12/06/2022 | Press release | Distributed by Public on 12/07/2022 00:19
As medical schools across the country grapple with the arduous process of revising their curricula to be anti-racist, students at the Icahn School of Medicine at Mount Sinai have turned a critical eye on the very textbooks that have trained medical students for years.
In their new paper, "A Framework for Antiracist Curriculum Changes in Nephrology Education, " published in Advances in Chronic Kidney Disease, these students worked with their faculty mentor to address a critical question: how to root out racism from bedrock curricula that have been used for decades?
Their framework, which describes a path forward for nephrology education, may be applicable more broadly to other areas of medicine. It hinges in large part on viewing racism, not race, as a risk factor.
"At Icahn Mount Sinai, we are working to move beyond a traditional biomedical model of disease, in which specific genes or environmental triggers lead to pathology, to a model that incorporates and reflects the myriad exposures that influence disease prevalence and differential outcomes between groups," says senior author Staci Leisman, MD, Associate Professor of Medicine (Nephrology), and Medical Education, Icahn Mount Sinai, and a mentor to the three student coauthors. "This newer model recognizes that access to healthy food, clean air, safe housing, and medications will all influence a patient's health. Because so many of these entities disproportionally affect Black communities, we think it is critical to provide a model that helps educators disentangle epidemiological differences from biological ones. In other words, race isn't a risk factor for disease; racism is."
Dr. Leisman and her three co-authors use two nephrology topics as a lens through which to describe a new anti-racist teaching framework. The first example focuses on a formula to estimate kidney function called the estimated glomerular filtration rate (eGFR). The formula contains a modification for "African American race," which presupposes a biological difference in kidney function in Black people compared to non-Black people, and leads to worse outcomes for Black patients, such as more difficulty qualifying for kidney transplants. In 2020, two of the study coauthors, Carina Seah, an MD/PhD candidate, and Paloma Orozco Scott, an MD candidate, crafted an online petition in which they advocated that Mount Sinai Health System stop using this race-based equation for its patients. The system later reported that it had eliminated the racial coefficient from calculations of eGFR in December, 2020. The second example involves HIV-associated nephropathy, or HIVAN, which has highly differential racial prevalence. In these two examples, the authors identify how conflating racial epidemiological differences with biological ones furthers the fallacy that racial groups exhibit meaningful biologic differences from one another.
The authors underline the importance of first defining the principles of anti-racism that need to be upheld in new assessments of curricula. Those principles include recognizing that 1) race is a sociopolitical category, not a biological one; 2) racism and racism-generated social determinants of health greatly impact health outcomes; 3) categories like "Black" do not capture the substantial cultural and genetic heterogeneity in African-descended subpopulations; and, 4) using race as a proxy for any variable where the variable is known is both inappropriate and pathologizes race.
Jerrel Catlett, a coauthor and MD/PhD student at Icahn Mount Sinai, pored over the three most referenced textbooks, all published within the past two years, to find every mention of "Black" race, "African" ancestry, or "African American ancestry" to understand how these descriptors were being integrated into teaching biology-focused topics, including HIVAN. His review uncovered several claims that HIVAN occurs "almost exclusively" in patients of African descent without mentioning that the main risk factor for HIVAN is a genetic variation that protects against trypanosomiasis (sleeping sickness) and thus has higher prevalence in patients of West African and sub-Saharan descent. Additionally, textbook authors did not provide critical context on how structural barriers to health could play a role in the racial disparities we observe clinically.
"While all of the textbooks primarily focused on histological features and clinical manifestations of the disease, my perception was that 'Black race' and 'African ancestry' were being used as a convenient proxy for factors that couldn't be neatly explained by the authors or were outside the scope of the chapter. Some examples of key considerations that are missing in these explanations include social determinants of health, historical racial discrimination in health care, and cultural practices," says Mr. Catlett.
To understand HIVAN, says coauthor Paloma Orozco Scott, "is to see the bigger picture of what racial categorization does to our science. To believe in and use racial categories as biological, the story may end with 'African Americans get HIVAN.' If we don't participate in the biologization of race, we ask different questions: 'Why is this happening?' 'What is unique to this population?' 'If I addressed some of the hypothesized reasons behind this difference, would this difference go away?'"
Of great importance, says Dr. Leisman, is to stop conflating race with biology or social determinants of health. For example, Dr. Leisman says lack of health care access would potentially increase an individual's risk for developing HIVAN, a disease that occurs in patients with higher viral loads. In other words, if HIV is undiagnosed and untreated, then an individual is more likely to develop HIVAN than a person who shares the high-risk genetic variant but is diagnosed early and started on anti-retroviral therapy to suppress HIV replication.
To address racism in the curriculum, the authors suggest training both students and faculty to critically appraise the use of race in both clinical practice and medical education. To do this, they propose a four-part process that begins with assessment of the problem and one's readiness for anti-racist changes, and works towards solutions and changes to elicit clarity, and finally, an assessment of the suggestions that will result in improved care.
"We chose the HIVAN and eGFR examples because they perfectly illustrate how wrong it is to make medical decisions by assuming that patients' race corresponds to their biology. We know that often the cause for racial disparities is sociopolitical, rather than biological. In the case of HIVAN, it's important to stress how social factors contribute to racial disparities, such as the stigma of HIV treatment, or the lack of access to care that Black patients experience due to betrayed trust by health care professionals," says study co-author Carina Seah.
"Undoing the harm will require intentional and repeated self-examination and education and, ultimately, actively working toward the goal of unlearning much that we have learned," says Ms. Seah.