Bridging the Gap: A Practical Approach to Discussing eGFR and Race with Medical Students.

“Change is the end result of all true learning.”―Leo Buscaglia, American author Within the past decade, US medical students and the nephrology community have sounded the alarm that using race as a biological risk factor rather than a social construct perpetuates systemic racism.1 The use of a race coefficient in the eGFR equation amplifies health disparities in the Black population by delaying nephrology referral, transplant eligibility, and insurance coverage for kidney disease education. In 2020, multiple US academic centers removed the race coefficient from their eGFR calculations. These events paved the way for further discourse within the field about race-based medicine. Shortly thereafter, in 2021, the American Society of Nephrology and National Kidney Foundation Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease recommended replacing contemporary race-based equations with a new creatinine–cystatin C equation without a race coefficient.2 This recommendation presented an opportunity for academic nephrologists to address the legacy of systemic racism. We redesigned our preclinical small group curriculum to address this subject directly and used the Kern six-step approach for curriculum development to provide our faculty with skills to improve their literacy and comfort in discussions of race-based medicine.3 First, we conducted a needs assessment of 23 faculty members who facilitate case-based small group sessions in the first-year kidney physiology course at the University of Washington in Seattle and its multistate educational program, including Eastern Washington, Wyoming, Alaska, Montana, and Idaho. Our survey included questions about their confidence in discussing the eGFR race coefficient, knowledge deficits, preferred format for education, and concerns. On the basis of faculty preferences, we created a 1-hour live virtual faculty development session with both didactic and interactive components. The didactic portion reviewed the effects of systemic racism and included feedback from former students on their perspectives. We additionally summarized data on the accuracy and precision of newly proposed equations for eGFR using creatinine and cystatin-C and the implications of removing the race coefficient. In the interactive portion, we provided the participants with our small group case scenarios in applying GFR equations to patients of different races. We asked them to raise questions from the point of view of students, which we then discussed as a group. At the conclusion of the course, the 17 faculty members who attended were asked to complete an anonymous survey about their experience leading their student small groups. Select open-ended survey questions were assessed through a conventional content analysis approach to construct overarching domains and themes directly from responses. Through this process, three key questions emerged, which we address below. Should Race Be Discussed in a Kidney Physiology Course? In our current 18-month preclinical curriculum, health equity and social determinants of health are covered in an Ecology of Health and Medicine course. This course includes three 1-week sessions that run between system-based blocks. However, students have previously voiced that these topics additionally deserve to be integrated into the systems curriculum. In our anonymous needs assessment, most (78.3%) of our faculty agreed that the eGFR race coefficient should be discussed in a preclinical kidney physiology course. Faculty members who disagreed were most concerned about the time constraints of the 3-week course (Table 1). The learning objectives for our original 2-hour eGFR case-based small group sessions were (1) describe clearance and steady-state conditions, (2) determine whether a substance undergoes net reabsorption or net secretion, (3) recognize the benefits and limitations of equations used to estimate GFR, and (4) calculate renal blood flow, GFR, filtration fraction, and clearance. In our modified cases, we spent the first hour on objectives 1 and 2 and the second hour on objective 3, including the clinical applications of eGFR in people of different races. Objective 4 was moved to independent study, but this change did not affect student examination performance on this content when compared with the previous year. This prioritization of class time for content better suited to a discussion format allowed us to broaden the curricular scope without sacrificing foundational concepts. Table 1. - Major domains and themes from targeted needs assessment and curriculum evaluative comments with representative quotations from nephrology faculty Targeted Needs Assessment of Faculty Major Domains and Themes Representative Quotations Sought perspective Students “…what's been most effective from a student perspective on facilitating these discussions?” BIPOC individuals “[It would be helpful] to speak directly with specialists who are from the BIPOC community.” Scientific community “There are differing opinions among nephrologists, geneticists, and epidemiologists…” Reflection Hesitancy to engage, complexity of content “…this is a new concept for many of the instructors, and we're still learning.”“It becomes confusing for students.”“[I’m concerned about] stumbling over my words and students inferring that I'm racist.”“Managing the situation if the conversation goes bad.” Recognition of importance “Ignoring it seems to miss an important part of medicine, but clearly so does presenting it without adequate training.”“Provided it is done well, I think our students would appreciate a discussion of this topic.” Implementation Timing “…not having sufficient time to have a proper discussion.”“...take away from the precious little time available during small groups to cover the much-needed medical content.” Content “I worry that just skimming over the topic will lead to miscommunication.” Curriculum Evaluative Comments Major Domains and Themes Representative Quotations Context Historical “[It was useful to discuss] the background/rationale for including race.”“Historical review of the race coefficient, data supporting elimination of the race coefficient, [and] discussion about potential questions/concerns about the race coefficient [were meaningful].” Evidence “Hearing the data about the newer equations without the race coefficient made me feel confident when I explained this to the students.” Preparation Language “The ability to organize my thoughts in a way that could be presented to others [was useful].”“Learning/practicing a script to use when discussing with students [was useful].” Facilitation skills “The faculty development session gave me more confidence in my ability to conduct discussions on this issue.”“I felt more confident going into the small group than I would have without the faculty development session.” Implementation Relevance “I appreciated the opportunity to discuss the race coefficient in a real-world case scenario. The students were engaged.” BIPOC, Black, Indigenous, People of Color. What Are the Most Challenging Aspects of Discussing Race and eGFR? Faculty members recognized the difficulty in facilitating discussions with students with variable medical, scientific, and sociopolitical understanding and backgrounds (Table 1). Many expressed uncertainty about their ability to distill a complex topic to the level of a first-year student with no previous clinical experience. They also appreciated that this topic was emotionally charged and requested training on how to moderate conflict among students. One faculty member specifically asked about managing the situation if the conversation goes bad—a common concern in high-stakes conversations, such as ones on race-based medicine. We found that simulation of these discussions in the controlled space of a faculty development session enabled faculty members to educate one another on the effects of their words before interacting with students. During our simulation session, faculty members tended to answer challenging questions by focusing on statistics and genetics. Some blended the race coefficient with a discussion of APOL1. As their answers became more complex, they created more confusion and lost sight of the central theme: Race is not a surrogate for genetics and using a race coefficient worsens outcomes for Black people. As moderators of the discussion, we conveyed these points and offered a path forward with the creatinine-cystatin C equation.4 We also explained that APOL1 is a risk allele for CKD that is more prevalent among Black people, but it does not affect the relationship between creatinine and eGFR and should not be included in this discussion. We encouraged responses grounded in humility and honesty when answers were unknown. How Can Faculty Meaningfully Engage in Discussions About Race? Since 2019, our nephrology division has hosted three nephrology grand rounds addressing race-based medicine, including a panel discussion of epidemiologists and Black nephrologists. The ensuing discussions among faculty and relevant stakeholders led to removal of the race coefficient in laboratory reporting in June 2020.5 Therefore, unsurprisingly, more than three fourths of faculty members stated that they felt they had the skills necessary to facilitate discussions on race-based medicine in our initial needs assessment. Despite this exposure, more than 85% of faculty reported learning new information from the faculty development session, and all participants stated they felt more equipped with the skills to facilitate discussions. They appreciated data on the performance of the new eGFR equations without the race coefficient and the effect of the race coefficient on health outcomes. Many also welcomed the opportunity to discuss potential questions and organize their thoughts (Table 1). We observed that case prompts about real-world scenarios, such as medication management and kidney transplantation eligibility, allowed faculty to draw from their clinical experience and discuss how GFR factors into clinical decision making. This perspective gave them the confidence to describe the practical challenges in applying eGFR without delving into the granular details of the equations. In our postsession survey, all (100%) faculty members stated that the case scenarios prompted a fruitful discussion about race and eGFR. These results demonstrated that our faculty development session improved knowledge deficits that were previously unrecognized and suggested that clinical scenarios can be an entry point to these discussions. In conclusion, medicine and medical education are reckoning with many practices that perpetuate systemic racism. Educators must be proficient in facilitating meaningful discussions on race-based medicine. We advocate for inclusion of a discussion of race coefficients when eGFR measurement is introduced in the preclinical medical school curriculum. Furthermore, faculty should receive additional didactic education and practical training before leading student sessions to reduce trepidation for faculty members and potential trauma for students of minoritized identities. Simply working in the academic environment is not sufficient preparation. Faculty must actively engage in their own education. Only then can meaningful change begin.