We found that race is often presented in our medical school lectures (and, we venture, most medical school lectures) without context or justification. For example, racial categories are used as independent risk factors for diseases such as sarcoidosis, cystic fibrosis, hypertension, and focal segmental glomerulonephritis. These racial associations are used as diagnostic “hints” in medical school exams, reflecting standardized clinical assessments such as the United States Medical Licensing Examination Step 1. On our second-year pulmonology examination, two questions included patient race. Both hypothetical patients were “African American,” and both had sarcoidosis. As previously mentioned, emphasizing and repeating race–disease associations may lead to harms such as delayed diagnosis and medical errors.32–38 As our medical school exams are designed to prepare students for licensing exams, these practices indicate the wider deployment of teaching race as a risk factor. Such practice enforces the use of race as a simplistic signifier of illness, which pathologizes race itself, treats it as an easily visualized diagnostic tool, and obscures its complex role in illness.
Other lecture slides teach the practice of race “correction” for highly variable physiological measures such as spirometry values and glomerular filtration rates. The principle of race correction relies on the idea that people of different racial categories are inherently and biologically different, and therefore their bodily measurements require correction using a white standard. Though disciplines such as medical anthropology, history, and sociology have problematized this practice, this controversy has not translated into clinical practice or medical education. Race-based adjustment of spirometer values, for example, stems from data produced during the era of plantation slavery, when civil war physicians compared the lungs of black and white soldiers. However, recent reviews of current spirometry data find that evidence for intrinsic racial variation is poor.45 Spirometer adjustments define a new physiologic normal for black patients; new literature suggests that this practice decreases black Americans’ eligibility for disability because of the difficulty of documenting disease on top of presumed worse lung function.45
Additionally, we opine that racial categories are often used indiscriminately in class lectures without consideration of their complex and varied meanings. A discussion of hemolytic anemia, for example, conflated black and African racial groups, using the labels “African” and “black” interchangeably despite their differing definitions. These slides highlight the poor examination of the distinctions and nuances of racial identity, geographic origin, and history in the formation of socially meaningful racial signifiers. Whereas the label of “African American” refers specifically to people with American nationality and African geographic ancestral origin who are exposed to the cultural, societal, and political repercussions of race in the United States, “black” refers only to black skin phenotype, which includes all nationalities and upbringings, as well as geographic origins from Sub-Saharan Africa, the Afro-Caribbean, the Middle East, or Latin America. This further calls to attention the point that the general usage of “race” often confuses matters of ancestry and social geography. The two categories actually refer to completely different social groups, neither of which in turn represents a discrete genetic or biological group.
Lecturers’ continued suggestion of race as explicit or implicit biology insinuates that differences in disease incidence can be explained by genetic or physiologic risk. This is problematic not only because race is not a firm biological category but, further, because this framing of health disparities allows ignorance of multifactorial social and structural determinants of disease. Such emphasis on biology fails to expose the complex reality of inequality as it pertains to race.
As a result of collected data, medical students at our institution organized in December 2014 to send a letter detailing the problematic aspects of teaching race as biology to the medical education administration. In 2015, as a result of continued conversations, the Medical Curriculum Committee created a Race in Medicine Task Force which seeks to execute a comprehensive internal review of preclinical lecture slides and introduce longitudinal changes to the curriculum.
Since the formation of the task force, students and administrators have collaborated to implement changes to first- and second-year orientation, doctoring, and preclinical courses as part of the creation of a longitudinal curriculum on race in medicine. First-year medical students were asked to read Blindspot: Hidden Biases of Good People,46 a book on implicit biases, and take the Implicit Association Test47 in preparation for a small-group discussion. Students were required to view the documentary American Denial48 and participate in dialogue with the film’s producer. The pulmonary, renal, and human reproduction blocks added one guest lecture and two small-group sessions, covering the use and history of the spirometer, racialized hypertension guidelines, and differences in morbidity and mortality in black and white children. The school has also added faculty development in which course leaders critically evaluated the concept of race. Finally, sessions on race and medicine are planned for both our medical school’s third-year clinical skills clerkship and longitudinal integrated clerkship.
In the eight months since the first student–faculty conversation on systemic curricular reform around race and medicine, there has been an expansion in school curriculum and culture. As we look towards incorporating further institutional changes regarding race in the medical curriculum, the opportunity for student, faculty, and administration collaboration is great. Our ultimate goal is the development of a robust infrastructure that is based in course work, faculty development, and institutional culture and that is coordinated by a committed staff member dedicated to working directly against racial health disparities.
Although race is often used in biomedical research, epidemiology, medical practice, and education, succinct guidelines for the appropriate use of race in medicine remain elusive and controversial. For medical students and physicians alike, the significance of race within the clinic is poorly understood, and thus poorly used. The operationalization of race in medical practice without proper grounding in sociopolitical context perpetuates bias among medical students. These biases manifest both as irreducible personal and implicit biases but also as ignorance of wider structural and systemic racism which produce profound inequities in health between whites and minorities, ultimately contributing to disparities in patient outcomes.
This article certainly does not aim for the elimination of race discussion in medical education. Indeed, removing race from the curriculum rather than expanding the conversation around race would dissolve opportunities to correct past mistakes. We are excited to see this conversation continue: Students at our institution and elsewhere are and have been committed to developing robust race and health disparities curricula for many years, and faculty as well as administrative response has been supportive. Through open conversation and examination around the value of racial signifiers, it becomes more possible to train physicians in both biology and structural determinants of health. Our work indicates that the current preclinical medical curriculum inadequately addresses the role of race in epidemiology, health disparities, medical research, and clinical practice. While we have added multiple opportunities for discussion as part of a longitudinal curriculum on race in medicine, we are hopeful that continued student–faculty partnership and administrative efforts will expand this work. We advocate for institutions of medical education to teach the controversies surrounding race in medicine so that future physicians will be equipped to comprehensively address disparity and inequity in their practice.
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