11.3 🩺 內科專科考前版
11.3.0.1 📌 一頁重點整理
- IOM 2003 + 22E 強化 disparities 是 system-level、structural racism issue
- SDOH framework 是 modern public health 核心
- Race-based vs Race-aware medicine：22E 議論 race 在 clinical algorithm 角色（如 eGFR、PFT race correction 已 phase out）
- 📍 台灣 disparities：城鄉、原住民、新住民健康差距
- Cultural humility > cultural competence
11.3.0.2 🧠 深度概念
11.3.0.2.1 Race-Based vs Race-Aware Medicine
22E 重要 update：移除 race-based clinical algorithm - eGFR race coefficient：CKD-EPI 2021 移除 race correction（之前 Black 加 1.16） - PFT race correction：被批評後 phase out - Cardiac risk algorithm（ACC/AHA pooled cohort）：race-specific 仍存 - VBAC calculator：race factor 移除
→ Race 是 social construct，不是 biological 變數
11.3.0.2.2 SDOH 與 Outcomes
22E 引述： - 80% health outcome 由 SDOH + behavior - Healthcare system ~ 20% - 對策應 prioritize SDOH
11.3.0.2.3 Structural Racism Examples
- Redlining 1930s：Black 社區被 marked “hazardous” → 銀行不貸款 → 無投資 → 持續低 SES
- Highway 規劃：高速公路 cut through Black 社區 → 污染、噪音
- School funding：local property tax base → 富區好 school、貧區差 school
- Healthcare：safety-net hospital vs academic medical center 資源差距
11.3.0.2.4 Implicit Bias 在臨床
22E 引述研究： - Pain mgmt：Black 病人 receive less analgesia - Specialist referral：Black 病人 less likely refer to cardiology - Surgical recommendation：disparity in cardiac、cancer surgery offer - 即使 controlled for clinical factors
11.3.0.2.5 對應 Strategies（22E 推薦）
11.3.0.2.5.1 Provider Level
- Implicit bias training（debate efficacy）
- Structured decision tools（reduce bias variability）
- Cultural humility（vs cultural competence）
- Trauma-informed care
- Active language access
11.3.0.3 🌟 Clinical Pearls (8 條)
- 「Race ≠ biology」：race 是 social construct
- CKD-EPI 2021 已移除 race correction：用 race-free eGFR
- Implicit bias universal，不是「壞人」標籤
- Cultural humility > competence：謙卑學習，承認 limit
- Professional interpreters > family：accuracy + privacy
- Address SDOH 是 long-term；day-to-day 仍要 advocate
- Disparities ≠ access alone：quality + bias also
- Trauma-informed care 對 marginalized 病人尤重要
11.3.0.4 🔍 特殊情境
11.3.0.4.1 1. Black F maternal mortality
- 3-4× white
- Pre-eclampsia、PPH、cardiomyopathy 漏診
- 對策：active screening、aggressive workup、low threshold for intervention
11.3.0.4.2 2. Native American health
- Diabetes、CV disease 高
- Indian Health Service 資源不足
- Historical trauma、intergenerational
11.3.0.4.3 3. Immigrants / Refugees
- Limited English proficiency
- Trauma history
- Healthcare access barrier
- Use professional interpreter
11.3.0.6 ⚠️ 老闆地雷區
- Race-based algorithms 不更新：仍用舊 eGFR race correction
- Implicit bias 否認：「我沒 bias」
- Cultural stereotype：用 group 標籤 over-rule individual
- Family interpreter 用於 critical communication
- 不問 SDOH：assume 病人有資源
- Disparities 視為 inevitable：不 advocate change
- 不 reflect on own bias：lack of self-awareness
11.3.0.8 📖 延伸閱讀
- IOM. Unequal Treatment, 2003.
- Healthy People 2030：health.gov
- WHO SDOH framework
- CKD-EPI 2021 update（race-free eGFR）
- 衛福部健康不平等報告
11.3.0.9 📚 三階段教材索引
- 醫學生概念 → Ch 11 medstudent.md
- 國考衝刺 → Ch 11 board-prep.md
- Harrison 22E 原文 → Ch 11
⚠️ 本 md 為 claude-opus-4-7 撰寫（2026-05-07），未經盧醫師驗證。