Race and Medical Curricula

Across the country, colleges and universities continue to examine their relationships with race and racism. Medical schools have been having their own conversations about the subject, focusing not only on how students of color are admitted to and treated in medical school but, additionally, what they are taught when they get there.

Physician bias based on patient race is well documented, and some say that medical schools have played a part in perpetuating that phenomenon.

“Medical schools are training the next cadre of not only physicians that serve on the front lines, but physician scientists that are generating the medical knowledge that we’re going to use in the future,” said Jaya Aysola, a professor of medicine at the University of Pennsylvania. “Medical schools define the individuals that are going to define the institutional structures, policies and practices of medicine tomorrow.”

Aysola and 10 co-authors recently released a paper in the New England Journal of Medicine, the result of examining 800 preclinical medical school lectures in 21 courses. They found medical education often reinforced the idea that race is a biological category, rather than a social one. That idea, they argue, is false.

“Today most physicians would probably say that race affects the social location and social circumstances of patients,” said Brooke Cunningham, a professor of family medicine and community health at the University of Minnesota, who teaches on race in medicine. But a large subset will also say that race is a biological category, she said, and affects what goes on beneath the skin.

Of course, there are documented differences in health outcomes and disease prevalence among people of different races. That’s led the medical establishment to develop certain race-based heuristics and diagnostic tools. Some lab tests, for example, are “corrected” for race. When a doctor is measuring the glomerular filtration rate, a measure of kidney function, the threshold of concern is higher for a Black patient than a white one, meaning that if the two demonstrated the same value, the white patient may be referred for a kidney transplant while the Black one would not. Medical students have called for re-examining the algorithm, and a few medical centers and schools have chosen to remove the racial coefficient. An influential August paper in NEJM cataloged how several of these race-adjusted algorithms could perpetuate health inequities.

“There’s a movement to reconsider if not outright abolish the use of race in medical decision making,” Cunningham said. But how people define or judge racial categories changes between societies and over time, indicating its social construction, she said. Post-Sept. 11, there was a conversation about whether Middle Eastern or Arab should be racial categories, next to white, Black and Asian, on the U.S. Census.

“As physicians and scientists, we need to do a better job than using race as a proxy. If people suspect there is a biological mechanism at play, we need to measure that biological mechanism. If it’s a genetic variant that people think is at play, then we need to run the genome and get that information.”

Aysola’s investigation found that medical school instructors would often present racial differences in disease burden without context or explanation. Sickle-cell anemia, for example, would be portrayed as a disease of Black people, when it is more specifically connected to groups whose ancestors had a high risk of malaria. Instructors were also observed teaching students that Black patients have higher rates of asthma than white patients, without discussing the residential segregation that many see as the cause of that differential. Race on its own does not cause either disease.

“Rather than presenting race as correlated with social factors that shape disease, or acknowledging race as an imperfect proxy for ancestry or family history that may predispose one to disease, the educators we observed portrayed race itself as an essential -- biologic -- causal mechanism,” the authors wrote.

Aysola said she doesn’t want educators or the medical establishment to completely stop considering race in treatment, but to use it accurately.

“We do not want to use race as a proxy for ancestry or genetic predisposition. We do want to use race when we’re trying to measure unequal care by structural racism or unconscious bias at the hands of the provider,” she said.

Part of that can start with using different words. The study suggested instructors could use more granular terms to describe patients (such as country of origin) and include ethnicity along with race when appropriate. How race and disease are discussed in lectures deserves careful consideration, the paper suggested, and medical journals, agencies and the designers of board examinations could all be called on to promote best practices.

The stakes are high for making a change, said Malika Fair, senior director of equity and social accountability at the Association of American Medical Colleges.

“When we simply rely on the association between race and disease, we risk perpetuating the unfounded theories of some of our founding fathers of medicine who believed there were substantial biological differences between races -- with some even thinking that Black people were a different species,” she said via email. “It is important for physicians to distinguish the impact of experiencing individual and structural racism in society from the role of ancestry, biomarkers, and genotypes and the relationship between them both. Using more precise language will allow us to shift from using race as shortcut association with disease to naming the underlying critical factors that cause health inequities.”

The AAMC, she said, is currently developing competencies in diversity, equity and inclusion that include antiracism in health care.

Cunningham said that medical schools and biomedicine in general have indeed been reckoning with race in the past year, since the killing of George Floyd, and putting more resources into teaching about health equity.

As the next generation enters medical school, things may change still. Aysola said the paper she worked on emanated directly from medical students at Penn who felt there was a disconnect between how race was talked about in their medical courses and their undergraduate liberal arts education.

“The students now, unlike us 20 years ago,” she said, “voiced their concerns.”