Racial disparities are rampant in healthcare. In addition to structural inequalities, the issues are partly due to racial bias among healthcare workers. These biases stem in part from the way race is presented in medical curricula. That's the topic of this week's Healthcare Triage.

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Race is a common topic in the realm of medical education, and for good reason. There are major racial disparities in both disease prevalence and disease outcomes. Having medical students understand this is critical, but unfortunately, the approach schools often take oversimplifies the issues, and worse, sometimes propagates false ideas.

Reviews of medical lectures from various institutions have found several themes that promote problematic racial bias. These include things like imprecision in the language used to talk about race and providing racial differences in the prevalence of disease rates without appropriate context.

It also includes the practice of pathologizing race, or linking minorities with particular pathologies. Race-based clinical guidelines are also an issue, as is direct racial diagnostic bias, which generally occurs when race itself is viewed as a risk factor for a disease.

Race is too often simplified in education without sufficient examination of what it actually is. Race is not a biologically defined concept that produces different health outcomes in different people.

Genetic studies tell us that there is no biological basis for race. Genetic and physical traits don't accurately and consistently stratify people to any consistent race. The narrowly defined racial groups in which we often place people are actually extremely diverse.

For example, the term "African-American" includes a huge spread of people from various nations whose families may have been forced into slavery or may have recently immigrated from African nations, meaning their ancestry and genetics would be very different.

So what, then, is race? It's a socially defined construct that leads to different experiences for different people, and it's those experiences that underlie racial disparities in disease and disease outcomes.

In a study of a popular pathology book used in medical education, seventeen of 31 statements that identified race as a risk factor for certain diseases could not be confirmed in the literature, and three were directly contradicted.

Rather than presenting racial differences in health status and health behaviors as a result of things like environmental and social inequities, these differences are presented as being based on innate, biological factors belonging to every person assigned to a racial group.

During classes, information about associations between race and health are often presented without meaningful context and nuanced discussion about why these associations exist.

One of the reasons that this distinction is so important is that when health disparities are chalked up to racial differences as a matter of biology, it leads medical professionals to form incorrect assumptions about patients, which can, and does, affect how patients are diagnosed and treated, which then exacerbates poor health outcomes among minority groups.

One study looking at a popular question bank for medical students looked at how often race being mentioned was central to the diagnosis.

When a patient was described as White or Caucasian, this was only "central" to the diagnosis around seven percent of the time.

When a patient was described as Black or African American, or Hispanic, that number jumped up to forty-three and thirty-three percent, respectively.

Native American ethnicity was rarely described, but when it was it was central to the diagnosis one hundred percent of the time.

To give an example of this in action, Hispanics in the United States are at very high risk for obesity. Presented without context, and without education on what race really is, this may easily be taken as a risk inherent to those categorized as Hispanic.

However, evidence suggests that this risk is actually related to environment, with the association actually being due to length of residence in the United States, poor health behaviors including diet increase as time in the United States goes on.

We can also think of sickle cell disease, which is often thought of as being most common among African Americans but can more accurately be described as a disease of people from areas endemic to malaria.

Cystic fibrosis is often thought of as being most common among White people, though it can more accurately be described as a disease of people from areas where cholera had a high prevalence.

Ignoring that context and instead ascribing these diseases to the non-biological concept of race can lead to diagnostic delays that unnecessarily harm.

For example, a Black patient with cystic fibrosis may experience a diagnostic delay because a physician associates this disease with White people.

Additionally, some guidelines or medical equations include race as a factor. Most notably, the equation classically used to evaluate kidney function includes a correction for race which can lead Black patients to receive medications that can cause harm and can result in delays on when they can be considered for a kidney transplant.

And sometimes, the problem is what's left out of medical education. For example, training images used in dermatology often fail to use a diversity of skin tones despite the fact that dermatologic conditions present differently on different skin tones.

Medical schools around the country have started to take action on these issues, often thanks to efforts led by medical students advocating for change. Some recommendations published in the New England Journal of Medicine include standardizing the language used to describe race and ethnicity, adding context in lectures to better understand racial and ethnic healthcare disparities, and furthering research on the issue of race in medicine through a more careful, nuanced lens. New medical equations that don't include race as a factor are being proposed.

This is great, but we've still got a long way to go, and we have to keep on pushing for change. Lives depend on it.

Special thanks to Eliot Rapoport who did the heavy lifting on this episode.

Hey did you enjoy this episode? You might enjoy this previous episode on how education affects health.

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