The practice of medicine—the traditions, diagnoses, treatments, and guidelines—is ever-changing, with new research and information flowing into clinical care at a pace that rivals the turbulence and abundance of a mountain stream in the spring. We now acknowledge human papillomavirus infection as the primary driver of cervical and now oropharyngeal cancer. Hormone replacement therapy is no longer routinely recommended for postmenopausal women. Rate control is preferred over rhythm control in atrial fibrillation. Prostate cancer screening is no longer reflexively ordered for adult men.
However, as we look back at the past hundred years, our profession has been glacially slow to release the vice grip that the concept of biological race has had on our science and our medical practice.
Most of us have heard and acknowledged the truth of the concept of race as a social construct. After sequencing the human genome, we are now confident that there is 99.9% genetic concordance across races, and a person of African descent is likely to have a more genetic similarity to a white Northern European, Asian, or Latinx person than another person of African descent. While we may accept the truth of this science in theory, the way we practice and teach medicine has not embraced this truth; in fact, alternatively, we often have perpetuated the myth of race and ethnicity as markers of disease. We begin our clinical presentations with “Patient is a 54-year-old African American female…” or similar phrases, and we infuse our guidelines and supposedly objective laboratory criteria like glomerular filtration rate with assumptions about biological consequences of race. We use race as a proxy for genetics, ancestry, and biology when it is not. Jennifer Tsai, in her blog post in Scientific American, wrote, “Rather than a risk factor that predicts disease or disability because of genetic susceptibility, race is better conceptualized as a risk marker—of vulnerability, bias or systemic disadvantage.” I wholeheartedly agree.
As I started advocating for this approach to how we view and use race in medicine, I was met with resistance. I have been told that if we treat all individuals without regard to observed biological race differences, we will do people of color a disservice. I do hear this criticism. It is an important one. We can’t ignore race. Negative health outcomes by race—particularly for US-born, African-American, and indigenous peoples—are staggeringly high. What we also can’t ignore is that these disparities are not easily delineated by societally-perceived race or an inherent physiological difference marked by “race.” Based on race, how do I determine how to treat siblings with one white parent and one black parent but who appear phenotypically different—one appears externally to be white, and one black? Which GFR calculation or ASCVD risk score do I use? Which first-line blood pressure medication do I start? Does self-perceived identity or external physical appearance matter more when determining race? Do either of them matter?
Racial health disparities are sociopolitically-produced outcomes, not inherently biological ones, resulting from historical, systemic, structural, widespread racism and its health effects, not of “race” itself. To effect meaningful change on health disparities, we need to focus on sociopolitical solutions, not creating and stratifying differing biological treatments for individuals based on race.
As family medicine educators, we are perfectly poised to lead in the elimination of race-based medicine. We treat the whole person, the whole family, and the whole community, and our holistic perspective allows us to zoom in and to zoom out.
We can critically evaluate the various ways that the current practice of medicine uses race inconsistently and incorrectly. We can push our certifying body to stop using race as a qualifier in board exam questions. We can carefully question research studies and protocols about how they classify and use race, and we can challenge guidelines when they ask us to treat different patients differently because of their externally-perceived or self-identified race.
Don’t blindly accept race as a proxy for genetics, ancestry, or biology. While not biologically real, race has had actual negative biological effects through racism. And we, as family medicine educators and practitioners, as citizens of a common humanity, can make real change by tackling the systemic and structural racism that exists in our communities and in the practice of medicine. Society needs us to do this work together, for our patients, for each other, for all of us.