My parents fell in love at a time when their union was illegal in 16 states. My father, who is white and who was a priest at the time, married my mother, who later became one of the first black women college presidents.
As a mixed-race kid growing up in Ohio, I often felt like a chameleon who could move in and out of different cultural worlds. Understanding various perspectives is a multiracial kid’s superpower, and I felt that I could almost fit in anywhere, though I fully fit in nowhere. I relish what Barack Obama and Trevor Noah have written about their similar childhood experiences.
The historic announcement of Kamala Harris as the Democratic party’s nominee for vice president coincides with a rapidly growing population of multiracial individuals in the United States. Their presence has been captured with more precision in the 2000 and 2010 Censuses. The 2020 Census will, for the first time, ask those who select white or black for their race to provide information about their heritage — such as Italian, Lebanese, African-American or Ethiopian.
As a primary care doctor for 20 years, I believe that medicine is overdue for similar update.
In medical school, I was diligently trained to report to my attending physicians the age, race, and gender of my patients — in that order. I often found myself wondering: If I were the patient on the examination table, how would a doctor describe me? Would she report me as a 25-year-old white female or a 25-year-old black female?
Medicine lacks the vocabulary to describe my skin tone and the technology to capture the genetic complexity that underlies it. The practice of medicine has not truly accounted for mixed-race individuals like myself, and lacks the precision to recognize our whole, inclusive identities.
Today, I still grapple with the role race plays in how I care for my patients. The New England Journal of Medicine recently published “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms.” The authors challenge the long-standing belief that race is a relevant element for diagnosis in most clinical settings, even as race-based algorithms, which are widely used by doctors to assess risk levels for certain conditions, often determine whether or not an individual will receive a specific treatment.
Even as a doctor, it wasn’t until I read the NEJM article that I really thought much about how my selecting my race/ethnicity when registering as a patient, or how a doctor perceives my race when treating me, might affect the dosing of my medications or the calculation of my 10-year cardiovascular risk. In many ways, medicine has failed to keep pace with the rapid swirl of diversity in America.
To realize the promise of 21st century health care, we should take advantage of the wearable digital tools and readily available genetic tests that can allow health care to routinely incorporate unique information about each individual. Patients should have seamless ways to interact with their health care providers through a combination of in-person care, telemedicine, and remote monitoring of vital signs. And their providers should be able to create care plans that take into account patients’ unique physiologic make-ups — longitudinal assessments that go beyond cruder categories such as race.
These new data streams create exciting possibilities that never before existed in health care. There is an unprecedented opportunity for clinicians and their teams to harness the power of this data flow to tailor care for the patients in front of us rather than making treatment decisions based on race-based equations developed nearly 50 years ago. America had an entirely different demographic composition at that time, before millions of multiracial Americans (including myself) were born.
As more diverse populations take part in clinical trials and other studies over time, assessments used in medicine will become more accurate and more meaningful, especially for people of color. I am inspired by the National Institutes of Health’s All of Us Research Program, which aims to build one of the most diverse health databases in history.
Medicine should be held to the same accountability as other sectors of American life. As millions march in the streets to demand and inspire long-overdue justice and equality for people of color, I enter a clinic room to treat one person at a time. I lay my hands on the patient — palpate here, percuss there. What is pulsating, what is cold, what is jaundiced? I review the medical research and conscientiously apply the most appropriate assessments to the patient I am with. Race and ethnicity may occasionally confer medical significance, say when considering the probability of sickle cell disease or melanoma. But the legacy of poverty, lack of access to care, and structural impediments to good health have far more influence on my patients’ health than race or skin color.
In this one-on-one interaction with a patient, there is space for a personal connection — stemming from the physician’s willingness to lead with curiosity, listen without bias, and recognize the whole patient beyond categories — as well as a technological connection through data that increasingly reveal the full patient.
The critical cultural moment we are in represents a perfect time to re-examine the use of race in medicine. I’d like to see medical students trained using cultural humility, assessments developed from diverse databases, and technology to connect holistically with their patients. If we are in charge of this charged moment — and we are — we must take the opportunity to leapfrog from archaic practices and enter into a more enlightened and inclusive era of medicine that looks far beyond skin color and race and into who patients really are.
Megan R. Mahoney is a family medicine physician, chief of staff for Stanford Health Care, principal investigator for Stanford’s Humanwide Project, and clinical professor of medicine at Stanford University School of Medicine.
Although research reveals infants demonstrate a preference for caregivers of their own race, any future racial biases generally are environmentally acquired.
One way of rectifying this bias is by allowing young children to become accustomed to other races in a harmoniously positive manner.
Adult racist sentiments, however, are often cemented by a misguided yet strong sense of entitlement, perhaps also acquired from rearing.
Fortunately, at a very young age I was emphatically told by my mother about the exceptionally kind and caring nature of our black family doctor.
She never had anything disdainful to say about people of color; in fact she loves to watch/listen to the Middle Eastern and Indian subcontinental dancers and musicians on the multicultural channels.
Conversely, if she’d told me the opposite about the doctor, I could’ve aged while blindly linking his color with an unjustly cynical view of him and all black people.
Thus essentially by chance I reached adulthood unstricken by uncontrolled feelings of racial contempt seeking expression.
Not as lucky, some people—who may now be in an armed authority capacity—were raised with a distrust or blind dislike of other racial groups.
Regardless, the first step towards changing our irrationally biased thinking is our awareness of it and its origin.
But until then, ugly sentiments must be either suppressed or professionally dealt with, especially when considering the mentality is easily inflamed by anger.
Great article! Thanks so much for sharing your personal journey and seamlessly connecting it to your vision for improving health care delivery with precision medicine. Using a social construct such as race in predictive clinical algorithms is an embarrassingly flawed approach. I’m grateful for the clinician advocates bringing us out of the dark ages of race base medicine.
Excellent article – and a great counter to the Jim Crow era’s “one drop of black blood = black” mandate that extended to scientific investigations.
My only comment is in regards to your statement “Race and ethnicity may occasionally confer medical significance, say when considering the probability of sickle cell disease or melanoma.” I would add systemic racism and adverse childhood experiences to this list – I suspect that they belong more in the area of epigenetics (chronic stress’ effect on neuro-hormonal development) rather than in genomics per se. Racism exists outside of poverty and poor access to care, though they frequently occur together – and its effects clearly have influence on our patients’ health.
Thanks for such great article! You’re definitely right. We currently use the social construct ‘race’ or ‘ethnicity’ in such an inaccurate way in medicine. All humans are closely related, and so our genomes are like a continuous variable, that differs slightly along a spectrum among different individuals. But when we use strict categories for ethnicity/race, it’s as though we took a continuous variable like height, and divided it into arbitrary categories eg above 150cm and below 150cm. That would be a very inaccurate way to wield the predictive power of a continuous variable. At least height can be objectively measured. The socially constructed categories on each Census form will differ from nation to nation, reflecting the socially constructed nature of this measure.