By Christina Amutah, B.A., Kaliya Greenidge, Adjoa Mante, A.B., Michelle Munyikwa, Ph.D., Sanjna L. Surya, B.A., Eve Higginbotham, M.D., David S. Jones, M.D., Ph.D., Risa Lavizzo-Mourey, M.D., M.B.A., Dorothy Roberts, J.D., Jennifer Tsai, M.D., M.Ed., and Jaya Aysola, M.D., D.T.M.H., M.P.H.
The New England Journal of Medicine, January 6, 2021
Conceptions of race have evolved and become more nuanced over time. Most scholars in the biologic and social sciences converge on the view that racism shapes social experiences and has biologic consequences and that race is not a meaningful scientific construct in the absence of context. Race is not a biologic category based on innate differences that produce unequal health outcomes. Rather, it is a social category that reflects the impact of unequal social experiences on health. Yet medical education and practice have not evolved to reflect these advances in understanding of the relationships among race, racism, and health. More than a decade after the Institute of Medicine (IOM, now the National Academy of Medicine, or NAM) issued its report Unequal Treatment, racial/ethnic disparities in the quality of care persist, and in some cases have worsened. Such inequalities stem from structural racism, macrolevel bias intrinsic in the design and operations of health care institutions, and implicit bias among physicians. The majority of U.S. physicians have an implicit bias favoring White Americans over Black Americans, and a substantial number of medical students and trainees hold false beliefs about racial differences.
These widespread problems are reflected in the fact that race is one of the most entrenched and polarizing topics in U.S. medical education. Efforts to advance health equity in medical education have ranged from implicit-bias training to supplementary curricula in structural competency, cultural humility, and antiracism. Researchers have highlighted the domains of misuse of race in medical school curricula and their potential role in propagating physician bias. In examining more than 880 lectures from 21 courses in one institution’s 18-month preclinical medical curriculum, we found five key domains in which educators misrepresent race in their discussions, interpretations of race-based data, and assessments of students’ mastery of race-based science.
Indeed, in all the authors’ home institutions we found similar misrepresentations of race.15 Social medicine or equivalent courses discuss race in a nuanced manner, but misrepresentations arise in all other courses, including organ-system blocks and basic science classes. Consideration of these five domains in the preclinical curricula (Table 1) inform our recommendations for correcting content that may reinforce or instill race-based biases (Table 2). (Use the link below to access the full article and the Tables.)
From the Recommendations
Medical education and research are intertwined and jointly responsible for perpetuating misunderstandings of race. Students carry such misinformation with them into the clinic, where their implicit biases and misconceptions perpetuate disparities in health care. We are not arguing that race is irrelevant, and our framework is not meant to trigger discussion of the advantages and disadvantages of using race in medicine; rather, we wish to provide evidence-based guidelines for defining and using race in generating and imparting medical knowledge. Race, though not a biologic concept, can be a starting point from which to generate hypotheses about environmental exposures and social processes that produce disparities in health outcomes. It is also vital to use race/ethnicity to measure and mitigate unequal treatment attributable to structural and individual implicit biases. Discussing race and naming racism are essential to promoting an antiracist culture. Rather than abandoning the use of race in medicine, we believe we should transform the way it is used, embracing a more rigorous, multidisciplinary, and evidence-based understanding of how race, racism, and race-based science contribute to inequities in health and health care.
By Don McCanne, M.D.
We all have our concepts of race and the consequences of racism, and in medicine it is particularly important to get it right, but we haven’t. The concepts presented in this article are relatively complex and cannot be communicated in brief excerpts. Thus the full article should be read and studied. Some may think that this article covers nuances of the topic, but it should be read as if these concepts represent the fundamentals.
Although this article indicates the need to introduce these concepts into the medical school curriculum, it should be obvious that those of us out in the field missed this in our training and thus would benefit, at a minimum, by the simple task of reading the full article.
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