• 1.

    Norton JM, et al. Social determinants of racial disparities in CKD. J Am Soc Nephrol 2016; 27:25762595. doi: 10.1681/ASN.2016010027

  • 2.

    Kim D, et al. Racial and ethnic disparities in excess deaths among persons with kidney failure during the COVID-19 pandemic, March-July 2020. Am J Kidney Dis 2021; 77:827829. doi: 10.1053/j.ajkd.2021.02.003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Bayliss GP, et al. Kidney mentoring and assessment program for students: A guide for engaging medical students in nephrology. Clin Kidney J 2019; 12:761766. doi: 10.1093/ckj/sfz108

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Lederer E, Lebowitz J. Current state of the workforce in nephrology. Adv Chronic Kidney Dis 2020; 27:281-290.e1. doi: 10.1053/j.ackd.2020.07.007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Rosenberg ME. Adult nephrology fellowship training in the United States: Trends and issues. J Am Soc Nephrol 2007; 18:10271033. doi: https://doi.org/10.1681/ASN.2006101169

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Chavon O, et al. Race disparities in U.S. nephrology fellowship training. Clin J Am Soc Nephrol 2011; 6:390394. doi: 10.2215/CJN.04450510

  • 7.

    Brotherton SE, Etzel SI. Graduate medical education, 2010-2011. JAMA 2011; 306:10151030. doi: 10.1001/jama.2011.1236

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    Brotherton SE, Etzel SI. Graduate medical education, 2019-2020. JAMA 2020; 324:12301250. doi:10.1001/jama.2020.14635

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    Association of American Medical Colleges. Diversity in Medicine: Facts and figures 2019. Executive Summary. 2019. www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019

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    ASN, personal communication, March 2021.

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    Association of American Medical Colleges. Table B5. Number of active MD residents, by race/ethnicity (alone or in combination) and GME specialty. 2020. www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2020/table-b5-md-residents-race-ethnicity-and-specialty

    • Search Google Scholar
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  • 12.

    Johansen KL, et al. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2021; 77 (4 Suppl 1):A7A8. doi: 10.1053/j.ajkd.2021.01.002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Cooper LA, Powe NR. Disparities in patient experiences, health care processes, and outcomes: The role of patient-provider racial, ethnic, and language concordance. The Commonwealth Fund. July 2004. https://collections.nlm.nih.gov/master/borndig/101669869/Disparities%20in%20patient%20experiences%20health%20care%20processes%20and%20outcomes.pdf

    • Search Google Scholar
    • Export Citation
  • 14.

    Casey BR, et al. Role of the clinical learning environment in preparing new clinicians to engage in quality improvement efforts to eliminate health care disparities. Am J Health Syst Pharm 2020; 77:3946. doi: 10.1093/ajhp/zxz251

    • Search Google Scholar
    • Export Citation
  • 15.

    Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in nephrology. July 1, 2020. www.acgme.org/Portals/0/PFAssets/ProgramRequirements/148_Nephrology_2020.pdf?ver=2020-06-29-162357-583

    • Search Google Scholar
    • Export Citation
  • 16.

    Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved 1998; 9:117125. doi: 10.1353/hpu.2010.0233

    • Crossref
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Naming and Eliminating Systemic and Institutional Racism in Nephrology Training

  • 1 Abinet Aklilu, MD, is a Nephrology Fellow with the Yale School of Medicine, New Haven, CT. Jason Cobb, MD, is with the Division of Renal Medicine, Emory University School of Medicine, Atlanta, GA. Javier A. Neyra, MD, MSCS, FASN, is with the Nephrology Department, University of Kentucky College of Medicine, Lexington, KY. Nimrit Goraya, MD, FASN, is with the Nephrology Department, Department of Internal Medicine, Baylor Scott & White Health, Dallas, TX.
Full access

There is no better time than now to start naming and eliminating systemic and institutional racism in nephrology training. Public displays of racial injustice recently captured on traditional and social media have finally brought attention to racism and racial disparities in various sectors of our community including healthcare and medical education. The impact of racism extends to our patients in the form of poor access to care and inadequate care delivery, often due to unconscious biases that lead to perpetuation of mistrust and unjust inequitable care (1). And these gaps in care were further exposed in the current pandemic (2, 3).

The landscape of racial diversity in nephrology has shown no significant growth over the past 20 years (4, 5). In 2000, 4.6% of trainees identified as Black (6). In 2010, the combined percentage of underrepresented minorities (URMs) in nephrology including Black, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander was 6%, and 6.9% were Hispanic (7). This remained unchanged in 2020, during which 4.6% of nephrology trainees, 4.7% internal medicine (IM) residents, and 7.6% medical students identified as Black; 7% of nephrology trainees, 6.7% of IM residents, and 6.7% of medical students identified as Hispanic; and American Indian/Alaska Native or Native Hawaiian/Pacific Islanders make up <1% of trainees at all levels (8, 9).

The training program director (TPD) and associate PD (APD) positions of nephrology fellowship programs mirror these trends. In 2020-2021, only 1.4% of the TPDs, 6.4% of APDs, and 3.7% of division directors are Black. Similarly, 4.1% of TPDs, 4.6% of APDs, and 2.7% of division directors are Hispanic (10). Perhaps this is not surprising, as 3.6% of full-time medical school faculty in 2018 were Black, and 5.5% were Hispanic (11). Minorities are highly underrepresented in our field and are out of proportion to the makeup of the US population despite the disproportionately higher adjusted prevalence of end-stage kidney disease (ESKD) in minorities and despite evidence suggesting improved patient satisfaction and outcomes with race-concordant patient-provider encounters (12, 13).

In our efforts toward building a culturally competent nephrology community, training programs play a crucial role (Table 1).

tbl1

Prior to proposing potential options, we first revisit the concept of institutional racism, which was coined by Stokely Carmichael in the 1960s. This theory brought to light the more pervasive type of racism that is tough to eradicate and represents a constellation of societal factors ingrained into the fabric of our systems and culture that are downstream effects of slavery and segregation and create disadvantages and hurdles on an individual's journey through life, work, and education because of their race.

Understanding the meaning and impact of institutional racism in the United States requires a reflection on the well-recognized downstream effects of 4 centuries of oppression of individuals as slaves, disparities in access to healthcare and education that result from segregation, and the unconscious biases people tend to harbor toward the unknown. Unconscious bias affects one's interaction with other individuals who are of a different background and influences decisions made about them. As humans first and physicians second, we are all prone to make assumptions about individuals that are often inaccurate and make impactful decisions based on those assumptions (14). In clinical practices, this can cause us to disqualify people from potentially life-prolonging treatment. In medical education, unconscious bias affects ranking and recruitment at all levels.

Diversity in leadership impacts diversity down to the training level. For example, lack of diversity in nephrology division leadership can affect representation in training program leadership, which can impact URMs in nephrology fellowship. The lack of diversity in their clinical learning environment (CLE) can negatively influence URM medical students and residents about choosing nephrology as a career path. Racism can be pervasive in our recruitment efforts, as unconscious biases can influence who we invite for nephrology fellowship interviews. Once applicants are invited, our biases can influence our applicant rankings, as rigid interview assessments can potentially be unfair to URM applicants. In addition, URM nephrology fellows can be impacted by an exclusive CLE where isolation and a lack of social support can affect fellow performance. Unconscious biases can negatively impact evaluations of URM nephrology fellows. The Accreditation Council for Graduate Medical Education (ACGME) has mandated efforts in diversity and teaching learners about healthcare disparities (14, 15).

Training programs have an important role in mitigating institutional racism, as they can build a culturally competent workforce through unconscious bias training, discussions, inviting experts in the area, and diversifying the workforce. Destigmatizing bias, recognizing it as a natural response we have, and focusing on strategies to recognize it and keep it in check are first steps. As such, the road to achieving cultural competency starts with cultural humility—a lifelong commitment to self-evaluation, i.e., acknowledging one may not fully understand another individual's background and challenges but is open to explore and learn to impact care of the underserved community (14, 16).

ASN's Diversity, Equity, and Inclusion and Workforce and Training Committees have collaborated to create dialogue and constructive programs that can impact racism in nephrology training. ASN's Town Hall, “Addressing Racism in Kidney Care and Training,” held in March 2021, was the first of its kind and a step forward. Racial disparities in the workforce were highlighted, and a new URM pipeline program has been proposed to promote recruitment into the field at the grassroots level (3). The Kidney Mentoring and Awareness Program for Students (MAPS) was sponsored by the ASN Workforce Committee from 2013 to 2015, and the society continues to provide resources for institutions that wish to start their own chapter. Currently, the Tutored Research and Education for Kidney Scholars (TREKS) program at the University of Chicago has a disparities and outreach module. In addition, there are plans to provide educational resources including unconscious bias training with nephrology-specific clinical vignettes that can be used to train decision-makers, including division leadership and interviewers of nephrology fellowship applicants. Furthermore, the production of a report providing statistics on racial disparities in nephrology on all levels, including leadership, workforce, training programs, and patients, is expected.

To ensure accountability in the efforts toward building a more diverse workforce at all levels of training and leadership, we also propose a metric of performance: a diversity score. The aim of this score is for nephrology divisions to self-evaluate and reflect on areas of improvement. Although it is encouraging to see this topic start to gain the attention it deserves, it will take time to see improvement up to the leadership level. It is time to come together and put an end to institutional racism in nephrology training and build a culturally competent community to ensure equitable care—an individualized but unbiased care.

References

  • 1.

    Norton JM, et al. Social determinants of racial disparities in CKD. J Am Soc Nephrol 2016; 27:25762595. doi: 10.1681/ASN.2016010027

  • 2.

    Kim D, et al. Racial and ethnic disparities in excess deaths among persons with kidney failure during the COVID-19 pandemic, March-July 2020. Am J Kidney Dis 2021; 77:827829. doi: 10.1053/j.ajkd.2021.02.003

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Bayliss GP, et al. Kidney mentoring and assessment program for students: A guide for engaging medical students in nephrology. Clin Kidney J 2019; 12:761766. doi: 10.1093/ckj/sfz108

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Lederer E, Lebowitz J. Current state of the workforce in nephrology. Adv Chronic Kidney Dis 2020; 27:281-290.e1. doi: 10.1053/j.ackd.2020.07.007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Rosenberg ME. Adult nephrology fellowship training in the United States: Trends and issues. J Am Soc Nephrol 2007; 18:10271033. doi: https://doi.org/10.1681/ASN.2006101169

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Chavon O, et al. Race disparities in U.S. nephrology fellowship training. Clin J Am Soc Nephrol 2011; 6:390394. doi: 10.2215/CJN.04450510

  • 7.

    Brotherton SE, Etzel SI. Graduate medical education, 2010-2011. JAMA 2011; 306:10151030. doi: 10.1001/jama.2011.1236

  • 8.

    Brotherton SE, Etzel SI. Graduate medical education, 2019-2020. JAMA 2020; 324:12301250. doi:10.1001/jama.2020.14635

  • 9.

    Association of American Medical Colleges. Diversity in Medicine: Facts and figures 2019. Executive Summary. 2019. www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019

    • Search Google Scholar
    • Export Citation
  • 10.

    ASN, personal communication, March 2021.

  • 11.

    Association of American Medical Colleges. Table B5. Number of active MD residents, by race/ethnicity (alone or in combination) and GME specialty. 2020. www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2020/table-b5-md-residents-race-ethnicity-and-specialty

    • Search Google Scholar
    • Export Citation
  • 12.

    Johansen KL, et al. US Renal Data System 2020 Annual Data Report: Epidemiology of Kidney Disease in the United States. Am J Kidney Dis 2021; 77 (4 Suppl 1):A7A8. doi: 10.1053/j.ajkd.2021.01.002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Cooper LA, Powe NR. Disparities in patient experiences, health care processes, and outcomes: The role of patient-provider racial, ethnic, and language concordance. The Commonwealth Fund. July 2004. https://collections.nlm.nih.gov/master/borndig/101669869/Disparities%20in%20patient%20experiences%20health%20care%20processes%20and%20outcomes.pdf

    • Search Google Scholar
    • Export Citation
  • 14.

    Casey BR, et al. Role of the clinical learning environment in preparing new clinicians to engage in quality improvement efforts to eliminate health care disparities. Am J Health Syst Pharm 2020; 77:3946. doi: 10.1093/ajhp/zxz251

    • Search Google Scholar
    • Export Citation
  • 15.

    Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in nephrology. July 1, 2020. www.acgme.org/Portals/0/PFAssets/ProgramRequirements/148_Nephrology_2020.pdf?ver=2020-06-29-162357-583

    • Search Google Scholar
    • Export Citation
  • 16.

    Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved 1998; 9:117125. doi: 10.1353/hpu.2010.0233

    • Crossref
    • Search Google Scholar
    • Export Citation
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