Fabricating an evidence base for anti-racism in medicine

There is always a price to silence.  

Increasingly over the last decade, many in medicine winced inside but said nothing as trash papers heralding the arrival of wokism in medicine found their way to elite medical journals.   Any serious critical analyzers of data would recognize the research as agenda driven pablum, but to say so risks being publicly tarred and feathered by the liberal fascists that now run the institutions of higher learning in medicine.  The cost of that silence is a largely unchallenged body of work that provides the ‘evidence base’ for cultists seeking to radically reimagine the medical profession in a dark, dystopian vision.

A recent op-ed in the Boston Review by Dr. Michelle Morse is a nice case study in the path shoddy research takes to becoming ‘evidence-based’ policy.  The personal story of Dr. Morse is an inspiring one.  Born in West Philadelphia to a public school teacher, Dr. Morse went to major in French the University of Virginia before going onto study medicine at the prestigious Perelman School of Medicine at the University of Pennsylvania in Philadelphia.  The next step was the  Doris and Howard Hiatt Residency in Global Health Equity and Internal Medicine at the elite Brigham and Women’s hospital in Boston.  This is a special training program for graduating medical students that aims to train doctors laser focused on the elimination of health disparities, in part by arming them with quantitative research tools from the top flight Harvard Chan School of Public Health.  

The goal of this training is to create an evidence base that demonstrates definitively racism is embedded in the structure of medicine, and that is exactly what happens.  In her op-ed, Dr. Morse references a publication in a collaboration with first author Dr. Lauren Eberly -- a current cardiovascular fellow at the University of Pennsylvania and another recent graduate of the Doris and Howard Hiatt Residency program.  This publication from 2019 is a retrospective review of the inpatient heart failure care a large urban academic medical center.  The eventual conclusion arrived at is robust - “This retrospective single-center study is one of the first to demonstrate that admission service for patients admitted with HF is an intrahospital driver of racial inequities in HF outcomes”.  This statement is based on the finding that white patients are more likely to end up being cared for by a cardiologist after being admitted for heart failure than black patients.  The subsequent finding that white patients have better outcomes than black patients is all the authors need to conclude that institutional hospital racism underlies the difference in outcomes.

The actual study and the data it contains are anything but robust.    The study is a chart review that identifies 7629 unique hospital admissions with a principal diagnosis of heart failure over 10 years, but ultimately only includes 1967 patients in their analysis.  That’s an average of 200 patients a year, or only ~4 patients admitted to the hospital per week. (A tiny sample to base the entire institution’s behavior on)

The patients who were included in the analysis were mostly white, and did end up on a cardiology service, but they also were much more likely to have been seen by a cardiologist in a cardiology clinic over the prior year.  The major weakness of retrospective studies - selection bias - rears its head.  The groups being compared have differences well beyond the groupings the researchers have chosen for convenience sake.  Patients who have seen a cardiologist in the year prior to being admitted for heart failure may be more interested in their health, may have greater access to health care resources, and are possibly more compliant with therapies shown to reduce morbidity and mortality related to heart failure, may be less sick, or abuse drugs less to just name a few potential known confounders.  The unknown or unmeasurable confounders may figure even more prominently in the outcome gaps that ultimately are measured between groups. Nothing that comes out of this type of analysis is strong even if there were large differences measured by race.  

As it is the researchers own results by race are anything but clear or significant.  After stratification by race, black patients discharged after admission to the general medical service had a higher risk of death within 30 days compared with black patients discharged after admission to cardiology (3% versus <1%, P=0.01), but there were no differences for white (4% versus 4%, P=0.82) or Latinx patients (3% versus 3%, P=0.85). If it is race that is the primary factor determining outcomes, how is it that black patients find their way onto the cardiology service at all?  And when they do find themselves on the cardiology service, how is it that they do better than their white counterparts?  This clear as mud analysis suggests that the ultimate determinant of outcomes in heart failure patients isn’t explained by the simple race based construct the study’s authors are desperate to prove. 

This is even more clear after adjusting for a number of different risk factors.  After adjustment, black race was independently associated with a reduced risk of death within 30 days (HR, 0.52; 95% CI, 0.30–0.91; P=0.02),  This suggests white patients are twice as likely to die at any given time point relative to black patients within 30 days of being discharged. Admission to the cardiology service was not associated with death.  The only positive finding was that admission to the cardiology service meant a lower chance of readmission to the hospital.  Armed with this outcome gap and the finding that white patients were placed on the cardiology service at a higher rate even after adjusting for a variety of known factors, the authors go on to cite the study as important proof of outcome differences driven by race.

This, despite the fact that the single biggest factor that seemed to drive admission to the cardiology service was a prior visit to cardiology in the year prior to admission, and that white patients appeared to die twice as often as black patients even after adjustment for risk factors.  The authors could have chosen to write a very different op-ed pointing out increased white mortality by a factor of two, yet instead chose to latch on to the signal of race based hospital readmission rates that aligned with the very hypothesis that made them embark on the research study in the first place.  

I will re-emphasize that in a study that should be almost entirely hypothesis generating because of its design, the big news to investigate is the massive differential by a factor of 2 of deaths of whites relative to blacks.  These are results that should be interpreted cautiously, with great humility, but eager to prove a point, the authors jump straight to the policy implications of their “groundbreaking” research.

“By assuming the existence of institutional racism across all American institutions, we can turn from research focused on documenting disparities and inequities to implementation research directed towards correcting them while ensuring that institutions like ours are accountable to the communities they serve. “

I can only imagine the poor editor tasked with reviewing this paper that allowed this line to go unchallenged.  Concluding institutional racism exists, and thrives in our hospitals was always going to be the end result of a study like this, regardless of what results were going to be found. 

Dr. Morse goes a lot further in her Op-ed citing their “landmark study” by specifically eschewing the traditional principle of color-blindness that most Americans associate with the progress ushered in by the civil rights movement of the 1960s and subsequently enshrined into law. Implicit bias training , and colorblind objective criteria are not nearly enough in this dystopian world.  Instead, a brand new frame that draws on Critical Race Theory (her exact words as presented below) is what the new world order needs to be based on.  

To summarize: the opinion piece that starts with over-reaching claims from a shitty retrospective chart review turns to a rationalization of neo-racist policies that the authors actually have gone on to implement in the Boston hospital Dr. Morse is employed by.  A flag in the electronic health record will now prompt admission to a specialty cardiology service in patients identified as black or Latinx. 

Preferential treatment based on race falls under the guise of new philosophers who subscribe to ‘applicative justice’ that seeks to give justice to those who don’t currently receive it.  I cannot stress enough that this all starts from a premise that black and latinx patients are being impacted by ‘unjust heart failure management’.  To be clear, there is no data presented to suggest heart failure management in the hospital for black/latinx patients is poorer.  There is nothing to suggest guidelines aren’t being followed with black/latinx patients relative to whites.  As noted earlier, whites, indeed, die at almost two times the rate of black patients.  Yet, if we are to accept that there is something very special about the cardiology service, to specifically exclude white patients from these services is an abhorrent action, and every physician participating should be ashamed. 

Morse even predicts an inevitable legal challenge from racially preferential policies because of the current antiquated “color-blind legal system”, but notes that the current President appears firmly in their corner and quotes a January 20th Executive order from the Biden administration that clearly draws from the same well 

There is little doubt that preferential policies that are based on race in medicine will result in injury to patients and physicians alike.  It is tragic enough that patients will be harmed by these policies, but the stain on the souls of physicians who take part in these heinous endeavors are certain to never be rubbed out.  The time for silence on the part of physicians watching this horror unfold is long past.  

Winston Marshall, the banjo player for the popular band Mumford and Sons recently penned an essay about why he was leaving his band because he felt increasingly queasy with the bargain he had made to quell the firestorm of controversy a tweet supporting a gay Vietnamese journalist had caused.  Increasingly the choice that faces Americans is to stay silent or risk you and everyone you love being caste out of pleasant society.  Marshall made the choice to not stay silent, quoting Russian novelist Aleksandr Solzhenitsyn who made his own hard choices when he fled his homeland to go to the West so he could continue his critique of the repressive Soviet regime of the time.  Solzhenitsyn’s words for those intellectuals and leading public figures who stayed behind and stayed silent should be heard well by every physician complicit in the current events of the day. 

“And he who is not sufficiently courageous to defend his soul — don’t let him be proud of his ‘progressive’ views, and don’t let him boast that he is an academician or a people’s artist, a distinguished figure or a general. Let him say to himself: I am a part of the herd and a coward. It’s all the same to me as long as I’m fed and kept warm.”

The price of silence grows greater every day. How many physicians are willing to keep paying?