Yale Daily News
Advocating for the transition of medicine away from race-based practices and toward a more race-conscious approach, Yale Medical School MD-PhD student Jessica Cerdeña GRD ’21, Yale Emergency Medicine physician Jennifer Tsai and Howard University PhD student Marie Plaisime recently co-authored an editorial for The Lancet, a peer-reviewed medical journal, this month about reforming medical education for future doctors.
The editorial characterizes the current practice of medicine as “race-based,” stating that physicians often infer that race has inherent biological significance, whereas in actuality race is merely a social construct. The authors say the future of medicine should move from this race-based approach to a “race-conscious” approach, with the end goal being a reduction in health inequities across racial lines. They advocated for emphasizing institutional inequities in healthcare during medical education, which they said would raise the cultural competency of future physicians.
“Race-based medicine uses and treats race as an essential biological variable that has utility in medical education and clinical practice,” Cerdeña said. “Race-conscious medicine understands that race is a social and power construct that changes for political utility over time, and that it is a poor proxy for human genetic variation. Instead, the more salient variable when it comes to differences in human groups that have been socially categorized in this way is the experience of racism and racialization … This idea that there are biological differences between racial groups comes from colonization. This is how white supremacy operates.”
The editorial was published in The Lancet after the prominent medical journal released a statement supporting the Black Lives Matter movement and its continuing commitment to advancing racial equality. This editorial was also published following a summer of racial unrest and protests around the country that advocated for putting an end to police brutality against Black Americans. The timing of the publication was significant to the authors.
“Certainly we were motivated by the very apparent murders of George Floyd, Ahmaud Arbery and Breonna Taylor, among others,” Tsai said. “But also because this is a very long-standing problem that I think all three of us have been working on, thinking about and advocating against beforehand.”
The article presented a wide range of examples in which race heavily influences physicians’ medical assessment of patients, such as the Atherosclerotic Cardiovascular Disease risk calculator equation. This online tool determines a given patient’s risk of having a cardiovascular event within ten years, Cerdeña said. These calculations involve categorizing the patient as either “Black” or “not Black.” If the patient is Black, the predicted risk is significantly increased, and the patient is more likely to start taking a certain medication earlier than patients of other racial groups.
The prescription dosage for certain drugs can also vary based on racial groups. According to Cerdeña, medical practitioners consider East Asian people to have different metabolisms, which means that a drug like Eltrombopag, a bone marrow stimulant, is started at half the normal dose for these people. This type of race-based medicine is condemned in the article.
“You can’t know someone’s pharmacokinetics, or the way that they metabolize a drug, by looking at them, or by their race,” Cerdeña said. “That’s the problem with race-based medicine.”
The Lancet piece includes different policy recommendations for researchers, clinicians and practitioners. According to Plaisime, It was crafted with care towards its intended audience of physicians, picking and choosing words that would be most accessible. The most important step in moving forward, Tsai said, is to change the curriculum of medical schools to be more race-conscious.
The authors also wrote this editorial from the perspective of their own experiences as women of color within the American healthcare system. Cerdeña is Italian and Chilean with Indigenous Mapuche ancestry, Plaisime is Haitian American and Tsai is Taiwanese American.
“As a Black woman, for sure there have definitely been times where I’ve been treated differently based on how I appeared in the clinical room, how I was spoken to,” Plaisime said. “Also being the daughter of Haitian immigrants, I know first-hand what it’s like to have your accent judged. Not just one isolated event that kind of sparked this, it’s my story, and I want to make sure that all people receive equitable care.”
The authors also emphasized that even research studies are subjected to racialization, despite undergoing objective screening processes instituted by peer-reviewed journals. Although race has no inherent biological significance, countless epidemiological studies include race as a critical variable when mapping out the prevalence of certain diseases.
In their article, the authors urged clinical research journals to include instructions in their publication guidelines that denounce the use of race as a proxy for biological variables such as genetics, pharmacokinetics and metabolism.
“Prestigious publications continue to allow research that [uses] problematic versions of race in their research,” Tsai said. “They still allow that to be published, which means this kind of data and this kind of thinking is continually generated and perpetuated.”
Plaisime, who is a medical sociologist studying the impacts of race and racism in clinical decision-making processes, explained that biologizing race is harmful. Prior to this collaboration, she had published a piece about the implications of using race in medicine.
She emphasized the need for using “evidence-based” treatments that do not rely solely on race as a factor of consideration, as this can often be detrimental to members of racial minority groups.
“The different biomarkers and tools they use aren’t necessarily based on science, but more on racist assumptions,” Plaisime said. “My work was based on how that kind of training impacts later on how patients receive care, and how medical students are trained.”
Cerdeña and Plaisime are both Robert Wood Johnson Foundation Health Policy Research Scholars, and Tsai is completing her residency at the Yale New Haven Hospital.
Anjali Mangla | anjali.mangla@yale.edu