Can medicine be “race-conscious” without being racist?

[ad_1]

Medicine should strive to be “race conscious without being racist,” David Jones, MD, PhD, said Tuesday during a webinar on racism in artificial intelligence (AI) in the field of health, sponsored by the National Institute for Health Care Management.

“Should doctors treat patients of different races differently because of their race and ethnicity? They clearly do,” said Jones, professor of epidemiology at Harvard University. “Researchers have documented many regrettable cases in which disparities in medical treatment reflect institutional or structural interpersonal racism.”

However, “racial medicine often has defensible logic,” he continued. “Researchers have documented racial differences in disease prevalence and treatment outcomes. Clinicians, in response, have factored race into diagnostic tests, risk calculators, and treatment guidelines.” But, sadly, “a lot of these race-appropriate tools are directing medical attention to white patients. It is perverse in an age when people of color suffer higher death rates from many diseases.”

Bias in risk calculators

Jones gave the example of a “stone score” used to predict the risk of kidney stones in patients with flank pain. In the scoring algorithm, “the non-black race is as important as the blood in the urine,” he said. “This consistently puts whites at a higher risk category and directs medical attention and resources – in this case, a CT scan – to them.”

Another example is a tool that predicts whether a pregnant person should attempt a vaginal birth after having previously had a cesarean. “Researchers looked at outcome data from over 7,000 women and found several factors associated with a high risk of poor outcomes, including weight, black race, Hispanic ethnicity, insurance status, marital status and tobacco use, ”Jones said. “But when they put those results into their risk calculator, they included weight, race, and ethnicity, but not the other factors, like they thought race was more important than others.”

Jones and his colleagues published an article in August 2020 on the topic and included examples of 13 tools from different specialties. “Several of them required a very thin evidence base; many tools rely on a dichotomous variable: black or non-black,” he said. “We were concerned that these tools, if used as directed, would exacerbate health disparities.”

Effect of the NFL controversy

Jones noted that tensions have flared recently with the revelation that the National Football League is using race-specific standards on psychological testing to deny concussion regulations to retired black players. “These efforts have sparked and energized Congressional hearings and inquiries,” he said. “Many medical companies have reacted and re-examined their use of race and embarked on an anti-racism program. Several have announced their intention to stop using race in their clinical algorithms,” with two of the most important tools – a kidney function test and vaginal birth risk calculator – since it was reformulated without race as a factor.

“But race cannot be ignored,” he added. “Health inequalities are ubiquitous in medicine. We must study race and racism if we are to eradicate inequalities.”

The fundamental question is “are humans basically the same or not?” Jones said. “Medicine currently works on the premise that we are different and that physicians can improve outcomes by focusing on racial differences.” There are certainly relevant differences between people of different ancestry; for example, “Tay Sachs disease is more common in people of Ashkenazi descent [Eastern European Jewish] ancestry, while the sickle cell trait is more common in people of West African descent. “

“But there is a danger in applying these differences carelessly,” he continued. “Even though the sickle cell trait is 25 times more common in African Americans than in white Americans, most African Americans do not have it, and it would be wrong to treat all African Americans differently because of it. a trait carried by a minority of them. “

In addition, the current way of categorizing people by race is also outdated, according to Jones. “Imagine three patients that a clinician might meet: a descendant of African slaves, another a second generation Ethiopian immigrant and a third, a student from a wealthy family in West Africa,” he said. he declares. “These people might have little in common in terms of lived experiences of racism, and little of shared ancestry as well. But our health care system would classify them as one type – Black – distinct from all other humans. just doesn’t make sense. “

“I’m not calling for color blind medicine,” Jones concluded. “As long as race and racism determine access to wealth, health, and social resources, we need to study them. I support race-conscious medicine; we just need to find the best way for medicine to be aware of race… If we believe that human differences are important and should inform medical practice, then we must invest the resources necessary to map and understand these differences. “

Using AI in everyday practice

Rajeev Ronanki, digital director of health insurer Anthem, Inc., explained how his company, the second largest insurer in the United States, is using artificial intelligence to improve patient care. Using a dataset that combines information on the social determinants of patient health with claims data and laboratory data, “today we are able to predict about 4,000 unique things. about a person’s future care path – everything from the likelihood of developing an opioid substance in the future, the risk of falling, the risk of skipping an appointment, and the risk of missing a critical gap in care “, did he declare.

“We integrate our knowledge into electronic medical records and other data points and workflows in a doctor’s office or the hospital system to enable them to see the whole of health,” he said. he continued. Doctors may then ask themselves: “Does this patient I see have access to transportation to come see me for my next appointment, or does this person have enough time in their day to do so?” spending time exercising and sleeping well? “

Anthem has also expanded its value-based care program “where we align the incentives and outcomes for each provider based on the number of actions they take on the information created by our algorithms,” he added. .

But in using the data in this way, “there is a critical dependency and you have to make sure that we take things like bias into account …” we are not missing anything because we are just using learning techniques. automatic to learn from what may already be a bias built into the system, ”Ronanki said. Anthem therefore created an Office of Responsible Use of AI and Ethics, “and this group is constantly reviewing the data, but testing for bias, as well as several other techniques” to make sure the algorithm is working. good.

Joyce Frieden oversees the coverage of MedPage Todays Washington, including articles on Congress, the White House, the Supreme Court, health professional associations and federal agencies. She has 35 years of experience in health policy. To follow

[ad_2]