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Episode 4 – Dismantling Race-Based Medicine Part 2: Clinical Perspectives

Learning Objectives
1. Explain how race-based medicine harms our ability to provide equitable care for all
2. Understand the role of race in eGFR and other clinical calculators and the challenges of teasing out its role
3. Describe what clinicians can do to identify race-based medicine and how they can adapt their practices to mitigate the potential harms of race-based medicine
4. Explain the roles of medical education and biomedical/epidemiological research in accurately describing and justly addressing differences in clinical outcomes that stem from racial inequality
5. Understand why race-conscious medicine—not colorblindness—is how we should move forward and beyond race-based medicine
1 Credit

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The Clinical Problem Solvers Antiracism in Medicine Podcast Series aims to equip listeners with the consciousness and tools to practice antiracism in their health professions careers. Learn more.

Audio Transcript

Utibe Essien MD, MPH: Hey everyone, this is Utibe Essien, and welcome back to the Anti-racism in Medicine series of the Clinical Problem Solvers Podcast. Whereas always, our goal is to equip our learners at all levels of training, with the consciousness and tools to practice anti-racism in their health professions careers. Today's episode is titled Dismantling Race-based Medicine Part 2: Clinical Perspectives and Race-based Calculators. And on today's episode, I'm joined by two of our amazing team members. And I'll let them introduce themselves, today's topics, and our guests.

Jazzmin Williams: Hi, everyone. I'm Jazzmin Williams. I'm a medical student at UCSF. And it's so awesome to be joining the team and talking to you all today, as these issues are the things that are really important to me and my work. And so it's just awesome to be able to learn so much from the rest of the team and the awesome guests that we have today.

Rohan Khazanchi: Hey, y'all, my name is Rohan Khazanchi. I'm currently an MD-MPH student getting my MD down at University of Nebraska Medical Center. And this year, I'm up in Minneapolis working on an MPH at the University of Minnesota School of Public Health. Totally echo everything Jasmine said stoked to be here and really excited to dive into today's episode. So let me give you an overview of where we're at in our three-part series that we're working on. This is episode number two in a three-part series on dismantling race-based medicine. And our goal for this series is to answer fundamental questions. What is and isn't race? How have the ways our medical community defines race changed over time? And most importantly, how should we think about these issues in the context of ongoing discourse about racism in medicine and beyond?

In our last episode, Professor Edwin Lindo dropped some serious knowledge about the history of race and racism within the medical field. Today, we're going to take the conversation into the clinical space by talking about how race-based medicine harms our ability to provide equitable care for all. Our incredible expert guests today will help us work through rapidly changing discussions about the role of race and estimated glomerular filtration rate or eGFR, and other clinical calculators and will give us insight about what we can do as clinicians to mitigate these harms.

Williams: So our guests today are Dr Jennifer Tsai, who's an emergency medicine physician, writer, educator, and advocate in New Haven, Connecticut. Using activism and disruptive pedagogy, she seeks to think in advance health and climate justice, expand social medicine practice, and support equity across health systems. She received a Master's of education from the Harvard Graduate School of Education in her academic work centers on the intersection between race medicine and equity and trauma-informed care. We're also joined by Dr Nwamaka Eneanya, who's currently an attending nephrologist and Assistant Professor of Medicine and Epidemiology at the University of Pennsylvania. She's also the Director of Health Equity, Anti-racism, and Community Engagement in the Nephrology Division. Dr Eneanya is a clinical investigator with research interests that center on palliative care, informed decision making, and health equity among patients with advanced chronic kidney disease.

Essien: So thank you, Jasmine and Rohan, for introducing this episode. Amaka and Jenny, or Dr Tsai and Dr Eneanya, can you please say a quick hello?

Nwamaka “Amaka” Eneanya, MD, MPH: Yeah, so thanks so much for having me on. It's such an honor to talk about something that has gained so much attention and so much passion over the last year. So I'm honored to be on here and I look forward to the discussion.

Jennifer Tsai, MD, MEd: Likewise, I'm so excited to be here. Thank you so much. And it's wonderful to be able to meet this group of people who I think we've all interacted with in some way or another through emails or Twitter to talk about something that's important to all of us in a really fun, creative way. I'm really excited to see where the discussion goes.

Essien: Well, so are we. And I get to start off with the very first question to my sister, Dr Eneanya. So as Rohan mentioned, in our last episode, we talked about how race is a social construct and introduced this important idea of the history of race-based medicine in our country. So I just want to start with you and say I was with you on the wards as my renal attending as a resident back in Boston. And I imagine that over the last few years, you've kind of seen race-based medicine play out in your clinical practice. Can you unpack a little bit of what that looked like for you?

Eneanya: Yes, so I think a lot of it has contributed to my decision to be a nephrologist, essentially in residency. I actually came into residency wanting to do endocrinology and wanting to really dive into diabetes care and disparities on that front and had a lot of ICU time, for whatever reason, as an intern and subsequent resident years. And saw that a lot of the patients that ended up in the ICU were dialysis patients and that the majority of the dialysis patients that I saw were disproportionately Black and brown. And so in addition to my palliative care research that kind of came from those experiences came really a continued passion to investigate health disparities.

I went to a historically Black medical school, Meharry Medical College. I also was a sociology major at Cornell University and minor in Africana Studies. And so this has really been kind of an ongoing decade's long scholarship for me and passion. And so in those circumstances, where I would see patients that disproportionately were affected by, for instance, diabetes, and kidney disease, I really saw clinicians, the healthcare team members using pejorative words, really treating those patients differently. And I was listening to how my residents were teaching us, and really just seeing patterns of patients being labeled, and having subsequent outcomes that were associated with the labeling and the stereotypical treatment. And so it's just been my passion to put an end to that. And I know, I'm an n of one, but I'm surrounded by a tribe of wonderful scholars such as yourself, and amazing friends that also are very passionate about this work.

And so really, that's brought us to the recent eGFR controversy that I wrote about a year ago with colleagues of mine at the University of Pennsylvania, to really reconsider the use of race. It's something that had been kind of grumbled about within nephrology, and then Beth Israel Deaconess Medical Center removed race in their reporting, and it was really driven by medical students at Harvard Medical School. And so that perspective piece really took the conversation to the next step and really brought a lot of attention to it. And I know we're going to delve into that a little bit more deeply, so, but that's what it looked like for me in terms of racism in health care.

Essien: That's really important. Thanks so much for that background and shout out to HBCUs for all of y'all listening who've been to them. Dr Tsai, I'll pitch that question to you as well. How have you seen race-based medicine play out in your clinical practice?

Tsai: Yeah, I think something that's become really clear is how tangibly and concretely. And I think this growing conversation discussion about eGFR, part of why it's so powerful is that there are these very, very clear and explicit decision-making points and influences at thresholds of 20, 30, 60.

Something that I've seen in the emergency department that was so striking to me, we had a patient who needed a CT scan for diagnostic purposes And their eGFR straddled the thresholds, for safe administration of IV contrast. And the radiologist directly called my attending and said, "Hey, can you take a look at your patient and tell me if they're Black because if they're Black we can use contrast and if not, we shouldn't just do a dry." And I watched this attending kind of look through the curtains and be like, "Oh, the patients so and so." And then the decision-making went from there. And I think it's…it's so clear how this influenced certain decision-making, and I think the scarier part is it's also kind of insidious and muddied and prevalent and pervasive in our culture without necessarily being that clear at times.

I think like Dr Eneanya, I was a Africana kind of ethnic studies major in college at Brown University and my thesis--so many of our conversations were about race as a power construct. How did this happen? And then going into medicine, seeing how freely racial biology was employed and operationalized, seeing how often it was discussed as a genetic component, I was apoplectic. I was so confused how I went from this world of American studies, ethnic studies, Africana studies where the literature was so clear; the scholarship was so decisive.

And going into this place where nobody seemed to take a second look at say, "Oh yeah, Black people, their nephrons are different. The physiology of that thing is genes, differences. That's why we have inequities." It was so jarring and that's why I think the work that I'm really interested in is really based in education. I really do think if we reform that area and really put our minds to it, there's so much work and so much progress that can be done just through it.

Khazanchi: Yeah. Thank you both for that great overview, and I think you both have published so extensively on this topic, right, that race is a social category and there are implications to using that category for decisions that posit a biological characteristic based on a racial group or a phenotype that we perceive as clinicians. So I think a lot of clinicians are left with hard questions, right? What should the role of race be when we make clinical decisions? And Jenny, I want to maybe pose this question to you first because I know you just published an amazing piece in The Lancet with a couple of great scholars, which talked a little bit about this notion of should we be race-conscious or race-blind or race-based? I mean, what is the way that we should approach this from a framework standpoint as clinicians thinking about all these algorithms that have race included right now?

Tsai: Absolutely. I think this is a misconception that happens a lot--a stumbling point. You get into these conversations where race is a social construct, race is a power construct. And that's a phrase now that's getting said over and over again. And then the intuitive question is, okay, so it's fake? It's arbitrary so we shouldn't use it? And I think that's dangerous in itself. I think part of it encapsulates the sort of erroneous imagination and intent towards colorblindness that we're seeing in contemporary times. And it's this narrow conceptualization that if racism happens when we think about race or think too much about race or pay too much attention to it, then the opposite and obvious solution is to not think about race; to treat everybody the same.

But I think there've been plenty of conversations as well about the difference between equity and equality. If you treat everybody the same when they come from historically different perspectives, realities, navigations. That's not actually going to advance health justice in the way we want that to be seen. So racism is not thinking about race; racism is thinking about race in the service of white supremacy or hierarchy or oppression. Right?

And I think it's actually very important that we are race-conscious, and we are paying attention to the ways that race and racism, racial inequality really does impact people's outcomes, people's navigation through life in so many different facets not only in medicine but in education and housing and neighborhood segregation. These are real realities not only with clear consequences on people's livelihood but their health. Right? We have from Nancy Krieger, Clarence Gravlee, these amazing scholars, this principle of embodiment: how does racism, how does stress, how does oppression in this way get under the skin to change our physiology, to change our cortisol levels, to damage our heart, our vessels, our lungs? That is a really clear health outcome, but it has nothing to do with this concept of race as biology or genetic difference; it has everything to do with how people can navigate this world with equity or not.

Williams: Dr Eneanya, you are on the National Kidney Foundation and the American Society of Nephrology Task Force, talking a lot about this issue, and so I'm curious to know from you what's the status of the current conversation around removing race from these eGFR calculations, and why is this decision to include or exclude race in eGFR so contentious?

Eneanya: Yeah. So that's a great question. And it's also a reminder for me to say that whatever I say is of my own opinion and not a reflection of any of the discussions of the Task Force. These are confidential deliberations, and so what I can tell you is that the purpose of the Task Force is to critically review the literature as to how we've gotten here and to really discuss next steps and what to do next to advance health equity for patients with kidney disease.

So I can just tell you from my personal opinion, the reason that things are so controversial with this is that there is this kind of one side of the camp that is focused on accuracy and really achieving the most accurate method of quantifying kidney function. And then the other side we have the ethical implications of using, for instance, race, a social construct, in a biological calculator. And these are the tensions that we're faced with now.

I think one of the biggest kind of missteps with race and eGFR conversations were that it's actually a very complicated science. I myself am not an equation person. And so actually, really going back to the literature and understanding how equations were developed, why they were developed, how does that relate pathophysiology-wise to the kidney takes a lot of time and kind of iteration to understand the science of it. And I think, initially, people were very focused, rightfully so, on the ethical implications of using race incorrectly in this biological calculator and actually not looking to see that the original eGFR studies actually showed differences, biologically differences, between the races. And the biggest question that no one can answer to this day is, why?

Oka so we know that the things that can absolutely affect, for instance, creatinine levels, which is the main biomarker that is used in eGFR equations are high-protein diet, muscle mass, generation of creatinine, tubular secretion, things like that, medications. None of those things were accounted for in the original eGFR equations. And if you actually look at the socio-demographic characteristics of the Black participants, for instance in the CKD-EPI [Chronic Kidney Disease Epidemiology Collaboration] study, versus the non-Black participants, you can see that many of them came from the AASK [African American Study of Kidney Disease and Hypertension] trial, which is a completely African-American cohort of individuals that was focused on hypertensive kidney disease. Up to 50% of the AASK participants had not graduated college or high school, and upwards of 50% had an income of less than 15,000.

So what does that mean in terms of their diet, in terms of any physical activity, in terms of occupational choice, in terms of medication? These are the things that we know, for a fact, can affect creatinine level. So whatever racial differences that were seen in those studies, we don't know what they were, and people have falsely attributed that to, again, inherent biological differences between Blacks and whites.

So I think you have one camp of people who are like, "Well, there are differences, so there has to be something that's biologically different between the race," and not really, again, focused on what Jenny said, structural racism and the things that we could have-- that could really explain the differences that we saw, and I think, in my opinion, in addition to the clinical teaching that we have to do on the wards and in medical school, we have to, basically, revamp our entire scientific community.

I think clinical trials really-- if you look at any NIH inclusion grid, it says Blacks, Hispanics, female, male, right? And it's just a quantification of how you diversify your clinical trials by race and ethnicity and gender, but it really should be across socio-demographic categories and in terms of educational attainment, in terms of income, in terms of many other variables that we know for fact, again, can really lead to true outpatient clinical outcomes and really look at how we're studying various different clinical research topics, and what does that mean in terms of diversification of our clinical trials, which we looked at around…there are approximately 1,800 or so Black participants in the CKD-EPI trial, so are we really going to use that amount of participants that may have been quite homogeneous, if you think about where they were coming from, and what their demographics look like, and we're going to now use that to represent the entire Black population. It doesn't matter if you're an immigrant, if you were born in the United States. That doesn't make sense. And so this is where the controversy is, is that people are very scared to let go of what was seen as true biological differences, but we actually don't know what caused that because none of those things that I told you that actually affect kidney function or affect creatinine levels were accounted for in the initial studies.

Tsai: Yeah. And if I could make a point too, I think it's important to clarify there's this kind of notion of ethics for science like it's racist that we shouldn't do it. But I think that's a false dichotomy that people sometimes bring up, and it actually does a disservice to this advocacy because, yes, absolutely, ethics, morals about, consent about, is this transparent about racism, about inequity, are certainly part of the conversation.

But a lot of the people who are advocating for this, do so because the science doesn't make sense. It's the science that we are critiquing as well, and I think that's important. So like as Dr Eneanya mentioned, when you go back and dissect some of these manuscripts out, there's a lot of conflation between what's ethnicity, what's race, what does it represent? Is it definite? Is it defined? Is their operational variable identified in a certain way, how do they standardize it? What does it mean to be Black? What does it mean to be African? What does it mean to be non-Black or white? Why were certain racial populations excluded from this? Why were certain ethnicities included in this? What is the difference? So there are all these technical issues and important scientific distinctions that aren't made.

And so a lot of the critique that that's being brought up is solely and very explicitly scientific as well. Absolutely, there's a moral component, but I just want to make sure that's very clear. As Dr Eneanya mentioned, yes, perhaps there are racial differences, and the crux is what you attribute them to. And how do you interpret that as being meaningful? So we can find correlations in a great number of things. We can say, people who wear green shoes more often than white shoes happen to have X, Y, and Z. And certainly, empirically, we may be able to find correlations about heart disease, whatever it may be. But using the proxy of green shoes doesn't make much sense when we have better science. We have the technology. We have the scholarship. We have the ability to ask much better questions without saying there are racial differences. We don't know why when race and ethnicity cover a huge bucket of things, is it exposure to oppression? Is it inequality financially? Is it difference in diet? Is it migration issues?

There are all these things that I can encapsulate. So the science of saying, "There's something there, but we don't know what," on top of a really problematic history of invoking differences in racial biology to talk about inferiority and superiority to obfuscate inequalities, to distract from social structural racism, I think, is a big part of the picture. But at the heart of it, it is about doing better science, and it is about serving our patients by making sure that we are as accurate as possible.

Essien: I really appreciate y’all, again, bringing in the history related to, not just the history of race in our country, but the history of these papers that we are using, not just to kind of do good research, but actually to care for patients. Right? And I think the research has come back to the forefront during COVID-19, where we've seen this resurgence of race-based speculation, and that you know the reasons we're seeing differences in Black or higher rates, for example, of COVID-19 in Black and brown communities is because of X, Y, Z or kind of genetic factor here. Dr Eneanya, you and I wrote a paper about how we prioritize equity during the pandemic. But I wonder how you see in those papers, how you or your colleagues have read them, and how you're thinking about this, again, seemingly new race-based speculation around the COVID pandemic as it relates to just what we've been discussing so far.

Eneanya: The thing is, it's not new, number one, as you and I have both discussed. And two, I think--DrTsai and I had this privilege of having this certain lens for the majority of our lives. Right? And so to other people that have, number one, never taken a Health Disparities class, never taken an Africana Studies, a Black American Studies class, this is very foreign to people. And so that, to me, is why people react so kind of aggressively with like, "What are you talking about? There are differences here." In my public health school, I was taught--I got my Masters of Public Health from Harvard School, the T.H. Chan School of Public Health, and world-renowned epidemiologists and statistical professors were saying, "Just put whatever in the--put whatever variable in the model that's going to have-- that's going to be clinically relevant and it's going to give you a p-value of less than 0.05. Just throw it all in." And no one is actually-- so this is how scientists are being taught, right, across the globe on how to do multivariable regression. And this is why we are where we are in COVID research, in nephrology research, is that there are-- scientists, for their entire lives, have conducted science in this matter.

So to me, there's no surprise why there is so much resistance and very aggressive resistance as to, "You guys don't know you're talking about. You're not scientists." No, we are, but we've had the privilege of, again, studying a scholarship of racial inequities in this country on the history and what that means. And so it makes perfect sense that when we're seeing the COVID research, and we're seeing that Black Americans have higher mortality because of this genetic allele, and it's super small numbers of less than 50 participants in this study, and all of a sudden, it's like, "Okay. What did I tell you? Black people are predisposed to this infection because of this thing in their nose, and they can get it more." It's just like, are we thinking about the crowded living environments? Are we thinking about what type of occupation they have? I mean, what are we talking about here? Are we serious?

And I think people still don't get it, and I actually think this should be a charge to the journals who are-- these are very high-- our top journals are publishing these papers over and over and over again, and you might see one line in limitations that says, "Oh, we really can't generalize this. This is a small study," at the end. And I don't think that should be the case. That should be in the review. That should be explicit criteria as to what the standards are to get these type of research studies published, and we should not be doing it anymore. We are perpetuating it. We're emboldening scientists that don't believe what the human genome project taught us for whatever reason, and we're giving them fuel to think that this is all made up, and that this is a political movement, this racial justice movement. I think we need to stop.

Tsai: Yeah. I think to add on that, I will never forget, I had a conversation after hearing this, again, world-renowned Black scholar professor, one of these incredible people who was on faculty at Harvard Medical School who had quite literally wrote [sic] the book, like the textbooks that I had seen and used in previous training. And he said--this person who is, by any measure, so, so qualified and so successful. He said, "When I was in medical school, this is how I was taught." And truly, there were moments when I reflected and I thought, "Maybe it's true. Maybe my brain really is biologically different. Maybe it is inferior, but I got lucky. And maybe I'm at the top end of the bell curve." He was like, "I really thought that way because that's how I was taught throughout my entire life," These smart people around me.

And this is, I think, so indicative of how deeply buried these ideas are, not only in medicine but beyond. And I think part of the work is to be able to recognize where it lies and where it sits. I've been lucky enough to present on this topic to talk about it in different grand rounds, resident conferences. And I'm really pleased that, oftentimes, I get emails or texts from people who say, "Oh, since your talk, I see it everywhere." It is everywhere in every organ system, in every specialty, in the way we talk about medicine, in the way we talk about science, scholarship, race, difference.

And once you're trained to see it, it's almost overwhelming how pervasive it is. Troy Duster, who's this eminent sociologist, refers to this so eloquently. He says that race in medicine has been buried alive. And this is absolutely an example, COVID and beyond, of how many forms of dangerous aspects of racism are so insidious and normalized to the point that they're invisible. To target them, I think we first have to be able to recognize where they live in our own house. And to add to Dr Eneanya's point about publications, I think part of it too is it's really easy to publish racialized research. It's easy to do regressions on, "Well, Black, white, what's the difference? We can get a paper out of this," and what kind of incentives are there to continue propagating this kind of research? So I totally agree. And in actuality, a lot of these journals have standard guidelines on how to use race, they're just not necessarily enforced.

Khazanchi: Yeah. These are really powerful points, and I appreciate you both sharing your perspective. I think this is definitely something that I've seen in the discourse lately. And it's helpful to have, kind of, your thoughtful expertise on this matter to work through some of the conversations we've been seeing. So I want to redirect a little bit back to the clinical space, and thinking about where we're going from here. So there have been calls, obviously, from folks like y'all and even members of our team to remove race from clinical algorithms. But I think one of the main points of opposition to this is a question of whether removing race from clinical algorithms will actually do harm to our patients. Because we've been stuck with these algorithms for decades now, and maybe we can make this moral argument that we're defining race wrong and so we should take it out because we have this history in medicine of making these decisions over and over again. But the question remains if we take race out of the algorithms, is this going to cause harm to our patients of color that we don't want to be causing? Is this actually dangerous? Is this potentially worse to take race out of the algorithm than it is to leave it in?

Eneanya: Yeah. So I can definitely speak, absolutely, to the race in the GFR calculator. So what I will say could cause harm is the way that it's done. And as of now, the institutions that have removed race from their eGFR reporting have done it in different ways. And so I think that's harmful to not have a-- first of all, there's already variability in what institution uses what eGFR calculator. Some are still using Cockcroft-Gault. I mean, these very old-fashioned ways of quantifying kidney function. One institution said high muscle mass, low muscle mass. Some institutions are doing a range of eGFR. That's not good. Absolutely not.

So I do think that some standardization of how we do-- removing race from your GFR reporting is extremely important. The argument of harming Black patients is again, coming from the accurate scientists or the accurate police in nephrology and that, "We're going to lose statistical accuracy in Black patients only." And so, "What are we doing? They're going to get incorrect dosing of medications. They're going to get kidney transplants if we removed race from eGFR reporting. They're going to start dialysis when they don't need to."

And, to me, that is just absurd. It is completely absurd. First of all, if you are anywhere near getting a-- if you are donating a kidney, the battery of testing that you have to do to be a donor is extensive, okay? So none of this stuff relies on one numerical value, same thing with dialysis. In fact, there's been a ton of literature that looked at early initiation of dialysis versus late, versus starting when your creatinine's 4, versus starting when you're eGFR is less than 50. There's been plenty of research to show that like, "Let's just go based off of symptoms." So we don't even use the eGFR calculator to be like, "Oh, you're going to start dialysis now," because the research has shown us that that's not helpful, it doesn't change outcomes. And so, in my personal opinion, I think any informed and well-trained clinician will engage in shared decision making with their patients about the limitations of eGFR calculators, which is exactly what I've been doing because I've had multiple Black patients that kind of hover along this, for instance, eGFR 20 where you can gain waitlisting time and had to kind of wait or be told that they have to wait to do their kidney transplant. I will use other methods of quantifying their kidney function, 24-hour creatinine clearance, cystatin C, whatever I can do, direct measurement of kidney function to get them on the list because I know that there's a 30% margin of error around eGFR calculations.

There's actually a margin of error around GFR measurements, our gold standard. And so, I like to discuss the limitations of these calculators and think about holistically what is best for that patient. How can I again use other methods of quantifying their kidney function to see if they qualify for some of the novel therapeutics like SGLT2 inhibitors, Metformin. So there's this fear that people are not going to get the medications that they need or they're going to be started on these huge life-changing treatments based on removing something that's not even that precise anyway. So to me, I don't understand that at all because that is just not how the majority of us are trained to practice medicine and maybe that's a little too narrow-minded but that that's just how I feel about that.

Tsai: This is something that came up last week too and part of it has to do with who has the burden of proving the harm, right? And so we've had decades of research that haven't been asked to prove that race corrections don't do harm but in order to eliminate them, in order to start talking or having the discussion about eliminating them all of a sudden there's such an expectation of perfect research and perfect proof that, "Oh, this absolutely does harm and there's no question about it." And that's part of the context at issue. Why is it so natural and normalized to think about racial difference and to think about embodied racial differences, essential is immutable as in our DNA and vessels and bones? Why is it so much harder? Why is it it takes so much harder? Why does it take so much more evidence and surveillance to try and disrupt that? And so, I think something in other—Another point that people don't always talk about is that no matter how big the race correction is, the presence of race corrections actually does harm in itself.

And part of it is because it still continues reifying and perpetuating these ideas that biologic variation is skin deep, is racialized, and is meaningful. Not only that, we know through social psychology research that when students are taught with these notions of biological essentialism, a number of things happen. They become less interested in social justice, they vote differently, they're less interested in welfare, they have more apathy to racial out-groups, they have more faith that people have different abilities. And it makes sense, right, because if you believe somebody is inferior by their DNA, there's nothing that you can do except for genetic alterations. So why support efforts and advocacy around that? There's no intuitive or rational point if you believe from the beginning that people of color are dying at inequitable rights because their bodies are somehow different and somehow dysfunctional causing them to die at a rate of an extra 300 a day. And I think that's ridiculous because that's essentially what's being said. These people are different. They're getting diseases at different rates. They're dying at different rates because they're inherently different and dysfunctional. It's their fault.

And that culpability, where you put that culpability, absolutely changes how you think about your solutions and what we do moving forward. So I think there is known danger in multiple ways when you use these race corrections and that have been proven multiple times in a way that there has not been proof that using these race corrections in eGFR, in ASCVD, in UTI, in VBAC. They have not actually shown any benefit to people of color. It's theoretical on their part even though a lot of the times, when we have these discussions and arguments, people who are in favor of abolishing race corrections are told, "Oh well, you don't have enough evidence. You're using a moral standpoint. It's based on your political beliefs." It actually is a strange juxtaposition and flipping of what I think we really should be talking about.

Eneanya: And I'll actually just chime in on--to jump on Jenny's point that it's like almost gaslighting, right? That you're calling how we're feeling emotional responses. I've heard anecdotal. How you feel is anec-- we all have anecdotes, but it's not science. And I think all of us that have given talks have seen multiple talks from the people in this group. We keep quoting this same study about implicit bias among these UVA students that showed that implicit bias led to--or false biological beliefs about Black patients led to rating them as having less pain and then effecting their treatments for their recommendations to treat pain. We keep quoting that one study because that's what we have, right, in that we don't have that robust body of literature because that's not where the funding is going, right. That's not where the journals are looking to publish. I think it's quote-unquote weak for whatever reason and so that's--it's almost like gaslighting like. Oh, I get it. It's hurtful. I mean it must be hard for you to think about this. So this is actually really affecting patient lives. I have kidney disease in my family. This is extremely personal for me. I've had family members affected by this cut point. And so this is not anecdotal, and I think it's something that we need to seriously, seriously consider and take... and hold the medical and scientific communities accountable for making this stop, yesterday.

Williams: These are such incredible points...And I feel like a lot of us, in this call and probably just listening to this podcast, can relate to someone telling them that they were appealing to moral ground and just not really sticking to the science. And we all know medicine's a very objective field. So that's such an insult to hear from someone that you're not sticking to the science. And exactly your point, Dr Eneanya, it does feel like gaslighting. And both of you, Dr Eneanya and Dr Tsai, pointed out so many ways in which incorporating race, in our research and in our clinical practice, have been harmful to our patients, objectively. And so from this it makes it-- one think, we should just abolish race altogether. I'm curious to know from both of you. Do we think that the abolition of race is best for the greater good in terms of health equity and in eliminating health disparities? There's just this whole conversation about abolition versus reform broadly, but including in race and medical practice. So, Dr Eneanya, I'll start with you.

Eneanya: I mean, I absolutely think that it's now race is so muddled with the direct effects of structural racism, of individual racism that we need to continue using it in science. I think the operative word is how we use it, right? And being mindful from the very design of your research study, or the very approach that you're using on the clinical wards, or how your teaching, is how you are using that.

So I know Dr Tsai just wrote this beautiful piece about racial conscious medicine and to stop actually using someone's race in that first one-liner clinical presentation that we all do on the wards like 41-year-old, something-something, male or female has to stop putting race into there because you're actually already introducing bias in the very first few seconds of the clinical presentation and so same thing goes for science. When you're actually doing your statistical regression model thinking about why you would put race into it and if you do, how are you going to and then interpret and discuss your findings in a scientifically responsible way? I think we still need it, absolutely, but we 100% need to stop completing it with biological differences.

A lot of discussion has come around ancestry and well, it's ancestry. It's not race. And that's also I think a very weak point. There's still a lot that we don't know about ancestry at this--this nice large study came out this summer in the Journal of Human Genetics. It showed that where we thought the Atlantic slave trade--where we thought that slaves were being stolen from is actually not where they were being stolen from and the contribution of the European DNA to the gene pool just really spoke of violence and destruction and how is that changing ancestry and how does that differ regionally in the United States. We can't use ancestry. I think that's also absurd to kind of just replace race with ancestry and think that we're doing good science. So I think those are the things that we need to be mindful of going forward.

Tsai: Yeah. I think there is like oh, okay, so you don't want to talk about race but what about African ancestry? But still, these are technical terms that aren't being used appropriately oftentimes and again people are making conclusions and interpretations about data and making conclusions about what that means about genetic difference when they're not using any genetic data. So it's inappropriate and I think essentially you're just placing a different label on it but operationalizing all the same problems. So it's not really solving anything.

Something that I think about a lot Nancy Krieger is an epidemiologist at the Chan School of Public Health who is just a goddess. When I met her my first thought was like I think I'm closer in brain to a slug than this woman. She's just incredible in so many ways. But she has this really amazing article about the battered child syndrome and talking about how this term was coined in the late 20th century and it brought on this whole wave of how do we study this? How do we prevent it? How do we monitor? How do we track? How do we do better for children who are battered and how do we help them? And one of the points she makes is it's not that this didn't exist until we had terminology for it but once we had terminology suddenly we began being able to study it, being able to talk about it, being able to watch for it in our emergency departments and our clinics.

And in the same way, it's not about kicking out race. It's not about throwing the baby out with the bathwater and saying oh, I don't see race at all. Everybody's just kind of a flesh-colored blob but I don't see color. Everybody's the same. The point is we have to be really thoughtful and nuanced and scientific, again, with how we interpret differences. It is absolutely true that people of color will face different outcomes. We see this in COVID. We see this in heart disease. We see this everywhere but how we interpret that and what we do to solve it completely just based on if we think that's due to biological difference or not.

And so in the same way that we think about battered child syndrome, how do we start tracking racism? How do we start talking about it, discussing, monitoring for it, treating it in our clinics, in the emergency department, and beyond? I think that's part of the conversation. And again, the point is better science, better scholarship, better for our patients. And part of this conversation that is sometimes mentioned, but I want to say explicitly, is that there is a sense of--there is a component of interest convergence to this. Race-based medicine is not only bad for people of color, for Black people, it's bad for everyone. We have had these conversations about the eGFR race correction, but at the end of the day, the point is, the eGFR, even the GFR, has a broad range of inaccuracy.

So how do we make sure we're being precise? And all this time that's being spent talking about the empiricism of racial differences, we know and have so much more robust data on differences based on diet, based on what medications you're on, based on if you have diabetes, based on if you're hospitalized, but none of those are systematically corrected for. Which means a whole host of other patients aren't getting the right calculations, and why aren't those being considered? I think that's a big part of the conversation is, how do we make sure we're doing right for everybody and certainly, certainly the race correction. Most harms and systematically harms Black Americans with the race correction in kidney disease. But also, these ideas about how we apply this knowledge is inherently hurting every other patient at the same time.

Khazanchi: Wow. So I mean, I think this has been an absolutely incredible and nuanced conversation. And I just want to get us closer to wrapping up since we're running out of time here. Something we'd like to do the end of all of our episodes is just break it down really straightforward, what are key takeaways for trainees and for our faculty clinician-educators. So let's start with trainees. I'm a medical student. I'm still thinking through this literature I'm digesting how I want this to inform my clinical practice going forward. What advice do you all have? What key takeaways do you have from this conversation for trainees thinking about how to navigate this discussion?

Tsai: One piece of advice that I have is I--let me think about how to say this. It can be really advantageous to simply ask questions that confront people of different hierarchy about this topic. I think I ran into certain times of, how do I bring this up without seeming antagonistic, especially in my you know early stages of training.

But I think the questions have been really helpful for me. One, because it causes them to confront and oftentimes, you realize there's no good answer. So something that I'd ask often is, "Why do we have a race correction for adults in nephrology but not for kids? What happens at 18?" I had a couple of attendings say, "Oh, I don't know. I've never thought about that." Some people say, "I don't know." Some people, kind of, brush it off. But I think part of this advocacy is acknowledging that a lot of trainees who are pushing this work forward are not currently in positions of power. So I think asking questions not only brings it up, but it is part of your training, and it is kind of a safe way to start these discussions without necessarily feeling like you might face retaliation or jeopardize your clinical grades or something like that. I think it's really innocent and really authentic and earnest to say like, "Hey, I don't really understand this. Can you teach me?" Because you are in a student role, they are in a teacher role, and it's difficult and, I would say, not always kind to you or your advocacy to take around this mantle of like, "I got to fight these attendings. I got to change what we're doing right now." I found, as a trainee, that it's really useful to ask questions very explicitly mostly to protect yourself as well.

Essien: Dr Eneanya, I’ll ask as someone who's been mentoring and guiding my early faculty career and research career, what would be a good takeaway for other early career folks, late career folks? You both mentioned the importance of education in this space. What would kind of be your tips for those who are in those roles right now as well?

Eneanya: Well, something that's always worked for me is to follow my passion. I mean, I'll just even use palliative care as an example. When I first wanted to do this--we have a for-profit dialysis industry. I was told multiple times like, "What you want to do doesn't make sense and you're not going to help anyone make money so why are you doing it?" And I just kept going and if you feel it's important, keep going. That's my mantra, number one. I think the other thing is that the patient voice has been left out of a lot of these discussions. I'm part of a research collaboration that I'm really excited about that will be doing qualitative work with patients about this topic not just in nephrology but just in broadly in medicine: how are we using this, are you aware, and what does that mean. And I'm really excited to kind of bring the patient voice in prominently in future considerations in research and I think that's the way that the-- I think that should be a research standard is that we should stop this paternalistic model that we have that what we say is correct. We all bring in our own biases, and we're trying to improve patient care. They need to be--they need to have a seat at the table.

And then, lastly, I would say that for those who are interested in health equity research, to really collaborate with people who have studied this and across this journey, my whole life, I've come across people who are interested but that don't want to do the work or there's an entitlement that they're right, but they actually haven't read the appropriate things to educate themselves about health equity or disparities or structural racism. That has to stop, okay? You have to do the work. You have to pair and to work closely with people - I would say scientists of color; I would say scholars of color - who have been doing this work well before I was born or any one of us were probably born. Read their books, collaborate with them if you have opportunities, or others who are very similar to them. I think that's that's very important going forward as we dismantle structural racism in clinical research and medicine.

Wilson: Thank you for that. And as our final question-- we always like to ask for our listeners who are going back into the clinical world, what's one thing that they can take away with them and start using today?

Eneanya: So I know I always teach the same thing when I'm on the wards and it just blows my mind that it's like brand new every single time. But I would say that, especially, when we're caring for patients that have been marginalized, oppressed, whatever have you from structural racism, it's not their fault. And I would say that-- I say that very, very assertively. We're very busy. Things happen like, "Oh, this person is a frequent flyer." You may have some difficult interactions with that patient for whatever reason. You just remember that you have all of the resources in the world as a medical student, as a trainee, as a faculty member. We are working in multibillion dollar health care institutions for the most part and many of the patients that have been oppressed or marginalized do not have access to the resources. Connect them. Be their advocate. It's not me against you. It should not be like, "Oh, this person was difficult. My coffee's cold right now. My day is ruined." No, that's entitlement. We all have privilege. Even us as people of color in the health care profession have privilege. Use that privilege to help people. That's what I would say and I literally teach this every single time I'm on the wards and there's someone who keeps coming back being readmitted and/or is seen as a difficult person. That's not fair. I mean, I never ever side with the health care team when it comes to that. I'm always on that patient side because we have all the resources in the world, and they don't. So I would say just remember that.

Tsai: Yeah, I think to go off of that, I absolutely agree and thank you for bringing us back to the real point which is how do we be good humans to each other? How do we be kind? How do we embody what justice really means? I think there's plenty of work to be done in scholarship, in theory, in talking about these things, but we all come from these institutions where the ivory tower stands so, so tall. And the point is how do we take these things, these critical perspectives, and employ them and make ourselves beholden to a practice that really is kind and compassionate and good towards other people? How do we embody justice in our work not just our scholarship?

Something that I come back to a lot is this poem, and she ends it by saying, "The work of the world is as common as mud," and I say that to myself almost every shift because I can talk about, "Oh, yeah, this piece in The Lancet on color consciousness and race consciousness-- and, "How do we reform this, this, and that?" but the point is like, "Am I going to get my ass up from my chair and update this patient more frequently? Am I going to call their parents or their family members like I said I would? Can I get them the blanket that I said that I would? Can I do that thing? Can I remember that they are humans that are in terrible situations?"

[music]

Essien: That was a perfect end to really an amazing hour with two brilliant scholars. Thank you so much, Dr Eneanya and Dr Tsai, for giving us the time to learn from you both. We have all of your references, citations, everything you've been talking about in our show notes. Thank you to my wonderful colleagues Rohan and Jasmine for joining me on this episode and please stay tuned to the next amazing episode coming soon. Thank you both.

...I've now stolen a second hour of Amaka's free time.

Eneanya: You almost scheduled me for another one in January. I just got an email.

Essien: Oh, yeah, yeah, yeah. We appreciate you, homie. That one at least you're-- that one is you're being compensated--not handsomely but in some capacity.

Tsai: Trident Layers?

Eneanya: What did you say, Jenny?

Tsai: Oh, I don't know if anyone remembers that commercial. There used to be this commercial for gum, for Trident Layers. I don't know if I just dated myself. They'd be like, "Will you pay me in Trident Layers?" All right, I'm going to go.

Eneanya: Well, now I got to stop.

Khamanchi: That is the perfect end to the episode.

Essien: Just end it. Just end it.

Audio Information

© Copyright 2022 The Clinical Problem Solvers, Inc. All rights reserved.

Disclaimer: The CPSolvers provides information for educational purposes only. It is not intended to be medical advice.

View show notes for each episode at https://clinicalproblemsolving.com/antiracism-in-medicine/.

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