Black or ‘Other’? Doctors may be relying on race to make decisions about your health | CNN

Editor’s Note: CNN’s “History Refocused” series features surprising and personal stories from America’s past to bring depth to conflicts still raging today.



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When she first learned about race correction, Naomi Nkinsi was one of five Black medical students in her class at the University of Washington.

Nkinsi remembers the professor talking about an equation doctors use to measure kidney function. The professor said eGFR equations adjust for several variables, including the patient’s age, sex and race. When it comes to race, doctors have only two options: Black or “Other.”

Nkinsi was dumbfounded.

“It was really shocking to me,” says Nkinsi, now a third-year medical and masters of public health student, “to come into school and see that not only is there interpersonal racism between patients and physicians … there’s actually racism built into the very algorithms that we use.”

At the heart of a controversy brewing in America’s hospitals is a simple belief, medical students say: Math shouldn’t be racist.

The argument over race correction has raised questions about the scientific data doctors rely on to treat people of color. It’s attracted the attention of Congress and led to a big lawsuit against the NFL.

What happens next could affect how millions of Americans are treated.

Carolyn Roberts, a historian of medicine and science at Yale University, says slavery and the American medical system were in a codependent relationship for much of the 19th century and well into the 20th.

“They relied on one another to thrive,” Roberts says.

It was common to test experimental treatments first on Black people so they could be given to White people once proven safe. But when the goal was justifying slavery, doctors published articles alleging substantive physical differences between White and Black bodies — like Dr. Samuel Cartwright’s claim in 1851 that Black people have weaker lungs, which is why grueling work in the fields was essential (his words) to their progress.

The effects of Cartwright’s falsehood, and others like it, linger today.

In 2016, researchers asked White medical students and residents about 15 alleged differences between Black and White bodies. Forty percent of first-year medical students and 25% of residents said they believed Black people have thicker skin, and 7% of all students and residents surveyed said Black people have less sensitive nerve endings. The doctors-in-training who believed these myths — and they are myths — were less likely to prescribe adequate pain medication to Black patients.

To fight this kind of bias, hospitals urge doctors to rely on objective measures of health. Scientific equations tell physicians everything from how well your kidneys are working to whether or not you should have a natural birth after a C-section. They predict your risk of dying during heart surgery, evaluate brain damage and measure your lung capacity.

But what if these equations are also racially biased?

Race correction is the use of a patient’s race in a scientific equation that can influence how they are treated. In other words, some diagnostic algorithms and risk predictor tools adjust or “correct” their results based on a person’s race.

The New England Journal of Medicine article “Hidden in Plain Sight” includes a partial list of 13 medical equations that use race correction. Take the Vaginal Birth After Cesarean calculator, for example. Doctors use this calculator to predict the likelihood of a successful vaginal delivery after a prior C-section. If you are Black or Hispanic, your score is adjusted to show a lower chance of success. That means your doctor is more likely to encourage another C-section, which could put you at risk for blood loss, infection and a longer recovery period.

Cartwright, the racist doctor from the 1800s, also developed his own version of a tool called the spirometer to measure lung capacity. Doctors still use spirometers today, and most include a race correction for Black patients to account for their supposedly shallower breaths.

Turns out, second-year medical student Carina Seah wryly told CNN, math is as racist as the people who make it.

The biggest problem with using race in medicine? Race isn’t a biological category. It’s a social one.

“It’s based on this idea that human beings are naturally divided into these big groups called races,” says Dorothy Roberts, a professor of law and sociology at the University of Pennsylvania, who has made challenging race correction in medicine her life’s work. “But that’s not what race is. Race is a completely invented social category. The very idea that human beings are divided into races is a made-up idea.”

Ancestry is biological. Where we come from — or more accurately, who we come from — impacts our DNA. But a patient’s skin color isn’t always an accurate reflection of their ancestry.

Look at Tiger Woods, Roberts says. Woods coined the term “Cablinasian” to describe his mix of Caucasian, Black, American Indian and Asian ancestries. But to many Americans, he’s Black.

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“You can be half Black and half White in this country and you are Black,” says Seah, who is getting her medical degree and a PhD in genetics and genomics at the Icahn School of Medicine at Mount Sinai in New York. “You can be a quarter Black in this country — if you have dark skin, you are Black.”

So it can be misleading, Seah says, even dangerous, for doctors to judge a patient’s ancestry by glancing at their skin. A patient with a White mother and Black father could have a genetic mutation that typically presents in patients of European ancestry, Seah says, but a doctor may not think to test for it if they only see Black skin.

“You have to ask, how Black is Black enough?” Nkinsi asks. And there’s another problem, she says, with using a social construct like race in medicine. “It also puts the blame on the patient, and it puts the blame on the race itself. Like being Black is inherently the cause of these diseases.”

Naomi Nkinsi is a third-year medical and masters of public health student at the University of Washington in Seattle. She has been advocating for the removal of race correction in medicine.

After she learned about the eGFR equation in 2018, Nkinsi began asking questions about race correction. She wasn’t alone — on social media she found other students struggling with the use of race in medicine. In the spring of 2020, following a first-year physiology lecture, Seah joined the conversation. But the medical profession is nothing if not hierarchical; Nkinsi and Seah say students are encouraged to defer to doctors who have been practicing for decades.

Then on May 25, 2020, George Floyd was killed by police in Minneapolis.

His death and the growing momentum around Black Lives Matter helped ignite what Dr. Darshali A. Vyas calls an “overdue reckoning” in the medical community around race and race correction. A few institutions had already taken steps to remove race from the eGFR equation. Students across the country demanded more, and hospitals began to listen.

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Four days after Floyd’s death, the University of Washington announced it was removing race correction from the eGFR equation. In June, the Boston-based hospital system Mass General Brigham where Vyas is a second-year Internal Medicine resident followed suit. Seah and a fellow student at Mount Sinai, Paloma Orozco Scott, started an online petition and collected over 1600 signatures asking their hospital to do the same.

Studies show removing race from the eGFR equation will change how patients at those hospitals are treated. Researchers from Brigham and Women’s Hospital and Penn Medicine estimated up to one in every three Black patients with kidney disease would have been reclassified if the race multiplier wasn’t applied in earlier calculations, with a quarter going from stage 3 to stage 4 CKD (Chronic Kidney Disease).

That reclassification is good and bad, says Dr. Neil Powe, chief of medicine at Zuckerberg San Francisco General Hospital. Black patients newly diagnosed with kidney disease will be able to see specialists who can devise better treatment plans. And more patients will be placed on kidney transplant lists.

On the flip side, Powe says, more African Americans diagnosed with kidney disease means fewer who are eligible to donate kidneys, when there’s already a shortage. And a kidney disease diagnosis can change everything from a patient’s diabetes medication to their life insurance costs.

Dr. Neil Powe says by simply removing race from the eGFR equations,

Powe worries simply eliminating race from these equations is a knee-jerk response — one that may exacerbate health disparities instead of solve them. For too long, Powe says, doctors had to fight for diversity in medical studies.

The most recent eGFR equation, known as the CKD-EPI equation, was developed using data pooled from 26 studies, which included almost 3,000 patients who self-identified as Black. Researchers found the equation they were developing was more accurate for Black patients when it was adjusted by a factor of about 1.2. They didn’t determine exactly what was causing the difference in Black patients, but their conclusion is supported by other research that links Black race and African ancestry with higher levels of creatinine, a waste product filtered by the kidneys.

Put simply: In the eGFR equation, researchers used race as a substitute for an unknown factor because they think that factor is more common in people of African descent.

Last August, Vyas co-authored the “Hidden in Plain Sight” article about race correction. Vyas says most of the equations she wrote about were developed in a similar way to the eGFR formula: Researchers found Black people were more or less likely to have certain outcomes and decided race was worth including in the final equation, often without knowing the real cause of the link.

“When you go back to the original studies that validated (these equations), a lot of them did not provide any sort of rationale for why they include race, which I think is appalling.” That’s what’s most concerning, Vyas says – “how willing we are to believe that race is relevant in these ways.”

Vyas is clear she isn’t calling for race-blind medicine. Physicians cannot ignore structural racism, she says, and the impact it has on patients’ health.

Powe has been studying the racial disparities in kidney disease for more than 30 years. He can spout the statistics easily: Black people are three times more likely to suffer from kidney failure, and make up more than 35% of patients on dialysis in the US. The eGFR equation, he says, did not cause these disparities — they existed long before the formula.

“We want to cure disparities, let’s go after the things that really matter, some of which may be racist,” he says. “But to put all our stock and think that the equation is causing this is just wrong because it didn’t create those.”

In discussions about removing race correction, Powe likes to pose a question: Instead of normalizing to the “Other” group in the eGFR equation, as many of these hospitals are doing, why don’t we give everyone the value assigned to Black people? By ignoring the differences researchers saw, he says, “You’re taking the data on African Americans, and you’re throwing it in the trash.”

Powe is co-chair of a joint task force set up by the National Kidney Foundation and the American Society of Nephrology to look at the use of race in eGFR equations. The leaders of both organizations have publicly stated race should not be included in equations used to estimate kidney function. On April 9, the task force released an interim report that outlined the challenges in identifying and implementing a new equation that’s representative of all groups. The group is expected to issue its final recommendations for hospitals this summer.

Race correction is used to assess the kidneys and the lungs. What about the brain?

In 2013, the NFL settled a class-action lawsuit brought by thousands of former players and their families that accused the league of concealing what it knew about the dangers of concussions. The NFL agreed to pay $765 million, without admitting fault, to fund medical exams and compensate players for concussion-related health issues, among other things. Then in 2020, two retired players sued the NFL for allegedly discriminating against Black players who submitted claims in that settlement.

01 race correction Kevin Henry Najeh Davenport SPLIT

The players, Najeh Davenport and Kevin Henry, said the NFL race-corrected their neurological exams, which prevented them from being compensated.

According to court documents, former NFL players being evaluated for neurocognitive impairment were assumed to have started with worse cognitive function if they were Black. So if a Black player and a White player received the exact same scores on a battery of thinking and memory tests, the Black player would appear to have suffered less impairment. And therefore, the lawsuit stated, would be less likely to qualify for a payout.

Race correction is common in neuropsychology using something called Heaton norms, says Katherine Possin, an associate professor at the University of California San Francisco. Heaton norms are essentially benchmark average scores on cognitive tests.

Here’s how it works: To measure the impact of a concussion (or multiple concussions over time), doctors compare how well the patient’s brain works now to how well it worked before.

“The best way to get that baseline was to test you 10 years ago, but that’s not something we obviously have for many people,” Possin says. So doctors estimate your “before” abilities using an average score from a group of healthy individuals, and adjust that score for demographic factors known to affect brain function, like your age.

Heaton norms adjust for race, Possin says, because race has been linked in studies to lower cognitive scores. To be clear, that’s not because of any biological differences in Black and White brains, she says; it’s because of social factors like education and poverty that can impact cognitive development. And this is where the big problem lies.

In early March, a judge in Pennsylvania dismissed the players’ lawsuit and ordered a mediator to address concerns about how race correction was being used. In a statement to CNN, the NFL said there is no merit to the players’ claim of discrimination, but it is committed to helping find alternative testing techniques that do not employ race-based norms.

The NFL case, Possin wrote in JAMA, has “exposed a major weakness in the field of neuropsychology: the use of race-adjusted norms as a crude proxy for lifelong social experience.”

This happens in nearly every field of medicine. Race is not only used as a poor substitute for genetics and ancestry, it’s used as a substitute for access to health care, or lifestyle factors like diet and exercise, socioeconomic status and education. It’s no secret that racial disparities exist in all of these. But there’s a danger in using race to talk about them, Yale historian Carolyn Roberts says.

We know, for example, that Black Americans have been disproportionally affected by Covid-19. But it’s not because Black bodies respond differently to the virus. It’s because, as Dr. Anthony Fauci has noted, a disproportionate number of Black people have jobs that put them at higher risk and have less access to quality health care. “What are we making scientific and biological when it actually isn’t?” Roberts asks.

Vyas says using race as a proxy for these disparities in clinical algorithms can also create a vicious cycle.

“There’s a risk there, we argue, of simply building these into the system and almost accepting them as fact instead of focusing on really addressing the root causes,” Vyas says. “If we systematize these existing disparities … we risk ensuring that these trends will simply continue.”

Nearly everyone on both sides of the race correction controversy agrees that race isn’t an accurate, biological measure. Yet doctors and researchers continue to use it as a substitute. Math shouldn’t be racist, Nkinsi says, and it shouldn’t be lazy.

“We’re saying that we know that this race-based medicine is wrong, but we’re going to keep doing it because we simply don’t have the will or the imagination or the creativity to think of something better,” Nkinsi says. “That is a slap in the face.”

Shortly after Vyas’ article published in The New England Journal of Medicine, the House Ways and Means Committee sent letters to several professional medical societies requesting information on the misuse of race in clinical algorithms. In response to the lawmakers’ request, the Agency for Healthcare Research and Quality is also gathering information on the use of race-based algorithms in medicine. Recently, a note appeared on the Maternal Fetal Medicine Units Network’s website for the Vaginal Birth After Cesarean equation — a new calculator that doesn’t include race and ethnicity is being developed.

Dorothy Roberts is excited to see change on the horizon. But she’s also a bit frustrated. The harm caused by race correction is something she’s been trying to tell doctors about for years.

“I’ve taught so many audiences about the meaning of race and the history of racism in America and the audiences I get the most resistance from are doctors,” Roberts says. “They’re offended that there would be any suggestion that what they do is racist.”

Nkinsi and Seah both encountered opposition from colleagues in their fight to change the eGFR equation. Several doctors interviewed for this story argued the change in a race-corrected scores is so small, it wouldn’t change clinical decisions.

If that’s the case, Vyas wonders, why include race at all?

“It all comes from the desire for one to dominate another group and justify it,” says Roberts. “In the past, it was slavery, but the same kinds of justifications work today to explain away all the continued racial inequality that we see in America… It is mass incarceration. It’s huge gaps in health. It’s huge differences in income and wealth.”

It’s easier, she says, to believe these are innate biological differences than to address the structural racism that caused them.



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Concern grows around US health-care workforce shortage: ‘We don’t have enough doctors’ | CNN



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There is mounting concern among some US lawmakers about the nation’s ongoing shortage of health-care workers, and the leaders of historically Black medical schools are calling for more funding to train a more diverse workforce.

As of Monday, in areas where a health workforce shortage has been identified, the United States needs more than 17,000 additional primary care practitioners, 12,000 dental health practitioners and 8,200 mental health practitioners, according to data from the Health Resources & Services Administration. Those numbers are based on data that HRSA receives from state offices and health departments.

“We have nowhere near the kind of workforce, health-care workforce, that we need,” Vermont Sen. Bernie Sanders told CNN on Friday. “We don’t have enough doctors. We don’t have enough nurses. We don’t have enough psychologists or counselors for addiction. We don’t have enough pharmacists.”

The heads of historically Black medical schools met with Sanders in a roundtable at the Morehouse School of Medicine in Atlanta on Friday to discuss the nation’s health-care workforce shortage.

The health-care workforce shortage is “more acute” in Black and brown communities; the Black community constitutes 13% of the US population, but only 5.7% of US physicians are Black, said Sanders, chairman of the Senate Committee on Health, Education, Labor, and Pensions.

“What we’re trying to do in this committee – in our Health, Education, Labor Committee – is grow the health-care workforce and put a special emphasis on the needs to grow more Black doctors, nurses, psychologists, et cetera,” Sanders said.

At Friday’s roundtable, the leaders of the Morehouse School of Medicine, Meharry Medical College, Howard University and Charles R. Drew University called for more resources and opportunities to be allocated to their institutions to help grow the nation’s incoming health-care workforce.

“Allocating resources and opportunities matter for us to increase capacity and scholarships and programming to help support these students as they matriculate through,” Dr. Valerie Montgomery Rice, president of the Morehouse School of Medicine, told CNN.

“But also, the other 150-plus medical schools, beyond our four historically Black medical schools, owe it to the country to increase the diversity of the students that they train,” Rice said, adding that having a health-care workforce that reflects the communities served helps reduce the health inequities seen in the United States.

Historically Black medical schools are “the backbone for training Black doctors in this country,” Dr. Hugh Mighty, senior vice president for health affairs at Howard University, said at Friday’s event. “As the problem of Black physician shortages rise, within the general context of the physician workforce shortage, many communities of need will continue to be underserved.”

A new study commissioned by the National Institute on Minority Health and Health Disparities estimates that the economic burden of health inequities in the United States has cost the nation billions of dollars. Such inequities are illustrated in how Black and brown communities tend to have higher rates of serious health outcomes such as maternal deaths, certain chronic diseases and infectious diseases.

The researchers, from Johns Hopkins University and other institutions, analyzed excess medical care expenditures, death records and other US data from 2016 through 2019. They took a close look at health inequities in the cost of medical care, differences in premature deaths and the amount of labor market productivity that has been lost due to health reasons.

The researchers found that, in 2018, the economic burden of health inequities for racial and ethnic minority communities in the United States was up to $451 billion, and the economic burden of health inequities for adults without a four-year college degree was up to $978 billion.

“These findings provide a clear and important message to health care leaders, public health officials, and state and federal policy makers – the economic magnitude of health inequities in the US is startlingly high,” Drs. Rishi Wadhera and Issa Dahabreh, both of Harvard University, wrote in an editorial that accompanied the new study in the journal JAMA.

The Covid-19 pandemic “pulled the curtain back” on health inequities, such as premature death and others, Rice said, and “we saw a disproportionate burden” on some communities.

“We saw a higher death rate in Black and brown communities because of access and fear and a whole bunch of other factors, including what we recognize as racism and unconscious bias,” Rice said.

“We needed more physicians, more health-care providers. So, we already know when we project out to 2050, we have a significant physician shortage based on the fact that we cannot educate and train enough health care professionals fast enough,” she said. “We can’t just rely on physicians. We have to rely on a team approach.”

She added that the nation’s shortage of health-care workers leaves the country ill-prepared to respond to future pandemics.

The United States is projected to face a shortage of up to 124,000 physicians by 2034 as the demand outpaces supply, according to the Association of American Medical Colleges.

The workforce shortage means “we’re really not prepared” for another pandemic, Sanders said.

“We don’t have the public health infrastructure that we need state by state. We surely don’t have the doctors and the nurses that we need,” Sanders said. “So what we are trying to do now is to bring forth legislation, which will create more doctors and more nurses, more dentists, because dental care is a major crisis in America.”

In March, Bill McBride, executive director of the National Governors Association, wrote a letter to Sanders and Louisiana Sen. Bill Cassidy detailing the “root causes” of the health-care workforce shortage and potential ways some states are hoping to tackle the crisis.

“Governors have taken innovative steps to address the healthcare workforce shortage facing their states and territories by boosting recruitment efforts, loosening licensing requirements, expanding training programs and raising providers’ pay,” McBride wrote.

“Shortages in healthcare workers is not a new challenge but has only worsened in the past three years due to the COVID-19 pandemic. Burnout and stress have only exacerbated this issue,” he wrote. “The retirement and aging of an entire generation is front and center of the healthcare workforce shortage, particularly impacting rural communities.”

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Only 5.7% of US doctors are Black, and experts warn the shortage harms public health | CNN



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When being truly honest with herself, Seun Adebagbo says, she can describe what drove her to go to medical school in a single word: self-preservation.

Adebagbo, who was born in Nigeria and grew up in Boston, said that as a child, she often saw tensions between certain aspects of Western medicine and beliefs within Nigerian culture. She yearned to have the expertise to bridge those worlds and help translate medical information while combating misinformation – for her loved ones and for herself.

“I wanted to go into medicine because I felt like, ‘Who better to mediate that tension than someone like me, who knows what it’s like to exist in both?’ ” said Adebagbo, 26, who graduated from Stanford University and is now a third-year medical school student in Massachusetts.

“The deeper I got into my medical education, the more I realized, if I’m in the system, I know how it works. I not only know the science, but I also know how the system works,” she said of how in many Black and brown communities, there can be limited access to care and resources within the medical system.

This has enabled Adebagbo to connect with patients of color in her rotations. She recognizes that their encounters with her are brief, she said, and so she tries to empower them to advocate for themselves in the health system.

“I know what to ask for on the patient side if I’m worried about something for myself. But then also, for my parents and my family,” Adebagbo said. “Because the way you have to move in the system as a Black person is very different, especially if you’re coming from a background where you don’t have family members that are doctors, you don’t know anyone in your periphery that went into medicine.”

Seun Adebagbo presenting her poster presentation as a first author at an international symposium and annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

Only about 5.7% of physicians in the United States identify as Black or African American, according to the the latest data from the Association of American Medical Colleges. This statistic does not reflect the communities they serve, as an estimated 12% of the US population is Black or African American.

And while the proportion of Black physicians in the US has risen over the past 120 years, some research shows, it’s still extremely low.

One reason why the percentage of US doctors who are Black remains far below that of the US population that is Black can be traced to how Black people have been “historically excluded from medicine” and the “institutional and systemic racism in our society,” said Michael Dill, the Association of American Medical Colleges’ director of workforce studies.

“And it occurs over the course of what I think of as the trajectory to becoming a physician,” Dill said. At young ages, exposure to the sciences, science education resources, mentors and role models all make it more likely that a child could become a doctor – but such exposures and resources sometimes are disproportionately not as accessible in the Black community.

“We can improve our admissions to medical school, make them more holistic, try to remove bias from that, but that’s still not going to solve the problem,” Dill said.

“We need to look at which schools produce the most medical students and figure out how we improve the representation of Black students in those schools,” he said. “That requires going back to pre-college – high school, middle school, elementary school, kindergarten, pre-K – we need to do better in all of those places in order to elevate the overall trajectory to becoming a physician and make it more likely that we will get more Black doctors in the long run.”

Many US medical schools have a history of not admitting non-Whites. The first Black American to hold a medical degree, Dr. James McCune Smith, had to enroll at the University of Glasgow Medical School in Scotland.

Smith received his MD in 1837, returned to New York City and went on to become the first Black person to own and operate a pharmacy in the United States, and to be published in US medical journals.

A few decades later, in 1900, 1.3% of physicians were Black, compared with 11.6% of the US population, according to a study published in the Journal of General Internal Medicine in 2021.

Around that time, seven medical schools were established specifically for Black students between 1868 and 1904, according to Duke University’s Medical Center Library & Archives. But by 1923, only two of those schools remained: Howard University Medical School in Washington and Meharry Medical School in Nashville.

In 1940, only 2.8% of physicians were Black, but 9.7% of the US population was Black; by 2018, 5.4% of physicians were Black, but 12.8% of the population was Black.

“The more surprising thing to me was for Black men,” said Dr. Dan Ly, an author of the study in the Journal of General Internal Medicine and assistant professor of medicine at the University of California, Los Angeles.

Data on only Black men who were physicians over the years showed that they represented 1.3% of the physician workforce in 1900, “because all physicians were pretty much men in the past,” Ly said. Black men represented 2.7% of the physician workforce in 1940 and 2.6% in 2018.

“That’s 80 years of no improvement,” Ly said. “So the increase in the percent of physicians who were Black over the past 80 years has been the entrance of Black women in the physician workforce.”

Over more than four decades between 1978 and 2019, the proportion of medical school enrollees who identify as Black, Hispanic or members of other underrepresented groups has stayed “well below” the proportions that each group represented in the general US population, according to a 2021 report in The New England Journal of Medicine.

Diversity in some medical schools also was affected in states with bans on affirmative action programs, according to a study published last year in the Annals of Internal Medicine. That study included data on 21 public medical schools across eight states with affirmative action bans from 1985 to 2019: Arizona, California, Florida, Michigan, Nebraska, Oklahoma, Texas and Washington.

The study found that the percentage of enrolled students from underrepresented racial and ethnic groups was on average about 15% in the year before the bans were implemented but fell more than a third by five years after the bans.

Now, the United States is reckoning with medicine’s history of racism.

In 2008, the American Medical Association, the nation’s largest organization of physicians, issued an apology for its history of discriminatory policies toward Black doctors, including those that effectively restricted the association’s membership to Whites. In 2021, the US Centers for Disease Control and Prevention declared racism a “serious public health threat.”

One encouraging datapoint says that the number of Black or African American first-year medical school students increased 21% between the academic years of 2020 and 2021, according to the Association of American Medical Colleges, which Dill said shows promise for the future.

“Does the fact that it’s higher in medical school mean that eventually we will have a higher percentage of physicians who are Black? The answer is yes,” he said.

“We will see the change occur slowly over time,” he said. “So, that means the percentage of the youngest physicians that are Black will grow appreciably, but the percentage of all physicians who are Black will rise much more slowly, since new physicians are only a small percentage of the entire workforce.”

But some medical school students could leave their career track along the way. A paper published last year in JAMA Internal Medicine found that among a cohort of more than 33,000 students, those who identified as an underrepresented race or ethnicity in medicine – such as Black or Hispanic – were more likely to withdraw from or be forced out of school.

Among White students, 2.3% left medical school in the academic years of 2014-15 and 2015-16, compared with 5.2% of Hispanic students, 5.7% of Black students and 11% of American Indian, Alaska Native, Native Hawaiian and Pacific Islander students, the study found.

The researchers wrote in the study that “the findings highlight a need to retain students from marginalized groups in medical school.”

During her surgical rotation in medical school, Adebagbo said, she saw no Black surgeons at the hospital. While having more physicians and faculty of color in mentorship roles can help retain young Black medical school students like herself, she calls on non-Black doctors and faculty to create a positive, clinical learning environment, giving the same support and feedback to Black students as they may provide to non-Black students – which she argues will make a difference.

“Despite the discomfort that may arise on the giver of feedback’s side, it’s necessary for the growth and development of students. You’re hurting that student from becoming a better student on that rotation, not giving them that situational awareness that they need,” she said. “That’s what ends up happening with students of color. No one tells them, and it seems as if it’s a pattern, then by the end of the rotation, it becomes, ‘Well, you’ve made so many mistakes, so we should just dismiss you [for resident trainees] or we can’t give you honors or high pass [for medical students].’ “

Seun Adebagbo, right, with the site director (second from left) and two peers on her last day of her surgery rotation.

Adebagbo says she had one site director, a White male physician, during her surgery rotation who genuinely cared, listened and wanted to see her grow as a person and physician.

“He has been the first site director who has legit listened to me, my experiences navigating third year as a Black woman and tried to understand and put it in perspective – a privilege I’m not afforded often,” Adebagbo said. “He made making mistakes, growing and learning from them a safe and non-traumatizing experience. Not everyone may understand the depths of what I’m saying, but those who do will understand why I was so grateful for that experience.”

But not all attending physicians are like her “mentor,” as she calls him.

For Dr. David Howard, one question haunted his thoughts in medical school.

During those strenuous days at Johns Hopkins University, when all-night study sessions and grueling examinations were the norm, his mind whispered: Where do I fit?

Howard, now a 43-year-old ob/gyn in New Jersey, reflects with pride – and candor – on the day in 2009 when he completed his doctoral degrees, becoming both an MD and a PhD.

At the time, “I felt like I didn’t fit,” Howard said. “I’m sure I’m not the only person who has thought those thoughts.”

Howard was one of very few men in the obstetrics and gynecology specialty, where most providers were women – and he is Black. He saw very few peers who looked like him and extremely few faculty in leadership positions who looked like him.

“When you’re going through a really difficult training program, it makes a big difference if there are people like you in the leadership positions,” he said, adding that this contributes to the disproportionate number of Black medical school students and residents who decide to leave the profession or are “not treated equally” when they may make a mistake.

Early on in his career, Howard shifted his thinking from “Where do I fit?” to “How do I fit?”

He even authored a paper in 2017, published in the American Journal of Obstetrics and Gynecology, about this self-reflection.

“Only slightly different semantically, the second question shifts focus away from the ‘where’ that implies an existing location. Instead, ‘how’ requires me to illustrate my relationship with existing labels and systems, rather than within them, allowing a multitude of answers to my question of ‘how do I fit?’ ” Howard wrote.

“Despite the challenges and realities of the medical field today, I fit wherever and however I can, actively shaping my space and resisting the assumptions that first prompted me to ask where I fit,” he said. “To finally answer my question: I don’t fit, but I am here anyway.”

The United States has made “some progress” with diversity in both clinical medicine and research – but diversity in medicine is still not at the point where it needs to be, said Dr. Dan Barouch, a professor at Harvard Medical School and director of the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center in Boston, who has been an advocate for diversity and inclusion.

That point, essentially, would be where diversity in the physician workforce reflects the diversity in their patient population.

“It’s particularly important to have a diverse physician workforce to aptly serve the patients,” Barouch said. “We want to increase diversity in academia as well, but it’s particularly important for doctors, because having a diverse workforce is critical for the best patient encounters, and to build trust.”

Service to patients and patient trust are both among the cornerstones critical to the status of public health, according to researchers.

One example of broken trust between physicians and Black patients happened in the 1930s, when the US Public Health Service and the Tuskegee Institute launched an unethical study in which researchers let syphilis progress in Black men without treating them for the disease. The study ended in 1972.

Among Black men, “there were declines in health utilization, increases in medical mistrust and subsequent increases in mortality for about the 10- to 15-year period following the disclosure event,” when the true nature of the study was exposed in 1972, said Dr. Marcella Alsan, an infectious disease physician and professor of public policy at Harvard Kennedy School.

Yet research suggests that when Black physicians are treating Black patients, that trust can be rebuilt.

For instance, the impact is so significant that having Black physicians care for Black patients could shrink the difference in cardiovascular deaths among White versus Black patients by 19%, according to a paper written by Alsan while she was attending Stanford University, along with colleagues Dr. Owen Garrick and Grant Graziani. It was published in 2019 in the American Economic Review.

That research was conducted in the fall and winter of 2017 and 2018 in Oakland, California, where 637 Black men were randomly assigned to visit either a Black or a non-Black male doctor. The visits included discussions and evaluations of blood pressure, body mass index, cholesterol levels and diabetes, as well as flu vaccinations.

The researchers found that, when the patients and doctors had the opportunity to meet in person, the patients assigned to a Black doctor were more likely to demand preventive health care services, especially services that were invasive, such as flu shots or diabetes screenings that involve drawing blood.

“We saw a dramatic increase in their likelihood of getting preventive care when they engage with Black physicians,” said Garrick, who now serves as chief medical officer of CVS Health’s clinical trial services, working to raise awareness of how more diverse groups of patients are needed to participate in clinical research.

Initially, “it didn’t look like there was a strong preference for Black doctors versus non-Black doctors. It was only when people actually had a chance to communicate with their physicians, talk about ‘Why should I be getting these preventative care services?’ ” Alsan said.

The researchers analyzed their findings to estimate that if Black men were more likely to undergo preventive health measures when they see a Black doctor, having more Black doctors could significantly improve the health and life expectancy of Black Americans.

The nation’s shortage of Black physicians is concerning, experts warn, as it contributes to some of the disproportionate effects that infectious diseases, chronic diseases and other medical ailments have on communities of color. This in itself poses public health risks.

For example, in the United States, Black newborns die at three times the rate of White newborns, but a study published in 2020 in the Proceedings of the National Academy of Sciences found that Black infants are more likely to survive if they are being treated by a Black physician.

Black men and Black women are also about six to 14.5 times as likely to die of HIV than White men and White women, partly due to having less access to effective antiretroviral therapies. But Black people with HIV got such therapies significantly later when they saw White providers, compared with Black patients who saw Black providers and White patients who saw White providers in a study published in 2004 in the Journal of General Internal Medicine.

And when Black patients receive care from Black doctors, those visits tend to be longer and have higher ratings of patients feeling satisfied, according to a separate study of more than 200 adults seeing 31 physicians, published in 2003 in the journal Annals of Internal Medicine.

“There’s plenty of evidence, and other research has shown that the more the workforce in a health care setting really reflects the community it serves, the more open the patient population is to recommendations and instructions from their doctor,” said Dr. Mahshid Abir, an emergency physician and a senior physician policy researcher at the RAND Corp., a nonpartisan research institution.

But it can be rare to find health systems in which the diversity of the workforce reflects the diversity of the patients.

During her 15-year career as an emergency physician, Abir said, she has worked in many emergency departments across the United States – in the Northeast, South and Midwest – and in each place, the diversity of the health care workforce did not mirror the patient populations.

This lack of diversity in medicine is “not talked about enough,” Abir said.

“The research that’s been conducted has shown that it makes a difference in how well patients do, how healthy they are, how long they live,” she said. “Especially at this juncture in history in the United States, where social justice is in the forefront, this is one of the most actionable places where we can make a difference.”

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Paging Dr. AI? What ChatGPT and artificial intelligence could mean for the future of medicine | CNN



CNN
 — 

Without cracking a single textbook, without spending a day in medical school, the co-author of a preprint study correctly answered enough practice questions that it would have passed the real US Medical Licensing Examination.

But the test-taker wasn’t a member of Mensa or a medical savant; it was the artificial intelligence ChatGPT.

The tool, which was created to answer user questions in a conversational manner, has generated so much buzz that doctors and scientists are trying to determine what its limitations are – and what it could do for health and medicine.

ChatGPT, or Chat Generative Pre-trained Transformer, is a natural language-processing tool driven by artificial intelligence.

The technology, created by San Francisco-based OpenAI and launched in November, is not like a well-spoken search engine. It isn’t even connected to the internet. Rather, a human programmer feeds it a vast amount of online data that’s kept on a server.

It can answer questions even if it has never seen a particular sequence of words before, because ChatGPT’s algorithm is trained to predict what word will come up in a sentence based on the context of what comes before it. It draws on knowledge stored on its server to generate its response.

ChatGPT can also answer followup questions, admit mistakes and reject inappropriate questions, the company says. It’s free to try while its makers are testing it.

Artificial intelligence programs have been around for a while, but this one generated so much interest that medical practices, professional associations and medical journals have created task forces to see how it might be useful and to understand what limitations and ethical concerns it may bring.

Dr. Victor Tseng’s practice, Ansible Health, has set up a task force on the issue. The pulmonologist is a medical director of the California-based group and a co-author of the study in which ChatGPT demonstrated that it could probably pass the medical licensing exam.

Tseng said his colleagues started playing around with ChatGPT last year and were intrigued when it accurately diagnosed pretend patients in hypothetical scenarios.

“We were just so impressed and truly flabbergasted by the eloquence and sort of fluidity of its response that we decided that we should actually bring this into our formal evaluation process and start testing it against the benchmark for medical knowledge,” he said.

That benchmark was the three-part test that US med school graduates have to pass to be licensed to practice medicine. It’s generally considered one of the toughest of any profession because it doesn’t ask straightforward questions with answers that can easily found on the internet.

The exam tests basic science and medical knowledge and case management, but it also assesses clinical reasoning, ethics, critical thinking and problem-solving skills.

The study team used 305 publicly available test questions from the June 2022 sample exam. None of the answers or related context was indexed on Google before January 1, 2022, so they would not be a part of the information on which ChatGPT trained. The study authors removed sample questions that had visuals and graphs, and they started a new chat session for each question they asked.

Students often spend hundreds of hours preparing, and medical schools typically give them time away from class just for that purpose. ChatGPT had to do none of that prep work.

The AI performed at or near passing for all the parts of the exam without any specialized training, showing “a high level of concordance and insight in its explanations,” the study says.

Tseng was impressed.

“There’s a lot of red herrings,” he said. “Googling or trying to even intuitively figure out with an open-book approach is very difficult. It might take hours to answer one question that way. But ChatGPT was able to give an accurate answer about 60% of the time with cogent explanations within five seconds.”

Dr. Alex Mechaber, vice president of the US Medical Licensing Examination at the National Board of Medical Examiners, said ChatGPT’s passing results didn’t surprise him.

“The input material is really largely representative of medical knowledge and the type of multiple-choice questions which AI is most likely to be successful with,” he said.

Mechaber said the board is also testing ChatGPT with the exam. The members are especially interested in the answers the technology got wrong, and they want to understand why.

“I think this technology is really exciting,” he said. “We were also pretty aware and vigilant about the risks that large language models bring in terms of the potential for misinformation, and also potentially having harmful stereotypes and bias.”

He believes that there is potential with the technology.

“I think it’s going to get better and better, and we are excited and want to figure out how do we embrace it and use it in the right ways,” he said.

Already, ChatGPT has entered the discussion around research and publishing.

The results of the medical licensing exam study were even written up with the help of ChatGPT. The technology was originally listed as a co-author of the draft, but Tseng says that when the study is published, ChatGPT will not be listed as an author because it would be a distraction.

Last month, the journal Nature created guidelines that said no such program could be credited as an author because “any attribution of authorship carries with it accountability for the work, and AI tools cannot take such responsibility.”

But an article published Thursday in the journal Radiology was written almost entirely by ChatGPT. It was asked whether it could replace a human medical writer, and the program listed many of its possible uses, including writing study reports, creating documents that patients will read and translating medical information into a variety of languages.

Still, it does have some limitations.

“I think it definitely is going to help, but everything in AI needs guardrails,” said Dr. Linda Moy, the editor of Radiology and a professor of radiology at the NYU Grossman School of Medicine.

She said ChatGPT’s article was pretty accurate, but it made up some references.

One of Moy’s other concerns is that the AI could fabricate data. It’s only as good as the information it’s fed, and with so much inaccurate information available online about things like Covid-19 vaccines, it could use that to generate inaccurate results.

Moy’s colleague Artie Shen, a graduating Ph.D. candidate at NYU’s Center for Data Science, is exploring ChatGPT’s potential as a kind of translator for other AI programs for medical imaging analysis. For years, scientists have studied AI programs from startups and larger operations, like Google, that can recognize complex patterns in imaging data. The hope is that these could provide quantitative assessments that could potentially uncover diseases, possibly more effectively than the human eye.

“AI can give you a very accurate diagnosis, but they will never tell you how they reach this diagnosis,” Shen said. He believes that ChatGPT could work with the other programs to capture its rationale and observations.

“If they can talk, it has the potential to enable those systems to convey their knowledge in the same way as an experienced radiologist,” he said.

Tseng said he ultimately thinks ChatGPT can enhance medical practice in much the same way online medical information has both empowered patients and forced doctors to become better communicators, because they now have to provide insight around what patients read online.

ChatGPT won’t replace doctors. Tseng’s group will continue to test it to learn why it creates certain errors and what other ethical parameters need to be put in place before using it for real. But Tseng thinks it could make the medical profession more accessible. For example, a doctor could ask ChatGPT to simplify complicated medical jargon into language that someone with a seventh-grade education could understand.

“AI is here. The doors are open,” Tseng said. “My fundamental hope is, it will actually make me and make us as physicians and providers better.”

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