Episode 148: Antiracism in Medicine Series Episode 4 – Dismantling Race-Based Medicine Part 2: Clinical Perspectives

This is the second episode of a three-part series on understanding and dismantling race-based medicine. We invite Drs. Nwamaka Eneanya and Jennifer Tsai to discuss the limitations and harms of race-based medicine in clinical practice. Our guests explain how we can incorporate race-conscious medicine in clinical settings, medical education, and biomedical/epidemiological research to responsibly recognize and address the harms of racial inequality.

Learning Objectives

After listening to this episode learners will be able to…

• Explain how race-based medicine harms our ability to provide equitable care for all
• Understand the role of race in eGFR and other clinical calculators and the challenges of teasing out its role
• 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
• 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
• Understand why race-conscious medicine–not colorblindness–is how we should move forward and beyond race-based medicine

Credits

• Written and produced by: Utibe R. Essien, MD, MPH, Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Dereck Paul, MS, and Jazzmin Williams
• Hosts: Utibe R. Essien, MD, MPH, Rohan Khazanchi, and Jazzmin Williams
• Show Notes: Naomi Fields
• Infographic: Creative Edge Design
• Guests: Nwamaka Eneanya, MD, MPH, Assistant Professor of Medicine at the Hospital of the University of Pennsylvania (@AmakaEMD) and Jennifer Tsai, MD, MEd, Yale Emergency Medicine Class of 2023 (@tsaiduck77)

Download Transcript Here

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

 Show Notes

Naomi F. Fields

Time Stamps

00:00    Mission, vision, and introductions of hosts

01:30    Background on three-episode series

02:26    Introductions of guests

04:16    How Dr. Eneanya has seen race-based medicine play out in clinical practice

07:19    How Dr. Tsai has seen race-based medicine play out in clinical practice

10:45    What role should race play in making clinical decisions?

13:16    Status of the current conversation on removing race from eGFR calculators: why is it so contentious?

19:05    Clarifying the “ethics vs science” argument and critiquing research techniques

22:00    Resurgence of race-based speculation in COVID-19-related research

25:57    Implantation of ideas about innate racial inferiority within medicine

28:32    Will removal of race from algorithms potentially harm our patients?

33:19    Danger of normalizing immutable, innate racial difference within clinical algorithms

38:10    What role should race hold as we move toward health equity?

45:50    Key takeaways for trainees

47:45    Key takeaways for faculty

49:17    Pointers to those interested in health equity research

50:17    One thing you can employ in your practice today

54:14    Bloopers!

Episode Takeaways:

Trainees

Asking thoughtful questions that challenge the “status quo” can prove an effective means of sparking discussions while minimizing the potential for negative retaliation. Dr. Tsai describes previously asking her attendings, “Why is there a race correction for adults in nephrology, but not for children? What happens at age 18 [to provoke the need for correction]?” Questions such as these can stimulate thoughtful inquiry and remind all of us of the responsibility to be critical practitioners.

Faculty

If you feel your cause is important, keep going — even when you are challenged by others. Attending physicians have tremendous power in dictating culture, and are so valuable in extending this work, especially given how the hierarchical nature of medicine can make it difficult for trainees to advocate firmly. Moreover, center patients not only in discussions about individual decision-making but in constructing and drawing meaning from the research. 

All

If you are interested in health equity, recognize that there is a breadth of research established in the fields of health equity, disparities, and structural racism. Be sure to do the work to educate yourself about the foundations of this work, and collaborate with those who have been studying and establishing it if you have the opportunity. 

Poet Marge Piercy has written, “The work of the world is as common as mud.” While there indubitably exists a need to advance scholarship and theory, we must also ground ourselves in the day-to-day actions that can bring comfort and kindness to our patients. Where can you give an extra inch to those for whom you are caring? 

Pearls

Role of Race in Clinical Reasoning

Harnessing the idea that “race is a social construct” to exclude consideration of race from medicine altogether does a disservice to our patients. Race, racism, and racial inequality have tangible impacts on people’s livelihoods, much less their experiences in the healthcare system. For instance, there is well-established research on how the stress of racism and racial inequality become “embodied” by modifying people’s cortisol levels to exert end-organ effects. Thinking about race is not racist in and of itself: It is the usage of race in the service of white supremacy or oppression that makes that transformation. Being race-conscious, or critically curious about the ways in which racism and racial inequality may affect our patients, can actually offer a starting point for advancing health justice. Much is akin to how naming the “battered child syndrome” catalyzed changes in our frameworks for addressing child abuse, critical curiosity in the space of racism can help us to develop thoughtful plans for tracking, discussing, and monitoring racism within in healthcare settings and beyond.

Race in eGFR Calculations — Why So Contentious?

eGFR equation-building is a complex science. Returning to the early literature that informs the equations reminds us that this research demonstrated racially stratified differences between Black and white cohorts. However, these studies did not account for many of the factors that can impact creatinine, the main biomarker used in eGFR calculations. These factors include a high-protein diet, muscle mass, creatinine generation, and certain medications. Many of the Black participants in the CKD epi study came from an African-American cohort (ASK trial) in which 50% of participants hadn’t graduated high school and over 50% made less than $50,000/year. These factors may have impacted their diet, physical activity, and medications, thus impacting their creatinine levels and the inputs that we use for GFR. This reminds us that using race as a catch-all can shroud other factors (ex. structural racism) that more rigorously account for differences observed between groups. And, as we think about revamping eGFR calculators, we must also ensure that there are standardized means of doing so across institutions.  

Ethics-Plus: Reforming our Approaches to Clinical Research 

Without question, there exists a strong ethical imperative to eradicate racism from biomedical science and to better use biomedical science in the service of health justice. There also exists an imperative to refine how we use race in research, given the scientific evidence that it is a social construct. Critiquing the cursory usage of race in studies illuminates the need to clearly define and standardize race as an operational variable, explain that to which racial differences are attributed, and describe how we interpolate meaning from these differences. Failing to do so may obfuscate the realities of social-structural racism, and obscure opportunities for improving understanding or intervention. Rigorous usage of race is not only ethically sound: it’s also better science.

In this vein, our researchers can take advantage of the technology that we have to ask more sophisticated questions that generate true accuracy, rather than those that simply accept race as a surrogate. We might critically think about why we might use race in a regression model, and proactively consider how we will interpret and responsibly discuss findings that may result. We might group people across socio-demographic categories (ex. education, income, number of previous hospitalizations) that also lead to clinical outcomes, not only race-based stratification. When racial differences are observed, we might further examine contributors to outcomes within a group. Our journals can help lead the charge by more diligently enforcing fastidious usage of race within papers they choose to publish. Rather than accepting racially-stratified differences in outcomes as inexorable and without further inquiry, we can seek to understand and address what underpins these phenomena. Consensus standards that guide authors on ethical use of race in scientific research exist. Our esteemed publications should ensure that investigations that utilize racial variables follow these guidelines before being published.

Addressing Potential Harms of Removal of Race from Clinical Calculators

Some have expressed fear that removing race from eGFR calculators will result in inaccurate therapeutic changes (ex. premature dialysis initiation, premature renal transplants, or inappropriate medication administration) that will primarily affect Black patients. However, the diagnostic approach used to determine changes in clinical management of renal disease (i.e. dialysis, transplant) is multifactorial; it is not based on eGFR alone. Additionally, research has shown that using symptom-prompted modifications to management, in the context of shared decision-making, can improve outcomes. Using the eGFR calculators as a sole determinant offers a limited metric with a ~30% margin of error. We can and should be incorporating other methods of evaluating kidney function (ex. 24-h Cr clearance, cystatin C) within a body of data. This can contribute to a more holistic understanding of disease progression and management.

How Bearing the Burden of Change Reinforces Racism

Some responses to the prospect of eliminating race corrections have asked proponents of these changes to prove that removing race corrections will not do harm to patients. In juxtaposition, research that established the corrections was not necessarily asked to prove that corrections are harmless. The additional evidence and surveillance needed to demonstrate the limited relevance of race belies a collective investment in the immutability of biological racial difference. However, race corrections do in fact cause both ideological and tangible harm in that they reify essential biological racial differences. Social psychology research demonstrates that when race is given this genetic basis, trainees display more apathy toward racial outgroups and a tendency to consider their physiology as innately dysfunctional. As a result, they demonstrate lower levels of accountability to creatively problem-solve for patients of color. It is also the case that many of these race corrections (eGFR, ASCVD, UTI, VBAC) about which people have been protective have not actually shown benefit to people of color.

Links

References discussed throughout episode

1. Tsai J. It’s Time to Talk about Racism in Medical Education. FIX19. https://feminem.org/2020/06/15/its-time-to-talk-about-racism-in-medical-education/
2. Tsai J. What Role Should Race Play in Medicine? Scientific American. September 12, 2018. https://blogs.scientificamerican.com/voices/what-role-should-race-play-in-medicine/ 
3. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med. 2016 Jul;91(7):916-20. doi: 10.1097/ACM.0000000000001232.
4. Tsai J. COVID-19’s Disparate Impacts Are Not a Story about Race. Scientific American. September 8, 2020. https://www.scientificamerican.com/article/covid-19s-disparate-impacts-are-not-a-story-about-race/
5. Tsai J, Cerdeña JP, Khazanchi R, Lindo EG, et al. There is no “African American physiology”: The fallacy of racial essentialism. J Intern Med. 2020;288(3):368-370. doi:10.1111/joim.13153
6. Eneanya ND, Yang W, Reese PP. Reconsidering the Consequences of Using Race to Estimate Kidney Function. JAMA. 2019;322(2):113-114. doi:10.1001/jama.2019.5774
7. Ahmed S, Nutt CT, Eneanya ND, et al. Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes. J Gen Intern Med. 2020. doi: 10.1007/s11606-020-06280-5.
8. Grubbs V. Precision in GFR Reporting: Let’s Stop Playing the Race Card. Clin J Am Soc Nephrol. Published online May 11, 2020. doi:10.2215/CJN.00690120
9. Powe NR. Black Kidney Function Matters: Use or Misuse of Race? JAMA. Published online July 29, 2020. doi:10.1001/jama.2020.13378
10. National Kidney Foundation, American Society of Nephrology. Establishing a Task Force to Reassess the Inclusion of Race in Diagnosing Kidney Diseases. Published July 2, 2020.
11. Vyas DA, Eisenstein LG, Jones DS. Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms. N Engl J Med. 2020;0(0):null. doi:10.1056/NEJMms2004740
12. Braun L, Wolfgang M, Dickersin K. Defining race/ethnicity and explaining difference in research studies on lung function. Eur Respir J. 2013;41(6):1362-1370. doi:10.1183/09031936.00091612
13. Chadha N, Lim B, Kane M, Rowland B. “Toward the Abolition of Biological Race in Medicine.” Institute for Healing & Justice in Medicine; 2020. https://www.instituteforhealingandjustice.org/download-the-report-here

Additional references and papers as mentioned in the episode

1. Essien UR, Eneanya ND, Crews DC. Prioritizing Equity in a Time of Scarcity: The COVID-19 Pandemic. J Gen Intern Med. 2020;35(9):2760-2762. doi:10.1007/s11606-020-05976-y
2. Krieger N. Embodiment: a conceptual glossary for epidemiology. J Epidemiol Community Health. 2005;59(5):350-355. doi:10.1136/jech.2004.024562
3. Gravlee CC. How race becomes biology: embodiment of social inequality. Am J Phys Anthropol. 2009 May;139(1):47-57. doi: 10.1002/ajpa.20983. PMID: 19226645.
4. Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI):
   1. Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate [published correction appears in Ann Intern Med. 2011 Sep 20;155(6):408]. Ann Intern Med. 2009;150(9):604-612. doi:10.7326/0003-4819-150-9-200905050-00006
5. African American Study of Kidney Disease and Hypertension (AASK):
   1. AASK Clinical Trial in the NIDDK Repository: https://repository.niddk.nih.gov/studies/aask-trial/
   2. Lewis J, Agodoa L, Cheek D, et al. Comparison of cross-sectional renal function measurements in African Americans with hypertensive nephrosclerosis and of primary formulas to estimate glomerular filtration rate [published correction appears in Am J Kidney Dis 2002 Feb;39(2):444]. Am J Kidney Dis. 2001;38(4):744-753. doi:10.1053/ajkd.2001.27691
6. Cooper BA, Branley P, Bulfone L, et al. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010;363(7):609-619. doi:10.1056/NEJMoa1000552
7. Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology [published correction appears in J Am Coll Cardiol. 2019 Jun 25;73(24):3234]. J Am Coll Cardiol. 2019;73(24):3153-3167. doi:10.1016/j.jacc.2018.11.005
8. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 
9. Micheletti SJ, Bryc K, Ancona Esselmann SG, et al. Genetic Consequences of the Transatlantic Slave Trade in the Americas. Am J Hum Genet. 2020;107(2):265-277. doi:10.1016/j.ajhg.2020.06.012
10. Krieger N. Does racism harm health? Did child abuse exist before 1962? On explicit questions, critical science, and current controversies: an ecosocial perspective. Am J Public Health. 2003;93(2):194-199. doi:10.2105/ajph.93.2.194
11. Piercy M. To be of use. In: Circles on the Water: Selected Poems of Marge Piercy. Alfred A. Knopf; 1982.https://www.poetryfoundation.org/poems/57673/to-be-of-use

Disclosures

Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education, but the views presented herein represent his own and not necessarily those of the AMA or the Council. Dr. Eneanya is a member of the National Kidney Foundation and the American Society of Nephrology Task Force; the views herein represent her own and not necessarily those of the NKF or the Task Force. The hosts and guests report no other relevant financial disclosures. 

Citation

Eneanya A, Tsai J, Williams J, Essien UR, Paul D, Fields NF, Nolen L, Ogunwole M, Onuoha C, Khazanchi R. “Episode 4: Dismantling Race-Based Medicine, Part 2: Clinical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes December 17, 2020.