I'm Andrea Darab, I really appreciate you all being here on this gorgeous Southern California Wednesday morning. I'm going to start by pointing out my contact information here, I'm going to show it again at the end, and let's just go ahead and get started. So the title of this talk is Reviewing Race in Robins, Why, How, and What Next? So as I already described, these are the three Robins textbooks that are used worldwide, so international education, this is not a niche topic, this is not some book that only sells a couple hundred copies. It's widely used, and the primary workhorses are going to be basic pathology, which is used in many U.S. medical schools, and pathologic basis of disease. We just brought out essential pathology a couple years ago, and I'm going to gray out Robins pathologic basis of disease because I do not play a role in that. Now before we go any further, let's open up our little devices and let's answer this question There are a total of three questions, stop when you get to number three. This statement comes from Dr. Charmaine Royal, who is a co-chair of a publication I'll mention later. She's a geneticist. So with that entered, all right, so mostly strongly disagree and disagree. Okay. There it is. Okay. Next question. Again, we're looking at race in medicine, so go ahead and enter this question. All right. So we're going to set that aside for now, and as I mentioned, there's this talk that I've been giving over the last couple of years. You'll hear a little bit more about it. Already heard, just raise your hands again if you have seen a version of this talk, either online or in person. Excellent. Okay. So we also do this nearly everything you learned about race and healthcare education is wrong because we talk to PAs and nurses and health insurance people, all sorts of people. And this is a link to the YouTube so that you can watch a version of this. And whenever I give this material, I have to stop and recognize the enormous contributions of my colleague, Dr. Joseph Graves Jr., who is an evolutionary biology professor at North Carolina A&T State University. So I have an undergraduate degree in evolutionary biology, which gave me a little bit of insight into the biology of human variation, but he brings the big guns to this. So this work is really dependent on him. And then my disclosure. As I mentioned, I'm an editor-author of two of the Robbins textbooks, but I have nothing else of any interest at all. All right. So over the next 50 minutes or so, we're going to discuss the scientific flaws inherent in race-based medicine, identify challenges to removing race-based medicine, and develop strategies to initiate individual, institutional, and systemic change. So first we have to define our terms. I'm an undergraduate medical educator, so I'm a big fan of defining. So race-based medicine is simply using race as a variable or risk factor in the practice of medicine. So saying, oh, that kid over there has a high likelihood of cystic fibrosis because he's European-American. Oh, this kid over here who's got chest pain, he's probably got sickle cell because he's African-American. So that is the concept of race-based medicine. And race-based medicine is founded on a belief in racial essentialism, which is that socially defined races, African-American, European-American, Asian-American, are biologically distinct groups. So the first question that I get asked a lot is, why did you start looking at race in Robbins? I'm an undergraduate medical educator at Duke. I teach the pathology course. Why did you start looking at race in Robbins? So this is an email from a student that we got on February 11th of 2020. So at Duke, we have a five-month-long pathology course. And in week three, we were discussing hypertension, atherosclerosis, circulatory dysfunction. And the student emailed her small group instructor and said, hey, could we discuss evidence related to racial disparities in blood pressure? Our class has gotten a lot of conflicting information about race and health disparities. At Duke, we have a longitudinal two-year course called Culture Determinants of Health and Health Disparities. And in that course, our students were taught that race is never a useful proxy or risk factor in health care. But other courses are like, oh, yeah, race is really important. So she wanted to know why race was so widely used, what's the evidence, and what factors contribute to this disparity? And she finished by saying, you know, I haven't been able to find much consistency in the literature. So the small group instructor and I met with that particular group. We talked about our thoughts about race-based medicine and its lack of utility. And class went on. Everybody was happy. Now, I mention this date because this is an important date in our history. Not this particular date, but what's happening around it. So about two weeks after I got this email, Ahmaud Arbery was shot to death while jogging in Georgia. A few weeks after that, Breonna Taylor was in her apartment, and she was shot to death. And as we all know, over Memorial Day weekend of 2020, George Floyd was slowly strangled by a police officer. Now, these were not unique events. This was on a background of multiple murders of African Americans by law enforcement. This is the slide I put together in March of 2021. I could not update it anymore because it would just simply be a sea of black. So in this ferment, where we have this drumbeat, this anxiety, this fury about this in the context of a pandemic, many people turn to see, what is it I'm doing? Am I doing enough? And for medical students, this became something they became very committed to. They hear a bunch of headlines from the Washington Post, San Diego Union Tribune, medical students demanding that we look at racism in medicine. Now, why are they asking us to look at this? Well, I'm not getting into this just because my students asked me to. There are very real, very tragic reasons why we need to pay attention to this. So if you look at maternal mortality, you can see, as you're very familiar with, the incredibly high mortality in African Americans, American Indians, and Alaska Natives compared to other populations. If you look at pretty much any type of malignancy, we're going to see higher cancer death rates in African Americans compared to other populations. And then here's just an example of another complex disease, hypertension as well as diabetes. This is what's called a heat map. So the authors are trying to show the prevalence of these diseases in what they call whites and what they call blacks. And if you look at this, you would be excused for thinking that, wow, it looks like hypertension and diabetes are really hitting whites hard in the Southeast. It doesn't look like it's so bad in these black people. Well, that's because they skewed their ranges. So actually, the top of the hypertension range in whites doesn't even get to the bottom of the hypertension range in blacks. And if we were to use a uniform scale, this is what it would look like, much less visually impactful for the authors. So clearly, there are big problems with race-based medicine and looking at health. So I think many of us became much more activated after the murder of George Floyd. And we look around at what we can do. So we have our circle of concern, all the things I care about. There's climate change. There's all sorts of things, but I really can't do much about that. So I have to look at my circle of influence, what I can actually do something about. And I encourage you to keep this in mind because there's so much work to be done in battling racism in medicine. Pick what you like. Pick what you're good at. There's plenty of room. So what you can do something about, for me, quite fortunately, Robbins Basic Pathology was right in the center of that because Vinay Kumar had asked me to join the editorial team about six months before this. I said, yes, I'd love to, but we need to look at race-based medicine. And he said, is that a thing? Is that something? What is that? I said, it's a thing. So how do we look at race in Robbins? So the way that I started doing this was I wanted to get an idea after that student asked me that question about hypertension, how much race is there in the textbook? Because I knew there was some in there because I teach it, but I never really paid attention to the overall amount. So I searched the electronic book using terms like Caucasian and African and Hispanic, and I found more than 35 diseases for which some sort of disparity, so it could be incidence or prevalence or prognosis or disease severity, was associated with socially-defined disease and socially-defined race. So here are just some actual quotes from that 10th edition. We have African-Americans and transthyretin mutations, carrier frequency of cystic fibrosis in Caucasians, cholesterol gallstones, who gets those? Yes, Native Americans, right? That's what we all learned in school. We've got EGFR mutations and pulmonary adenocarcinomas in whites and Asians. And then here's the sentence that got that student interested, which is the high blood pressure in African-Americans. So we're using a lot of racial terms here. So let's step back and again define our terms, what is race? So in modern biology, race is defined by two criteria, the amount of genetic variation within and between groups, and phylogenetic evidence of a unique lineage. So because of population admixture, populations emigrating, immigrating, flowing across all the continents except Antarctica, we do not have a unique lineage. And because of that admixture, it's long been known that humans show more variability within so-called races than between them. We do have geographically-based genetic and physical differences. We're not pretending like we're all identical, because we see that. We see people look different. But we share 99.9% of our DNA. Now we talk about this idea that there's more variability within so-called races. I'd like to highlight for you the fact that Africa has more genetic variability than anywhere else on the planet. The reason is that's the cradle of humanity. That is where there's the most expansion of genetic variability. As populations left, they had decreased variability. So what this means is if I were to arbitrarily pick two Africans and compare their genomes, and I was to pick an African and a European, the African and the European would have more genes in common than the two Africans. So the next time you look at someone and say, oh, that person's African-American, I see their phenotype, I know their genotype, just know you're wrong. So biological race does not exist in modern humans. It does exist in some large mammals, not us. But we do have something quite special. We have socially-constructed or socially-defined race, which is arbitrary use of aspects of appearance, geography, culture, et cetera. And it is explicitly, expressly, to set up a social dominance hierarchy. It's not like people looked around and were like, oh, you're different and you're different, but we're all the same. We're all equal. No, it's like you're different and I'm above you. So that's what socially-defined race is. So here is some of the origin of that. This is from the 18th century, Johann Friedrich Blumenbach showing the five types of humans, these skulls. This is whence the term Caucasian, that pseudoscientific term that gets bandied around a bit. If you do choose to use that, please stop. So now these five skulls and their names may look a little familiar to you because not much has changed in the intervening hundreds of years. This is, these are the categories our U.S. Census Bureau uses, the OMB. So we have the classification of white. So original peoples of Europe, Middle East, or North Africa. But how much? How much does it take before you qualify as white? Particularly if we compare this with black or African American origins in the black racial groups of Africa. Again, how much? What do you do if you have a European American and an African American who have a child? How do you define what that person's race is? Because of systemic racism in this country, we know where do we go with that in our society. And again, just calling someone African American or black doesn't tell you anything about their genotype because they have more genetic variability than the rest of the world. Now American Indian and Alaska Native are also quite interesting because while we're looking at original peoples of North, South, and Central America, there's also a cultural criterion. So they have to maintain tribal affiliation or community attachment. So a Navajo woman who says, you know what, I'm done, I'm leaving on Monday, by Tuesday is no longer a Native American. So that, I think, shows you how silly some of these classifications are. Native Hawaiian or other Pacific Islander, again, we get to the question of how much does it take before you meet this criterion. And we're going to finish up with Asian. So this is the original peoples of the Far East, Southeast Asia, or Indian subcontinent. And then the census gives a long list of countries. And it's just like, really? This is a huge expanse of land. And let's take a look at a map. I'm a big fan of maps. Here you can see how big Asia is. So 44 million kilometers squared, 4.7 billion people. Are you going to tell me that someone that you pick up from here is going to have a very similar genotype to someone you pick up from here? There's actually a fantastic study in nature genetics just on South Asia that I'd be happy to talk about at some point. Now why does distance matter? Well, because with increasing geographic distance, we get increasing genetic variance. So what you can see here is that as the kilometers increase, we have increasing genetic variance. So again, lumping all the people in that huge geographic expanse makes no scientific sense. So again, I like maps. We're talking here about diseases. So let's take a look at how geography affects these diseases. So this is a map showing the distribution of a variety of hemoglobinopathies. As you will recall, these become prevalent because they offer protection against malaria. So what these maps are showing us is not political boundaries, like this is where the border of Senegal stops. It's showing where there are mosquitoes. And so the clearest example of that, I think, is this big white expanse here where there are no hemoglobinopathies, no thalassemia, no sickle cell, no hemoglobin C. That's because this is where the Sahara Desert is. No water, no mosquitoes, no mosquitoes, no malaria, no malaria, no hemoglobinopathies. So this is telling us that these ideas that we have of using continents to define our races is folly. The other point to make here is that because of global patterns of emigration and immigration, any person on any continent can get any disease. And these heuristics we have, like, ah, these are the diseases that people from Africa get, do not serve us, and even worse, they do not serve our patients. So things get even more complicated. I talked about patterns of migration. What about population admixture, right? So this is what I talked about if you have one European-American parent and one African-American parent. And this is what we see here reflected in this graph, which is looking at mean African and European ancestry using ancestry informative markers. And you can see there's a lot of variability. So these are all people who self-describe as African-American. And they may have up to 30% or more European ancestry here in West Virginia, very high component in Washington State as well. Whereas in other areas, we see very little European comparison, contribution. Things get even more complicated when we look at our Latin American patients because they have a triad mixture. So now we're not just talking African and European. We're also bringing in American Indian. And again, you can see how much this varies. So this idea that someone says, oh, this disease is more prevalent in Latin Americans or Hispanics is going to be absolutely meaningless. So let's take a look now at a map looking at some original countries because some people get excited about this. Let's look at the distribution of these types of tumors in Colombia. Someone wanted to look at brain tumors in Colombia, and I explained why I thought that was a bad idea. So here you can see these are little pie graphs showing for four countries, Puerto Rico, Mexico, Colombia, and Peru, how much Amerindian, European, and Sub-Saharan contributions they have. And you might be thinking, look, these look pretty different. I mean, Puerto Rico is really different from Peru. So we could compare these two and see if there's anything interesting. Let's cone down on Colombia, though, just for a moment. So admixture is going to depend on history. While we can look at the global contribution, it really comes down to looking at various populations. And the populations are much smaller than these so-called races or these ethnicities. So if we were to look at the genomics of individuals in Medellin, which is an urban center, the genotype is going to pretty much be what we see in the rest of the country. But if we look at Chocó, which was an area of plantation agriculture and had many enslaved Africans brought to these shores, you can see that this is going to mimic much more what we see, for example, in the southeastern United States. So intense variability here. And these people don't think of themselves as blacks or whites. They're Colombians. They come to our country, and they're told, ah, you're black, and you are white. So race is not a biologically useful construct. And despite this, lots of money, lots of time, and lots of effort are poured into doing all sorts of studies to prove that there are biological differences between the so-called races. So I want to have this quote here from Cooper from the New England Journal of Medicine in 2003 to remind you that when we're talking about genetics, variation is continuous and discordant with race. Systematic variation according to continent is very limited, and there is no evidence that units of interest for medical genetics correspond to what we call races, right? So all those exciting projects that residents and young faculty are excited about, these are not going to shed light. So but here's the question, is it a socially useful construct, right? So I want to pause here. I have an asterisk. Using race is critical for public health, right? Are people getting vaccinated? Do they have access to care? Do they happen to be near a Superfund site? Are they exposed to a lot of toxins? Public health requires the use of socially defined race in order to ensure equity. But there has been this trend to use socially defined race as a social construct, as a proxy for exposures to toxins or to stress or whatever. So let's look with a little bit more detail. We're going to go back to Asia. This is again a variation of the Census Bureau's description of what is an Asian, where you can see it can either be the continent, and then we actually can cone down to some smaller groups. So Hmong are Vietnamese. They are a subset of Vietnamese. So let's take a first blush. This is largely information from the Pew Research Organization. If we're going to compare income with European Americans and Asian Americans, we can see that it looks like Asian Americans have a bit of a bump over European Americans, although it's a little curious that there are more living in poverty, and that's the first indication that there might be something off about this homogeneous group of Asian Americans. So let's take a look at these 19 ethnicities, which are defined and examined by the Pew Research Group, and look at median annual household income, percentage living in poverty, and educational attainment. So here is our median annual income. You can see that we have Indians in the United States topping up at 119,000 per year, while we have Burmese, who are at about 44,000. So there's a huge range across these different groups. If we now look at percentage living in poverty, we can see that while we did have a good mean annual income for Asian Americans in general, that we have 12 of 19 that have poverty rates as high or higher than the U.S. average. This is for our Burmese and Mongolians. This is 25%. A quarter of them are living in poverty. We see here Indians are about 6%, again, reflecting that higher income. And this is tied, of course, to educational attainment. So we know that in general, 54% of Asian American adults have a bachelor's degree. That's going to climb to 75% of Indian adults, which is going to help us with the annual income as well as poverty rates. But we have some groups that have very little education. So these four have more than half of their group has high school education or less. So Laotians, Cambodians, Burmese, and Bhutanese. And it's important to keep this in mind as you think about your group composition and who it is that you are bringing in. Now, there's one thing that I'd like to say here, which is that these are all objective measures. There's something we can't really measure, and that's trauma. So if you have people from a particular country who frequently come to this country for advanced degrees, they are going to have a different trauma profile than people fleeing conflict or people who are being persecuted and are seeking asylum. So we can't mark that there, but I would encourage you to keep that in mind, that these objective measures, while easy, do not communicate the entire picture. So now we've talked about this idea of race-based medicine and the problems inherent in using socially defined race to classify humans. So what do we do next? So I'm an educator, so I educate. And what I got interested in, I have a PhD, I love getting down to the details. For those more than 35 diseases, I did a deep dive into the literature, and I generated this 80-page document with figures and references and share that widely. And if anyone wants it, feel free to email me, I'll send it to you. We also look at terminology, inclusivity, and context. And the way that I share this is I have a website, pathologycentral.org, which has a lot of race in medicine videos. I have a YouTube channel where you can find that. And then I've been giving these little grand rounds talks. You know, like we give a couple of grand talks, everyone gives a couple of grand talks a year. So the first one I gave on race in medicine was on March 6th of 2021. Since that time, the intervening two years, these are all of the pathology organizations or departments to whom I've presented with Dr. Joseph Graves. So you can see that we're getting out there pretty vigorously. But it's not just pathologists who are interested in this. These are all the non-pathology groups to whom we have spoken, including the National Board of Medical Examiners, an insurance group who's part of the insurance marketplace in North Carolina, dermatology, pediatrics, radon, neurology, everything. So there's a lot of interest in this countrywide. In fact, we've also spoken in Canada. So one of the things that we try to do is to illuminate how this is such bad science. So these are a variety of quotes looking at keloids. Now, keloids, as you'll recall, are those really exuberant, somewhat disfiguring scars that can arise in the site of vaccinations or trauma or surgery. And you can see there's this figure, 16%, sprinkled all the way through, up-to-date, stat pearls, Medscape, a textbook on scar management, the California Department of Public Health, all of them using this. Where is this coming from? And I also want to point out that we have somewhere it says Hispanic and African. We have African, Asian, Hispanic. We have Africans. We have Zaire. And then we have, again, African, Hispanic, and possibly Asian. So there's a lot of lumping here of melanated people. Bet there's some really good research on that, don't you think? All right, so where did this 16% figure come from? It had to have been a really good study. So I went back and back and back through the literature, and I found it. So this is a paper from May 17th, 1931. It is in French. So if you're struggling to read it, that's one of the reasons. These are the reportings of a proceedings of a dermatologic meeting in Strasbourg, France. And what happened there was Monsieur Lespin got up and gave his talk about tattoos and keloids and negros of the Congo. And Monsieur Staub from Leopoldville, Belgian Congo, stood up and, as so often happens at scientific meetings, did not ask a question but presented his own research. He said, that was very interesting, but let me tell you what I saw in the Congo. What I saw was I looked at 1,205 black adults, and I examined them. Now let's just pause for a moment and acknowledge the colonial exploitation here, right? So he examines these 1,205 workers, and he found, miraculously, 16% of them had keloids. Now with these data, you could say 16% of adult male workers in this region have keloids. That's about it. You can't say 16% of people in the Congo, 16% of people in Africa, more genetic variability than everywhere else on the planet. You certainly can't then expand that to African Americans, African descent, and hey, let's throw in some Asians and Hispanics as well, right? So while that is problematic, there's something that I find even more frustrating, which is that on that very same day, May 17th, 1931, at that very same meeting, someone else got up and he gave his talk. Now this was Professor Nagley from Bern, Switzerland. He was also fascinated by keloids, but he didn't have a Congo research site, so he looked at adults and children in Switzerland, Europeans, lightly pigmented skin. And what he found was that 13.3% of them had keloids. Now this may be statistically significant, right? We can talk about that. Well, you know, clinical significance, zilch, right? It just means, you know, a certain population, a certain percentage is going to get keloids. Best thing to do is to look at the patient, see if they already have keloids, right? And if they don't have any, you can ask your brothers and sisters, cousins, parents, et cetera. Let's get an idea of your personal genetic ancestry. Let's not look at your skin and say, oh, it's black, you'll get keloids. So one of the problems, and also there's a video, you can, it's on my website, but this is my keloid video, which got used to change the California Department of Public Health. They removed that 16% thing. We'll get to you at the end, I promise. So then this brings up, but what about? So I'm going to be talking a little bit about pushback. So when you use a data-based approach, someone's going to say, but what about these? These show, see, look, look, 7% of African-Americans and 0.8% of African-Americans. And I look at these data and I say, well, okay, first of all, how did you define your terms, right? The first study was in Canada and they didn't say how they defined the different groups. But the other thing here is that we take 7.1, 0.8, 16, and compare that to 0.5, 0.1, and 13.3. You can see that these numbers are all over the map. And why is that? You cannot speak about specific populations if the populations themselves are not specific. And they are not because socially defined race does not correlate with genetics. So I'm going to step into pushback because I think it's important. We're all in here together and we all love each other and we're doing DEI. You're interested in DEI. You're here on a Wednesday morning, right? But it's not all happy out there. So some of the things that we've heard through anonymous comments to our talks has been DEI work has no place in medicine. Leave that to the politicians. And my comment is, well, people are dying. And we're physicians or we're physician-allied, we're in healthcare. We want to help people. That's why we do this. So it's not enough for me to say, I'm sure Jim Jordan's going to take care of this. We have to step in ourselves. And it's not just how we look at them using race-based medicine, it's access to care. It is a much bigger picture. One of the comments of one of the Robbins editors when I said we need to do this was, you're just being politically correct. We said no. We're being scientifically correct. It is not scientifically correct to say 16% of African-Americans, Asians, and Hispanics get keloids. That's false. And then these are some comments that I've edited lightly. This is anonymous comments from a national pathology organization that asked their membership, how is our DEI working for you? DEI is absolute garbage with no basis in fact. And you hate white people. This progressive bullshit is a waste of time. It's a fad. Toss it out with the rest of the trash. Treat people as individuals and don't rank them by race. Well, if we hadn't done that 400 years ago, we wouldn't be in this position now. But the issue is that when your rank is here, you sort of like staying there. And then there's this, this is just annoying virtue signaling. And I would just put a little flag there because it can be. And that's why we're here doing this work is we don't want to be doing performative work. We don't want to be doing virtue signaling. We're not going to be just handing you a little enamel button saying Black Lives Matter. Okay, we're done. We are doing the work. And then something that I find really heartbreaking is that I have good colleagues who consider themselves progressive, open-minded, non-racist. And yet because they have been steeped so long in this tea of racial essentialism and race-based medicine, it terrifies them to let go of race as a variable. And so I've had this one colleague who keeps sending me papers, this one, and this one, this one, it's important. Hydranatus suppurativa. I'm like, yeah, no. So let's take a look at something that just came up in the College of American Pathologists PIP cases last year. All right. So this was a case of amyloidogenic cardiac hypertrophy. The patient in this one was listed as a 50-plus African-American man. And in the discussion, this is what they say. This variant was a hitherto unrecognized cause of cardiomyopathy in individuals of African and Hispanic ancestry. Now because I had put together my disparities document, I did a deep dive into cardiac amyloidosis. So I knew a lot about this. This is the paper that it was based on. This is a 2019 paper from JAMA looking at, as you can see, African and Hispanic slash Latino ancestry. But because I had done my disparities document, I had actually read this paper, which came out in 2016. And this was a very good study looking at the distribution of this particular allele in Africa. And it appears, as you can see, these darker orange areas that the allele arose here and then spread throughout Africa. So I'm looking at this paper. I'm like, no, man, the allele arose in Western Africa. Why are you talking about Latin Americans? That makes no sense. So here is the data from that 2019 paper. You can see here in Western Africa, we have a very high percentage of carriers of this allele. The little white circles mean that none was found. And the size of the circle just means it's a bigger population. So they were able to get a whole lot more people in the United States than they were in these other areas. Now one thing to point out is, OK, this is also actually a Hispanic country. So we can't actually, that's one of the problems with using Hispanic as a label. No, none of that allele there. So you may be looking and saying, yes, look, it is in people of African and Latin American descent. Well, remember this. This is an allele that arose in Africa. What we are seeing in our Latin American populations is due to population admixture. Because remember, in Choco, we're going to be seeing something like 70% contribution from African alleles. Nonetheless, this is what this paper says. Their conclusions says that individuals of African, Hispanic, Latino ancestry significantly associated with heart failure. Now they do talk about population admixture in the discussion. But if you're like most busy professionals, you read the title, the abstract, and move on. And this is a new fact that shows race is important. So it's going to go in that little special bin that you can use to argue with people with. So that I find really quite challenging. So what can we do next? So what are things we can do? Again, the field is wide open. If you love giving lectures, give lectures. If you like doing policy, do policy. There is nothing, there's no area here that is untouched. So these are things I'm interested in. Removing race from assessments. So like our NBME Step 1, NBOME, RISE exams, specialty boards. Encouraging our governing bodies, societies, editors, and authors to do DEI work and publicize it. Because I sort of wonder if you do it and you don't tell anybody about it, did it really happen? Education is again what I'm really into. So the grand rounds that we do. And then teaching colleagues about the use of appropriate population descriptors. And this is going to be very exciting. We'll talk about that in the end. So why do I care about race in assessment? Right? You know, so this is a website from 2015 called crashingresident.com, giving tips for students getting ready to take their board exams. And the bottom line is be as racist as possible. Now as you look at this, right, you're probably feeling upset, distressed, maybe nauseated. But you're also seeing recognition. I'm like, oh yeah, I learned that when I was getting ready to take my Step 1. Sarcoid, sickle cell, keloids, high blood pressure. Bing. That's it. I've learned that. And if they start the sentence with a 35-year-old African-American man, I'm thinking, it's going to be one of these. So this is problematic. So why are we including this? Why do we have a 35-year-old African-American man presents with a three-day history of headache? It has always been thus. This is academia, right? So this is, we've always done it this way. This parallels the use of like the one-liner when a resident or a student is presenting a patient on the wards that are attending. We do not teach that at Duke. At Duke, they are taught a 35-year-old man presents with a three-day history of headache. And they get to the wards and the attending is like, and what race is he? So there's a top-down problem. One thing that people have said is, well, if you don't put race, if you just say a 35-year-old man presents with a three-day history of headache, people are going to picture a white guy. I'm like, really? I don't know if that works, and I don't think we should. So I'm not giving that much weight. And the other is, this makes it more realistic. It's like it's more real life. I'm like, yeah, no, it's a high-stakes multiple-choice exam. There's nothing real about it. And, right? No, seriously, that's what the NBME told me. Seriously, if you want to make it realistic, let's make him a Sagittarius, a left-handed Sagittarius who has three payday loans. But why is it problematic? Why am I beating my head against the NBME, the NBOME, the AMA, saying, come on, we've got to do this? Why is it even problematic? It's no big deal. So it perpetuates racial stereotypes. And it cannot help but increase the concept of biological disease, of biological race. And the reason that I always refer to socially defined race, well, I'm this socially defined race, or these three socially defined races, is because we elide so smoothly into race must have a biological component. And that's why all of these research papers are doing, oh, we looked at colon cancer from 1,000 African-Americans and 1,000 European-Americans, and we found this difference. Population admixture, all these things, mixed populations, meaningless, but we're still churning out this research. And then there's this idea of harmful heuristics. Oh, that's a white kid who's got a fever, recurrent fever, coming back with a cough, must be cystic fibrosis. The same patient who's African-American, now it's got to be something else, right? So we have these heuristics. Now, we all know, thinking fast and slow, we're all about that, right? We're teaching that in medical school. Do we really need to think that fast? I don't think so. I think actually these types of shortcuts are shortchanging patients. And then there's stereotype threat. Does anyone know what stereotype threat is? Anyone? Yes, Melissa Upton, of course, who recommended this book to me. Highly recommend Whistling Vivaldi. So this is written by Claude Steele. It's an outstanding book. So what is stereotype threat? So it's the fear of confirming a negative stereotype related to my gender, social defined race, ethnicity, et cetera, right? So, for example, I'm Asian-American, and I come in, I'm like, hey, here we go. I'm like, oh, I'm supposed to be demure. I'm supposed to be sort of lower energy. That's how my mom is. This takes cognitive load. I'm now thinking about that, right? I'm not thinking what is the answer to this mathematical question. I'm thinking, oh, I need to be more inside myself. And it's been shown that if you have this worry, it is going to decrease your academic performance. Now, I don't know. No one's done the study. I think it'd be fantastic for like the NBME to have one that did have race and ethnicity and one that didn't, and then look to see how people of different social defined races do on that, right? Did it have an impact? I suspect it does, but since we don't know, let's just not do it. So my other thing is get the word out. So Dr. Graves and I have talked with a number of national organizations, and they'll be like, yes, yes, we did remove race and ethnicity from our assessments. I'm like, that's great. Did you tell anybody? No. I'm like, okay. So if I'm doing the test, my eye is going to catch what I see. You've included African-American, or you've included Asian-American. I might not notice if it's not there. I'm not going to come up like, wow, that was great. They didn't mention race or ethnicity. I'll be like, God, was that really a spindle cell lipoma? God, I don't know. So if you don't do this, if you don't do it, say it, explain why you did it, then you're sort of not taking the full courageous path. And I understand there are reasons why people don't do this, and we've got some workarounds for that. One is, it's like when you tell everybody, look, this is what we're doing, then you get pushback. But let me show you how it can be done. This is how the American Academy of Pediatrics does it, right? So this was May 2022, and they were very explicit. They had a press release. They're putting all this guidance under the microscope to eliminate race-based medicine and resulting health disparities. Love the pediatricians. They're out there. They're fighting for their little patients. So they've begun purging outdated advice, committed to scrutinizing this entire catalog, including guidelines, educational materials, textbooks, and newsletter articles. Now, just as an aside, this news release came two months after our article in which Dr. Graves and I and a pediatrician savaged their textbook, the American Academy of Pediatrics textbook, pointing out the problematic use of race and ethnicity, which included such gems as Latin Americans sometimes urinate in their children's eyes for conjunctivitis, right? That needed to go. All right. Now, this brings us to the final realm of what we can do, which is appropriate population descriptors, okay? What do we call we're doing the study, right? So I've got leiomyosarcomas, and I happen to notice they occur in various socially defined races. Do I publish it? What do I say about it? How to define them? So this is very real in pathology. So this is an example. So the NCI has a cooperative human tissue network with biorepository material. We're all collecting stuff. And they will get an application saying, could you please send the samples of prosthetic adenocarcinoma from 30 blacks and 30 Caucasians? Because we're going to do some genetics work on it. We want to look at it. This is extremely problematic. These are socially defined races. You're looking for genetics. How are these defined? So we met with the CHTN Southeastern region, and we explained to them how this was incredibly problematic. So research in genetics and genomics is evolving incredibly quickly. And just as I showed you with that prostate cancer analogy, race-based categories are underlying the science of modern genetics and genomics, right? I'm going to be saying, you know, well, this gene is upregulated in African-Americans, and it's downregulated in European-Americans, right? So this falsehood is being perpetuated. This calls into question the scientific accuracy of all genetics and genomics research. And if you look at any genetics and genomics paper, it mentions race. You should feel your stomach sort of turn over. And part of the problem is, unless we stop this, it generates more of that avalanche that supports race-based medicine. So what is a person to do? Thank heavens. There's a new publication, just came out 2023. It's by the National Academies of Sciences, Engineering, and Medicine called Using Population Descriptors in Genetics and Genomics Research. It's big, thick. Has anyone read this? Anyone? I am the only clinician who has read it cover to cover. I'm no geneticist. Even the people at the biorepository haven't read it. We suggested they read it, but it's really, no one reads this. But I'll have a workaround for you. So after we talk, you don't have to read this whole messy thing. This is some verbiage that the Cooperative Human Tissue Network is trying to put on their website, because Dr. Graves and I said, you got to say something. You can't let people keep asking for prostate cancer for blacks and whites. You know, you have to explain why it's a problematic. And they're like, that's not our job, and that's not what we do, and we don't have that, we don't know how to do that. Like, yeah, but that's not good enough. So they are, this verbiage is not even been accepted yet, because the NIH is afraid there will be a misstep. Because everyone is afraid of making a misstep. And I'm like, we've been misstepping for 400 years. Why don't we just take a risk and stomp somewhere else? So they mentioned, well, there's evolving scientific rationales and methodologies. And we know about this publication. They didn't say we've read it, because no one has read this. And they urge the researchers themselves to really look into this and think about it before you ask for your 30 black and 30 white prostate cancers. And we also said, where are you getting these descriptors for? They're like, well, I don't know. I'm just telling them we get the tissue. It says it's a black person. I'm like, okay, you got to know that. So they said, well, most of it comes from medical records. And so it's self-reported, but we don't really know. So all of that biorepository material is meaningless, unless you take a step and you do analysis for genetic similarity, which is covered in this amazing article. So you're thinking, gosh, I really need to read this, but it sounds like it's not a lot of fun, because no one's read it, and it doesn't seem, you know, to come like in a graphic novel form. But we got you covered. So ASCP has you covered. We're going to be doing a companion society meeting at USCAP, Brighton. I know you guys like Brighton Early, 8 o'clock in the morning on Sunday, March 24th. And Dr. Graves will be there, and I'm also bringing in a biological anthropologist, because as physicians, we do not know this. And we believe things we learned in Robbins years and years ago. So this came out in the Washington Post yesterday, and what I like about it, this guy Charles Hoyt, who is, Carlos Hoyt is a psychologist, psychotherapist. He's not, you know, he doesn't do medical stuff or medical research. But his quote is naively beautiful. To recognize that race is a false concept, but to keep doing it anyway, there's something intellectually problematic about it. Why, yes, there is. I'll let you take a picture, and then we're going to go. All right. There is much work to do. Let's do it. Now, get out your little mobile things again. We're going to do those three questions again. And you know what? I'll send you my presentation. You don't need to take pictures. And then you can just move on to the next one. You can just zip down through all three. It's ugly. It is what it is. All right. So here are my references. Take questions and answers. Look at that. I've still got 12 minutes. That's astounding. So there's all my contact information. If you want my PowerPoint, shoot me an email. Check out the videos, et cetera. So now I will take questions. I know you had one, and I stopped you. So I will let you go first. Right. Well, and there's another thing, which is that what tends to happen is if a person is European-American, it's called a hypertrophic scar. And if you're African-American, it's called a keloid. Because my stepdaughter has a hypertrophic scar called, you know, but that's what it's called. So additional questions? So we have a little mnemonic. Does anyone know the Vindicate mnemonic for differential diagnosis? Where V is vascular, I, inflammation, and neoplasia. Anyone teach medical students? Does that mean anything to anybody? No. Well, it's like when you're in medical school, and you're like, you have the patient, and you want to make sure you do a complete differential. So you have, like, the systematic way of going through it. We added a D to the end, so it's Vindicated. And there's a video on it on my website, where the D is disparate diverse populations. Am I making a diagnosis assuming something about this person's population? Right. Because we're not saying the first time a little kid who's African-American comes in with cough and fever, we think, oh, it could be cystic fibrosis. Right. Because in the talk that I give that I have a link to, there's an African-American girl who was not diagnosed until she was eight. And she presented multiple times with cough, fever, and it was only when a radiologist who literally could not see the color of her skin was like, hey, who's the kid with the CF that the diagnosis was made? So, you know, to have that thing of checking yourself. Trying to explain. The battle to remove race-based medicine from the 11th edition of Robin's Basic Pathology was hard, bitter, and extremely stressful. We were able to remove about 75% of it. It now has a section on social determinants of health. It has a discussion of socially defined race versus biological race, which does not exist. And we have skin lesions shown in multiple skin types. So I can watch the video that I link to. The 10th edition, everybody had, all the cartoons had pink skin, right, and blue eyes. And I'm like, yeah, this has to go. And I was, that guy doesn't look Caucasian. I'm like, okay, first of all, we're not using Caucasian. And second of all, yes, it looks like Mark Zuckerberg. So we removed that. And it was a lot. It was very painful. It was very hard. And I was supposed to be continuing on to do pathologic-based disease, essential pathology, basic pathology, and Robin's Review. And I told the editors I no longer wish to work with them. I, we did a really good job improving the 11th edition. I think I am one of the people who sees what's still there. And I'm still bitter and angry about it because it was not based on science. And for example, I mean, I fought very hard. So we talk about multiple myeloma. Multiple myeloma is more common in African Americans. So I say to John Astor, when I gave the Stanley Robbins talk at Harvard, I went after him there. And I said, look, you know, yes, yes, it is twice as common. We're talking 6 in 100,000 versus 12 in 100,000. That is absolutely no clinical significance at all, right? It's not going to help you with your positive predictive value. It's not going to help you with, you know, your differential diagnosis. Someone's going to come in with a variety of symptoms, and that's how you make the diagnosis. We don't bring in 100,000 of one social defined race and 100,000 of another and say 6 of you got it, 12 of you got it. And he said, well, you know, yeah, but I think it's interesting. And you can protect them in the preclinical years, but once they get on the wards, it's going to come out. I'm like, okay, so it's going to get racist in two years, so I might as well get started now. And he says, and the NIH thinks this is important. Now, they address that in the publication of population descriptors, right? So we do need to put social defined race for, to document the populations we're examining. It can't be just like, yep, we got 100 white dudes, we're good, right? We have to be sure we are doing clinical trials on a wide range of people. But what they recommend, what I've said for a while is you don't put that in your data. You don't report it as your results, right? So you can say, yeah, we had 100 of these people, 100 of those, 50 of these, 25 of those. Overall, trends show this and do not go into race, right? You want to acknowledge that you are looking at populations, but you're not trying to biologize it or impugn something from it. And the problem is that because of publish or perish, a lot of times when you do look at social defined race, there will be something significant between them because environment has such a tremendous impact on health, right? And so now you've got something significant in a paper that's otherwise garbage, but you want to publish it, so ha, there it is. This is more common in African Americans and they have a worse prognosis. So we have to really be vigilant and really question why we do what we do and what is our intention, and my intention is better care of patients and social justice. Now, it's basically the people get into problems when they say things about race, right? By removing it, right, we're not really, you know, we're not saying this race is better than that race. We are saying there's some association, but it's very matter of fact, right? It's like this is what the lesion looks in darker skin types, this is what it looks in lighter skin types. There are a couple, you know, like the hand waving thing is the, for unknown reasons, this is more common in this population, like, you know, that's not enough. You don't just get to put a sticker there and that means you can make this race-based association. The only part that I think could be problematic would be the section we have on health disparities where Dr. Graves and I, that was my chapter, environmental pathology, so I hammered it on in there, about, you know, socially defined race is, you know, there's no biological race. I don't see pushback. Oh, yeah, let me just get that. Absolutely. This is why I'm so passionate about this because as an educator, I know if it's not on the test, they don't learn it, so let's take race off the test, right? I mean, it's just so obvious. So I had two very good meetings with the National Board of Medical Examiners and after the first meeting, they told me, the person who was in charge said, we are removing all race and ethnicity, we're not removing race-based medicine, we're removing race and ethnicity from our question stems, but they never announced it, okay? So we gave a second talk. We're like, you know, you have to announce it. Still didn't announce it. Now that person left. He was fantastic. Met with the new people. They're like, yeah, we're fine. We don't need your help. We're doing great. We don't tell people. I'm like, look, if you have removed it, can you tell people? We don't tell people what's on the boards. We don't give that sort of guidance. It's biochemistry. I'm like, okay, yeah, but we're talking social justice. We're talking patient harm. Can you just do this? So the answer was no. So then I reached out to the AMA because I'm thinking, you know, when you've got a 400-pound gorilla, go find an 800-pound gorilla to beat it with. So I had a meeting with the AMA. It was actually surprisingly hopeful, but policy takes a long time, right? And so I'm optimistic. One way that I'm looking at doing this, anyone who wants to jump in, right, my plan is to go after the specialty boards first because there's like 20 of them, right? So if we can find one of them, so I want to do a survey, find out, do you have a DEI thing? What do you do? Do you use race-based medicine, blah, blah, blah? If we can do that, document practices, we can say, look, the pediatricians are doing it great, and you people in orthopedics are doing a terrible job. By that, you get group peer pressure. There's no group peer pressure on the MBME. The only thing that can really push that is going to be perhaps the AMA, but even that is tough. So I'm one of those people who just like to peck at things, and I have lots of little projects, and the more people who are pecking along with me, so, you know, let me know. But no, it's tough, and, you know, I met with one national group, and they're like, yes, we removed race and ethnicity, but except when our experts say it's really important. I'm like, okay, like what, you know, what is so important? So, and they still hadn't made an announcement, and I was like, oh, by the way, I was looking at your stuff, and you do still have race-based medicine in there, and they're like, well, it takes a long time to get out. And then the other issue, so people say like questions, like we have this question bank. Oh, it's too hard. It's too long. We cannot do this. So Joe Graves said, hey, man, if you had something in there that talked about nucleated red blood cells in humans, you'd be like, oh, my God, we have to get that out, scientifically wrong. We're teaching race-based medicine is scientifically wrong and needs to go. So, thank you so very much. Please do reach out. Thank you.

race-based medicine

medical education

racial disparities

genetic variation

systemic racism

health disparities

public health data

Robbins textbooks

social justice