Race Correction in the UTI Guidelines

October 16, 2020 | By Justin Berk

A Companion Episode w/ Dr. Pat Poitevien

Summary

This short companion episode to our Pediatric UTI episode dives deeper into the race correction factor present in the UTI guidelines. We speak with guest Dr. Patricia Poitevien, the Program Director of Brown’s Pediatric Residency, the current President of the Association of Pediatric Program Directors,  and Assistant Dean for the Office of Diversity and Multicultural Affairs at the Warren Alpert School of Medicine at Brown University. Dr. Poitevien breaks down why it is important for academic medicine to be thinking critically about race as a social construct, how race-based medicine may cause more harm than benefit, and the next steps for how to move forward in a curious, engaged, and evidence-based manner. 

Credits

• Producer: Justin Berk MD, Becca Raymond-Kolker
• Writer: Justin Berk MD
• Infographic:  Becca Raymond-Kolker
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD
• Editor:Justin Berk MD
• Guest(s): Patricia Poitevien MD, MSc, FAAP

Time Stamps

• Why we made this episode: 0:12
• Introducing our guest, Dr. Patricia Poitevien (@DocPatTeachOne): 0:53
• Context of Anti-Racism in Academic Medicine: 2:25
• Race is a Social Construct: 3:45
• Disparities should make us curious: 5:05 
• Why is Race a Risk Factor for Disease?: 6:15
• How to Approach Existing Race-Based Guidelines: 7:28
• UTI Calculator as Example of Race-Based Medicine: 8:30 
• Race as an Ill-Defined Variable: 9:00
• Where to Learn More: 11:14

Race Correction in the UTI Guidelines: Pearls

1. Race is a Social Construct
2. Disparities Should Make Us Curious 
3. Ask: How is Society Impacting Different Racial Groups to Create Different Outcomes?
4. Race is a Poorly Defined Variable in Clinical Research

UTI Companion Episode Notes 

Why We Made this Episode

As a companion to our recent episode on UTI guidelines, as a team we felt it was important to address and think critically about the presence of race as a risk factor for diagnosis in the current UTI guidelines. A recent viewpoint article in JAMA Pediatrics advocates for the removal of race from these guidelines. We felt it was important to highlight this important conversation here on The Cribsiders. The Cribsiders have a commitment to Health Equity and Anti-Racism, and a key part of this commitment is to question race-based medicine in how we create and evaluate medical evidence as part of our dedication to health equity.

Systemic Racism in Medicine

One of the risk factors for diagnosis using the UTI Guidelines and its subsequent calculator is race. Why is this concerning? What is race-based medicine? It’s an important moment in our history to examine race and racism. Medicine is taking a reflective look at structural racism to investigate our field and to examine what we’re doing to make sure our patients are safe and that we are mitigating the impacts of racism as much as possible when it comes to our patients (NEJM, AAP).

Race is a Social Construct 

Race is a social construct. In discussing race-based medicine, it is important to try to understand how the construct of race has impacted how we provide care for our patients. Race does impact how patients live and function in the world. In other words, race does matter. 

Legacy of Race as Biology in Medicine

In medicine, however, there is a long-standing presumption (with a troubling history, see section 2)  that race is biologic. However, this presumption is highly contested as increasingly race is understood to be a social, historical construction that varies across time and place. So if we know that there is no biologic meaning to race, then physicians have to be very careful when we think through how race impacts those disease processes. 

Disparities should make us curious

A fallacy in clinical thinking in that it makes sense that outcomes would be different between white and Black patients. Differential outcomes across races should raise a red flag and make us think more about what else is going on, how else race impacts each of those individuals, as opposed to accepting that a presumed biological difference across race is to account for those differences. 

Why is race a risk factor for disease?

Health disparities across race are real. When we see disparities, we should ask why race is a risk factor for disease and not simply attribute differences and disparities as secondary to biologic differences. We need to ask: how is it that different races are living within our society that would make their outcomes different? It’s important to notice distinctions and disparities of different races. But when we notice these differences, we should always ask why? It’s important to not just assume that there is some innate biological difference between different racial of people. We need to ask how is society impacting different racial groups and how is that societal impact then manifesting as different health outcomes?

How do we reconcile being advocates and good evidence-based clinicians? 

Expert opinion: Stay curious! Part of being a clinician and scientist is that you cannot be intellectually lazy. When we see different outcomes, we have to ask ourselves: does this make sense? And then ask, why does the data show us this?

Looking Closer at the UTI Research

Some questions to ask in the UTI research is, does this data make sense? Another question to ask is, who gets to decide what a patient’s race is? Many of the UTI calculator articles break down race in a dichotomous variable: either white or not white. This binary doesn’t make much logical sense when you look at current racial categories in the United States. Race is an ill-defined variable in clinical medicine. In any data that shows racial disparities, it is important to fully interrogate and think critically about what may have led to this difference. 

The presumption of biological difference between races has a fraught and violent history. In one article that the UTI Guidelines cite, the authors discuss that the difference between white and Black girls could be due to racial differences in blood group antigens on the surface on uroepithelial cells (Editor’s note: In the audio, the speaker states endothelial cells in lieu of epithelial cells). The presumption of biologic difference between races hearkens to the medical history of eugenics. This history does not mean we should ignore racial disparity data, but we should apply scientific rigor to the data and we should dive deeper and ask more questions. We should start from the presumption that racial disparities don’t make sense given that race is a social construct, and from that starting point ask more questions to interrogate these differences. 

Towards a Better UTI Calculator

We do need a risk calculator for UTIs that can help our patients. But a concern with the current algorithm is that the current calculator may lead to underdiagnosis of UTI in Black girls. This has the potential to do harm to our kids of color. 

Where to Learn More:

Dr. Poitevien recommends reading Dorothy Roberts’s Fatal Invention and watching her TedTalk on The Problem with Race-Based Medicine. [Editor’s note: For even more learning, this editor recommends reading Medical Apartheid by Harriet Washington for a comprehensive history of anti-Black racism in medicine and Breathing Race into the Machine by Lundy Braun for an example of how structural racism and history has led to race correction in the field of pulmonology.]

Links

1. The Cribsiders Commitment to Health Equity and Anti-Racism 
2. UTI Guidelines
3. The Problem with Race-Based Medicine TedTalk by Dorothy Roberts
4. Fatal Invention by Dorothy Roberts

Goal

Listeners will understand the basic definition of race-based medicine as evidenced in the current pediatric UTI Guidelines. Listeners will be able to define race as a social construct and understand the concerns of attributing biological differences to different racial categories. Listeners should come away with new skills to further analyze data that looks at racial disparities in medicine and feel empowered to incorporate this analysis into their clinical practice. 

Learning objectives

After listening to this episode listeners will: 

1. Define race as a social construct
2. Describe concerns with race-based medicine
3. Gain skills in evaluating race as an ill-defined variable
4. Develop curiosity about structural and societal disparities that contribute to racial disparities and differences in illness 
5. Describe resources or authors that can help clinicians learn more about this important topic

Disclosures

Dr. Poitevien reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Poitevien P, Raymond-Kolker R, Berk J,. “Race Correction in the UTI Guidelines.” The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ October, 2020.