Advancing Race-Conscious Medicine: Using Debate to Promote Critical Appraisal of Race in Medical Literature.

Advancing Diversity, Equity, and Inclusion in Scientific Publishing

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Medical curricula implicitly teach that race has a biological basis. Clinical rotations reinforce this misconception as race-based algorithms are used to guide clinical decision-making. This module aims to expose the fallacy of race in clinical algorithms, using the estimated glomerular filtration rate (eGFR) equation as an example. We created a 60-minute module in consultation with nephrologists. The format was an interactive, case-based presentation with a didactic section. A third-year medical student facilitated the workshops to medical students. Evaluation included pre/post surveys using 5-point Likert scales to assess awareness regarding use of race as a biological construct. Higher scores indicated increased awareness. Fifty-five students participated in the module. Pre/post results indicated that students significantly improved in self-perceived knowledge of the history of racism in medicine (2.6 vs. 3.2, p < .001), awareness of race in clinical algorithms (2.7 vs. 3.7, p < .001), impact of race-based eGFR on quality of life/treatment outcomes (4.5 vs. 4.8, p = .01), differences between race and ancestry (3.7 vs. 4.3, p < .001), and implications of not removing race from the eGFR equation (2.7 vs. 4.2, p < .001). Students rated the workshops highly for quality and clarity. Our module expands on others' work to expose the fallacy of race-based algorithms and define its impact on health equity. Limitations include a lack of objective assessment of knowledge acquisition. We recommend integrating this module into preclinical and clinical curricula to discuss the use of race in medical literature and clinical practice.

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Philosophy, ethics, medicine and health care: the urgent need for critical practice

Use of race and ethnicity is common in medical tests and procedures, even though these categories are defined by sociological, historical, and political processes, and vary considerably in their definitions over time and place. Because all societies organize themselves around these constructs in some way, they are undeniable facets of the human experience, with myriad health consequences. In the biomedical literature, they are also commonly interpreted as representing biological heterogeneity that is relevant for health and disease. We review the use of race and ethnicity in medical practice, especially in the USA, and provide 2 specific examples to represent a large number of similar instances. We then critique these uses along a number of different dimensions, including limitations in measurement, within- versus between-group variance, and implications for informativeness of risk markers for individuals, generalization from arbitrary or nonrepresentative samples, perpetuation of myths and stereotypes, instability in time and place, crowding out of more relevant risk markers, stigmatization, and the tainting of medicine with the history of oppression. We conclude with recommendations to improve practice that are technical, ethical, and pragmatic. Medicine has evolved from a mystical healing art to a mature science of human health through a rigorous process of quantification, experimentation, and evaluation. Folkloric traditions, such as race- and ethnic-specific medicine will fade from use as we become increasingly critical of outdated and irrational clinical practices and replace these with personalized, evidenced-based tests, algorithms, and procedures that privilege patients' individual humanity over obsolete and misleading labels.

IntroductionDespite the ubiquitous use of race within scientific literature, medical trainees are not taught how to critically appraise the use of racial categories. We developed a tool to appraise the use of race in medical literature and a workshop to teach this approach.MethodsThird-year medical students and second- and third-year residents participated in workshops between 2015 and 2018. We evaluated our UME workshop with a postworkshop survey. We evaluated our GME workshop with a pretest, immediate posttest, and 6-month posttest on self-assessed knowledge, skills, and use of the Critical Appraisal of Race in Medical Literature (CARMeL) tool in subsequent journal clubs.ResultsWe delivered this workshop to 560 students and 82 residents. Of the initial 140-student cohort evaluating the workshop, 99 (71% response rate) highly rated clarity of presentation, quality of teaching, and quality of slides. Of PGY 2 and PGY 3 residents, 67 (82% response rate) rated the workshop greater than 4.5 out of 5 on quality, clarity, and appropriateness of content. Residents had significant improvements in self-assessed knowledge and skills immediately after the session and 6 months later. Of residents, 74% reported using the CARMeL tool in subsequent presentations.DiscussionWe designed the CARMeL tool and a workshop to teach it. Trainees rated this workshop as useful, with the majority of residents later applying the tool. Limitations included a lack of objective assessment of knowledge acquisition. We recommend that institutions invest time in faculty development and pair new faculty with those experienced in anti-oppressive facilitation.

Research ObjectiveColorblindness is an ideology or worldview that minimizes the role of systemic racism in shaping outcomes for people of color and attributes racial disparities to the bad choices and poor behavior of racial minorities. Physicians who adhere to a color‐blind ideology may be less likely to critically interrogate the role of racism in shaping health outcomes, and, therefore, less likely to challenge race‐based treatment guidelines. The purpose of this study is to determine if colorblindness is associated with the use race in medical decision‐making.Study DesignThis is a cross‐sectional analysis of survey data. Our online survey included demographic questions and two validated surveys: the Color‐blind Racial Attitudes Scale (CoBRAS) and the Racial Attributes in Clinical Evaluation (RACE) scale. CoBRAS measures colorblindness using three continuous subscales to measure respondents' unawareness of (1) racial privilege (scored 7–42); (2) institutional discrimination (scored 7–42) and blatant racial issues (scored 7–36). Higher scores indicate a lack of awareness and thus higher levels of colorblindness. The RACE scale (scored 0–28) was used to determine the extent to which physicians used race in medical management, with a higher score indicating a greater use of race. Multivariate regression analyses were used to assess the relationship between a color‐blind racial ideology and the use of race in medical decision making.Population StudiedIn September 2019, the survey was sent to the 2039 members of the Minnesota Academy of Family Physicians (MAFP). MAFP membership includes active and retired family medicine physicians, family medicine residents, medical students and “other members” (honorary, inactive and supporting members). Only family medicine physicians and residents completed the survey.Principal FindingsOur response rate was 14% (267/2039). Higher CoBRAS scores were associated with an increased use of race (β = 0.05, p &lt; 0.01), after controlling for physician age, gender, race, location of training and practice characteristics. Of the three CoBRAS subscales, only unawareness of institutional discrimination was significantly associated with an increased use of race (β = 0.18, p = 0.01), after controlling for the aforementioned covariates. Additionally, physicians under 40 years of age, who worked in urban clinics, or had a clinic population consisting of at least 70% racial/ethnic minorities were significantly less likely to use race in their treatment decisions than physicians who were 40 years of age and older, worked in rural clinics, or had a clinic a population consisting of less than 30% racial/ethnic minorities, respectively.ConclusionsPhysicians who adhere to a color‐blind racial ideology, particularly those who deny institutional racism, are more likely to use race in their screening and treatment decisions.Implications for Policy or PracticeIn July 2020, American Academy of Family Physicians adopted a policy advising against the use of race in medical decision‐making. As the use of race may be due to colorblind racial ideology, and therefore due to a poor understanding of how systemic racism affects health, more physician education about racism as a health risk is needed. Additional research is also needed to evaluate physician motivations and beliefs as it relates to race‐based medical guidelines and policies.Primary Funding SourceMinnesota Academy of Family Physicians.

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