Episode 84: Smells in medicine. 

Intro about race in algorithms. Self-reported case of anosmia by Dr. Arreaza. Some common smells in medicine are discussed with Dr Grewal, for example, halitosis, bromhidrosis, and fetor hepaticus. Parosmia is also mentioned as a sequela after COVID-19 infection. 

Intro: Race in clinical algorithms.  
By Brandy Truong, MS4, Ross University School of Medicine.

The year 2020 was not only the beginning of the pandemic but also a time when our country finally took the time to learn more about systemic racism. Many members in the medical community have been fighting racism in medicine for years and unfortunately have often gone unheard. However, in the past few years, people decided to start listening. 

The New England Journal of Medicine published an article in 2020 looking at different algorithms that have a race component and how that can be harmful to patients and perpetuates systemic racism. Let’s take a dive into some of those clinical algorithms. 

Something that has gained a large movement, is getting rid of a test that helps determine kidney function based on race. This test is called estimated glomerular filtration rate, or what we call eGFR which considers a person’s age, gender, race, and levels of creatinine. When it comes to the race category, it considers if someone is African American or not. Therefore, there are different normal eGFR values for African American and then all others. 

The test was based on an assumption that Black people have higher muscle mass on average which led to higher kidney function. This becomes problematic because assuming all Black people have higher kidney function can delay a patient’s referral to a specialist or getting a transplant. This leads to higher rates of end-stage kidney disease and death due to kidney failure compared to the overall population. 

Many physicians and medical students at top universities have pushed their administration to get rid of the eGFR values based on race. Some hospitals like Mass General no longer use eGFR based on race. The National Kidney Foundation and American Society of Nephrology are still evaluating if they recommend the current algorithms. 

When it comes to looking at heart failure risk, the American Heart Association recommends a Heart Failure Risk Score that predicts the risk of death in patients admitted to the hospital. When a patient identifies as not Black, their score increases by 3 points which puts Black patients at lower risk due to a lower score. This score helps us decide on referrals to cardiology and general care. This becomes problematic because Black patients may not receive the care they need if assumed they are lower risk. 

This was shown when a study done in 2019 showed that Black and Latinx patients that presented to an emergency department in Boston with heart failure were less likely than White patients to be admitted to the cardiology unit.

Another algorithm that puts Black patients at lower risk is the STONE score which predicts the likelihood of kidney stones in patients who present in the ER with flank pain. The score increases by 3 points for patients who don’t identify as Black, which once again puts Black patients at lower risk due to a lower score. 

Black maternal mortality is drastically much higher compared to White women. Something that can contribute to it is an algorithm called Vaginal Birth after Cesarean which predicts the risk in a trial of labor for someone who had a prior cesarean section. This algorithm predicts a lower level of success for mothers identified as Black or Hispanic. 

It’s also important to note that the study used to create the algorithm found that variables like marital status and insurance type also correlated with the success of vaginal birth after cesarean, but those factors weren’t included in the algorithm. 

The benefits of having a vag