“We need to address the underlying preventable factors that cause more Black Americans to die of heart attacks and strokes and suffer from high blood pressure and diabetes complications than white Americans instead of focusing on non-existent biological differences. I would like to see the scientific disciplines unite to call out the mislabeling of race as a biological category and stop using race in place of structural racism, toxic stress caused by discrimination, and systemic inequities in social determinants of health.

Instead of emphasizing our biological differences, the research community needs to focus on the real problems Black Americans continue to face that increase their risk of illness and death.”

Carmen Presti is a nurse practitioner.

She shares her story and discusses her KevinMD article, “Remove race from clinical guidelines.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Carmen Presti. She is a nurse practitioner, and she wrote the KevinMD article “Remove race from clinical guidelines.” Carmen, welcome to the show.

Carmen Presti: Thank you, Kevin, and thank you for this opportunity to share my perspective.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Carmen Presti: Sure. Nursing is my second career. I’ve been a critical care nurse since 1999 and an acute care nurse practitioner since 2007. I also teach at the University of Miami. I’m an assistant professor there, and I teach the acute care nurse practitioners, and I’m so happy I have two jobs. I also practice as a critical care, acute care nurse practitioner in the cardiovascular ICU, and I also float to the general surgery ICU, where I see transplant patients and general surgery patients. But really, my area is cardiovascular surgery post-op care. I take care of patients with left ventricular assist devices, heart transplants, ECMO, and then your CABGs, valves, and thoracic surgery as well.

I’m also an op-ed fellow, and this is a group that promotes underrepresented voices in the media. So this was my impetus for this op-ed, as well as another op-ed that I recently was able to publish in U.S. News & World Report. So that was kind of the push, even though for the last couple of years, I think like many of us, my eyes have been starting to open a little bit about issues around racial inequities and disparities in health care.

So I have many jobs. I’m also the secretary of the Miami chapter of the National Association of Hispanic Nurses, so I’m trying to get more involved as well. I am Cuban, born and raised here in the state, so I am Hispanic. All of those things have come together to help me look at some of these issues that I didn’t learn about in school and that I’m not really hearing about in the clinicals.

Kevin Pho: So one of the things that we always talk about on KevinMD is that it’s important for us in health care to have a voice and speak up, because, as you said, this isn’t something that is often taught to us. So tell me, was there something that lit that fire to really write an op-ed, speak out, share your voice, and share your stories? Was there an event that made you want to do this?

Carmen Presti: I think I wrote about COVID disparities in health care and cardiovascular disease disparities because Black Americans are the number one disproportionately affected group from cardiovascular disease. I started to look into that topic because my unit also became a COVID unit, as many of ours did, and I did float to even other areas in the hospital. So I really started to see that disparity, and that kind of triggered me to start to look at cardiovascular disease disparities. It started to open up the conversation for myself: Why are Blacks and people of color more ill, dying more often, and having worse outcomes than their white counterparts? And race as a construct started to show up for me.

And then, recently, the estimated glomerular filtration rate guidelines have shifted, and it’s been shown that there’s really no evidence, no true evidence, for stratifying Blacks differently than whites, scientifically or biologically. Both of those things started to come together for me.

I talked a little bit in the article about a patient that I had when I was first in a trauma ICU, back in the early 2000s. This patient had suffered devastating burns from almost head to toe, and when I walked into the room to manage the care of that patient, the first thing that struck me was that, first of all, I couldn’t identify what their race was. And next was, does it really even matter? Am I going to take care of this burn victim differently than I would someone who is, whatever the color of their skin was? That’s always stuck with me for years and years.

It’s funny, because when I shared this idea with a non-provider, a non-health care person, they said, “You’re going to really tell me that you didn’t know what race they were?” And I said, “No, honestly, I did. I could not tell.” That patient always stayed with me. Here it’s many, many, almost 20 years later, and I still think about that. Is it different? Does the melanin in our skin really make us biologically that much more different than others, and should we be tailoring clinical guidelines to that? So I think that was kind of a long answer to your question, but it wasn’t one particular thing. It was several topics coming together for me.

Kevin Pho: Your article is titled “Remove race from clinical guidelines.” Now, for those of you who get a chance to read your article, what are some other examples where you see race influencing clinical guidelines through your lens in the critical care unit?

Carmen Presti: So I teach, and this is another thing that is important for me. I’m teaching ASCVD, prevention for atherosclerotic cardiovascular disease, and I bring up the calculator every single time. I kind of show students how they would input patient data and then how the risk changes depending on the data that you put in. And sure enough, when you put Black versus white, the risk is higher for atherosclerotic cardiovascular disease just based on that one factor: Is the patient Black, or is the patient white? And as you see the numbers change, it’s, what am I teaching here? That just because a person is Black, they’re going to be at a high risk for atherosclerotic cardiovascular disease? And is that really true?

Back in the early 2000s, the Human Genome Project discovered, really, that we’re over 99 percent the same biologically. We’re all one race, Homo sapiens. And so, therefore, how can we be tailoring all these medications, screening tools, management, and interventions based on that point, whatever it is, 0.06, I think, or maybe another estimate is about 2 percent different? What I discovered, which I was kind of surprised by, because again, this is not something that I really learned on my own, was that really a lot of our differences are more on geographic migration patterns out of Africa, not on our color, and truly, scientifically, we really are only one race, which is the Homo sapien race.

I delved into that, and I was astonished to find how science has had these discriminatory views, even though after 2000, when we were able to map the human genome, we discovered that there’s really no evidence, no scientific basis. Geneticists called it out. Francis Collins, who just retired from the NIH, called for a stop to using race in studies and guidelines in medicine as a defining factor. So why do we keep doing this?

I started to discover that these policies, these concepts, really run deep in our history in medicine, in the 1800s, and really, up until even 1937, we had a eugenics study going, which was basically supporting the idea that we should have a clean race of superior white people, and I was floored.

The other thing I was surprised about, when I talk about this issue, and one thing that was great about getting this op-ed accepted and being able to share it with colleagues, was how some of my provider colleagues, some attending physicians, were very aware of this problem, and others that are fellows. I’m so lucky to work in a teaching institution where I can tap into what’s going on today in the training of fellows, and a fellow that I work with, who’s a very bright, brilliant person, had no idea about any of this. So I think we’re not teaching, we’re not showing this side of medicine and where some of these policies actually came from, and these ideas of using race as a factor and defining race based on our color biologically.

Kevin Pho: Now, can you share a story or a case study of how a race-based clinical guideline led to a disparity in care?

Carmen Presti: So actually, recently, in 2020, the New England Journal of Medicine put together a beautiful perspectives article, and they went through several areas, and this is not even a comprehensive list. But in cardiac and cardiology, the Get With The Guidelines-Heart Failure risk score actually gives more points of risk for patients that are non-Black. In cardiac surgery, the Society of Thoracic Surgeons uses a risk calculator that basically puts Blacks at higher risk for surgery, so you can obviously see, then, that patients who may need surgery may be deferred because they’re too high risk because they’re Black.

And it goes on. The one that I talked about, with estimated glomerular filtration rate, always gave Black people less risk because they were Black. So the connotation, then, is that they’re going to be sicker anyway, so you shouldn’t start treating them earlier, which doesn’t even make sense. Organ procurement and transplant, obstetrics, vaginal birth after C-section, even others, how we calculate UTIs, renal cancer survival. I mean, there are quite a few tools that are based on, obviously, clinical guidelines, osteoporosis risk or pulmonary function tests. These give a real difference in how they’re scoring Blacks versus non-Blacks, and not in favor of Blacks getting better care, actually the reverse of that. They often lead to less care and less intervention and reserve higher resource-based treatments for non-Blacks.

So the disparities are there. They’re real. They go across multiple areas of specialty. It’s not just the American College of Cardiology or the ADA. It’s really rampant, and there’s no good, we are supposed to be science-based, right? And there’s no good scientific reason for why we are using race in these calculators, in these guidelines.

Now, what there is good reason for, which I’m assuming you might, is social determinants of health, right? So some people, yes, are going to have less access to good, healthy food and to exercise, have more stress, have lower-paying jobs, less access to health care, and less education. Absolutely, we are seeing those disparities, and they show up in health care. But it’s time that we call things for what they are, which is, truly, why are Blacks more prone to some complications from diseases? It’s not because they are Black. It’s not that they have an inherent weakness or a biological reason for getting sicker. It’s because they are not receiving the same access to health care, education, good-paying jobs, nutrition, the ability to exercise, right?

I mean, the AHA can say, “You have to do 150 minutes a week of cardiovascular exercise,” but if you live in a neighborhood where there are no sidewalks, and you can’t pay for the gym, and it’s not safe for you to go for runs or long walks, then obviously we’re not calling things for what they are. We’re labeling a race instead of looking at the disparities that we have in society.

Kevin Pho: We’re talking to Carmen Presti. She’s a nurse practitioner, and she wrote the KevinMD article “Remove race from clinical guidelines.” Carmen, what do you envision the next steps to be to help remove race from clinical guidelines?

Carmen Presti: Well, I think it’s time that when we put together these boards across these societies, first of all, we are well represented, that people of color are well represented and start to speak their truth. Why do we need race here? What’s the underlying reason? Is there a scientific reason for it? We did see the eGFR removed. Now, I personally think we really need to tackle cardiovascular disease, right? Because this is the number one killer and has, I would say, the largest amount of disparity in care and management.

So it’s going to be time to be looking at some of these guidelines that are up there. They’re due soon. This is really just a call for scientists, health care providers, researchers, and geneticists who are sitting on those boards to examine the use of race in clinical guidelines and to start to instead use tools that identify inadequacies in those social determinants of health, which, by the way, are really where we work, live, and play, those determinants that really do put some of us at a higher risk for poor outcomes in health care.

So start to call things for what they are. Start to screen patients appropriately. Do they have housing? Do they have access to good food, and so forth? Like I mentioned before, start calling those issues out for what they are, not blaming it on someone’s race. So that’s really what I would like to see happen in the next few years, when these guidelines go up for review.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Carmen Presti: My take-home message is to question everything. When we’re providers and we’re prescribers, especially nurses and physicians, question what you’re doing and why you’re doing it, and ask yourself, “Is this in the best interest of my patient? Should I prescribe a calcium channel blocker, or should they really get an ACE inhibitor, just because a guideline says so?” Maybe they have a good, great reason for it, and maybe it doesn’t. We have to start to question things and take a risk. Ask those questions that are difficult, and be curious. Be curious about what you’re doing for your patients and why you’re doing it, and talk to the patients.

I’ve heard people say, “Oh, this patient, their organ failed because they became noncompliant.” I go and talk to the patient, and I find out that it’s not because they were noncompliant. It’s because they had a gap in their health care coverage, and that one month of not being able to afford their anti-rejection immunosuppressive medication made them reject their organ. So ask questions, be curious, and be a patient advocate.

Kevin Pho: Carmen, thank you so much for sharing your time and insight, and thanks again for being on the show.

Carmen Presti: Thank you.