Race as a Risk Marker, Not a Risk Factor: Revising Race-Based Algorithms to Protect Racially Oppressed Patients.

Emerging consensus in the medical and public health spheres encourages removing race and ethnicity from algorithms used in clinical decision-making. Although clinical algorithms remain appealing given their promise to lighten the cognitive load of medical practice and save time for providers, they risk exacerbating existing health disparities. Race is a strong risk marker of health outcomes, yet it is not a risk factor. The use of race as a factor in medical algorithms suggests that the effect of race is intrinsic to the patient or that its effects can be distinct or separated from other social and environmental variables. By contrast, incisive public health analysis coupled with a race-conscious perspective recognizes that race serves as a marker of countless other dynamic variables and that structural racism, rather than race, compromises the health of racially oppressed individuals. This perspective offers a historical and theoretical context for the current debates regarding the use of race in clinical algorithms, clinical and epidemiologic perspectives on "risk," and future directions for research and policy interventions that combat color-evasive racism and follow the principles of race-conscious medicine.

Invited Commentary: Undiagnosed and Undertreated-the Suffocating Consequences of the Use of Racially Biased Medical Devices During the COVID-19 Pandemic.

While medical technology is typically considered neutral, many devices rely upon racially biased algorithms that prioritize care for White patients over Black patients, who may require more urgent medical attention. In their accompanying article, Sudat et al. (Am J Epidemiol. 2023;XXX(XX):XXX-XXX) document striking inaccuracies in pulse oximeter readings among Black patients, with significant clinical implications. Their findings suggest that this resulted in racial differences in delivery of evidence-based care during the coronavirus disease 2019 (COVID-19) pandemic, affecting admissions and treatment protocols. Despite the medical community's growing awareness of the pulse oximeter's significant design flaw, the device is still in use. In this article, I contextualize Sudat et al.'s study results within the larger history of racial bias in medical devices by highlighting the consequences of the continued underrepresentation of diverse populations in clinical trials. I probe the implications of racially biased assessments within clinical practice and research and illustrate the disproportionate impact on patients of color by examining 2 medical tools, the pulse oximeter and pulmonary function tests. Both cases result in the undertreatment and underdiagnosis of Black patients. I also demonstrate how the social underpinnings of racial bias in medical technology contribute to poor health outcomes and reproduce health disparities, and propose several recommendations for the field to rectify the harms of racial bias in medical technology.

Race, Ethnicity, and Immigration Status in a Medical Licensing Educational Resource: a Systematic, Mixed-Methods Analysis.

BACKGROUND: Medical students preparing for the United States Medical Licensing Exam (USMLE) Step 2 Clinical Knowledge (CK) Exam frequently use the UWorld Step 2 CK Question Bank (QBank). Over 90% of medical students use UWorld QBanks to prepare for at least one USMLE. Although several questions in the QBank mention race, ethnicity, or immigration status, their contributions to the QBank remain underexamined. OBJECTIVE: We conducted a systematic, mixed-methods content analysis to assess whether and how disease conditions might be racialized throughout this popular medical education resource. DESIGN: We screened 3537 questions in the QBank between May 28 and August 11, 2020, for mentions of race, ethnicity, or immigration status. We performed multinomial logistic regression to assess the likelihood of each racial/ethnic category occurring in either the question stem, answer explanation, or both. We used an inductive technique for codebook development and determined code frequencies. MAIN MEASURES: We reviewed the frequency and distribution of race or ethnicity in question stems, answer choices, and answer explanations; assessed associations between disease conditions and racial and ethnic categories; and identified whether and how these associations correspond to race-, ethnicity-, or migration-based care. RESULTS: References to Black race occurred most frequently, followed by Asian, White, and Latinx groups. Mentions of race/ethnicity varied significantly by location in the question: Asian race had 6.40 times greater odds of occurring in the answer explanation only (95% CI 1.19-34.49; p < 0.031) and White race had 9.88 times greater odds of occurring only in the question stem (95% CI 2.56-38.08; p < 0.001). Qualitative analyses suggest frequent associations between disease conditions and racial, ethnic, and immigration categories, which often carry implicit or explicit biological and genetic explanations. CONCLUSIONS: Our analysis reveals patterns of race-based disease associations that have potential for systematic harm, including promoting incorrect race-based associations and upholding cultural conventions of White bodies as normative.

Addressing the Health Impacts of Racism on Children and Youth: Equity Until Equality.

Race is a sociopolitical construct based on physical characteristics, not a biological construct. Racism is a system that ascribes value and resources based on the sociopolitical construct called "race." In the United States and other countries around the world, racism is associated with disparate health outcomes and shortened life expectancies. Health equity employs health-related systems (eg, health care providers, insurance companies, hospitals, research, pharmaceutical companies) across multiple sectors (eg, housing, education, business, government) to allocate resources and services to correct and promote political and social determinants associated with health and wellness. Applying health equity practices and policies ensures that each child, youth, and adult receives comprehensive, evidence-informed, culturally relevant, and needs-based services to achieve optimum health. This article provides an overview of the impact of racism embedded in systems and policies that challenge optimal health for children and youth and offers evidence-supported paths forward to advance health and wellness in the United States. Until each child and adolescent enjoys optimal and equal health outcomes, health equity practices and social justice are mandatory.

Prolonged Boarding and Racial Discrimination and Dissatisfaction Among Emergency Department Patients.

Importance: Emergency department (ED) boarding times have increased rapidly, but their health equity outcomes are unknown. Objective: To investigate whether prolonged ED boarding is associated with increased perceived racial discrimination and dissatisfaction and whether associations vary between patients from marginalized racial and ethnic groups vs non-Hispanic White patients. Design, Setting, and Participants: This is a cross-sectional study of hospitalized adults who boarded in the ED during internal medicine admissions at a large, urban hospital in Boston, Massachusetts, from June 2023 to January 2024. Equal proportions of non-Hispanic White patients and patients from marginalized racial and ethnic groups (American Indian or Alaska Native, Hispanic, non-Hispanic Black and/or African American, and multiracial) were selected randomly. Exposure: The duration of ED boarding was categorized as less than 4 hours (reference), 4 to less than 24 hours, and 24 or more hours. Main Outcomes and Measures: Primary outcomes were odds of reporting (1) discrimination via the Discrimination in Medical Settings scale, and (2) dissatisfaction via the adapted Picker Patient Experience-15 questionnaire. Marginalized race and ethnicity was tested as an effect modifier. Multivariable logistic regression models adjusted for patient age, sex, language, and insurance payer. Results: Of 598 patients approached, 527 were enrolled, and 525 completed the surveys (response rate, 87.8%). The mean age (SD) was 60.6 (18.7) years, 300 patients (57.1%) were female, 246 patients (47.3%) identified as non-Hispanic White, and 274 (52.7%) were from a marginalized racial or ethnic group. In total, 135 (25.7%) boarded less than 4 hours (reference), 202 (38.5%) boarded 4 to less than 24 hours, and 188 (35.8%) boarded 24 hours or longer. Compared with less than 4 hours, boarding 24 hours or longer was associated with increased perceived discrimination (odds ratio [OR], 1.84; 95% CI, 1.14-2.99; P = .01). An increased association was observed in the subgroup of patients from racial and ethnic marginalized groups (OR, 2.36; 95% CI, 1.20-4.65; P = .01); effect modification was not significant (P for interaction, .10). For all patients, boarding 24 hours or longer was associated with increased dissatisfaction with care (OR, 1.77; 95% CI, 1.03-3.06; P = .04); effect modification was not significant (P for interaction, .80). Conclusions and Relevance: In this cross-sectional study, hospitalized patients who boarded in the ED 24 hours or longer reported more discrimination and dissatisfaction with care, which may disproportionately affect patients from marginalized racial and ethnic groups. As ED boarding times increase nationally, it is critical to recognize their potential to exacerbate health inequities and to respond with equity-focused solutions.

Implicit and explicit racial prejudice among medical professionals: updated estimates from a population-based study.

Background: Prior research provides evidence of implicit and explicit anti-Black prejudice among US physicians. However, we know little about whether racialized prejudice varies among physicians and non-physician healthcare workers relative to the general population. Methods: Using ordinary least squares models and data from Harvard's Project Implicit (2007-2019), we assessed the associations between self-reported occupational status (physician, non-physician healthcare worker) and implicit (N = 1,500,268) and explicit prejudice (N = 1,429,677) toward Black, Arab-Muslim, Asian, and Native American populations, net of demographic characteristics. We used STATA 17 for all statistical analyses. Findings: Physicians and non-physician healthcare workers exhibited more implicit and explicit anti-Black and anti-Arab-Muslim prejudice than the general population. After controlling for demographics, these differences became non-significant for physicians but remained for non-physician healthcare workers (ß = 0.027 and 0.030, p < 0.01). Demographic controls largely explained anti-Asian prejudice among both groups, and physicians and non-physician healthcare workers exhibited comparatively lower (ß = -0.124, p < 0.01) and similar levels of anti-Native implicit prejudice, respectively. Finally, white non-physician healthcare workers exhibited the highest levels of anti-Black prejudice. Interpretation: Demographic characteristics explained racialized prejudice among physicians, but not fully among non-physician healthcare workers. More research is needed to understand the causes and consequences of elevated levels of prejudice among non-physician healthcare workers. By acknowledging implicit and explicit prejudice as important reflections of systemic racism, this study highlights the need to understand the role of healthcare providers and systems in generating health disparities. Funding: UW-Madison Centennial Scholars Program, Society of Family Planning Research Fund, UW Center for Demography and Ecology, the County Health Rankings and Roadmaps Program and the National Institutes of Health (NIH).

The impact of neighborhoods and friendships on interracial anxiety among medical students and residents: A report from the medical student CHANGES study.

OBJECTIVE: To examine the experience of interracial anxiety among health professionals and how it may affect the quality of their interactions with patients from racially marginalized populations. We explored the influence of prior interracial exposure-specifically through childhood neighborhoods, college student bodies, and friend groups-on interracial anxiety among medical students and residents. We also examined whether levels of interracial anxiety change from medical school through residency. DATA SOURCE: Web-based longitudinal survey data from the Medical Student Cognitive Habits and Growth Evaluation Study. STUDY DESIGN: We used a retrospective longitudinal design with four observations for each trainee. The study population consisted of non-Black US medical trainees surveyed in their 1st and 4th years of medical school and 2nd and 3rd years of residency. Mixed effects longitudinal models were used to assess predictors of interracial anxiety and assess changes in interracial anxiety scores over time. PRINCIPAL FINDINGS: In total, 3155 non-Black medical trainees were followed for 7 years. Seventy-eight percent grew up in predominantly White neighborhoods. Living in predominantly White neighborhoods and having less racially diverse friends were associated with higher levels of interracial anxiety among medical trainees. Trainees' interracial anxiety scores did not substantially change over time; interracial anxiety was highest in the 1st year of medical school, lowest in the 4th year, and increased slightly during residency. CONCLUSIONS: Neighborhood and friend group composition had independent effects on interracial anxiety, indicating that premedical racial socialization may affect medical trainees' preparedness to interact effectively with diverse patient populations. Additionally, the lack of substantial change in interracial anxiety throughout medical training suggests the importance of providing curricular tools and structure (e.g., instituting interracial cooperative learning activities) to foster the development of healthy interracial relationships.

Race-based medicine in the point-of-care clinical resource UpToDate: A systematic content analysis.

Background: Race-based practices in medical education and clinical care may exacerbate health inequities. Misguided use of race in popular point-of-care clinical decision-making tools like UpToDate® may promote harmful practices of race-based medicine. This article investigates the nature of mentions of Black/African American race in UpToDate®. Methods: We conducted a systematic content analysis of UpToDate® articles mentioning Black or African American race to assess for biological interpretations of racial categories. Following a simple text search for the terms "Black" and "African American" in UpToDate® on January 24 and March 19, 2020, respectively, removal of duplicates yielded an analytical sample of 208 documents. We adopted a deductive coding approach and systematically applied 16 a priori codes to all documents, refining the codebook to achieve a final inter-rater reliability of 0.91. We then developed these codes into two themes: (1) biologization of race and (2) racialized research and practice. Findings: Biologization of race occurred nearly universally across all documents (93.3%), with discussions of inherent physiological differences between racial groups and presentation of epidemiologic disparities without context emerging most frequently. Sixty-eight documents (32.7%) included codes related to racialized biomedical research and clinical practice, including references to racialized patterns of behavior and cultural practices, insufficient data on Black populations, research limiting study to a specific racial group, and race-based clinical practices guidelines. Interpretation: Our findings suggest that UpToDate® articles often inappropriately link Black race to genetics or clinical phenotype-without considering socio-structural variables or the health effects of structural racism-thus perpetuating a false narrative that race is inherently biological. UpToDate® articles may also promote unequal treatment by recommending race-based clinical practices. Such racial essentialism risks exacerbating racialized health inequities. Funding: The study is supported by the Health Policy Research Scholars Program, Robert Wood Johnson Foundation, Medical Scientist Training Program, National Institutes of Health, the National Science Foundation, the JPB Foundation, the Minnesota Population, the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD), and the Center for Antiracism Research for Health Equity at the University of Minnesota.

Mentorship: The necessity of intentionality.

A large body of research exists that is dedicated to exploring and defining mentoring. It is widely recognized that mentorship is a process informed by one's personal experiences. Yet, mentorship literature primarily centers around advancing technical proficiencies, and very little focuses on individual characteristics, such as honesty, consistency, and transparency. Individual wisdom is an invaluable tool for intentional mentorship. Intentional mentors catalyze the ability to understand and tap into one's own power, promote awareness of individual strengths and limitations, and clarify personal vision. Through intentional mentorship, mentors identify, improve, and implement strategies and skills that they acquired throughout their career. After conducting a self-assessment and identifying the personal skills that can be attributed to effective mentoring, mentors advance along the mentorship continuum to improve, and subsequently implement, these skills. Given the changing landscape of the scientific workforce in general, faculty mentors must be intentional about seeking avenues for growth. Beyond individual implementation, it is essential for educational institutions to also take a systemic approach when it comes to supporting faculty advisors and their mentees. A few tools and resources are offered to encourage mentors in taking a proactive role as they intentionally develop and enhance their individual mentoring process. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Healthcare Providers' Formative Experiences with Race and Black Male Patients in Urban Hospital Environments.

OBJECTIVE: We explored health providers' formative personal and professional experiences with race and Black men as a way to assess their potential influence on interactions with Black male patients. METHODS: Utilizing convenience sampling with snowballing techniques, we identified healthcare providers in two urban university hospitals. We compared Black and White providers' experiences based on race and level of training. We used the Gardener's Tale to conceptualize how racism may lead to racial health disparities. A semi-structured interview guide was used to conduct in-person interviews (n = 16). Using the grounded theory approach, we conducted three types of coding to examine data patterns. RESULTS: We found two themes reflective of personally mediated racism: (1) perception of Black males accompanied by two subthemes (a) biased care and (b) fear and discomfort and (2) cognitive dissonance. While this latter theme is more reflective of Jones's internalized racism level, we present its results because its novelty is compelling. CONCLUSIONS: Perception of Black males and cognitive dissonance appear to influence providers' approaches with Black male patients. This study suggests the need to develop initiatives and curricula in health professional schools that address provider racial bias. Understanding the dynamics operating in the patient-provider encounter enhances the ability to address and reduce health disparities.