Why doctors still use race as a way to diagnose patients : Code Switch We've probably said it a hundred times on Code Switch — biological race is not a real thing. So why is race still used to help diagnose certain conditions, like keloids or cystic fibrosis? On this episode, Dr. Andrea Deyrup breaks it down for us, and unpacks the problems she sees with practicing race-based medicine.

In the world of medicine, race-based diagnoses are still very real

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GENE DEMBY, HOST:

What's good y'all? You're listening to CODE SWITCH, the show about race and identity from NPR. I'm Gene Demby. On this episode, race science is embedded in our medical system. So what do we do about it?

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DEMBY: OK. So let's say you're thinking about getting a new piercing, right? - septum, a new earring, maybe someplace more ouchy, maybe? And you go to the place, and you get a little stab through your skin with some metal - such are the wages of being fly. And you got your dope new piercing. And it's shiny, and you're getting compliments on it - all that good stuff. And then some time passes and - oh, no - you got a scar.

ANDREA DEYRUP: So most people, when you get, like, a small cut, it just heals right back up. And, you know, several months later, you can't even tell that you had a cut there.

DEMBY: But the scar is raised and maybe a little painful. And now you've got to take your new piercing out to deal with it. Ugh.

DEYRUP: Other people, when they get a small cut or a puncture wound or vaccination, get this really exuberant scar that forms, and that's called a keloid.

DEMBY: That voice you're hearing, by the way - it belongs to Andrea Deyrup. Andrea is a medical professor or, more specifically...

DEYRUP: The course director for pathology at Duke University School of Medicine.

DEMBY: And Andrea said the thinking has long gone that keloids are kind of a Black people thing.

DEYRUP: It's very common in the medical literature to say that African Americans or individuals of African descent have an increased risk of keloids.

DEMBY: There's this figure that's out there - that's been out there forever - up to 16% of Black people will get keloids.

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DEMBY: So Andrea had been doing a deep dive into how race was being used in one of the textbooks she used when she was teaching her medical students. It was a textbook, coincidentally, that she was helping to edit. Anyway, each time that textbook referenced some sort of medical disparity based on race, she would go back and dig through the scientific literature and try to find out where that information was coming from. And one of the early examples she came across was keloids. And she thought, OK, this one's easy.

DEYRUP: Literally, I was like, everyone knows they're more common in people of African descent. Everyone knows this. And a keloid is so boring to soft-tissue pathologists 'cause we're looking at, like, really, you know, challenging - you know, things with chromosomal translocations and things like that. So this was going to be boring, and I'll find a couple of things and expand on it.

DEMBY: She started looking where a lot of doctors might - this kind of Wikipedia thing for physicians called UpToDate. Here's Andrea giving a lecture about it on YouTube.

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DEYRUP: Now, because of my work for my students, not only have I read UpToDate, which is always a great place to start, but I'd actually also read reference five by Robles and Berg.

DEMBY: She starts actually reading through all the layers of references. What was the origin of that 16% number? Who were the references referencing?

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DEYRUP: These two references that Robles and Berg are using...

DEMBY: And what Andrea thought would be a cut-and-dry lookup for the citation turned into kind of a quest.

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DEYRUP: Not looking at Hispanics or Blacks - it is looking at earlobe keloids in individuals in Turkey. And here are the three references they use.

DEMBY: It was one that took her back decades and decades...

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DEYRUP: Koonin from '64 and Oluwasanmi from 1974.

DEMBY: She reached out to medical institutions and researchers around the world to try to track down the source of this number.

DEYRUP: I actually had to email a journal office in South Africa, saying, look, there's this paper. I really - I'm trying to find this 16%, and it may be in your paper. Can you send me a copy? I was like a dog with a bone. I went all the way back until I found it, and it was in a journal from 1931.

DEMBY: 1931.

DEYRUP: And that number had come through 90 years.

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DEYRUP: And what had happened was there was this meeting in Strasbourg, France, and someone was talking about keloids - a guy who's from the Belgian Congo. And he says, well, I was in the Belgian Congo, and I looked at - let's see, he looked at 1,205 Black adult workers. And I counted the keloids - 16% of them had keloids.

DEMBY: OK. So if you don't know the history here, the Belgian Congo was the site of some of the worst atrocities during the so-called Scramble for Africa in the late 1800s and early 1900s. Andrea said that this was the backdrop in which this European dude - a doctor - observed that 16% of the workers he saw had keloids.

DEYRUP: And think now - that figure that we see on UpToDate - that 5- to 16% - this is where that 16% comes from. It comes from 1931, non-peer-reviewed literature from a meeting.

DEMBY: Again, one study, one dude, and here we are today. But Andrea said, OK, OK. Even if you want to wave away the very messed-up social context in which this dude observed these scars on workers in the Belgian Congo...

DEYRUP: You certainly can't say everyone from Africa or anyone of African descent has a risk of keloids.

DEMBY: Africa is the most genetically diverse continent on the planet. Like, genetically speaking, a random Black person in the United States and a random white person in the United States might have more in common genetically than a Black person from South Africa and a Black person from the Congo. But back then, people believed that race was a biological fact with real, identifiable biological boundaries. And today, we know that that's just not true.

DEYRUP: So here's what makes it even worse, OK? So on that very same day in 1931, someone else had got up and gave his talk, right? And this was a guy who lived in Switzerland. And he was also interested in keloids. And he just walked around Switzerland, and he looked at people there. And he looked at a total of - let's see - 834 adults in Switzerland. And he found that 13.3% of them had keloids.

DEMBY: Andrea said in practice, the difference between 16% of these workers in the Belgian Congo and 13.3% of Swiss randoms is...

DEYRUP: Minuscule when you're talking about something clinical.

DEMBY: But over nearly nine decades, the differences between how we see scars on the skin of lighter-skinned people and scars on the skin of darker-skinned people has become codified into medical textbooks. These ideas about Black folks and keloids affect diagnosis and affect treatment. And the research she put into all this convinced UpToDate - you know, the widely used reference for physicians - to remove the links between race and keloids. They did that in 2022. And so a bunch of the ways a doctor might handle treating your scarred-up piercing, you know, that's been bothering you for this entire hypothetical - it might be totally different now. Andrea's obsession with answering this question about keloids and what she found was just one part of this ongoing project of hers to look into what other janky race science stuff is still infecting - no pun intended - the ways we think about race and medicine today. So I started asking Andrea about what problems she saw in the way race and medicine continue to be braided together.

DEYRUP: So one of the things I think that most laypeople don't understand is how much race plays a role in medicine. We teach medical students - and I learned as a medical student - that certain races are predisposed or have a greater tendency to certain diseases. So, for example, we're taught that cystic fibrosis is something that we see in European Americans. And the problem with this is - there are multiple problems. So one is that really pretty much anybody can get any disease. So there are people of African descent who get cystic fibrosis and people from Latin America who get cystic fibrosis. And we're not doing a good job of identifying those people.

The other issue is when we talk about something like sickle cell disease and we say it's something African Americans get, African Americans are not a homogeneous group at a genetic level, and so to make assumptions like this is something that we do as clinicians. So if an African American child presents to the emergency department four or five times with a cough and a fever, that person might not be recognized as having cystic fibrosis, whereas if someone comes in and they're European American, they'll say, oh, cough and fever multiple times - this child might have cystic fibrosis. And so we are able to make the diagnosis more clearly.

DEMBY: So biological race isn't real - at least it has no biological basis in fact, right? So what does it mean when people say something like Black people are way more likely to get sickle cell than white people? Like, what are we talking about when we say those things?

DEYRUP: So it's a heuristic or a shortcut, right? So we know that sickle cell disease originated in areas where there was malaria. So having that particular mutation in your hemoglobin gene is protective against malaria. So we actually will see it in parts of sub-Saharan Africa as well as Western Africa, which is where many enslaved Africans were taken from, which is why we associate sickle cell disease with African Americans. But we also see it in parts of southern Europe like Greece and Italy. We see it in the Middle East. We see it in parts of India. So you have the mutation that causes sickle cell disease, right? That is a spontaneous mutation. So someone had that mutation in their DNA, and that person had a survival advantage and was able to have children.

DEMBY: OK.

DEYRUP: So we have other mutations that have arisen in other parts of the world. So there are the thalassemias, which we can see in parts of Africa as well as parts of southern Europe. So there are a lot of different adaptations that protect against malaria. But this gets really complicated because of population admixture. And so a lot of assumptions are made. You look at someone who has an appearance of someone who descended from Africa, and you say, ah, that's an African American. That person is at risk for sickle cell. Well, it depends on where their ancestry is from. If they didn't come from an area that had that historically, then they're not at greater risk. This is really complicated.

DEMBY: If I go - but if I go - so if I go to a doctor's office and it's my first time at, like, a GP, they're using my racial identity as - given that I'm Black - as a sort of, OK, we need to probably do an additional screen to see if this person has sickle cell trait.

DEYRUP: Right. Well, so sickle cell trait itself does not cause significant problems. So you can have sickle cell trait and be really perfectly healthy. The issue would be if you were planning on having a child, you and your partner would want to get tested to see if that child would be at risk for that. For example, I have a friend who's African American, and she knows that she carries one of the sickle cell alleles. An allele is just - it's a name for the type of gene. And her husband is European American. And so they were going to have a child, and she said, OK, you need to get screened for sickle cell. And he's like but I don't need to because I'm white, right? White people don't get sickle cell.

DEMBY: Right.

DEYRUP: Well, actually, a lot of white people can, and we can't tell by looking at somebody, how they appear to us, what their genotype is, what their genes actually are. So what happens is we have this vast oversimplification of who can get a disease and who is less likely to. And this informs how a patient is seen by their clinician. And this can have an effect on the appropriate tests being ordered, appropriate care being given, so that's - a delay in diagnosis is - can be associated with what we call race-based medicine. And so race-based medicine is this idea that race is an important variable in your health and that it's important for me to know your race because this will help me to know what diseases are more likely.

Now, there's a whole nother really complicated aspect of that. So what I'm really talking about, and what you referred to earlier, is biological race. So we know - and I want to make this absolutely clear, and you said it yourself - there are no biological races in humans. But we do have socially defined or socially constructed races. You're very familiar with that. That's what the census does, you know?

DEMBY: Right.

DEYRUP: And we cannot discount the impact that socially defined race has on humans - right? - from exposure to toxins, lack of access to care, lack of access to nutritious food, increased stress leading to weathering - all of that. And so that can confuse the issue when we're talking about the importance of looking at race in medicine. On the one hand, we want to be sure we're not implying that there are biological races. On the other, we have to be aware of the additional burdens that some populations bear because of their socially defined race.

DEMBY: That seems like a really difficult demarcation to get people to sit with, right? Like, if people were like, oh, well, because we know that Black women suffer from weathering - right? - I imagine a lot of people are like, well, who cares whether it's biological, whether it's - this is a function of, you know, the conditions of living in America, right?

DEYRUP: Ah. So here's the important thing, right? If you think there's biological race and you see an unhealthy person from a subordinate population or from - you know, from one of the groups, it doesn't have access to everything, you're like, oh, they've got bad genes, or they don't take care of themselves. They have risky behaviors, right? So what that implies is it's that person's fault, right?

The other problem is that if we say, for example, oh - and there's - there have been studies on this - African American kids and Latin American kids in public housing in urban centers have higher rates of asthma, OK? And there are researchers who's like, oh, there's a genetic reason for it. Well, let's look at the environmental reasons. So we know that areas that were historically redlined have higher burdens of particulate pollutants that exacerbate or can cause asthma and respiratory illness. We know that there's more rodent and pests in the area that can cause allergens, can lead to asthma.

If we say it's something biological, then we don't have to focus on cleaning that area up or taking care of those kids and making sure they have a clean, safe place to live. We're like, oh, they just have bad genes.

DEMBY: So it sort of changes the focus of where people put their public health emphasis.

DEYRUP: Yeah.

DEMBY: Right? Like, these are conditions that we can mitigate in some way, right? Like, then maybe we can actually do something about these health outcomes, right?

DEYRUP: Right. Right. So it's a question of blaming the patient or recognizing the role of the environment and saying we need to fix the environment so these kids don't get sick. One costs money, and the other's easy.

DEMBY: Coming up, where doctors are learning this race-based medicine.

DEYRUP: Just because it's in the textbook doesn't mean students learn it. They learn it because it's on the test.

DEMBY: Stay with us.

Gene - just Gene this week. CODE SWITCH. So we're talking to doctor Andrea Deyrup. She's the head of the pathology department at Duke University. And for years, she's been trying to help students and physicians unpack some of the messed-up ways that they're taught to use race to make diagnoses for their patients.

DEYRUP: So where are doctors learning race-based medicine, right? I mean, it's like, someone has to be teaching it to them, right? I mean, I have a talk that I give called Nearly Everything You Learned About Race In Medical School Is Wrong. And I've given that with my colleague, Dr. Joe Graves Jr., about 70 times across the country. So just because it's in the textbook - right? - doesn't mean students learn it, right? They learn it because it's on the test.

So in order to become a physician, you have to take a series of exams. These are called your board exams. And for MDs, for medical degrees, they have Step 1, Step 2. And the Step 1 exam is one that tests your basic understanding of all of the basic sciences. So one of the issues is that the questions in the board exams test race-based medicine. And this is very well known, you learn these associations. And so what happened in this 2017 study by Ripp and Braun is that, I mean, we can't go to the board exam itself. So that's run by the National Board of Medical Examiners. We can't say, hey, can we see your questions? We want to see how much race-based medicine you have. We can't do that because that's proprietary. So what they did was the next best thing. So they looked at one of the most widely used test preparation programs worldwide. It's called UWorld. And apparently, about 250,000 students every year use this for health care professions.

DEMBY: Wow. OK.

DEYRUP: So nursing, medicine, etc. And so what these two researchers did was they looked at the questions for what's called Step 1, so the first exam that you take on your way to becoming an MD, and they just catalogued whether race was used in the question stem. So for example, a 35-year-old African American man presents with a three-day history of cough. Or a 17-year-old Native American girl presents with X, OK? So they found that, you know, race wasn't used often. I think it was about 463 times out of over 2,000. And they classified this as to whether race was being used as a descriptor. So it had nothing to do with getting to the right answer. So say, for example, it could be a European American man who's in a car accident. So that has absolutely nothing to do with what his socially defined race is.

DEMBY: Right.

DEYRUP: Or it was central. Like, if you knew that person's race, you were going to be able to get the right answer and you needed to make that association. So it was an African American. It would be someone maybe with sickle cell, right? and what they found was that if you're looking at the category - and the terms they used were white and Caucasian - that about 93% of the time it was purely descriptive. It had nothing to do with getting the right answer. So what that's telling you is that the person just happened to be white and something happened. And then about 7% of the time, knowing that person was white was going to help you get to the right answer.

DEMBY: I see.

DEYRUP: And if you look at how many times people were white in the entire study, that was about 86% of the time. According to the 2020 census, the white population is about 62% of people. So we would say this is, like, centering whiteness.

DEMBY: Absolutely.

DEYRUP: Now, what I find even more problematic about that study is if you look at the category of Native American. So there were only three questions that mentioned someone who was Native American. And in every single one of them, that person didn't just happen to be Native American, it wasn't a Native American who was in a car accident, it was a Native American who had a Native American disease like, there's one called severe combined immunodeficiency, you know, we commonly associate gallstones with people who are Native American as well as lactase insufficiency. And so that, for me is very problematic because we're teaching these young students, these young physicians to be, that certain races get certain diseases. And if you look at someone who comes in and she's, you know, Native American and she says, oh, you know, I've got this pain here in the right, upper part of my abdomen. And you think, oh, it's a Native American. She's got gallstones. Because that's the link that we teach our students...

DEMBY: Right.

DEYRUP: ...The truth of the matter is she could have acute appendicitis, or she could have an atopic pregnancy, and that could kill her while you're thinking, oh, Native American with gallstones, just like I learned in my textbook. So it - the problem here - and this is one of the things that Dr. Graves and I have done - was actually met with the National Board of Medical Examiners three times to talk with them about removing race and ethnicity from their questions and not testing race-based medicine.

We have met with the National Board of Osteopathic Medical Examiners, and we've met with the American Board of Pathology, and in each time, we're trying to say to them, if you teach race-based medicine, if you test race-based medicine, they will learn it, and this is going to carry on. And I would say that the response from all three groups of people who write the assessments that people need to pass to become licensed physicians, or in the American Board of Pathology to become licensed pathologists, we're told we are going to keep race-based medicine.

DEMBY: What is the risk of using race as a diagnostic tool, as using it as a heuristic?

DEYRUP: So when we look at people, we can easily say, you know, that this is - this person is this race and that person is that race, but 99.9% of our DNA is the same. So whatever differences that we have, which we have, I mean, and that's one of the things, I think, that makes race so difficult to dissociate from biology. I can see someone has darker skin. I can see someone's hair texture or eye shape. And so that makes me think because I can see this difference, they must be different. But the truth of the matter is, is that the differences there are tend not to be medically relevant.

You know, human beings are - our genome is incredibly complex. And so we have some diseases that are caused by a single mutation, like cystic fibrosis and sickle cell. But for other diseases, it's many different genes that are working together that cause the soil to be ready for a particular disease to grow. And those genes are going to interact with your environment. And so part of the challenge is if we look at the environment experienced by different socially defined races in this country, they are vastly different. So the environmental exposure for someone who identifies as Black are typically very different from what you see in someone who identifies as white. And that environment is going to have an impact on their genome. And what people are saying is that no Black people get this because of their biology. Well, it's an interaction of biology and their environment, and the environment tends to be much more toxic for certain populations in our society.

I also think in addition to just the pure issue of missing diagnoses, right? So, like, the - one of the anecdotes that I tell in the talk I give is of an 8-year-old girl who presented multiple times to her physician with fever and cough, and, you know, they treated her, and that was fine. And at the age of 8, there was a radiologist who looked at her chest film, and literally, he could not see the color of her skin. And he said, who's the kid with cystic fibrosis? No one made that diagnosis when they saw her because she was African American, and African Americans don't get cystic fibrosis is what they had been taught. So it's really important that we diagnose people early with cystic fibrosis because if you give them appropriate care early on, they'll live much longer.

Now, there's another embedded part of systemic racism in this, which is that when, you know, a baby is born - we can do a genetic test looking to see if they have cystic fibrosis. And the issue with cystic fibrosis is there are lots and lots of different mutations that can cause it. There's, you know, a hundred different mutations. So it's very expensive to sequence an entire gene. So what they'll do is they'll do something looking at 20 or 40 different mutations, and the mutations that they're looking at are primarily ones that are seen in Europeans. And so that's one of the reasons why we're not picking up cystic fibrosis in children who are not of European descent, because we're not using the right screening test.

Delay in diagnosis is one issue, but I also think there is this whole weight where - I mean, Joe Graves has a paper called "The Myth Of The Genetically Sick African." There is this way that we are putting down African Americans as being unhealthy in this belief that this population - there's something wrong with it. I mean, we had something once where we do pulmonary function tests, which is to see how well your lungs are functioning, right? You breathe through a tube. And we had someone come up, and it was an African American woman, and she did her pulmonary function test and was told, oh, that's impressive because African Americans don't typically have very good pulmonary function. Well, that comes back from Thomas Jefferson, right? Thomas...

DEMBY: What?

DEYRUP: ...Jefferson made a comment about that, right? So Lundy Braun has a book called "Breathing Race Into The Machine," and the machine being the lung spirometer, which is the one that tests pulmonary function. And there was a lot of racism in medicine early on because a lot of it was being used to prove that Africans were better suited for the hard work and toil that was part of slavery because it helped them with their lungs, or they were better able to withstand the heat, so they should be doing this.

And, I mean, you know, from the Tuskegee syphilis study to early surgeries by one of the early gynecologists...

DEMBY: Gynecologists, yep.

DEYRUP: ...On doing surgery - yeah, so I mean, it - I mean, just horrible stuff, and it trickles through. I mean, I feel like you can't get away from your origins unless you turn and face them and you call them out for what they are.

DEMBY: How should we be thinking about racial disparities when it comes to health, right? Like, when COVID first struck the United States, Black people were dying at far higher rates than white folks were. And no one is saying, and it's probably because of the social determinants of health. That's not what's happening after that, right? People were just saying that and letting it lie, because those disparities are important, and they matter. But...

DEYRUP: Yeah.

DEMBY: ...How should we also be contextualizing those disparities? You know, people who are disseminating this information - right? - like, how do we both underline that those disparities are important and those disparities come from the sort of arrangement - the way we decided to arrange our society?

DEYRUP: I think the way you just said it just sums it up, you know? It's that. you know, I have a long list that I talk about with my students. And I basically say, whenever someone says to you, ah, this is more common in or has a worse prognosis in this socially defined race, is to look at all the extrinsic causes and say, what could this be?

The other thing - and this is something that Dr. Graves and I are in deep agreement with - is that if you really want to have an impact on health disparities in this country, we need to have universal health care because it is the lack of access to care and the lack of access to good care, the lack of access to consistent care, that is a primary driver.

And this is - I mean, there are lots of other issues as well. For example, we know that because of the experience of the African American community - that there is lack of trust in physicians. And based on my reading, I think it is well placed. And we don't have enough African American physicians - again, part of structural racism. We know that patients do better - like, African American patients do better with an African American doctor. So we need to, as a society, work to support having physicians who can represent the populations that they are serving. So there are many other issues, but universal health care would do so much for disparities.

DEMBY: How would you respond to a doctor who said to you, all right, I hear what you're saying, but we're also really busy. We're really overworked. And they're like, look, I'm in a clinic. I'm interacting with patients, lots of them. I don't have time to go through family histories with everybody I speak to. So I'm going to make recommendations to those patients based on what we know immediately - like, you know, race - as the clinician or as the patient identifies it, right? So what do you say to those people when they say that?

DEYRUP: I say people are dying and people are suffering. And you came into medicine - first, do no harm. So I agree that clinics are really full. And because we have now a health industrial complex, where profit motive is a very strong factor in medicine, one of the pieces of advice that I give to young physicians is work part time. Say that you'll work 50% or 75% of the hours. So you work, say, three days a week, but you go in five days a week. Physicians earn enough as a salary that you can work shorter hours and still have a comfortable life.

So I said, say you go to work 25 hours a week, but work 50, because that will enable you to give the care that you want to give. You'll be able to spend more time with that patient.

I don't know if anyone has actually taken me up on that. It is something that I did as a pathologist - was I cut back on my clinical hours so that I could spend more time working on each of those cases. If we're just rushing to get through because we're overwhelmed, we're not taking good care of our patients.

DEMBY: What's so interesting about what you're arguing - and, like, sort of hard to digest, but, like, important to sit with - is that so many of us use race as a shorthand all the time, right? Like, outside of the context of medicine, we talk about race as if it's a biological phenomenon. It's not just doctors. How do you think your research should affect the way that those of us who are laypeople talk about race in our everyday lives?

DEYRUP: I actually don't have a real comment about that because we know that social defined race has a huge impact on all of our lives. You know, the fact that it's not biological doesn't mean it's irrelevant.

DEMBY: Right.

DEYRUP: I would say that - the most important thing I would say to laypeople is to really question your clinician - your physician - when you see them, right? So when they say, oh, it's probably this, then to say, well, is there something that you're thinking of because of my race? So there is a mnemonic that we use to teach students how to come up with a good differential diagnosis.

So a differential diagnosis is someone presents to you, and they have five or six symptoms. And we never know - well, we usually don't know - right when you look at them - what the disease is. So you'd say, OK, here's, like, my top number one thing I think it could be. But it could also be two, three, four or five. When you get to the end, you think, OK, here's number five. These are my five things I think it is - is you stop and you say, is there something that I would think about if this person were a different social defined race or ethnicity? But I understand the power dynamic between a patient and a physician is really tough.

You know, I actually think that U.S. healthcare is a really perilous place to be, no matter what your socially defined race. And I don't know how I would manage my care or the care of my friends and family if I were not a physician. And in fact, it's very difficult for me to figure out sometimes what I need to do. And I'm actually a physician in a large academic center.

DEMBY: Right.

DEYRUP: It can be very confusing. So I guess I would just recommend that patients - be stubborn. You know, don't worry about being seen as a bad patient. Really ask your questions, and don't just put your faith in the system. And I understand that many people don't because the system is broken. And I really think the onus is not on the patient. It's really on us as physicians. And I guess, you know, you say how my work could have an impact on, like, broader society as a whole.

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DEYRUP: It's basically to say, look, we're all 99.9% the same. And the more we can recognize that we are really all pretty much the same and we all need to help each other out, the better it would be.

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DEMBY: Andrea Deyrup is a professor of pathology at Duke University's School of Medicine. Andrea, thank you for coming on. I appreciate you.

DEYRUP: My pleasure. Thank you so much for inviting me.

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DEMBY: All right, y'all. That is our show. You can follow us on Instagram - @nprcodeswitch. If email is more your bag, ours is codeswitch@npr.org. And subscribe to the podcast on the NPR app or wherever it is you get your podcast. And another way to support our work here is to sign up for CODE SWITCH+. It's small, but it really makes a difference for us over at CODE SWITCH. You get to listen to every one of our episodes without any ads. You can check us out at plus.npr.org/codeswitch. And thank you to everybody who's already signed up.

This episode was produced by Jess Kung. It was edited by Leah Donnella. Our engineer was Josh Newell. And we'd be remiss if we did not shout out the rest of the CODE SWITCH massive. That's Christina Cala, Xavier Lopez, Cher Vincent, Dalia Mortada, Veralyn Williams, B.A. Parker and Lori Lizarraga. As for me, I'm Gene Demby. Be easy, y'all.

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