

Results: A total of 72 students completed the end of clerkship exam, with three questions related to diversity, equity, and inclusion. Data was sorted both by questions and whether the student planned to apply for an Emergency Medicine residency. The total percent correct was 54.63%. The total percent correct for students present for the oral boards case was 54.69% while that of students who were not present for the case was 54.17% (p=0.96). When looking at students applying for emergency medicine, the total percent correct was 61.90% compared to 47.75% correct for students who were not applying for an Emergency Medicine residency (p=0.037).

Discussion: This case demonstrates an original way to teach core emergency medicine content and meet AAMC Diversity, Equity, Inclusion competencies. The case not only provides a realistic example of downstream effects of racial disparities and not addressing a patient's social determinants of health, but effectively illustrates how to integrate knowledge of inequity into patient care.

Topics: Undifferentiated chest pain, pulmonary embolism, PERC Score, Well's Score, occult hypoxemia, racial bias in reporting glomerular filtration rate (GFR), social determinants of health, diversity, equity, inclusion (DEI).