Uprooting Race-based Medicine in a Frequent Reference Source

It happens every day in doctors’ offices: A patient describes symptoms. The physician listens carefully and then checks UpToDate^® before making a recommendation.

UpToDate^® is a clinical search tool that more than two thirds of hospitals and health systems in the United States—and 90% of teaching hospitals—routinely use to access research, read literature, and find up-to-date suggestions. A panel of editors recruits those who they believe are experts in a topic to inform articles. The articles are then peer-reviewed and updated frequently as new research is published.

Here’s where things get tricky: Let’s say that patient is Black. According to a recent study in eClinical Medicine, published by the Lancet, more than 93% of studies mentioning race on UpToDate^® have biologized it, suggesting differential disease parameters or treatments for non-white patients.

“We thought that UpToDate^® may be imparting these messages to clinicians, and that was exactly what we found,” says Jessica Cerdeña, PhD, now an MD candidate at Yale School of Medicine, who led the study. “It was very overwhelming the degree to which race was biologized, Black race in particular.”

Cerdeña and her co-researchers had suspected race or ancestry was assigned a clinical meaning, but they needed to show empirically that this was happening. By performing a search on UpToDate^® using the words “Black” and “African American,” they were able to analyze how race was mentioned in research. Race came up in specific and broad topics alike. For instance, an article on potty training generalized that Black families potty train earlier than white families, contributing to stereotyping.

“It’s baked in; it’s part of the system that we enmesh ourselves in,” says Cerdeña, referring not only to everyday tools like UpToDate^®, but also textbooks and board questions.

“We disagree with some of the authors’ assessments,” UpToDate says in a statement about the study. “They imply that every one of their defined codes describes a negative aspect of the content. However, in our review of these text examples, we believe that some were applied to appropriate and clinically relevant content.” Examples the statement cites include genetic variants found only in patients with African ancestry and described as such. And in areas where UpToDate agrees the study's analysis may have merit, "We have specifically stressed the importance of having our contributors examine any mention of race/ethnicity and either remove it if it is irrelevant or add language addressing the societal factors and health care disparities that may account for any observed differences. In fact, most of the topic areas from January to March 2020 the authors used as examples had already been revised [by the time the study was published] as part of our ongoing work to address racism in medicine." The statement, including other specific examples, can be read in full here.

“The problem with attributing health disparities to genetics is manyfold,” Cerdeña says. “First, it distracts from the true problem.” The true problem, she says, is more complicated. Such conditions as hypertension, kidney disease, and diabetes are influenced by many genes and many environmental interactions. And biologizing race, she says, excuses policymakers who differentially expose people to harmful life circumstances that adversely impact their health.

“When we look at racialized health disparities in the United States, we see health consequences of racist policies like redlining, Jim Crow, and environmental racism,” says Cerdeña. “Race was truly an invented phenomenon to advance these kinds of political goals, and really, it’s backward thinking to try to see if there are racial differences in genetics.”

Co-researcher Marie Plaisime, PhD, MPH, a National Science Foundation postdoctoral fellow at Harvard, studies social dynamics that affect health and how medical providers are trained to understand race and racism. “The literature shows that physicians lack consensus on what race is – there’s still debate over whether it is genetic or a social construct,” she says.

Plaisime asserts that the historical impact of scientific racism and the traditional approach that assigns characteristics to race are partly to blame for its biologization. “If you haven’t been trained to unpack what race is, then you are at risk of creating race-based assumptions," Plaisime says. “I think that our neglect to explain structural factors that impact health, like housing and education, creates additional harm and unintended consequences.”

Cerdeña advises clinicians and researchers alike to think critically about race in medicine. Using genetics as a framework for treating patients “cheapens the kind of work you’re going to do,” she says. Under that pretense, a physician might assume a Black patient is at higher risk for a condition and administer more tests or treatments, or they may throw their hands up in defeat. Cerdeña urges clinicians to think about how a patient is racialized and how that can shape how they navigate life in a sociopolitical framework.

For researchers, Cerdeña recommends analyzing race thoughtfully. Rather than focus on genetics, consider the effects of racist policies and the effects of counteracting those policies at the higher education level, state level, and so on. “The focus on biologizing race has distracted us from where we need to invest time, money and resources to develop the methodological rigor to properly assess the effects of policy,” says Cerdeña.

Plaisime recommends that medical institutions hire experts such as sociologists and anthropologists to conduct training on social constructs such as race, class, and gender. She would also like to see more diverse textbooks and faculty. “There are so many ways we can intentionally help medical students,” says Plaisime.

Plaisime hopes this line of research continues to spark conversations among medical students, medical systems, and other health professions such as nursing. “Medical students have been at the forefront of movements to remove race-based tools,” she says. “I hope that it will encourage medical schools or systems to generate more creative interventions on how they train their providers to understand the differences between genetics and race.”