Taking on Racism ASN Panel Addresses Next Steps for Dismantling Systemic Racism in Nephrology

During ASN’s recent webinar on Going Beyond the Statement: Dismantling Systemic Racism in Nephrology, a panel of nephrologists delved deep into the ways structural and overt racism affects patients and the profession and what to do about it (1).

“We hope and envision this will be the start of an important ongoing conversation that engages the broad community of our organization,” said ASN’s Secretary-Treasurer Keisha Gibson, MD, MPH, who moderated the panel.

Nephrologists and ASN must play a greater role in changing policies, practices, and beliefs that prevent Black, Indigenous, and other people of color from achieving their full potential, said panelist Will Ross, MD, Associate Dean for Diversity and professor in the Division of Nephrology at Washington University School of Medicine in St. Louis. Housing, transportation, and nutrition policies all have major impacts on health, particularly among disenfranchised and under-resourced populations, he said.

“The ASN has realized we can effect change,” he said. “We can advocate for those policies; it is in our purview.” Ross argued for more use of rigorous implementation of science to ensure the use of evidence-based interventions to reduce health disparities.

Panelist J. Kevin Tucker, MD, director of the Brigham and Women’s Hospital/Massachusetts General Hospital Joint Nephrology Fellowship Program, said it was the first time in his 25-year career in nephrology that he felt the profession was having this difficult discussion. He noted that often people dance around the topic because it is so uncomfortable to talk about race and racism with colleagues.

“We have to be willing to have difficult conversations,” Tucker said.

Advocating for equity

The ASN Council and ASN Diversity and Inclusion Committee (renamed the Diversity, Equity, and Inclusion Committee) have begun drafting a road map for addressing systemic racism in nephrology and will dedicate two of its eight mission-based committees to this work starting in 2021, Gibson said. The Health Disparities and Social Determinants of Health Committee will focus on improving social determinants and health disparities and the combined effects of COVID-19 and high-profile acts of racism on patients. The Diversity, Equity, and Inclusion Committee will tackle institutional racism in academic medicine, patient care, research, education, and administration at healthcare institutions. A joint ASN-National Kidney Foundation Task Force has also been created (2) to reassess the use of race in diagnosing kidney disease, as a growing number of institutions around the country eliminate race in estimated glomerular filtration rates (3).

“Success of these efforts will require that this work permeates the entire fabric of our organization,” Gibson said, noting that the committees will work closely with the Council and throughout the organization.

Battling bias

Physicians and institutions also need to consider how their own attitudes or practices might disadvantage people of color. Dana Mitchell, MD, a private-practice nephrologist and chief executive officer of the Global Kidney Center in Houston, Texas, recommended implicit bias training for clinicians and education about other cultures and people to empower clinicians to have better patient interactions.

Overt or implicit biases can come in many forms and may limit patient care options. Gibson noted that her aunt was almost denied access to peritoneal dialysis because her nephrologist was worried that her high school-level education would limit her ability to do home dialysis, but Gibson was able to advocate for her. Criteria for transplant might also disadvantage patients working lower-paying jobs. Vanessa Grubbs, MD, MPH, spoke about a patient who was almost denied a transplant after he was late for dialysis because he could not leave his job as a dishwasher early without fear of being fired. Grubbs is associate professor at the University of California, San Francisco, and a living kidney donor. “If anything, that’s all the more reason for him to get a transplant,” she said. “With a kidney transplant, he’d be able to work and sustain himself without fear of being penalized for having kidney failure.”

A new approach is also needed for the way researchers and journals present studies about health disparities, Grubbs argued. She said they need to stop presenting race as a biological construct and instead acknowledge it as a social construct. Too often, she said, researchers try to attribute health disparities to unknown genetic factors that may not exist.

“We need to stop talking about race as a risk factor, rather than racism as a risk factor,” Grubbs said. She recommended that researchers, reviewers, and editors apply new standards for publishing on health inequities, outlined in a Health Affairs blog post authored by health equity advocate Rhea Boyd, MD, MPH, and colleagues (4).

Representation matters

Greater representation of Black, Latino, Indigenous, and other under-represented groups in nephrology is key to improving care for patients, panelists noted.

There is evidence that patients receive better care from physicians who look like them, Gibson said. Yet only 3.8% of nephrology residents are Black (5), and data from the Association of American Medical Colleges show only 5.3% of medical trainees are Latino. Less than 0.3% are Indigenous (6).

Washington University School of Medicine’s Ross said having emeritus professor of nephrology Aubrey Morrison, MBBS, as a renal physiology instructor was pivotal to his path to nephrology. Many participants echoed the importance of having nephrology mentors who looked like them in attracting them to the field.

Tucker also emphasized a need to build a better pipeline for under-represented students into medicine and nephrology starting with kindergarten through high school education by addressing school quality and growing re-segregation. He also recommended recruiting talent from junior colleges or historically Black colleges and universities (HBCUs).

“We have to look at expanding the pipeline by trying to find talent in places we don’t often look,” he said. The assurance that nephrology salaries are competitive with other specialties is also essential to recruiting under-represented physicians who are less likely to come from wealthy families and are more likely to carry substantial student loan debt.

Addressing racism’s effects in academic institutions

Grubbs said it is also important to address racism at academic institutions that may hinder admission or advancement for Black trainees. She noted that admissions criteria too often “favor the already highly favored.” For example, when she was interviewed for medical school, she was asked about her volunteer work, but she hadn’t volunteered because she was working three jobs. The interviewer did not ask about her job experience. Ross recommended that medical school and residency admissions committees use holistic review processes (7) that take into account applicant experiences and attributes in addition to more traditional metrics, such as test scores or grades.

Minority faculty and trainees need to be supported when they face racism in practice, either from within the institution or from patients, Tucker said. He cited an essay by a former Brigham and Women’s resident about dealing with a racist patient and not feeling supported (8).

Academic institutions also need to revamp promotion and tenure policies to reward the work of physicians from under-represented groups. For example, minority faculty are often asked to help serve on admissions committees to help improve recruitment or to serve on diversity or inclusion committees, but this work may not be rewarded in promotion or tenured decisions.

“If you want to retain Black faculty, you should pay us,” Grubbs said.

Tucker said all faculty, not just an under-represented minority faculty, should be engaged in health equity and inclusion work. “It makes us as a field, as physicians, and as a medical community better if we are all engaged,” he said.

Although efforts to build the ranks of under-represented physicians are in progress, Ross argued for greater use of advanced practice nurses from under-represented groups to provide culturally appropriate care to communities of color. He also recommended the use of community health workers who can help patients access basic necessities, such as food and housing, and also navigate the health system.

ASN President Anupam Agarwal, MD, promised to make addressing racism a priority.

“I’d like to commit as ASN president that this is a top priority for ASN within our organization to ensure that all aspects of systemic racism are completely dismantled within our society and going forward for every level, whether it’s trainees, clinicians in private practice, faculty, and academia,” Agarwal said. “We really need to address this head on. We cannot do this alone. We need your help.”

References

1. 

American Society of Nephrology. Going beyond the statement: dismantling systemic racism in nephrology. YouTube. September 15, 2020. https://www.youtube.com/watch?v=bE0kmXLibx0&feature=youtu.be

2. 

NKF and ASN form joint task force to focus on use of race in eGFR. Kidney News Online August 24, 2020. https://www.kidneynews.org/kidney-news/leading-edge/nkf-and-asn-form-joint-task-force-to-focus-on-use-of-race-in-egfr

3. 

Medical students lead effort to remove race from kidney function estimates. Kidney News Online July 2020; 12. https://www.kidneynews.org/kidney-news/current-issue/medical-students-lead-effort-to-remove-race-from-kidney-function-estimates

4. 

Boyd RW, et al On racism: a new standard for publishing on racial health inequities. Health Affairs July 2, 2020. doi: 10.1377/hblog20200630.939347; https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/

5. 

Onumah C, et al Race disparities in U.S. nephrology fellowship training. Clin J Am Soc Nephrol 2011; 6:390–394. doi: 10.2215/CJN.04450510

7. 

Association of American Medical Colleges. Holistic Review. 2020. https://www.aamc.org/services/member-capacity-building/holistic-review

8. 

Jain SH. The racist patient. Ann Intern Med 2013; 158:632. doi: 10.7326/0003-4819-158-8-201304160-00010; https://www.acpjournals.org/

October-November 2020 (Vol. 12, Number 10 & 11)