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PHILADELPHIA – Medical school curriculums may misuse race and play a role in perpetuating physician bias, a team led by Penn Medicine researchers found in an analysis of curriculum from the preclinical phase of medical education. In a perspective piece published Tuesday in the New England Journal of Medicine, the researchers identified five key categories in which curriculum misrepresented race in class discussions, presentations, and assessments. The authors recommend that rather than oversimplifying conversations about how race affects diseases’ prevalence, diagnosis, and treatment, medical school faculty must widen the lens to “impart an adequate and accurate understanding of the complexity of these relationships.”

“In medical school, 20 years ago, we often learned that higher rates of hypertension in certain racial and ethnic groups, was due to genetic predisposition, personal behaviors, or unfortunate circumstances. Now we know this is not true. There are no characteristics innate to racial and ethnic groups, biological or otherwise, that adequately explains these differences. They stem, instead, from differential experiences in our society — it’s structural racism, not race,” said the study’s senior author Jaya Aysola, MD, MPH, assistant dean of Inclusion and Diversity in the Perelman School of Medicine and executive director at the Penn Medicine Center for Health Equity Advancement. “When we speak of dismantling structural racism, we must begin with medical education, where these sorts of race-based biases are still being reinforced in the classroom.”

Though the researchers focused on lectures from a single medical school, the study authors from other institutions found similar misrepresentations of race in their preclinical medical curriculums. The five categories of biases that the research team identified were: semantics, prevalence of disparities without context, race-based diagnostic bias, pathologizing race, and race-based clinical guidelines.

For example, the study authors noted the use of “African American,” is a socially and politically meaningful identity for many people, but not for all people of African descent. Moreover, they write, it is a poor proxy for genetic difference, since it lumps people from many different ancestral populations together. The researchers also found that educators regularly pathologized race, describing poor outcomes for minority patients, without referencing research on racism’s effects on health. Structural racism, such as policies that segregate neighborhoods by race, creates differential opportunities for education, employment, and optimal health. “Students are rarely exposed to such research or its implications,” the researchers write. The researchers also highlighted the teaching of guidelines that endorse the use of racial categories in the diagnosis and treatment of diseases. One course they analyzed, for instance, encouraged the use of race-adjusted glomerular filtration rate, or GFR, equations, which many experts now say limits care for Black patients and exacerbates health disparities.

“Race is not a biomedical term, and it is a poor proxy for ancestry. Yet, we continue to generate, impart, and assess medical knowledge with this imprecision. In doing so, we perpetuate biases and ignore the actual contributors to the race-based differences we see,” Aysola said. “There are several aspects of the medical education apparatus that we have to fundamentally change in order to get to the ideal state where we’re dismantling the structures that perpetuate racism.”

The authors recommend that medical schools:

  • Standardize language to describe race and ethnicity, such as using a country of origin to discuss genetic predisposition to disease, rather than “Asian” or “African American.”
  • Appropriately contextualize racial and ethnic differences in disease burden, including always considering the structural and social determinants of disease.
  • Generate and impart evidence-based medical knowledge when it comes to race, such as reforming board examinations to avoid testing students on race-based clinical guidelines and racial heuristics.

“We are not arguing that race is irrelevant, and our framework is not meant to trigger discussion of the advantages and disadvantages of using race in medicine,” the authors write in closing. “Rather, we wish to provide evidence-based guidelines for defining and using race in generating and imparting medical knowledge.”

Penn authors Christina Amutah, Kaliya Greenidge, Adjoa Mante, Michelle Munyikwa, Sanjna L. Surya, Eve Higginbotham, Dorothy Roberts, and Risa Lavizzo-Mourey also contributed to this work.

Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation’s first medical school) and the University of Pennsylvania Health System, which together form a $8.9 billion enterprise.

The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $496 million awarded in the 2020 fiscal year.

The University of Pennsylvania Health System’s patient care facilities include: the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center—which are recognized as one of the nation’s top “Honor Roll” hospitals by U.S. News & World Report—Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; and Pennsylvania Hospital, the nation’s first hospital, founded in 1751. Additional facilities and enterprises include Good Shepherd Penn Partners, Penn Medicine at Home, Lancaster Behavioral Health Hospital, and Princeton House Behavioral Health, among others.

Penn Medicine is powered by a talented and dedicated workforce of more than 44,000 people. The organization also has alliances with top community health systems across both Southeastern Pennsylvania and Southern New Jersey, creating more options for patients no matter where they live.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2020, Penn Medicine provided more than $563 million to benefit our community.

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