The Racism Built into One Simple Medical Protocol
An Unhelpful “History”
According to an article in Scientific American for June 7, 2021, there’s a common charting tool that health care providers routinely use that is probably furthering the spread of medical racism.
Known as the “history of present illness” (HPI), the tool in question provides a typically chronological summary of how a patient’s illness manifested itself. Under the HPI, physicians record the site, severity, and duration of any pain, any physical activities that precipitate the pain, and more, including any additional signs and symptoms. Many physicians also record patient characteristics that they find significant in terms of diagnosis and treatment, including race.
In traditional medical thinking, it’s helpful to know a patient’s race in order to identify additional risk factors and plan appropriate treatment. It’s often considered of such importance that it appears in the first line of a patient’s medical history.
But new research reported in the Scientific American article and elsewhere shows that race-based labels are often inaccurate, can overshadow genuinely important risk factors and potential contraindications, and can interfere with patients obtaining the best, most appropriate care by perpetuating biases.
Lack of Patient Agency
At least one problem with the HPI lies in its execution; more specifically, instead of asking patients to self-identify with respect to race, physicians will often make that determination on their behalf, which is not only disrespectful, but also potentially dangerous. Because phenotype can differ markedly from genotype, the way someone presents might have little if anything to do with the physical and biochemical characteristics that would aid a physician in providing treatment.
When researchers conduct clinical trials, they typically ask participants to self-identify in terms of race and ethnicity - which means that data gathered from research can vary significantly from data gathered for HPIs as filled out by frontline physicians. And that lack of congruence increases the risk of medical errors.
Genetics Isn’t What You Think
The entire problem can serve as an example of the extent to which notions of “race” are a social construct. It’s notable that a groundbreaking study originally published in Science revealed that any two Europeans might be closer in terms of genetic inheritance to someone of Asian descent than they are to one another.
The 2016 Scientific American article delineating this study’s findings noted that “racial categories are weak proxies” for true genetic diversity - which also means that, even if we were to use patients’ self-reported race, we still wouldn’t necessarily have the right story on their biological heritage.
The early 20th-century sociologist and civil rights activist W. E. B. Du Bois once stated that “black” and “white” as racial categories bear no resemblance to the reality of human diversity. Although it has taken a while, mainstream medical science has finally caught up in understanding that, as a social construct, “race” doesn’t accurately describe biological or genetic factors at all.
One public health professor interviewed for the 2016 Scientific American piece said that the notion of distinct races constitutes a notion “too crude to provide useful information.” Additionally, studies have found that when physicians concentrate on race as a factor worth recording in patient notes, their ability to provide demonstrably high-quality care becomes compromised.
Data That Doesn’t Add Up
Another problem with HPI data is its inconsistency. For example, if a health care worker believes a patient is Black, they are more likely to note that in the HPI than would be the case for a patient perceived as white. As in most other fields of human endeavor, “white” appears to be the default.
So, what about the idea that specific conditions, including diabetes or heart disease, are found more frequently among African Americans and that physicians must therefore use real or perceived race as a determining factor for diagnosis?
In fact, the connection between race and these diseases is multifaceted and less well-understood than we might like to think. On the other hand, there are significant known socioeconomic and lifestyle factors at play in several diseases that are far more important and useful in clinical practice than race.
By disregarding these additional factors, including stress levels, food security, and environment, from the discussion, physicians often mistakenly account for a patient’s condition on the basis of “race” rather than various risk factors correlated with low-wage frontline service jobs, poor nutrition, environmental toxins, and the like.
Doing It Better
Experts point out that, if a physician believes that knowing more about a patient’s genetics would assist in diagnosis and treatment, the proper course of action is to conduct genetic mapping rather than assigning a “race” label as a stand-in for detailed genetic information.
From this outline, we can see that, as practiced today, recording race in a patient’s HPI can not only reinforce racist misconceptions within medical culture, but also produce tangible harm to Black and brown patients. Experts have figured out that the limitations created when using “race” as a deciding factor can even prevent patients of color from receiving potentially life-saving treatments in situations involving, for example, childbirth, psychiatric conditions, or kidney failure.
So, it’s probably time to bring medicine into the 21st century by abandoning haphazard designations of “race” in charting medical histories, turning instead to sophisticated tools that will both do no harm and improve patient outcomes.