Racial and Ethnic Diversity is a Tool for Eliminating Unequal Racial and Ethnic Kidney Health

Unequal racial and ethnic health, including kidney health, inflicts serious adverse consequences on US society. We at JASN have tried to elevate the importance of this issue in our pages, including our series “Addressing Racial and Ethnic Disparities in Kidney Disease,”¹ which emphasized the need to devise, test, and then implement solutions. This racially and ethnically driven unequal health distribution is woven into nearly every major issue facing American medicine today and must be considered an aberration rather than normalized.

Health systems play a critical role in our goal to eliminate this unequal distribution of health driven in large part by the long history of racism in the United States. Our health systems strive to restore health to all with illness and disease, provide evidence-based guidance as to health maintenance to all, and be inclusive of all who seek to contribute to its mission to generate and distribute knowledge that drives health restoration and its maintenance. Optimal success in these missions requires a racially and ethnically diverse workforce in our health systems.^2,3 This long-standing recognition of the importance of racial and ethnic diversity of our research, clinical, and educational workforces makes achieving racial and ethnic diversity a practical imperative and not just a moral aspiration. Although moral motives certainly (and thankfully) drive the work that we in the health care workforce do, our colleagues in the business world recognize that racial and ethnic diversity of the business workforce, particularly in its leadership, drives desired hard outcomes and innovation.⁴ As eloquently articulated by Dr. Herbert Nickens, this makes achieving diversity “not only the right thing to do, but also the smart thing to do.”² We in the kidney community have the opportunity to apply this tool toward the racially and ethnically driven unequal distribution of kidney health that persists and is not dissipating organically.⁵ The diversity tool is applicable to achieving excellence in each component of our tripartite mission.

Diversity in the academic medical environment promotes research that is inclusive of the needs and concerns of minoritized groups in the United States.⁶ One notable example of the practical effectiveness of a racially and ethnically diverse research group is the great success of the African American Study of Kidney Disease trial, one of the most successful large-scale trials conducted by the National Institutes of Health.⁷ These investigators helped advocate for this groundbreaking trial from which investigators continue to derive important pathophysiologic and clinical insights. This diverse group of investigators also helped drive practical strategies that helped make the trial the great success that it is. Because of the tragic history of abuse by some US researchers, Black participants justifiably have been reluctant to enter into clinical trials.⁸ In recognition of this history, Black investigators involved with the trial encouraged hiring of Black study coordinators who helped the trial attain its recruitment goals. Having faculty from other racially and ethnically under-represented groups can inform research to help reduce racially and ethnically driven unequal kidney health distribution, and how best to get it done. Unfortunately, little progress has been made in increasing the racial and ethnic diversity of US medical school faculties,⁹ particularly basic science faculty.¹⁰ Recent Supreme Court decisions have made achieving this goal even more challenging.¹¹ In addition, more work is to be done to increase the proportion of faculty from under-represented groups advancing to more senior faculty levels, including leadership positions.⁹ Early data support that racially and ethnically under-represented faculty are more likely to engage in research that can lead to a reduction in racially and ethnically unequal health distribution disparities.^9–11

Increasing the diversity of the physician and other health professional workforce is purported to improve access to health care for underserved populations, many of whom are minoritized populations.¹² An Institute of Medicine report suggests that racism, prejudice, and stereotyping by health care providers contribute to differences in care provided to patients seen.³ In this report, minoritized patients were less likely to receive needed services, including clinically necessary procedures, even when they had similar health insurance and ability to pay compared with non-minoritized patients. Moreover, this report suggested that racial and ethnic differences in patients' attitudes, such as patient preferences for treatment, did not adequately explain these racially and ethnically driven unequal health distributions. Subsequent studies support similar findings regarding racially and ethnically unequal kidney health.⁵ Racial and ethnic concordance between patients and physicians is associated with better patient satisfaction with the care they receive,¹³ but further studies will help determine whether this translates to better health, including better kidney health, outcomes.

Diversity of teaching faculty and trainees, such as residents and fellows involved in the education mission, as well as diversity among the recipients of medical education, improves medical education.⁶ Racial and ethnic diversity improves medical education by contributing to cultural competence, that is, an awareness and appreciation of cultural differences among racial and ethnic groups. Cultural competence in minoritized and non-minoritized educators and providers helps promote more effective health care delivery to a diverse patient population.⁶ Racially and ethnically under-represented faculty importantly sensitizes the faculty as a whole as to important issues of the population being served and how best to address them. In addition, a group of trainees, notably medical students, and house staff, with greater proportions of racially and ethnically under-represented members enhances the learning experience for the individual learner, leading to better educated, more culturally competent physicians and to better quality care for minoritized patients.¹² The current low numbers of racially and ethnically under-represented medical students and faculty suggest that residencies are similarly affected. Because house staff play critical roles in the education of medical students and more junior house staff, it is anticipated that greater proportions of racially and ethnically under-represented resident and fellow trainees will enhance cultural competence among trainees. Having a diverse academic medical center faculty helps achieve the goals of providing quality medical education that promotes delivery of high-quality care and helps inform research agendas, including those that addresses the health concerns of all members of society.⁶ Increased representation of racial and ethnic faculty brings needed cultural sensitivity to medical education and helps non-minoritized faculty become aware of, and appropriately sensitive to, these important issues of patient care.

Despite decades of its documentation, racially and ethnically driven unequal distribution of health, including kidney health, persists. Our health systems play a critical role in eliminating this unequal health and increasing the racial and ethnic diversity of its workforce is an effective tool in its arsenal by which this critical goal is going to be achieved. Health system leaders are encouraged to use their “bully pulpit” to incorporate and implement this effective tool.

Disclosures

D. Wesson reports Consultancy: Tricida, Inc. until January 31, 2023; Research Funding: Tricida, Inc. (South San Francisco, CA); Honoraria: Brigham and Women's Hospital, Medscape, The Methodist Hospital (Houston), UCLA Medical Center, University of Buffalo Medical School, University of Rochester School of Medicine, and U of Southern California Medical Center; Advisory or Leadership Role: American Journal of Nephrology Editorial Board; CJASN Editorial Board, JASN, Deputy Clinical Editor, Journal of Renal Nutrition Editorial Board, Kidney International Editorial Board, and Tricida Scientific Steering Committee (ending January 31, 2023); and Other Interests or Relationships: Paid consultant of the Texas Kidney Foundation.

Funding

None.

Author Contributions

Conceptualization: Donald E. Wesson.

Formal analysis: Donald E. Wesson.

Writing – original draft: Donald E. Wesson.

Writing – review & editing: Donald E. Wesson.