Hundreds of Interlaced Fingers: A Kidney Doctor’s Search for the Perfect Match

Hardcover, 261 pages, Amistad

The effect of disparity on kidney transplant

In Hundreds of Interlaced Fingers: A Kidney Doctor’s Search for the Perfect Match, Dr. Vanessa Grubbs describes her personal journey from a primary care physician never really interested in nephrology to meeting and falling in love with a man on dialysis, to volunteering as a kidney donor, and finally, to deciding to specialize in nephrology. During this journey, she recognized the implicit racism that continues to exist in the medical community, where assumptions are made on the basis of preconceived ideas regarding ability to pay for medications, keep follow-up appointments, and understand the complex regimens required for success after transplantation.

This implicit racism shows up in slow referrals for transplantation (her husband waited a year for referral), delayed response to a surgical complication (a surgeon may have responded more urgently if the patient was not black), and continued beliefs that there are real biological differences in our “made-up race categories.”

“This series of assumptions and shortcuts in medicine … (where) we use race as a diagnostic tool … restricts our thinking, making it lazy at best,” Dr. Grubbs states. A broader concern expressed is that race-based generalizations are made and accepted as true with little to no evidence basis.

The title is an analogy to the similarities of an electron scanning micrograph of the structure of the glomerulus to hundreds of interlaced fingers. A primary reason Dr. Grubbs chose to specialize in nephrology was to focus on research topics to learn more about why racial disparity persists in transplantation. One proposal included looking at how many patients referred for transplant evaluation actually received transplants by race and how many people were involved in deciding who got kidney transplants by race. In addition to this quantitative research, she proposed a qualitative piece “to get at all the reasons why the numbers of who had kidney failure and who got kidney transplants didn’t add up.” Senior faculty thwarted this project as too controversial and an attempt to show the transplant system is racist. And maybe it is. As Dr. Grubbs states, “I probably would ask different research questions if I weren’t black or had different experiences, which is the very reason why it is important to have people from different backgrounds doing research.”

In 2007, Dr. Grubbs published an article, “Good for harvest, bad for planting” in Health Affairs (Millwood) (1). This article is more tightly focused on the disparities she noted in the distribution of donated kidneys. Hundreds of Interlaced Fingers, while including concerns about these racial disparities, also recognizes the effect of low health literacy on referral for transplant. Patients with low health literacy had an almost 80% lower likelihood of being referred for kidney transplant evaluation. Perhaps in response to this finding, sections of her book explain in layman’s terms the decline of kidney function, how dialysis works, and the risks and stresses of dialysis.

Dr. Grubbs acknowledges the incremental improvement in racial disparities that can be attributed to the recent change in the deceased donor kidney allocation system, while pointing out the feelings engendered by their evaluation at the transplant center: “The message we took away was, ‘The kidney transplant system doesn’t like black people.’”

Here is the challenge posed by this book for the nephrology community: receiving a kidney transplant “has everything to do with if a person with advanced kidney disease knows they have advanced kidney disease and has access to a nephrologist who thinks they are a good candidate for transplant, and the nephrologist actually refers them—a cascade of requirements vulnerable to the effects of personal bias and racism at an institutional level.” Step one in meeting this challenge is recognizing our own biases and taking deliberate steps to overcome them.

Kidney News Editorial Board member Glenda Payne, MS, RN, is Director of Clinical Services at Nephrology Clinical Solutions in Lisle, IL.

Reference

1. Grubbs V. Good for harvest, bad for planting. Health Affairs 2007; 26:232–237.

 

October/November 2017 (Vol. 9, Number 10 & 11)​