Health Equity
From hypertension guidelines to calculating kidney function, race is a key component of how pharmacists are taught to identify which medication a patient should be taking and whether a medication is needed. But data have shown that using race to drive medication therapy choices is not the best way to care for patients.
Selecting a treatment regimen based on how a patient looks instead of considering genetics, diet, socioeconomic status, and environment may lead to making a suboptimal choice for the patient, said authors of a guide called “A Clinical Pharmacology and Therapeutics Teacher’s Guide to Race-Based Medicine, Inclusivity, and Diversity,” published in 2022 in Clinical Pharmacology and Therapeutics.
While race-based recommendations may seem simple, choosing the best medication for a patient is often complicated by the decision of whether or not the patient fits in the guideline category. A three-part NEJM podcast from July 2024 explores this further.
For example, obstetricians use an online calculator to determine whether a vaginal birth after cesarean section is appropriate for a patient.
“If you enter two women’s characteristics into the calculator with exactly the same biologic characteristics, but you enter one woman as Black and one woman as white, then systematically the calculator will say the Black woman has a significantly lower chance of successful trial of labor,” said Darshali Vyas, MD, a pulmonary and critical care fellow at Massachusetts General Hospital in episode two of the podcast. “We know that successful vaginal births have a lot of health benefits compared to C-sections. This includes lower infectious risks, lower complications, lower complications for subsequent pregnancies. And so, when there is a chance of successful vaginal birth, it’s important that we’re picking those people correctly.”
Some changes to clinical practice have already been seen, too.
In January 2024, AHA released a new calculator for health care practitioners to use in calculating the risk of cardiovascular disease events. This new tool removes race as a factor and adds kidney and metabolic function as well as zip code. Because a patient’s zip code can be indicative of education, income, employment, and access to transportation, it may be a better option to consider than race when evaluating a patient.
The problem
The 2022 guide, written by clinical pharmacology and therapeutics instructors, aimed to help health professionals reflect on the teaching of race-based guidelines in curriculum for their respective professions. The authors cited an analysis which found that 96% of lecture slides mentioning race presented it as a risk factor for disease without explaining that race is a social construct that is prone to bias, in contrast to a biological risk factor.
Most race-based recommendations are based on research that involved self-reporting of race by the participants. These same studies often fail to measure other complex factors such as pharmacogenetics, diet, sun exposure, and others that play a role in the overall health of an individual. Within a set of individuals who self-report having the same race, many differences in these other factors can be identified.
The study authors believed that portraying race as a social construct may cause students to see people of a shared race as biologically and genetically homogenous. Instead of teaching race-based recommendations as true for all individuals of a race, these recommendations should be taught as reflecting the average of a heterogeneous group of people, said researchers. Assuming that all individuals of a certain race should be treated the same has the potential to increase health care disparities that already exist.
Potential solutions
The authors of the guide also provided several recommendations for how race-based guidelines should be taught to future health care professionals. One of the things they suggest is carefully designing patient cases and assignments.
They stated that, “Too often, the race of a patient is stereotypically connected to their disease or a direct and oversimplified clue to the ‘correct’ answer in case-based examinations or exercises. By designing our assignments in this manner, we reward our students for their bias and teach them to see such characteristics as markers.”
Instead, they suggest that patient cases should reflect individual patients that do not meet the norm, since no actual patient in clinical practice is average in all respects.
They also advise including diversifying traits for the patients in cases. Traits should be mentioned regardless of the topic being taught. For example, sexual orientation should not only be mentioned on cases about HIV treatment and management. The authors believe this will help prevent students from forming stereotypical associations with health-related topics. ■