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.
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.
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.
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.