In my first year of medical school, I walked into a study room to find a Venn diagram on the whiteboard. Underneath the title “Diseases Drake is at Risk for Developing” floated two intersecting circles, subtitled “Black Daddy” and “White Jewish Mommy.”

Drake is the multimillion-dollar rapper with the most charted songs for a solo artist in the history of the Billboard Hot 100. But on this whiteboard, he’s just a man with a Black Daddy and a White Jewish Mommy. What struck me was how crudely a hypothetical patient had been reduced to his race.

Courtesy Jennifer W. Tsai
A Venn diagram titled “Diseases Drake is at risk for developing” drawn on a whiteboard during a first-year medical school course. Courtesy Jennifer W. Tsai

The diagram hadn’t been drawn maliciously. It was a study aid for students preparing for Step 1 of the United States Medical Licensing Examination — the brutal, nine-hour assessment that medical students must take before graduation. One of the time-saving tricks we learn is to associate race with disease. A black child under 10 years old? Sickle cell disease. An Asian patient with weak pulses? Takayasu’s vasculitis. Urban man of color? Think drug use or violent trauma. A Mexican patient with gastrointestinal distress? Parasites from contaminated water. A white newborn that hasn’t passed meconium? Bet on cystic fibrosis.

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Medical training and licensing examinations reward students who memorize racial associations the best way they know how: with points. These forms of pattern recognition — “if-black-worry-about-this; if-white-suspect-that” — sound and look remarkably like how stereotyping works and how prejudice is born. It’s the same instinctual logic that might lead someone to believe that a black man sitting at Starbucks for two minutes is a criminal; that a black woman napping in her own dormitory is a trespasser; or that barbecuing while black is reason to call the police.

Race associations are as common in medical training, from lectures and prep books to practice tests and board exams, as they are unquestioned. An analysis of a licensing exam question bank found that the number one disease associated with white patients is cystic fibrosis. Black patients are most commonly coupled with sickle cell and sarcoidosis. These ties are so recognizable they’ve been turned into jokes.

Such racial associations are simple — too simple. They aren’t helping students learn and they might be harming patients.

It’s hard to think outside the box when everything you’ve been taught fits inside it. The trouble is that no genetic mutation or disease is specific to race.

In 2004, emergency physician Dr. Richard Garcia published an essay describing how his childhood friend Lela, who is black, was not diagnosed with cystic fibrosis — a disease usually detected in the first 6 months of life — until the age of 8. And even then it happened only because a radiologist, blinded to race by a gray X-ray film, asked, “Who’s the kid with CF?” “If she had been a white child,” Garcia concluded, “she would probably have gotten the correct diagnosis and treatment much earlier.”

These forms of pattern recognition — “if-black-worry-about-this; if-white-suspect-that” — sound and look remarkably like how stereotyping works and how prejudice is born.

These trained expectations start early. In the second year of medical school, after an exam on lung diseases, a classmate participated in the masochistic dance of “what was the answer to question so-and-so.” She asked about the correct diagnosis for a white patient with a cough, swollen lymph nodes at the root of both lungs, and skin lesions.

An answer was quickly convened. “Slam dunk sarcoidosis.”

“But she was white,” my classmate responded. “Oh, crap. I’m totally racist.”

This classmate, like Lela’s physicians, had seen obvious symptoms of a disease but missed the diagnosis because the patient’s race didn’t fit what they had been taught to envisage. The learned race associations, which frequently link sarcoidosis with black patients, had undermined clinical judgment.

Or take sickle cell anemia. A doctor might examine at an Italian woman or South Asian man exhibiting “slam-dunk” symptoms of sickle cell anemia, then rule out the diagnosis based on appearance because the disease is classically associated with black people. Yet some of the highest rates for sickle cell disease come from the Mediterranean and India, while large regions of South and North Africa are generally unburdened by the disease. In other words, a diagnosis of sickle cell disease is dismissed in thousands of patients with its signs because they are white, Asian, Middle Eastern, or Hispanic.

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Diagnoses based on race are problematic for another reason: they often teach doctors that race and disease both stem from biology. This logic removes social inequality as a source of disease. Instead of pointing a finger at the vast national inequities in housing, health care, nutrition, and education that rob people of color of good health, racial associations imagine race as an internal defect that drives health disparities. Race becomes a symbol for inferior genes that cause illness.

When racial associations are part of the everyday medical lexicon, what do we actually learn? What do we miss? And who do we marginalize?

Across the nation, efforts to critically examine the way medicine operationalizes race are underway. But these advances will have little effect if licensing exams continue to treat race associations as an integral part of learning. Memorizing ties between race and disease may help snag extra exam points, but it also encourages reductive notions of race that are the roots of bias and error.

Studying for medical board exams should equip trainees to care for future patients, not harm them. When race is employed in these coarse ways, they become simple signposts that can lead students astray. Physicians are taught to imagine the physicality of race as a clue to literally prompt suspicion — of disease, of behavior, of background. This preoccupation with race as part of biology teaches us that race is an integral part of diagnosis and treatment, a characteristic that becomes indelible from pathology.

We need better ways to learn, teach, and test knowledge on race, epidemiology, and disease. Drake can’t help us there.

Jennifer W. Tsai is a fourth-year medical student at the Warren Alpert Medical School of Brown University.

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  • Congratulations, Ms. Tsai. You have initiated an important discussion and gained prominent attention. This is how beneficial change occurs.

  • On behalf of representatives and committee members of the National Board of Medical Examiners and the Federation of State Medical Boards, the co-sponsors of USMLE, we congratulate Ms. Tsai for bringing attention to the important topics of stereotyping in medicine, bias in medical training and assessment, and health inequities. Since much of her article relates to assessment, we’d like to offer a few clarifications, as well as an update on USMLE progress in this area over the past few years.

    Many USMLE assessments are designed to measure diagnostic reasoning. Among the case vignettes in USMLE questions, characteristics of the patient, such as age, sex, gender identity, and occupation may be mentioned. Some patient characteristics can be important inputs into the diagnostic reasoning process. Others may lead to incorrect conclusions and misdiagnoses. Among the latter are characteristics that often stereotype or misrepresent patients.

    The USMLE program treats race as a social construct not linked to biology or susceptibility to disease. This is similarly true of someone’s ethnicity or heritage. If these social constructs are to be considered, they should be on the basis of self-report of the individual, not the assumption of a health care provider. Alternatively, ancestry, if known, may be biologically important, and thus may be relevant to factors relating to health and disease. This approach affirms our belief that each patient should be treated as an individual.

    We would differ with Ms. Tsai’s assertion stating, “….licensing examinations reward students who memorize racial associations the best way they know how: with points.” Some of her assertions are based on test-preparation material not developed or endorsed by the USMLE program. The items on USMLE are carefully designed to specifically measure accurate diagnosis, not assumptions, associations or stereotypes. On USMLE items, when an examinee selects the correct diagnosis, they are given credit because they are demonstrating what the examination item is designed to measure.

    We do not contest that some of the claims Ms. Tsai makes about USMLE items may have been true in the past. However, the examination has evolved significantly since its introduction in 1992, thanks to the more than 400 volunteer medical faculty from medical schools across the United States who contribute to USMLE each year. The individual faculty members and clinicians who write USMLE test questions and cases today follow guidelines that encourage thoughtful consideration of patient characteristics, while at the same time strive to promote diversity and present patients that reflect the US population.

    The USMLE is in the process of reviewing our entire item pool to eliminate questions and cases which promote biases or stereotypes. We are committed to contributing to the shared goal of eliminating these stereotypes and biases in clinical practice. Given the scope of the USMLE’s item and case pool, we expect that full review will take some time. In the meantime, our end-of exam survey will soon seek examinee feedback on whether any patient or physician portrayals in the test promoted unwanted stereotypes in medicine. We will be tracking survey responses to this question as a critical part of our review process. Examinees will also begin to notice that certain characteristics, specifically those that relate to social factors such as race, ethnicity, heritage, if presented, will be done so by the patient as “self-reported.”

    Thanks again go to Ms. Tsai for bringing this important issue to the attention of all of us in health professions education and assessment.

    Michael A. Barone, MD, MPH – Vice President Licensure Programs, National Board of Medical Examiners
    David A. Johnson, MA – Senior Vice President Assessment Services, Federation of State Medical Boards
    Reena Karani, MD, MHPE – Chair, USMLE Management Committee Patient Characteristics Task Force
    Suzanne McEllhenney – Director, Program Management, USMLE, National Board of Medical Examiners
    Lewis R. First, MD, MSc – Chair, Diversity and Inclusion Task Force, National Board of Medical Examiners
    Pat Mastors, Chair, Public Stakeholders’ Committee, National Board of Medical Examiners

  • These Racial and Gender biases are well documented, yet they persist. They are reinforced by medical publications. Even when the numbers prove the existence of this bias, Phsyicians choose to remain in denial. They have similar prejudices against low income Americans, and blue collar workers. These topics are spun by mass media, which is really evident after the reports on black women dying in childbirth. Instead of showing the danger and costs of racial discrimination, the mass media spun it to blame the women themselves. In local media they ran clever stories about a nice clinic (70 miles away) that treats black woman) to offset the factual news. A Hispanic woman and her fetus were killed in a roll over accident, she was forced to travel 150 miles round trip, because they closed the clinic in her area. The local news spun that too, turning it into an Advertorial for an overtaxed Midwifery “Clinic.”
    In Post Fact America, there is profit either way, so this topic will not be acknowledged, or even tracked.
    Interesting Fact, the Sickle Cell gene is responsible for Malaria resistance, so when Global Warming kicks in it might produce an evolutionary advantage. My father fought in Korea, and was the only one in his troop that did not get Malaria, thanks to our Mediterranean genes.

  • The author might do well by reading Ashley Montague’s “Man’s Most Dangerous Myth”, which 75 years ago dethroned race as a biological category. This common misunderstanding of race as a biological category should not even be implicitly accepted amongst medical students (even as “problematic”). Physical Anthropologists concluded decades ago, “there is no necessary concordance between biological characteristics and [race]”.

    Race is a social construct. However, it is also (like other social constructs) a critical and essential factor in considering diagnosis – not determinate, but certainly essential. I would be horrified if doctors didn’t consider sickle-cell first for African-American patients, because the incidence is 25 times higher. It has taken decades to even get this far that physicians even consider it for diagnosis amongst African-Americans. And to clarify, sickle-cell, a heritance that derived from its protection from malaria, is not common amongst Italians, rather only somewhat amongst Sicilians, and at that, only 400 “Italian” patients exist (Sickle Cell Society). And only 3 “blond, blue-eyed” patients exist in Sicily. Symptoms, also, are less commonly severe in southern Italy (due to genetic differences in the defect).

    Therefore, yes, Drake’s skin color (his ‘social race’ and inherited traits) “can help us here”. It would be irresponsible to suggest otherwise.

  • Thank you, Ms. Tsai, for your thought-provoking and appropriate article. May you have a long and influential career.

  • Well, point taken. However a wise friend of mine said. ‘It takes a lifetime to become a good doctor’? And altho’ I am not a doctor this is true for any profession mostly. Maybe instead of criticism just undertake to note how we are all subject to think inside the box in many ways and overcome it in yourself. And then teach and update the curriculum. And see if you can overcome your own boxes.

  • The bigger issue to me is that medical students are taught to think deterministically rather than probabilistically.

    Sure — some diseases are *more common* in one race or region than another. But it doesn’t mean they are unheard of in other races or regions. Forming an appropriate ‘pre-test probability’ which is in part based upon race or family history is absolutely appropriate and in fact good medicine. But too few MDs are taught to think probabilistically and appreciate natural variability.

  • In the veterinary world – we call it signalment – age, sex, weight and breed. This info is basic and helpful. Diseases happen at certain ages – knowing the age of a patient and using that in assesssment of patients does NOT make a physician an “agist”. Knowing if a patient is obese is relevant, and doesn’t make a physician a “fat-shamer”. And knowing breed helps as certain breeds are predisposed to certain diseases. The author may not have heard the phrase “not every case reads the book”. But she should have by now. Knowing race of a human patient seems to be basic signalment that is valuable info.. if a physician misses a diagnosis because of relying too heavily on signalment – it’s their fault. But not because they are racist, but because they forgot another basic – not every case reads the book.

    • Age and weight should be treated differently than race? The point is that these stereotypes don’t help as much as we like to think they do. I’m sure obesity and old age are pretty good predictors of a lot of things…

    • Yes, except that unlike breeds in dogs, race is an indicator for socioeconomic, cultural, and lifestyle differences rather than biological differences. There is no genetic basis for race. By using race to infer disease risk, we make assumptions about the relevant socioeconomic, cultural, and lifestyle factors. As the author points out, judging disease risk based on appearance in north America may lead a physician to infer that a black African person has higher risk of sickle cell anemia than a white Italian person, however the opposite may be the case.

    • The veterinary world might as well be another planet when it comes to this discussion. Breeding animals has led to selection of traits in a way that humans have never experienced.

  • Ok so if a transgender physically female identifies as male, we allow them to get uterine, breast and cervical cancer and die from it? We tell them to turn our heads and cough, we’re willing to pay for that?
    Race is a place to start somewhere, not finish. “When you hear hoofbeats, think of horses, not zebras”. Its more like you are asking for tons of wild goose chases before starting with the obvious and going out from there.

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