COVID-19 aggravated several pre-existing racial health inequities, ushering in a racial reckoning in medicine. As a response, several medical institutions have endeavoured to make significant adjustments in their teaching and clinical environments to address systematic racism. The history of present illness (H.P.I.), a tool utilized by practically every physician daily, may, nevertheless, continue to perpetuate medical racism.
“Diabetic ketoacidosis was evident in a 21-year-old African American female who presented to the emergency department.” A patient’s race is frequently mentioned in the first line of their medical history. Many doctors believe race is a crucial component to consider when making clinical decisions, as it can help them discover risk factors and treatment alternatives. On the other hand, these labels are poor proxies for risk factors and treatment contraindications and can even harm patients. These designations, in particular, may reinforce racial biases and hinder patients from receiving routine medical care.
Instead of asking patients to self-identify, doctors frequently decide on racial and ethnic identities. Providers who are not racially/ethnically concordant with their patients—that is, who are from distinct racial or ethnic backgrounds—may conflate race, ethnicity, and ancestry inappropriately. Patients are also frequently requested to self-identify in clinical trials. As a result, while selecting patient descriptors, clinicians may reinforce biases rather than elucidate a biological relationship discovered by studies. In actuality, many patients do not self-identify into the research categories, rendering the categorization procedure obsolete.
Beyond doctors mislabeling patients based on their race, research has shown what intellectuals like W.E.B. Du Bois and Derrick Bell have been saying for decades: race is a social construct. In particular, a person’s phenotype, or physical appearance, may not provide helpful information about their genotype or genetic make-up. For example, a groundbreaking study published in the journal Science discovered that two persons of European heritage might be more genetically similar to one another than to each other. As a result, even when patients self-identify as black or white, race is not a clinically helpful identification.
Finally, the technique is inconsistently applied; for example, if a patient is a Black American, health care practitioners are more likely to incorporate race in their H.P.I. This tendency among professionals demonstrates how labels are frequently used as a cumbersome outlet for bias rather than evidence-based clinical treatment. Focusing on race has been shown to detract from rather than enhance treatment, negatively affecting patient care areas such as the time allocated for a visit.
The link between race and diseases, including diabetes, sarcoidosis, and lupus, is complicated and poorly understood. Some clinicians may argue that knowing a patient’s race is crucial for determining their differential diagnosis. Yet, there is a constellation of symptoms that elucidates the clinical picture of these disorders that renders it unnecessary. Physicians who use race as a risk factor for diseases like diabetes, cancer, and cardiovascular disease may miss diagnoses and misinterpret upstream socioeconomic determinants of health as natural genetic variations in some circumstances.
The medical field unfairly focuses on a patient’s genetics by ignoring these changeable elements (e.g., access to healthy food, socioeconomic status, stress levels, access to health care, environmental health, etc.) perpetuated by systemic racism. Because many people rely on the medical establishment to comprehend biological intricacies and operate on neutrality, this approach can foster racial bias among the general public. Physicians may be perpetuating the mistaken assumption that racial difference has scientific merit rather than being a clumsy product of the profession by utilizing this antiquated practice.
Unfortunately, this behaviour can inflame racial attitudes and do immediate bodily injury to Black and brown people. Plugging a Black or nonwhite Hispanic patient’s race into specific medical formulas, such as estimated glomerular filtration rate (eGFR) and vaginal birth after Cesarean section (VBAC), could prevent them from having a kidney transplant or being offered a vaginal delivery.
Furthermore, a patient’s race being included in their medical records may prevent them from receiving high-quality care. Because of the fear of benign ethnic neutropenia (B.E.N.), defined as an absolute neutrophil (a type of white blood cell that supports a person’s immune system), counts below 1,500 microliters, clozapine, an effective antipsychotic, is underprescribed among Black American populations. B.E.N. is a diagnosis that was coined in the 1940s when it discovered that African American folks had lower neutrophil counts than white Americans. This reduced white blood cell count, on the other hand, was only relative and did not indicate an increased risk of infection. Today, many Black American patients who may benefit from clozapine are either not provided medication because of physician concerns about B.E.N. or choose not to take it since it requires intrusive blood draws and regular monitoring.
The perceived link between African Americans and B.E.N. has influenced the treatment of African American breast cancer patients. According to studies, there are differences in breast cancer survival rates between Black and White Americans. Aside from socioeconomic position and health-care disparities, the disparities may be connected to the fact that, in African Americans, physicians are more likely to reduce doses and cease chemotherapy treatments due to a lower baseline absolute neutrophil count, affecting survival rates.
It’s worth noting that B.E.N. patients do not have an elevated risk of infection or neutropenic fever after starting chemotherapy compared to other cancer patients. As a result, race-based therapeutic decisions may be causing more harm than benefit. Overall, employing race as a medical tool in a patient’s H.P.I. has social, historical, and medical ramifications that it must reconsider.
Many doctors believe it is critical to include a patient’s race in the medical record. They argue that it is a crucial medical indicator and a good substitute for genetics. However, the genetic mapping should be used in high-risk patients to determine if they are carriers of allelic genetic variants that cause severe medication reactions (e.g., antiepileptic drugs causing toxic epidermal necrolysis in people with HLA-B*15:02 alleles) or put them at a significantly higher disease risk (e.g., the Duffy antigen/receptor chemokine gene and neutropenia). Using racial suspicions to deny individuals gold standard treatments—which have higher health outcomes and side effect profiles—is hardly cost-effective, even though genotyping is a more expensive choice.
This form of gradated punishment is harsh.
Some doctors are already aware of the absence of evidence for using race-based medicine. For example, the highly renowned weekly part “Case Records of the Massachusetts General Hospital” in the New England Journal of Medicine does not include race in the opening phrase of patients’ histories, or at all. Neither the Canadian Medical Association Journal nor the Canadian Journal of Surgery discloses race in their case reports, despite Canada’s large racial variety and good health results. To be clear, a “colour-blind” approach isn’t the best option either. The study of health inequalities necessitates a thorough grasp of race. However, it can be collected in a self-identified, consistent, and consensual manner in research contexts.
In the end, medicine will reach a tipping point. The National Kidney Foundation recently announced that race would no longer be used when calculating eGFR for kidney function and transplant urgency. Changes like this demonstrate that these aren’t just radical social justice arguments. They’re logical, scientific ideas based on evidence-based medicine to provide the greatest possible patient care at their core.
When combined, genetic inaccuracy, a lack of patient self-identification, and doctors’ biased use of racial labels when writing H.P.I.s make it more likely to perpetuate racism than improve patient health. In general, listing a patient’s face in the first line of their medical history is not clinically useful in identifying their illness or developing a treatment plan. Medically significant factors include a patient’s family history, insurance status, work, transportation, nutrition, and housing situation. If the medical profession is serious about addressing racial health inequities, some of its most basic tools may need to be reconsidered. “The master’s tools will never wreck the master’s house,” wrote civil rights leader Audre Lorde. We may never eliminate racial health inequalities if we continue to blindly embrace methods designed by the medical profession’s predominantly white forebears.
