For decades, race has been included as one of the essential components of the introduction to case scenarios in clinical education.1,2 On hearing the case introduction, the student is taught to begin the clinical reasoning process and consider the information in this case stem as a foundation for determining the patient's potential risk factors. Examples such as “a 49-year-old African American woman with abdominal pain” or “an 8-year-old Hispanic boy with respiratory distress” are commonplace in case-based learning and imply that age, sex, and race are equally as relevant to the case as the chief complaint.
This practice is problematic in many ways. More often than not, race has no bearing on the trajectory or outcome of the case scenario, and its mention prominently in the case stem may lead students to search for a connection where there is not one. Educators who try to diversify their case scenarios may inadvertently use examples that support stereotypes and misinformation about racial groups.3 This not only perpetuates bias and profiling in clinical practice but also further marginalizes students from underrepresented backgrounds right in their own learning environment.4 Fundamentally the greatest concern is that teaching students to have preconceived notions about a patient on the basis of race ignores one of the central tenets of nursing: patient-centered care.
This article describes the historical background behind the misuse of race in case-based clinical education and identifies the factors that contribute to this problem. Alternative approaches are provided to promote appropriate and effective incorporation of race into case-based learning that better supports cultural sensitivity and social context in patient-centered nursing education.
The Misuse of Race as a Biologic Risk Factor
The practice of incorporating race as an essential feature of case scenarios is in part based on the theory that knowing a patient's race provides the student with important biological information related to the patient's risk for disease or response to therapy.1,2 While age and even sex may provide evidence-based information relevant to physiologic and genetic considerations for diagnosis and treatment, the value of race in this regard is questionable.1,4 For example, in the previous scenario of a patient with abdominal pain, the fact that she is a female in her late 40s offers important information related to the potential for gynecological conditions or risk for cancer that would be different if the patient were younger or male. But the fact that she is African American offers no information that is essential to the student's clinical reasoning or assessment process for this case. Similarly, for the patient with respiratory distress, age can help narrow differential diagnoses (eg, asthma vs bronchiolitis) or treatment options (choice of medication or oxygen delivery system), but the fact that he is Hispanic or male has no bearing on the case at this point.
Substantial evidence shows that genetic differences among individuals from the same racial group vary significantly and that race alone is not enough to predict genetic influences on disease or treatment response.4-7 The assessment of race in clinical encounters is primarily subjective and occurs either when patients self-identify their racial background or the nurse assumes the patient's race simply by looking at skin color or other physical features.1 The use of either of these subjective determinations as a proxy for biological information is flawed because it gives no objective information about the patient's true genetic profile or other individual characteristics. The African American woman with abdominal pain may share very few genetic similarities with other black patients who are African or Caribbean-born, and yet subjectively they would likely be grouped into the same racial category. Similarly, the Hispanic boy from Honduras with Mayan ancestry may have a different genetic profile than an Argentine boy who descends from European lineage, but in an electronic health record, they are both labeled in the same racial group.
There are certainly genetic variations in individuals that may predispose them to certain diseases or affect their response to therapy. However, the factors that contribute to these variations are more complex than race alone and may involve variables such as ancestry, geographic origin, or sociocultural background.5-7 By teaching students to make race-based assumptions about a patient's biological risk factors without individual genetic information, we may set them up to overlook diagnoses, withhold potential treatments, or otherwise deliver inequitable care to patients.5,7
The Misuse of Race as a Proxy for Diversity and Culture
In light of current political events and concerns from an increasingly diverse student population, more attention has rightfully been paid to the importance of diversity and inclusion in health care education. In response, educators have attempted to make readings, lectures, or other learning activities more representative, often without having been well trained in how to do so effectively.8-10 The result has been a perpetuation of misinformation or health inequities across health care education contexts, from course content11 and textbooks12-14 to lecture slide presentations15 and oral presentations in the clinical setting.16
Race may also be included in a case scenario to stimulate discussions of cultural factors that are thought to play a role in a patient's illness course or treatment plan. Although well intentioned to provide an opportunity to discuss the importance of culture in nursing care, the implication that race and ethnicity or culture are interchangeable constructs only further perpetuates misinformation.1,3 Poorly constructed cases may also include simplistic descriptions of cultural practices based on limited knowledge.11,13 Furthermore, such approaches support the improper notion that a nurse should make assumptions about a patient's beliefs or traditions solely based on race.3 Nursing educators require proper training to dialogue with students about race in a meaningful and profound way and may need additional guidance or support to acknowledge their own biases and need for humility when exploring these concepts.8-10,13
Recommendations for Case Scenarios in Nursing Education
This is not to imply that race should never be included in case-based teaching. On the contrary, discussions of race and ethnicity are critical to a student's understanding of health disparities and the role of racism and bias in health care.3,13,17 The inclusion of race must be relevant, purposeful, and evidence based and include context to be effective.8 For example, the educator who presents content on type 2 diabetes in the United States and is interested in teaching about health disparities would be correct in reporting that the prevalence of this disease is higher in non-Hispanic black or American Indian populations as compared with whites.18 But to provide such information without any additional explanation may leave students wondering why, or worse yet, assuming that the explanation is that people of color are simply biologically predisposed to the disease. An accurate and evidence-based discussion would include the larger and significant context of systemic health and social inequities that have historically impacted racial minority groups' access to healthy foods, safe areas for exercise, or access to health care—all of which are evidence-based measures for the prevention of type 2 diabetes. It is also an opportunity for the discussion of epigenetics and the metabolic effects of chronic stress19 that may impact marginalized populations due to generations of exposure to discrimination and injustice.
If race is included in a case scenario for the purposes of discussing disparities within a social context or some other relevant reason, it does not necessarily need to be mentioned in the case stem. It is acceptable to include this information later in the case such as in the family history, or in the patient's social history along with occupation or living situation. Doing this more appropriately contextualizes its relevance and primes the student to consider the social context of race instead of misinterpreting it as solely a biological construct. It may be useful to include race in less prominent areas of case scenarios, even when it is not directly relevant, to foster students' ability to filter out irrelevant information and potentially identify their own unconscious biases during the clinical reasoning process. However, for this approach to have its intended effect, the educator must facilitate deliberate and meaningful discussions about these concepts to avoid perpetuating misconceptions and bias.
In a time when health disparities among underrepresented racial groups continue to be rampant worldwide, it is important to educate faculty and nurses with the skills to promote equity in health care. The misuse of race in case-based clinical teaching works against this goal and potentially contributes to worsening the problem. Recommendations include the following: (1) if a patient's race is not directly relevant to the learning objectives of a case scenario, leave it out; (2) if race is essential to the case or learning objectives, consider including it in the patient's family or social history rather than the stem; (3) if race is included in a case scenario, be mindful to provide evidence-based context as to why it is relevant and avoid the use of harmful stereotypes; and (4) above all else, stress the importance of patient-centered care that is respectful and responsive to the individual's background and needs.
The author acknowledges Dr Kupiri Ackerman-Barger for her encouragement and review of the original draft of this article.
1. Acquaviva KD, Mintz M. Perspective: are we teaching racial profiling? The dangers of subjective determinations of race and ethnicity in case presentations. Acad Med
2. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race matters? Examining and rethinking race portrayal in preclinical medical education. Acad Med
3. Lancellotti K. Culture care theory: a framework for expanding awareness of diversity and racism in nursing education. J Prof Nurs
4. Braun L, Saunders B. Avoiding racial essentialism in medical science curricula. AMA J Ethics
5. Barr DA. The practitioner's dilemma: can we use a patient's race to predict genetics, ancestry, and the expected outcomes of treatment? Ann Intern Med
6. Fofana MO. The spectre of race in American medicine. Med Humanit
7. Moscou S, Baker S. The role of race in clinical decision making. Nurse Pract
8. Acosta D, Ackerman-Barger K. Breaking the silence: time to talk about race and racism. Acad Med
9. Montenery SM, Jones AD, Perry N, Ross D, Zoucha R. Cultural competence in nursing faculty: a journey, not a destination. J Prof Nurs
10. Starr S, Shattell MM, Gonzales C. Do nurse educators feel competent to teach cultural competency concepts? Teach Learn Nurs
11. Brennan AM, Cotter VT. Student perceptions of cultural competence content in the curriculum. J Prof Nurs
12. Sheets L, Johnson J, Todd T, Perkins T, Gu C, Rau M. Unsupported labeling of race as a risk factor for certain diseases in a widely used medical textbook. Acad Med
13. Byrne MM. Uncovering racial bias in nursing fundamentals textbooks. Nurs Health Care Perspect
14. Curry MD. Patterns of race and gender representation in health assessment textbooks. J Natl Black Nurses Assoc
15. Martin GC, Kirgis J, Sid E, Sabin JA. Equitable imagery in the preclinical medical school curriculum: findings from one medical school. Acad Med
16. Nawaz H, Brett AS. Mentioning race at the beginning of clinical case presentations: a survey of US medical schools. Med Educ
17. White-Means S, Zhiyong D, Hufstader M, Brown LT. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities. Med Care Res Rev
18. Centers for Disease Control and Prevention. National Diabetes Statistics Report
. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
. Accessed March 1, 2019.
19. Van Dijk SJ, Tellam RL, Morrison JL, Muhlhausler BS, Molloy PL. Recent developments on the role of epigenetics in obesity and metabolic disease. Clin Epigenetics