Do no harm is the ultimate rule of practicing medicine and taking an evidence-based approach is recommended to uphold this standard. But when guidelines and clinical algorithms are based on inaccurate race-based corrections, patients of color are often disadvantaged, which can lead to deadly consequences.
At the American Academy of Physician Associates (AAPA) national conference held May 20 to 24, 2023, in Nashville, Tennessee, Kara Caruthers, MSPAS, PA-C; Howard Straker, PA-C, EdD, MPH; and Susan LeLacheur, DrPH, PA-C, presented on how eliminating race-based practices in clinical care can save lives.
Medical Reparations: Addressing Harmful, Outdated Guidelines
Race is a social construct with no biological definition. When calculations based on race are incorporated into staging guidelines without a clinical reason, inadequate assessment of patients of color can have the severity of their disease misdiagnosed and experience delays in care.
Continue Reading
For example, in 2021, the National Kidney Foundation and American Society of Nephrology called to end race-based adjustments to calculating the glomerular filtration rate (GFR). The task force urged an immediate shift to the estimated GFR 2021 creatinine equation that estimates kidney function without a race variable. Until this adjustment was made, Black patients were needlessly spending a longer time on kidney transplant lists compared with White patients because of guidance published in 1976 that assumed that Black patients had more muscle mass and thus higher calcium levels.
However, simply adjusting the guidelines is not enough to ensure that the new standards are being applied to patients. In January of this year, clinicians and patient advocacy groups began to contact kidney transplant centers around the country and ask them to recalculate the GFR values for Black patients using the new race-neutral method.
“When we talk about reparations, the way I see it is that it really means ‘repair.’ So how do you repair the damage that has been done? In regards to medical reparations for this specific case, it is having those centers … recalculate those kidney function values,” Ms Caruthers said. The recalculation can reduce United Network for Organ Sharing (UNOS) waitlist time for kidney transplant from 5 years to 2 years, she noted.
Updated Electronic Medical Records
Updates to electronic medical records (EMRs) can help remind clinicians to reconsider outdated guidance. Some hospitals now have a reminder system that sends a notification to clinicians about the potential need for intensive care when a Black patient presents with acute heart failure in the emergency department (ED).
“Using the American Heart Association’s guidelines, [Black patients] are less likely to be placed in a cardiac unit or an intensive care unit,” said Dr Straker. Black patients “now have something in their chart to remind clinicians that they need to go to more intensive treatment and not just depend on those [outdated] guidelines on where you should send them.”
But when updated technology does not come with updated guidelines, it becomes harder for the new guidelines to be adopted. Spirometers, for example, use a race-based correction that assumes Black patients have a 10% to 15% smaller lung capacity and Asian patients have a 4% to 6% smaller lung capacity than White patients.
This correction, which dates back to the 1860s and was removed in 2021, biased reports of COVID-19 severity among Black patients. It also uncovered an increased prevalence and severity of lung disease, such as restrictive complications, among Black patients than previously thought.
“Black patients were put in a normal range when they should have been noted for decreased lung function. That [error] has now been removed but it’s [still programmed] in the [spirometry] machines, and it’s still being used,” said Dr LeLacheur. “There has been, to date, no similar push to bring back all of those people who were misdiagnosed [before the correction], and that’s a place where a lot of work still needs to be done.”
Race-Based Corrections in Pediatrics
The American Academy of Pediatrics (AAP) recently reviewed all of its guidelines to remove race from all calculations. For example, the AAP used to include a race-based adjustment for diagnosing urinary tract infections (UTIs), causing many children of color to go undiagnosed.
Delays in care for children of color can be life-threatening, or diminish quality of life, as in the case of pain management for bone fractures.
“Black children who have bone fractures are still not being treated for pain management because of the misconception that they don’t feel pain the same way because their skin is thicker,” Ms Caruthers said. “Some of those misconceptions and false beliefs are still there.”
A World Designed Only for White Patients and People
At the height of the COVID-19 pandemic, much discussion was made about pulse oximeters and whether or not they could accurately read the blood oxygen saturation level of Black patients. The public health crisis called attention to the shortcomings of devices programmed to see light skin as normal.
The technology that causes automatic sinks to turn at the swish of a light-skinned hand but does not recognize a person of color is the same technology that prevents clinicians from quickly capturing blood oxygen saturation levels for Black patients. While generally accurate when a patient is able to breathe without issue, when oxygen levels decrease, pulse oximeters become less accurate for patients with darker skin.
“How do we effectively say that we have a population of our neighbors who are dying excessively, who are not getting treatment, and who are being mistreated? How do we all call for reparations and mitigation of that loss so that we can do better?” Ms Caruthers said.
The Next Generation of Clinicians
The presenters encouraged clinicians to have conversations with the students they precept about how assumptions based on race can cause harm to patients, and recommended that all clinicians ask themselves 3 questions to critically analyze race-based practices:
- Is there a need for race-based correction based on robust evidence and statistical analysis, with consideration given to internal and external validity, confounders, and bias?
- Is there a plausible mechanism of racial difference to justify race correction or are researchers using race as a substitute for genetics?
- Will implementing a race-based correction relieve or exacerbate health inequities?
“As we talk about evidence-based medicine, are we doing it because someone told us to, or [are we doing] it because we looked at it and it makes sense?” Ms Caruthers said.
Visit Clinical Advisor’s meetings section for more coverage of AAPA 2023.
Reference
- Caruthers K, Straker H, LeLacheur S. Critical thinking: eliminating race-based practices in clinical medicine. Presented at: AAPA national conference; May 20-24, 2023; Nashville, TN.
