Solving the issue of diversity in medicine and dentistry is multifaceted, but elucidated challenges from the undergraduate student perspective offer targeted areas where intervention may help remedy barriers and decrease pipeline leakiness.
Our study results suggest that significant racial and ethnic disparities exist in the ESI scores assigned to patients during nursing triage evaluation and in the intensity of services provided during physician evaluation for patients presenting with the same acute chief symptoms. When nurses assign White patients more acute ESI scores at triage, they may also order diagnostic tests prior to a physician's involvement, leading to downstream increases in wRVUs. Additional decisions made at triage associated with race, ethnicity, and socioeconomic status, such as assignment to a room or hallway bed, may also influence physicians. 6 However, our findings suggest that when controlling for triage, significant racial and ethnic disparities persist in physicians' evaluations, particularly for Black and Hispanic patients.This study has several significant limitations, including a smaller proportion of patients identifying as Asian and American Indian or Alaska Native and a heterogenous other race or ethnicity category, limiting our ability to draw conclusions about these populations. More work is needed to determine where in the triage and physician evaluation processes these disparities arise and what can be done to remedy them.
images in clinical medicineT h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 367;11 nejm.org september 13, 2012 e15 A 38-year-old man presented to the emergency department with facial paresthesias and upper-extremity muscle cramping. His symptoms were progressive, beginning as mild paresthesias on postoperative day 1; by the time he presented, they had been getting worse for about 24 hours. His medical history was noteworthy only for papillary thyroid carcinoma, for which he had undergone a total thyroidectomy 2 days earlier. Physical examination revealed apparent Chvostek's sign ( Fig. 1A and Video 1) and Trousseau's sign ( Fig. 1B and Video 2), a result of postsurgical acquired hypoparathyroidism. His total calcium level was 5.8 mg per deciliter (normal range, 8.4 to 10.3) (1.45 mmol per liter [2.1 to 2.6]), his free calcium level was 1.68 mEq per liter (normal range, 2.24 to 2.64) (0.84 mmol per liter [1.12 to 1.32]), and his serum phosphate level was 6.6 mg per deciliter (normal range, 2.7 to 4.5) (2.13 mmol per liter [0.87 to 1.45]). The parathyroid hormone level was 7 pg per milliliter (normal range, 15 to 65). Chvostek's sign is described as the twitching of facial muscles in response to tapping over the area of the facial nerve (Video 1). Trousseau's sign is carpopedal spasm that results from ischemia, such as that induced by pressure applied to the upper arm from an inflated sphygmomanometer cuff (Video 2). Chvostek's sign is neither sensitive nor specific for hypocalcemia, since it is absent in about one third of patients with hypocalcemia and is present in approximately 10% of persons with normal calcium levels. Trousseau's sign, however, is more sensitive and specific; it is present in 94% of patients with hypocalcemia and in only 1% of persons with normal calcium levels. Our patient's symptoms resolved with intravenous administration of calcium gluconate, and he was discharged with instructions to begin oral calcium supplementation and to maintain close follow-up with his endocrinologist.
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