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Futterman J, Bi C, Crow B, Kureshi S, Okah E. Medical educators' perception of race in clinical practice. BMC MEDICAL EDUCATION 2024; 24:230. [PMID: 38439004 PMCID: PMC10913645 DOI: 10.1186/s12909-024-05232-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/27/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND While several medical societies endorse race as a social construct, it is still often used as a biological trait in medical education. How medical educators employ race while teaching is likely impacted by their beliefs as to what race represents and its relevance in clinical care. Understanding these beliefs is necessary to guide medical education curriculum reform. METHODS This was a qualitative survey study, conducted in June 2020, of Georgetown University Medical Center faculty. As part of the survey, faculty were asked to rate, on a 5-point Likert scale, the extent to which they perceived race as a biological trait and its importance in clinical care. Self-identified clinical or preclinical faculty (N = 147) who believed that race had any importance were asked to provide an example illustrating its significance. Free-text responses were coded using content analysis with an inductive approach and contextualized by faculty's perspectives on the biological significance of race. RESULTS There were 130 (88%) responses categorized into two major themes: race is important for [1] screening, diagnosing, and treating diseases and [2] contextualizing patients' experiences and health behaviors. Compared to faculty who perceived race as biological, those who viewed race as strictly social were more likely to report using race to understand or acknowledge patients' exposure to racism. However, even among these faculty, explanations that suggested biological differences between racial groups were prevalent. CONCLUSIONS Medical educators use race primarily to understand diseases and frequently described biological differences between racial groups. Efforts to reframe race as sociopolitical may require education that examines race through a global lens, accounting for the genetic and cultural variability that occurs within racial groups; greater awareness of the association between structural racism and health inequities; movement away from identity-based risk stratification; and incorporation of tools that appraise race-based medical literature.
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Affiliation(s)
| | | | - Brendan Crow
- Mountain Area Health Education Center, Asheville, NC, USA
| | - Sarah Kureshi
- Georgetown University School of Medicine, Washington, DC, USA
| | - Ebiere Okah
- Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA.
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Okah E, Glover L, Donahue KE, Corbie-Smith G, Dave G. Physicians' Perceptions of Race and Engagement in Race-Based Clinical Practice: a Mixed-Methods Systematic Review and Narrative Synthesis. J Gen Intern Med 2022; 37:3989-3998. [PMID: 35867305 PMCID: PMC9640482 DOI: 10.1007/s11606-022-07737-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Using race-a socially assigned identity that does not adequately capture human genetic variation-to guide clinical care can result in poor outcomes for racially minoritized patients. This study assessed (1) how physicians conceptualize and use race in their clinical care (race-based care) and (2) physician characteristics associated with race-based care. METHODS PubMed, CINAHL, EMBASE, and Scopus databases were searched. Qualitative, quantitative, and mixed-methods studies written in peer-reviewed, English-language journal articles evaluating US physicians' perceptions of race and physician factors associated with race-based care were included. Risk of bias was assessed using the Mixed Methods Appraisal Tool. Qualitative studies were evaluated using thematic analysis, and quantitative findings were summarized and combined with qualitative findings in a narrative synthesis. RESULTS A total of 1149 articles were identified; 9 (4 qualitative, 5 quantitative) studies met inclusion criteria. Five themes emerged: (1) the belief in race as biological; (2) the use of race to contextualize patients' health; (3) the use of race to counsel patients and determine care; (4) justifications for race-based practice (evidence-based, personal experience, addresses disparities, provides personalized care, increases compliance); and (5) concerns with race-based practice (poorly characterizes patients, normalizes disparities, patient distrust, clinician discomfort, legitimized biological race). In quantitative studies, older age was positively associated with race-based care. DISCUSSION Physicians had varied perceptions of race, but many believed race was biological. Concern and support for race-based practice were related to beliefs regarding the evidence for using race in care and the appropriateness of race as a variable in medical research. Older physicians were more likely to use race, which could be due to increased exposure to race-based medical literature, in addition to generational differences in conceptualizations of race. Additional research on the evolution of physicians' perceptions of race, and the role of medical literature in shaping these perceptions, is needed.
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Affiliation(s)
- Ebiere Okah
- Department of Family Medicine, School of Medicine, University of North Carolina, NC, , Chapel Hill, USA.
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, NC, , Chapel Hill, USA.
| | - LáShauntá Glover
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, NC, , Chapel Hill, USA
| | - Katrina E Donahue
- Department of Family Medicine, School of Medicine, University of North Carolina, NC, , Chapel Hill, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, NC, , Chapel Hill, USA
| | - Giselle Corbie-Smith
- Department of Medicine, School of Medicine, University of North Carolina, NC, , Chapel Hill, USA
- Department of Social Medicine, School of Medicine, University of North Carolina, NC, , Chapel Hill, USA
- Center for Health Equity Research, School of Medicine, University of North Carolina, Chapel Hill,, NC, USA
| | - Gaurav Dave
- Department of Medicine, School of Medicine, University of North Carolina, NC, , Chapel Hill, USA
- Department of Social Medicine, School of Medicine, University of North Carolina, NC, , Chapel Hill, USA
- Center for Health Equity Research, School of Medicine, University of North Carolina, Chapel Hill,, NC, USA
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Okah E, Thomas J, Westby A, Cunningham B. Colorblind Racial Ideology and Physician Use of Race in Medical Decision-Making. J Racial Ethn Health Disparities 2022; 9:2019-2026. [PMID: 34491564 PMCID: PMC8898981 DOI: 10.1007/s40615-021-01141-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Colorblindness is a racial ideology that minimizes the role of systemic racism in shaping outcomes for racial minorities. Physicians who embrace colorblindness may be less likely to interrogate the role of racism in generating health disparities and less likely to challenge race-based treatment. This study evaluates the association between physician colorblindness and the use of race in medical decision-making. METHODS This is a cross-sectional survey study, conducted in September 2019, of members of the Minnesota Academy of Family Physicians. The survey included demographic and practice questions and two measures: Color-blind Racial Attitudes Scale (CoBRAS; measuring unawareness of racial privilege, institutional discrimination, and blatant racial issues) and Racial Attributes in Clinical Evaluation (RACE; measuring the use of race in medical decision-making). Multivariable regression analyses assessed the relationship between CoBRAS and RACE. RESULTS Our response rate was 17% (267/1595). In a multivariable analysis controlling for physician demographic and practice characteristics, CoBRAS scores were positively associated with RACE (β = 0.05, p = 0.02). When CoBRAS subscales were used in place of the overall CoBRAS score, only unawareness of institutional discrimination was positively associated with RACE (β = 0.18, p = 0.01). CONCLUSIONS Physicians who adhere to a color blind racial ideology, particularly those who deny institutional racism, are more likely to use race in medical decision-making. As the use of race may be due to a colorblind racial ideology, and therefore due to a poor understanding of how systemic racism affects health, more physician education about racism as a health risk is needed.
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Affiliation(s)
- Ebiere Okah
- Department of Family Medicine, University of North Carolina School of Medicine, 590 Manning Dr, Chapel Hill, NC, 27514, USA.
| | - Janet Thomas
- Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrea Westby
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Brooke Cunningham
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
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Callier SL, Cunningham BA, Powell J, McDonald MA, Royal CDM. Cardiologists' Perspectives on Race-Based Drug Labels and Prescribing Within the Context of Treating Heart Failure. Health Equity 2019; 3:246-253. [PMID: 31289785 PMCID: PMC6608680 DOI: 10.1089/heq.2018.0074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Purpose: Cardiologists are known to consider patients' race when treating heart failure, but their views on the benefits and harms of this practice are largely undocumented. We set out to explore cardiologists' perspectives on the benefits and harms of race-based drug labels and guidelines. Specifically, we focused on isosorbide dinitrate and hydralazine hydrochloride (sold in a patented form as BiDil), a combination of drugs recommended for the treatment of black patients receiving optimal medical therapy for symptomatic heart failure and reduced ejection fraction. Methods: We conducted 81 semistructured interviews at an American College of Cardiology Annual meeting to assess cardiologists' and cardiology fellows' attitudes toward the use of race in drug prescribing. Investigators reviewed and coded the interviews using inductive qualitative analysis techniques. Results: Many participants believed that race-based drug labels might help doctors prescribe effective medications to patients sooner. More than half of the participants expressed concerns, however, that considering race within the context of treating heart failure could potentially harm patients as well. Harms identified included the likelihood that patients who could benefit from a drug may not receive it because of their race; insufficient understanding about gene–drug–environment interactions; and simplistic applications of race in the clinic. Conclusions: Few participants expressed approval of using race in drug prescribing without recognizing the potential harms, yet most participants stated that they continue to consider race when prescribing isosorbide dinitrate and hydralazine hydrochloride. Within the context of treating heart failure, more open discussions about the benefits and harms of race-based drug labels and prescribing are needed to address cardiologists' concerns.
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Affiliation(s)
- Shawneequa L Callier
- Department of Clinical Research and Leadership, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,Center for Research on Genomics and Global Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland
| | - Brooke A Cunningham
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Jill Powell
- Center on Genomics, Race, Identity, Difference, Duke University, Durham, North Carolina
| | - Mary Anne McDonald
- Center on Genomics, Race, Identity, Difference, Duke University, Durham, North Carolina
| | - Charmaine D M Royal
- Center on Genomics, Race, Identity, Difference, Duke University, Durham, North Carolina.,Department of African & African American Studies, Duke University, Durham, North Carolina
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Physicians' knowledge, beliefs, and use of race and human genetic variation: new measures and insights. BMC Health Serv Res 2014; 14:456. [PMID: 25277068 PMCID: PMC4283084 DOI: 10.1186/1472-6963-14-456] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 09/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding physician perspectives on the intersection of race and genomics in clinical decision making is critical as personalized medicine and genomics become more integrated in health care services. There is a paucity of literature in the United States of America (USA) and globally regarding how health care providers understand and use information about race, ethnicity and genetic variation in their clinical decision making. This paper describes the development of three scales related to addressing this gap in the literature: the Bonham and Sellers Genetic Variation Knowledge Assessment Index--GKAI, Health Professionals Beliefs about Race-HPBR, and Racial Attributes in Clinical Evaluation-RACE scales. METHODS A cross-sectional, web survey of a national random sample of general internists in the USA (N = 787) was conducted. Confirmatory factor analysis was used to assess the construct validity of the scales. Scale items were developed through focus groups, cognitive interviews, expert advisory panels, and exploratory factor analysis of pilot data. RESULTS GKAI was measured as a count of correct answers (Mean = 3.28 SD = 1.17). HPBR yielded two domains: beliefs about race as a biological phenomenon (HPBR-BD, alpha = .69, 4 items) and beliefs about the clinical value of race and genetic variation for understanding risk for disease (HPBR-CD alpha = .61, 3 items). RACE yielded one factor (alpha = .86, 7 items). CONCLUSIONS GKAI is a timely knowledge scale that can be used to assess health professional knowledge of race and human genetic variation. HPBR is a promising new tool for assessing health professionals' beliefs about the role of race and its relationship with human genetic variation in clinical practice. RACE offers a valid and reliable tool for assessing explicit use of racial attributes in clinical decision making.
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Bonham VL, Knerr S, Feero WG, Stevens N, Jenkins JF, McBride CM. Patient physical characteristics and primary care physician decision making in preconception genetic screening. Public Health Genomics 2009; 13:336-44. [PMID: 19940457 DOI: 10.1159/000262328] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2009] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There has been growing emphasis on preconception care as a strategy to improve maternal and child health since the 1980s. Increasingly, development of genetic tests will require primary care providers to make decisions about preconception genetic screening. Limited research has been conducted on how primary care providers interpret patients' characteristics and use constructs, such as ethnicity and race, to decide whom to offer preconception genetic screening. OBJECTIVE This report assessed the influence of patient characteristics on decisions to offer preconception genetic screening. METHODS A web-based survey of family physicians was conducted. Physicians reviewed a clinical vignette that was accompanied by a picture of either a black or a white patient. Physicians indicated whether they would offer genetic screening, and if yes, what tests they would offer and what factors influenced their decisions. RESULTS The majority (69.2%) of physicians reported that they would not offer genetic screening. Respondents who reviewed the vignette accompanied by a picture of the black patient were more likely to offer screening (35% vs. 26%, p = 0.0034) and rated race as more important to their decision to offer testing than those who viewed the picture of the white patient (76% vs. 49%, p < 0.0001). CONCLUSIONS Our findings suggest that patient race is important to physicians when making decisions about preconception genetic testing and that decision making is influenced by patients' physical characteristics. The reticence of physicians in this sample to offer preconception screening is an important finding for public health and clinical practice.
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Affiliation(s)
- V L Bonham
- Social and Behavioral Research Branch, National Human Genome Research Institute, NIH, Bethesda, Md. 20892-2152, USA.
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