What does systemic racism look like in healthcare?
One place it crops up is in the numbers and calculations that healthcare providers nationwide use when they make treatment decisions. For decades, one measurement of kidney health – the estimated glomerular filtration rate (eGFR) – has been automatically adjusted based on the race of the patient. Black patients had one set of guidelines, and non-Black patients had another.
Not any more. Later this year, M Health Fairview will stop using this eGFR adjustment after a task force of our doctors and experts evaluated the effect of this practice on patient care and found it at best, problematic. They shared their findings in Minnesota Medicine – in an essay titled “Reckoning with History.”
This change is necessary because the science that underpins the race-adjusted eGFR rests on incorrect assumptions about race. Race is not biological; it is a social construct. Yet adjusting the eGFR algorithm for Black patients labels a Black person biologically different from any other person. It’s bad science – and it can have significant consequences for that person’s healthcare.
“The race-adjusted eGFR algorithm makes a Black person’s kidneys seem healthier than they may really be,” said M Health Fairview Hospitalist Kristina Krohn, MD. Krohn, who also serves as an assistant professor in the Department of Medicine at University of Minnesota Medical School, chaired the task force. “That can result in delays if that person needs access to nephrologists or counseling to manage their chronic kidney disease, including delays in being listed for kidney transplant. As we find a better way, we need to stop doing what we know is causing harm.”
Leading healthcare organizations across the country are beginning to reevaluate calculations like these, driven in part by the grassroots efforts of scientists, providers, medical students, and the nationwide racial justice movement. In June 2020, M Health Fairview physicians established their task force, which ultimately recommended removing the race-based adjustment.
“Medicine has to reckon with its role in the process of justifying exploitation and oppression,” said M Health Fairview Internist Brooke Cunningham, MD, PhD. Cunningham was a member of the eGFR task force, and serves as an assistant professor in the Department of Family Medicine and Community Health at the University of Minnesota Medical School. “We need to interrupt that legacy, and one way to do that is by interrogating the ideas grounding these calculators and algorithms. If the origin of the calculator is based on a biological construction of race, we need to change it. This is not a final step; it’s an intermediate step. I’m hopeful that eventually we won’t see race as a proxy for anything. We’ll get down to the mechanisms that actually affect kidney function.”
The task force’s work led to a better understanding of the ways that structural racism is enmeshed in medicine, Krohn said. Removing the eGFR adjustment is a small step toward building a health system that provides equitable, accessible care for all. There is still much more work ahead – efforts guided by the HOPE Commission’s vision to create transformative and sustainable change in healthcare by eliminating systemic racial and gender discrimination.
“M Health Fairview is taking a critical look at the way it operates on both very granular levels, such as this, and on broader levels,” said Internist and Pediatrician Taj Mustapha, MD, a member of the eGFR task force and M Health Fairview’s HOPE Commission. Mustapha is also an assistant professor in the Department of Medicine at the University of Minnesota Medical School. “Reckoning with the inequities and flawed constructs that are embedded within healthcare and medicine will take time and work, and this is just one example of such work that is happening across the enterprise.”