Written by: Neil Lin and Leena Ghani
Racism is a pervasive barrier to well-being, and those affected by it face health disparities that are worsened by the implicit biases reinforced in medical schools. Racialized groups, particularly Black communities, experience unequal treatment due to marginalization and unconscious racial bias within the healthcare system. Medical education often implies race as a biological risk factor interchangeable with ancestry and genotype, rather than acknowledging its complex historical, environmental, and social factors. This notion underlies the teaching of race corrections in diagnostic tools, which can produce adverse patient outcomes. Furthermore, educational materials underrepresent people of colour, rendering future physicians unprepared to identify certain conditions in their patients. These issues can be addressed with anti-bias training and revisions of core science courses that may inadvertently perpetuate implicit racial bias through their teachings. Although amending medical curricula will be challenging, it is critical to developing a generation of future physicians who can provide equitable care regardless of race.
Racism has long been a detriment to the health of marginalized populations who face greater stress and adverse social determinants as a consequence of discrimination.1 Marginalized patients often receive suboptimal healthcare services across clinical settings, driven in part by physicians’ subconscious biases and implicit discrimination perpetuated by the medical curriculum.2 During their training, medical students are taught in a manner that may enhance bias and misconceptions about race, genetics, and the sources of health inequity.3
Misrepresentation and Misdiagnosis
Notably, medical education faces shortfalls in its representation of people of colour in lecture slides and textbooks.4 For instance, erythema migrans, a rash that occurs in early-stage Lyme disease, is frequently only shown on white skin in established medical textbooks.5 Consequently, physicians have difficulty identifying the condition in people of colour. Studies show that Black patients experience delays in Lyme disease diagnosis, and more diagnoses are made late in the arthritic stages of the disease compared to white patients.6 Therefore, even if ethnic underrepresentation in the curriculum is unintentional, it can result in severe diagnostic errors and treatment disparities for racialized people.
Medical education is failing to prepare students against racial misconceptions. Hoffman et al. found in a sample of 222 medical students and residents that 50% reported believing at least one false biological difference between Black and White people to be possibly, probably, or definitely true.7 Some false beliefs reported are that Black people have thicker skin than white people, are less sensitive to pain, and are more fertile. The students who reported at least one of these false beliefs were shown to be less accurate in their treatment recommendation for pain, directly affecting patient outcomes.7
Teaching Race Corrections
Although socially-constructed racial categories are not reflected in genetics, the concept that there are innate physiological differences between races has deep historical roots that have enabled it to persist in modern medical education.8 For instance, since Samuel Cartwright and Benjamin Gould first proposed racial differences in lung capacity based on observations of African American slaves, the idea has endured in clinical medicine.9,10 Many physicians are still taught to input race as a modifying variable in pulmonary function tests, and spirometers have race corrections built into their software.11,12 Likewise, widely established kidney function equations assign a higher estimated glomerular filtration rate (eGFR) to Black patients because they are assumed to have higher creatinine levels based on historical studies.8,13 For example, the race coefficient in the Chronic Kidney Disease Epidemiology Collaboration equation increases eGFR by about 16% in Black patients.13 These racial corrections are problematic because doctors are often required to assess a patient’s race subjectively, and two people who have otherwise identical organ function might be treated differently based solely on perceived race.11,13 The use of race as a risk factor and coefficient persists despite new evidence that it reinforces implicit bias and worsens health outcomes.14
One approach to addressing racism in medical education is direct anti-racism training. A prevailing element of anti-racism training is the Implicit Association Test (IAT), where students evaluate their automatic biases and stereotypes.15 It was found that medical students who completed the Black-White IAT in their curriculum reduced their reported implicit bias over the course of their education. While use of the IAT to measure bias is contestable, it serves to promote self-awareness and can be used in combination with complimentary racism-awareness education.15 For instance, Rutgers New Jersey Medical School has introduced a first-year course featuring racial bias workshops integrating the IAT with group case studies.1These cases framed key aspects of racism in the context of practicing medicine, highlighting the power and privilege dynamic of the physician-patient relationship and systemic discrimination.1 Since the curriculum changes were introduced, medical students at Rutgers have expressed increased awareness of internal bias and the impact racism has on patient care.1 This approach may be more beneficial than the IAT alone as discussions between peers enable a safe space to reflect on perspective-taking and share experiences. When Hardeman et al. polled a focus group consisting of faculty from racialized groups, they expressed concerns that implicit bias training alone may not be enough to lessen prejudice. Instead, they advocated for exploring structural racism and race-based privilege to promote critical dialogue among students.16Thus, explicit health equity training, addressing both systemic biases and the origins of structural racism, could be a practical strategy to combat racism in medicine.
Revisions to the Curriculum
Even if the multifaceted roots of racism are addressed with training, implicit biases are still propagated if science courses continue to suggest race as a biological difference. In the current medical curriculum, race is often taught as an inherent risk factor for disease, leading students to conclude a biological difference exists.9,14 After evaluating medical school exams, Tsai et al. found that scenario-based questions presented patients’ race as hints to correct answers, thus requiring students to learn automatic associations between race and certain pathologies.9 To avoid exacerbating implicit biases, it is critical to amend non-empirical depictions of race in science courses. Professors should be required to provide evidence to justify cases where race is presented as a harbinger of disease.7,14 Increasing racialized groups’ representation in textbooks, examples, and teaching cases will also improve physicians’ racial awareness and health outcomes for their patients. For instance, the leading producer of case-based courses used by over 95% of U.S. MD schools, Aquifer, has received feedback from medical students regarding its underrepresentation of racial and cultural diversity.17 With student input, new guidelines are being developed to avoid racial stereotyping and promote awareness of the sociocultural causes of health disparities. Case revisions such as presenting leukemia in a black child instead of sickle cell anemia or including images of conditions on various skin types will help avoid implicit associations and improve students’ ability to holistically treat racialized people in the future.17
The challenge of implicit racial bias in healthcare is enduring, and addressing its complex challenges will not happen overnight. However, integrating anti-bias training, evidence-based instruction, and greater representation into medical curricula may help ameliorate hidden discrimination in clinical medicine going forward. Rather than teaching students about the Krebs cycle or diseases they might see once or twice in their careers, it may be more valuable to teach cultural humility or even something as simple as how rashes look on dark skin. While further evidence is needed to support these changes, if medical education strives to uncover the roots of racial health disparity, then the doctors of tomorrow will be prepared to see beyond the veil of race and better serve their patients.
1. DallaPiazza M, Padilla-Register M, Dwarakanath M, Obamedo E, Hill J, Soto-Greene M. Exploring racism and health: An intensive interactive session for medical students. MedEdPORTAL. 2018;14. Available from: doi:10.15766/mep_2374-8265.10783.
2. Marcelin JR, Siraj DS, Victor R, Kotadia S, Maldonado YA. The impact of unconscious bias in healthcare: How to recognize and mitigate it. J Infect Dis. 2019;220(2):S62-S73. Available from: doi:10.1093/infdis/jiz214.
3. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health. 2015;105(12):e60–76. Available from: doi:10.2105/AJPH.2015.302903
4. Martin GC, Kirgis J, Sid E, Sabin JA. Equitable imagery in the preclinical medical school curriculum: Findings from one medical school. Acad Med. 2016;91(7):1002–6. Available from: doi:10.1097/ACM.0000000000001105.
5. Khan S, Mian A. Racism and medical education. Lancet Infect Dis. 2020;20(9):1009. Available from: doi:10.1016/S1473-3099(20)30639-3
6. Fix AD, Peña CA, Strickland GT. Racial differences in reported Lyme disease incidence. Am J Epidemiol. 2000;152(8):756–9. Available from: doi:10.1093/aje/152.8.756.
7. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301. Available from: doi:10.1073/pnas.1516047113.
8. Braun L, Saunders B. Avoiding racial essentialism in medical science curricula. AMA J. Ethics. 2017;19(6):518–27. Available from: doi:10.1001/journalofethics.2017.19.6.peer1-1706.
9. Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race matters? Examining and rethinking race portrayal in preclinical medical education. Acad Med. 2016;91(7):916–20. Available from: doi:10.1097/ACM.0000000000001232.
10. Braun L. Race, ethnicity and lung function: A brief history. Can J Respir Ther. 2015;51(4):99–101. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4631137/ [cited 2020 Dec 20].
11. Scanlon PD, Shriver MD. “Race correction” in pulmonary-function testing. N Engl J Med. 2010;363(4):385–6. Available from: doi:10.1056/NEJMe1005902.
12. Lujan HL, DiCarlo SE. Science reflects history as society influences science: Brief history of “race,” “race correction,” and the spirometer. Adv Physiol Educ. 2018;42(2):163–5. Available from: doi:10.1152/advan.00196.2017.
13. Eneanya ND, Yang W, Reese PP. Reconsidering the consequences of using race to estimate kidney function. JAMA. 2019;322(2):113. Available from: doi:10.1001/jama.2019.5774.
14. Nieblas-Bedolla E, Christophers B, Nkinsi NT, Schumann PD, Stein E. Changing how race is portrayed in medical education: Recommendations from medical students. Acad Med. 2020;95(12):1802-6. Available from: doi:10.1097/ACM.0000000000003496.
15. van Ryn M, Hardeman R, Phelan SM, Burgess DJ, Dovidio JF, Herrin J, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: A medical student changes study report. J Gen Intern Med. 2015;30(12):1748-56. Available from: doi:10.1007/s11606-015-3447-7.
16. Hardeman RR, Burgess D, Murphy K, Satin DJ, Nielsen J, Potter TM, et al. Developing a medical school curriculum on racism: Multidisciplinary, multiracial conversations informed by public health critical race praxis (PHCRP). Ethn Dis. 2018;28(Suppl 1):271-8. Available from: doi:10.18865/ed.28.S1.271.
17. Krishnan A, Rabinowitz M, Ziminsky A, Scott SM, Chretien KC. Addressing race, culture, and structural inequality in medical education: A guide for revising teaching cases. Acad Med. 2019;94(4):550-5. Available from: doi:10.1097/ACM.0000000000002589.