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Our Role in Racism

Medical trainees and physicians must be vigilant against biases, including their own

The New Physician October 2012

In my renal course, I was taught that since the GFR (glomerular filtration rate) of African Americans is slightly different from that of whites, there is a calculation that shows up on the labs automatically to help "adjust" for this. In my small group, a biracial friend joked with me, "So do I just average these two together to get my GFR or what?" We laughed, mostly out of frustration. Unfortunately, this question is one of many race-associated differences–hypertension, transplant outcomes, life span–that are documented and taught to us during medical school, but are either poorly explained or glossed over entirely.

In a 2003 Journal of the American Medical Association (JAMA) article on the subject of race and ethnicity, Judith Kaplan and Trude Bennett wrote: "Membership in a given racial/ethnic group may be a risk marker for a particular medical condition if the incidence or prevalence of the condition is higher in that group than in other racial/ethnic groups. However, membership in that group is not necessarily a risk factor for the condition. The likelihood of developing the condition may vary considerably among members of the group, and those who are actually at risk may share relevant characteristics with people in other racial/ethnic groups."

However, one important thing minority groups in the United States share is the perception of their race by others. As Dr. Camara Jones explains in a 2000 article in the Journal of Public Health, "The race noted on a health form is the same race noted by a sales clerk, a police officer or a judge, and this racial classification has a profound impact on daily life experience in this country. That is, the variable 'race' is not a biological construct that reflects innate differences, but a social construct that precisely captures the impacts of racism. For this reason, some investigators now hypothesize that raceassociated differences in health outcomes are, in fact, due to the effects of racism."

This is a powerful statement: Racism is the underlying cause behind differences in health outcomes. Racism can decrease access to better education and income, leading to segregation into areas of cities with more pollution, crime and poor quality housing, creating a chronic stress that results in major adverse health effects through a variety of physiological mechanisms of which we health professionals are well aware.

Jones explores three layers of racism: institutionalized, personally mediated and internalized. She defines institutionalized racism as "differential access to the goods, services and opportunities of society by race." Personally mediated racism is defined as "prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives and intentions of others according to their race, and discrimination means differential actions." Finally, internalized racism is "acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth."

At the University of Minnesota, Dr. Sandra Turbes and her colleagues examined case studies used in the medical school curriculum and found, as they wrote in the resulting 2002 Academic Medicine article, a "standard in medical education in which white, male and heterosexual are placed in a central, normative position." This is an excellent example of institutionalized racism (as well as sexism and heterosexualism), where power and information are differentially accessible. This is also something we, as medical students, can demand our schools address.

In one study published in JAMA in September 2011, Dr. Adil Haider and a number of colleagues examined the association of unconscious race and social bias using a vignette-based study. While the study focused on "unconscious bias," an example of personally mediated racism was clear in the summary, where of the 202 students who were surveyed, 78 of them (39 percent) answered that they explicitly preferred white people to other races. While this may not manifest during well-thought-out responses to clinical vignettes, it may come to light after a 24-hour call shift when fatigue and frustration set in.

Furthermore, we must be aware of a global history of eugenics and historical propensity for preference of lighter skin. This is not just an issue of the past. In fact, as we begin to use genetic testing more frequently in pursuit of "personalized medicine," medical racism, inadvertent or deliberate, may become even more challenging.

So what can we do about it, as medical students and future physicians? Rudolf Virchow, who described not only the hypercoagulable triad and a suspicious lymph node, wrote, "If medicine is to fulfill her great task, then she must enter the political and social life. Do we not always find diseases of the populace traceable to defects in society? Physicians are the natural attorneys of the poor, and social questions fall to a great degree in their jurisdiction."

Dr. Don Berwick, former director of the Centers for Medicare & Medicaid Services, in a graduation speech at Harvard Medical School, spoke of our second duty as physicians: "Maybe this second is not a duty that you meant to embrace; you may not welcome it. It is to cure, not only the killer leukemia; it is to cure the killer injustice."

As we continue our medical education and become practicing physicians, it is important for us not to forget the rights that society gives us. Not only can we cut someone open and give them dangerous drugs without being thrown in jail, but our opinions and ideas also matter in a way that we may or may not have earned. We take an oath to do no harm, and as such, our silence about the ails of society and injustice may be more harmful than we think.

Glenna Martin is currently pursuing an M.P.H. between her third and fourth year of medical school at the University of Washington in Seattle.