Lynette Reid describes the work done at Dalhousie University to diversify the case-based learning curriculum in the medical program.

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In the first post of my series on Dalhousie medical school’s case diversification process, I wrote that our work expanded when it became clear that we weren’t just diversifying the identities of patients portrayed in the case-based learning (CBL) tutorial materials. We also reviewed evidence to help clinical and basic science case authors respond to recent practice developments. This was especially true for race.

Medical education and the medical sciences reproduce and maintain biological conceptions of race. We began the project just as the American Medical Association House of Delegates affirmed that race is a social construct and should not be used as a proxy for biology or genetics. Many specialties were and are re-evaluating their race-based clinical algorithms, and adopting changes.

It is absurd that where there are bodily differences on which the ideology of race is built (skin colour), the health professions ignore them, teaching how to recognize diagnostic signs on white skin alone. Meanwhile, with disturbing frequency, where there are no racial differences (in the basic biology of health and disease), medical sciences promote hypotheses that reify race.

Photo Credit: pexels. Image Description: A photo showing a multiracial group of people.

The result is that medical professionals are not equipped to evaluate conditions like jaundice or cyanosis in patients who are not white, while they have been taught to rattle off stats about racial disparities in diseases prevalence, reproduce claims that these persist despite controlling for the social and structural determinants of health, and then offer “just so” evolutionary stories as explanations (e.g. the discredited thrifty gene hypothesis for diabetes and slavery hypothesis for hypertension). Our curriculum was no different.

To take one example, we reviewed pediatric cardiology cases with multiple babies described as “pink”. We asked for a more inclusive description, but I was so struck that this high-powered subspecialty was using such informal and obviously biased language. By coincidence, the NHS in the UK had just released a report on the inadequacies of the Apgar newborn assessment (which rates babies, among other things, on the extent to which their bodies are “pink”). This was one of many moments where we realized our white-women naivety about the extent of medical racism.

Medical students are now more racially diverse than in the past and are taking action to provide images to support diagnosis in diverse skin colours. This is not just an issue for dermatology. Many conditions have diagnostic signs that are visible in the skin. As we worked through the cases, we replaced or augmented images. Despite the rich resources emerging from student activism, we were still sometimes unable to locate appropriate sources. (The librarian involved in the project advocates on this issue with textbook publishers at medical library conferences.)

At the end of every component, I thought, “whew—at least in [the next specialty] there won’t be so much race-based medicine to review.” And—white woman naivety again—I was usually wrong.

As we proposed revisions on race adjustments in examples such as lung function and kidney function, we were helped by having on faculty at Dalhousie and in our working group a physician with strong public health expertise (our Associate Dean for Serving and Engaging Society, Gaynor Watson Creed), a lung function epidemiologist who is playing an important role internationally in the scientific re-evaluation of race adjustments in that field (Sanja Stanojevic), a social scientist with a national leadership role in queer Black health holding the JR Johnston Chair (OmiSoore Dryden), and a biomedical researcher with knowledge of how oppressive paradigms influence basic science reasoning (Keith Brunt). When clinicians were uncertain about our working group’s recommendations to present race as a social construct and racism as a structural determinant of health, I could invite the group’s clinical experts and scientists into the conversation.

Each specialty has its specific commitments to biological accounts of disease disparities or treatment response, and each specialty is on its own journey to unravel the errors that led them to this point. Curriculum leaders differed in whether they wanted to teach students to adhere to current guidelines or enter into critical reasoning and anticipate the direction of change.

Some of these reassessments include unpacking the blatant racist assumptions about the physiology of persons held in slavery in the US (lung function). In some cases, the supposed racial disparities evaporate with more careful attention to genomic ancestry (compared to self-identified or clinically-ascribed ancestry) and better control for the social determinants of health, for example in hypertension and prostate cancer and prenatal alpha-fetoprotein screening.

The re-evaluation of race adjustments in hemoglobin levels for the diagnosis of anemia is interesting: it involves understanding how people committed to addressing racial inequities sometimes perpetrate biological accounts of race in medicine. In this case the data apparently offered confirmation of this bias—not, ultimately, because race is real, but because of the genetics and environment of specific sub-populations. Lower hemoglobin levels on average in African Americans are probably due to the greater prevalence of sickle cell in some African Americans. Sickle cell affects populations exposed to endemic malaria over their evolutionary history, and this genetic adaptation exists across so-called races. This biases the population average when all African Americans are inaccurately lumped together as a “race.”

Other specialties whose cases we reviewed were committed to reifying race not because of racist science from the distant past, but because of the current avalanche of research in personalized medicine, or pharmacogenomics. We met with case authors ready to die on the hill of race’s biological reality out of non-maleficence concerns (to avoid patient harm). Our literature review uncovered limitations in race-based guidelines for prescribing allopurinol for gout, and we proposed an identity for the patient in this case that helped illustrate the need for better guidance in light of global genetic variation in the HLA-B*5801 allele, and the problematic nature of the guidance currently offered.

In the next post, I will outline some of our committee’s contributions to teaching medical students about the current revolution in medicine’s role in creating, sustaining, and now challenging so-called “scientific” racism and the challenges in practice they may face given the ways that pharmacogenomics uses racial concepts.

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Lynette Reid is an associate professor in the Department of Bioethics at Dalhousie University.