COVID-19 exacerbated various preexisting racial health disparities, which ushered in a racial reckoning in the medical field. As a result, many medical institutions attempted to implement meaningful changes to dismantle systemic racism within their teaching and clinical environments. Yet, a tool used daily by almost every physician, the history of present illness (HPI), may still perpetuate medical racism.
“A 21-year-old African American female presented in the emergency department with diabetic ketoacidosis.” The first line of a patient’s history often includes their race. Many physicians believe race is an important aspect of clinical decision-making, useful for identifying risk factors and treatment options. However, these labels are inaccurate proxies for risk factors and treatment contraindications and can even hurt patients. In particular, these labels could reinforce racial biases and prevent patients from receiving standard medical treatments.
Physicians often determine racial and ethnic labels themselves rather than asking patients to self-identify. Providers who are not racially/ethnically concordant with their patients—that is, both come from different racial or ethnic background—may incorrectly conflate race, ethnicity and ancestry. Additionally, patients are typically asked to self-identify in clinical trials. So, when choosing patient descriptors, doctors may reinforce biases rather than exact some biological relationship identified by researchers. In reality, many patients do not even self-identify into categories used by researchers, making the entire process of categorization obsolete.
Beyond the issue of physicians using inaccurate racial labels, research has proven what scholars like W.E.B. Du Bois and Derrick Bell stated for decades: race is a social construct. In particular, a person’s phenotype, how someone physically presents, may not hold meaningful clues for their genotype, someone’s genetic make-up. For instance, a landmark study in the journal Science found that two people of European descent may be more genetically similar to an Asian person than they are to each other. Thus, even when patients self-identify, their race is not a clinically valuable identifier.
Finally, the practice is inconsistently used, where health care providers were more likely to include race in a patient’s HPI if they were a Black American. This pattern by clinicians highlights how these labels are often an unwieldy outlet for bias rather than evidence-based clinical practice. In fact, when physicians focus on race it is more likely to detract from care than bolster it, negatively affecting aspects of patient care like the time allotted for a visit.
The relationship between race and certain diseases, such as diabetes, sarcoidosis and lupus, is complex or not well understood. Some doctors may argue that patients’ race is needed to crystallize their differential diagnosis but, outside of race, there is a constellation of symptoms that elucidate the clinical picture of these diseases, which makes it an unnecessary addition. Physicians who ascribe race as a risk factor for diseases like diabetes, cancer and cardiovascular disease might miss a diagnosis in some cases may also misconstrue upstream, social determinants of health as innate genetic differences.
By erasing these modifiable factors (e.g., access to nutritious food, socioeconomic status, stress levels, access to health care, environmental health, etc.), which are maintained by systemic racism, the medical field unfairly places onus on a patient’s genetics. This practice has the potential to fuel racial bias amongst the general public, as many people look to the medical community to understand biological minutia and operate on objectivity. By using this outdated practice, physicians may be reinforcing the incorrect idea that race differentiation holds scientific value instead of being a clumsy artifact of the profession.
Unfortunately, this practice may not only stoke racist beliefs but also introduce immediate bodily harm on Black and brown bodies. In certain medical formulas, such as estimated glomerular filtration rate (eGFR) and vaginal birth after Cesarean section (VBAC), plugging in a Black or nonwhite Hispanic patient’s race into the calculations could preclude them from receiving a kidney transplant or being offered a vaginal birth.
In addition, codifying a patient’s race in their medical records may limit them from receiving high-quality treatment. Clozapine, an effective antipsychotic, is underprescribed in Black American populations because of the fear of benign ethnic neutropenia (BEN), defined as an absolute neutrophil (a type of white blood cell that aids a person’s immune system) count below 1,500 microliters. BEN is a diagnosis that was created when African American populations were found to have lower neutrophil counts compared to white Americans in the 1940s. However, this lower white blood cell count was simply relative and did not confer an increased risk of infection. Today, many Black American patients who would benefit from receiving clozapine are either not offered it, consequent to physician fear of BEN, or forgo it themselves when told they will need invasive blood draws and frequent monitoring.
The preconceived correlation between Black Americans and BEN has also affected breast cancer treatment in African American patients. Studies demonstrate there are breast cancer survival disparities between Black Americans and white Americans. Aside from socioeconomic status and health care differences, the discrepancies may be related to the fact that, out of concern for lower baseline absolute neutrophil count, physicians more frequently reduce doses and discontinue chemotherapy treatments in African Americans, in turn, lowering survival rates.
It is important to note that, when compared to other cancer patients, BEN patients are not at an increased risk of infection or neutropenic fever after initiation of chemotherapy. So, these race-based clinical decisions may be doing more harm than good. Altogether, using race as a medical tool in a patient’s HPI has social, historical, and medical consequences and needs to be rethought.
Many physicians believe it is crucial to incorporate race into a patient’s note. They argue that it is an important medical indicator, a convenient stand-in for genetics. But, if physicians are truly trying to discern if patients are carriers of genetic allelic variants that cause severe medication reactions (e.g., antiepileptic drugs causing toxic epidermal necrolysis in people with HLA-B*15:02 alleles) or put them at an immensely higher disease risk (e.g., the Duffy antigen/receptor chemokine gene and neutropenia), then genetic mapping should be used in high-risk patients. Although genotyping is a more costly option, using racial suspicions to deny patients gold standard treatments—that have better health outcomes and side effect profiles—is hardly cost-effective. Most importantly, this type of gradated treatment is inhumane.
Some medical professionals already recognize the lack of basis for employing race-based medicine. For instance, the New England Journal of Medicine’s highly regarded weekly section “Case Records of the Massachusetts General Hospital” does not include race in the first sentence of patients’ histories or really at all. In Canada, a country with immense racial diversity and good health outcomes, neither the Canadian Medical Association Journal nor the Canadian Journal of Surgery reports race in their case reports. To be clear, a “color-blind” approach is not ideal either. The understanding of race is important for health disparities research. Yet, when it is collected in research settings, it can be done in a self-identified, consistent and consensual manner.
Ultimately, medicine is reaching a tipping point. The National Kidney Foundation recently announced that it would no longer be using race as part of its eGFR calculation for kidney function and transplant urgency. Changes like these illustrate that these are not just radical arguments embedded in social justice. They are sound, scientific arguments embedded in evidence-based medicine, with the goal of providing the best patient care possible at their core.
Together, the genetic inaccuracy, lack of patient self-identification and biased use of racial labels by providers when writing HPIs make it more likely to perpetuate racism than optimize patient health. In general, noting a patient’s race in the first line of their history is not clinically useful in understanding their disease or creating a treatment plan. Factors like a patient’s family history, insurance status, work, transportation, nutrition and housing situation are more medically indicative. If the medical profession is serious about addressing racial health disparities, it may need to rethink some of its fundamental tools. Civil rights activist Audre Lorde wrote, “The master’s tools will never dismantle the master’s house.” If we continue to unquestioningly use tools developed by the mostly white forefathers of the medical profession, we may never actually change racial health disparities.