Data-driven and determined: Evaluating race in medical curricula
“It wasn’t enough to simply not be racist myself, but I had to actively engage in antiracism as a moral imperative.”
A fourth generation PhD, Andrea Deyrup MD, PhD (@ATDeyrupMDPhD) will tell you she never thought about going into medicine. “I’ve always loved teaching,” she told listeners during her interview with Dr. Michael Williams (@bluehatcomics85) on his podcast Diversify in Path (@DiversifyInPath). Dr. Deyrup’s journey to and through medicine is rich with adventure in both academia and personal life experiences, all of which she covers in her extensive interview with Dr. Williams. We encourage you to check out episode 18 to learn more about Dr. Deyrup.
In this blog post, you will hear from Dr. Deyrup herself about her love for teaching and passion for antiracism efforts in medical education, including editing the upcoming edition of Robbins & Kumar Basic Pathology and starting a new website, www.pathologycentral.org. Without further ado, here is Dr. Deyrup.
Connection through education
I really enjoy connecting with people in an authentic way. When we’re trying to share a concept or communicate a mechanism, when we’re at the edge of understanding, that is the sweet spot where our minds and hearts are opened by curiosity and the drive to grasp the truth. Where we are a bit vulnerable and a bit unsure of ourselves, hoping that we will see the answer. I’ve been teaching my entire life: coaching soccer, teaching French and English as a foreign language, acting as a teaching assistant at the University of Chicago, picking up whichever lectures I could give to the medical students as a resident. I just love teaching.
I helped start a medical school in Greenville, South Carolina and greatly enjoyed the opportunity to get involved with curriculum design and test item writing, figuring out new and interesting ways to engage with learners. The students in the charter class were absolutely fantastic and a real pleasure to teach. However, my days in South Carolina were numbered when I married a man who lives in North Carolina. I retired in October of 2013 and moved to Chatham County, North Carolina.
I’d only been in North Carolina about a year and a half when Duke University reached out to me to ask if I would be interested in taking on the position of course director for their medical school pathology course. It wasn’t what I was planning on, but the opportunity to engage again with dedicated students and to contribute to the future of medicine was irresistible. If there's something I can do to create better physicians, I’m all in. It has been an incredibly enriching experience with so many interesting opportunities for collaboration and for teaching and learning.
Health disparities in medical education
When we talk about health disparities in medical education, what we’re really talking about is the teaching of race-based medicine. In race-based medicine, we link certain socially defined races with disease risk and prognosis. Examples would be focusing on a higher incidence of cystic fibrosis in individuals of European descent, increased prevalence of EGFR mutations in Asians with pulmonary adenocarcinomas and the prevalence of pathologic effects of hypertension in African Americans. Historically, the thinking in medical education has been that these epidemiologic data would help future physicians develop broad and reasonable differential diagnoses, order appropriate laboratory tests and design optimal therapeutic regimens for their patients. We are now realizing that race-based medicine does not actually help us take better care of our patients. In many instances, it actually contributes to harm, not only to our patients but to ourselves and our society.
Recognizing race in medicine
Race-based medicine has been taught for generations. In 1974, the first edition of Robbins Pathologic Basis of Disease mentioned the link between keloids and African descent, an association that we now know to be false and to be based in systemic racism. When I learned about race associations with disease in medical school in the 1990’s, they were taught as important facts and were an important component of exam questions, including the national Board exams. Like nearly everyone else in my medical school class, I believed that these data were helpful, not harmful.
When I began working at Duke in 2015, my awareness grew during multiple conversations with Dr. Kenyon Railey, a BIPOC faculty member who was the founding course director for a longitudinal course called “Cultural Determinants of Health and Health Disparities.” He helped me to see that racializing medicine through using socially defined race and ethnicity in clinical vignettes for teaching and exam questions was extremely problematic. My students have been instrumental in helping me to see more clearly by questioning the emphasis of race in medicine. Another important initiator for me was reading Damon Tweedy’s book “Black Man in a White Coat” in which he discussed his feelings as an African American student at Duke medical school listening to lecturers say, again and again, that this disease or another was more common or had a worse prognosis in African Americans.
Discussing the data
In the fall of 2019, Dr. Vinay Kumar invited me to join the Robbins editorial team as a co-editor for the 11th edition of Robbins & Kumar Basic Pathology, along with Dr. Abul Abbas and Dr. Jon Aster. We had just finished the first edition of Robbins Essential Pathology, of which I was also a co-editor. I still felt quite junior in that role and although I did recommend some edits regarding the use of race in that textbook, I wasn’t very pushy. However, since I had been using Robbins Basic Pathology as a course text for many years, I was very familiar with the extent of race-based medicine in that book and I knew it was something we needed to address.
In order to get a better idea of the depth and breadth of the issue, I searched the electronic version of the 10th edition of Robbins Basic Pathology using search terms like “Caucasian”, “African”, “Asian” and “Hispanic”. I found more than 45 diseases for which socially defined race was associated with prognosis or incidence. The next step was to do a deep dive into the literature to better understand where these associations came from and the extent of their validity. It was a lot of work and resulted in a 70+ page document with references and figures that I shared with my students to provide context for the information in the textbook. Based on my findings, I put together a Grand Rounds that I presented to my department in March of 2021 called “Race in Robbins: Data or Distraction?”. In that talk, which I have continued to refine and improve, I present the data in a very logical and scientific way. In the face of the evidence, I think the harm of race-based medicine becomes quite obvious.
That talk was instrumental, I believe, in bringing the other Robbins editors on board. At first, I don’t think they were as convinced as I that race-based medicine was a problem. Like me, they had been taught these racial associations, believed them to be valid and considered them a valuable part of medical care.
Antiracism in action
I’m so excited that we are updating Robbins with an equity lens and a focus on being scientifically correct, not politically correct. For that, it was important for us to bring in an expert in the field. Since geographic ancestry and population genetics are so critical to this understanding, we brought in Dr. Joseph Graves, Jr., a professor of evolutionary biology at North Carolina Agricultural and Technical State University as a consultant for Elsevier. It has been a fantastic collaboration and I have learned so much from him. Dr. Graves has published widely on race in medicine, most recently in his book with Dr. Alan Goodman, Racism Not Race: Answers to Frequently Asked Questions. Dr. Graves and I have been co-presenting a Race in Medicine Grand Rounds across the country to pathology and clinical departments as well as to the test development committee of the National Board of Medical Examiners. We’re scheduled to present at a plenary panel discussion of the National Invitational for Clinical Educators, hosted by the NBME in June. We’re working hard to get the word out!
Regarding Robbins, we have examined every instance where race is invoked in the pathophysiology of disease and either removed associations that are not supported by evidence or provided appropriate context. While a major focus has been ensuring that socially defined race is not conflated with biological race (which does not exist in modern humans), we also need to recognize that socially defined race contributes significantly to health disparities; this edition of Robbins will be the first to include a section on disparities in disease. Furthermore, we have worked to ensure that we have better representation of different skin types in the depiction of pathologic lesions as well as more inclusive descriptions in the text. This is a widespread issue in the medical and scientific literature. I think that the final product will be an extraordinary step forward in a more mindful approach to medical education and should serve as a model for other textbooks.
Although my initial focus has been addressing race in Robbins, race-based medicine is absolutely ubiquitous. You will find it in UpToDate, surgery textbooks, pediatrics textbooks, internal medicine textbooks, journals. Absolutely everywhere! The inappropriate use of race must be addressed in every source. In fact, Dr. Graves and I have a collaborative project with one of my former mentors from the University of Chicago, Dr. Lainie Ross, and a third-year medical student in which we evaluated the use of race in a popular pediatrics textbook. That will be coming out soon in Academic Medicine and we hope it will further spread the word on the need to reevaluate race in medicine.
Dr. Graves and I also have a Perspectives piece in press with the New England Journal of Medicine in which we address some of the central problems of race-based medicine in medical curricula.
Although I am half Chinese, my lived experience is one of white privilege, something that I did not adequately recognize. Though my commitment to antiracism is fueled by outrage and passion, especially as I continue to educate myself and to work with historically marginalized populations, at the most basic level, my actions are the product of a logical and rational evaluation of the facts. As a scientist, I am trained to assess data and when, in the wake of George Floyd’s murder I took a serious look at the contributions I had made to antiracism, I realized that I had not done nearly enough. The reading I did in the aftermath of that event helped me recognize that it wasn’t enough to simply not be racist myself, but I had to actively engage in antiracism as a moral imperative. Racism harms all of us.
Birth of Pathology Central
I’m not a video person. I’m a reader. If I have an option of reading an article or watching a talk on the same topic, I’ll read the book. But I know that videos are a very popular medium for communicating ideas, particularly with today’s students. Although Dr. Graves and I are reaching a fairly wide audience since we’re presenting nearly every week, this message is so important that I wanted to expand our reach.
I had been practicing “Yoga with Adriene” on YouTube for about a year and I really liked and respected her decision to offer quality videos for free to make an at-home yoga practice more accessible. In the first week of October in 2021, I popped up one morning and said, “I’m going to make a YouTube channel with pathology and antiracist content! It will be free and available to everyone!” I had minimal experience with YouTube; my husband is a world-famous mandolin player, so I had created a YouTube channel to upload videos of his performances. It was more along the lines of “here it is, enjoy,” not “I really need to get the word out on this!”
I also had a little experience with creating a website since I had created one for my husband, www.mandolincentral.com (which is where the name Pathology Central comes from; Mandolin Central has been the name of his business for decades and I thought it would be sweet to model my website after his). I got everything up and running in about a week. It’s still pretty rudimentary: my primary focus is on generating content and I haven’t spent much time on the visual appeal. If anyone would be willing to help out with that, it would be much appreciated!
In addition to my antiracism videos, I wanted to also produce quality videos for free for medical students. There are so many videos for medical students online. It seemed to me that many of them were focused on helping students do well on tests whereas my focus is to help students be better doctors. I believe that a deep understanding of pathophysiology is necessary to be an excellent clinician. My videos are focused on helping to provide that deep understanding. I’m excited to be doing them on YouTube and on my website so that they are available worldwide for free.
Thank you, Dr. Deyrup, for your perseverance in bringing us not only invaluable pathology content, but by educating us about race-based medicine. As scientists and researchers, our eyes and hearts have been opened to falsehoods we were taught in school. We encourage physicians, educators and students in all specialties and at all career levels to visit Pathology Central and watch Dr. Deyrup’s videos on Race in Medicine. Antiracism is everyone’s responsibility; we must act boldly and courageously. As Dr. Deyrup wrote, “It wasn’t enough to simply not be racist myself, but I had to actively engage in antiracism as a moral imperative.”
Do you have questions for Dr. Deyrup? She can be contacted by emailing pathologycentral@gmail.com. Be sure to visit Pathology Central at pathologycentral.org. Watch the videos, leave a comment; be part of the discussion. Importantly, take action.
Dr. Andrea Deyrup received her undergraduate degree from Princeton University in the Department of Ecology and Evolutionary Biology in 1991 before joining the University of Chicago for her Ph.D. (Pathology, 1997), M.D. (2000) and residency (Anatomic Pathology, 2000-2003). She completed her formal training in soft tissue pathology at Emory with Dr. Sharon Weiss and joined the faculty there in 2004. She has published extensively in the field of soft tissue and bone pathology. Since 2015, Dr. Deyrup’s career has focused on medical education. At that time, she joined the faculty of the Duke Pathology Department as Course Director of the first-year medical school pathology course; in January of 2019, she was named the Director of Undergraduate Medical Education for the Pathology Department. She also serves on the Undergraduate Medical Education Council for the Association of Pathology Chairs, participated in the 2020-21 Duke Teaching for Equity Fellows Program and was a member of the Duke School of Medicine Health Professions Anti-Racism Task Force. Dr. Deyrup is one of the co-editors of the new Robbins pathology textbook, Essential Pathology and of the upcoming 11th edition of Robbins Basic Pathology. She has served on the Editorial Board of Human Pathology since 2007, as the Treasurer for the International Society of Bone and Soft Tissue Pathology from 2008 to 2013 and Associate Editor for Case Studies for Human Pathology from 2017-19.
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