Can use of race in medical decision-making widen outcome disparities?

The fact that patients from minority communities generally experience worse health outcomes than whites is often used to justify race-based practice, i.e. including race as a factor in medical decision-making. But a new study finds that unless doctors acknowledge that race is mostly a cultural concept, its use in decision-making can actually worsen outcome disparities.

The study in the American Journal of Preventive Medicine investigates whether ascribing racial differences in health to genetics or culture rather than social conditions is associated with race-based practice. The difference is significant, the authors write, because “using race [in decision-making] without recognizing it primarily as a sociopolitical construct can stigmatize the racially minoritized as biologically inferior and…worsen health disparities by codifying them as normal.”

To test the link between race-based practice and attitudes about the reasons for health disparities, the researchers surveyed 689 practicing family physicians across the country. Respondents completed the Racial Attributes in Clinical Evaluation scale, for which a higher score implied a greater use of race-based practice. In addition, they were asked the extent to which they believe that:

• genetic differences contribute to differences in health outcomes between racial groups,
• differences in social conditions, such as income and education, contribute to differences in health outcomes between racial groups, and
• differences in culture, such as the value of diet or exercise, contribute to differences in outcomes between racial groups

The results showed that respondents overall ranked differences in social conditions as the greatest contributor to race-based health differences. However, those who ascribed differences in health to genetic or cultural differences were more likely to self-report using race in their clinical care. Conversely, belief in social conditions as the cause of racial differences in health was not associated with self-reported race-based practice.

The authors note that the lack of association between race-based practice and believing that racial differences in health result from differences could manifest in a variety of ways, including a belief that race-based algorithms worsen health disparities. They cite the example of the vaginal birth after Cesarean calculator (VBAC), which estimates the probability of a successful vaginal delivery following a Cesarean.

The VBAC had assigned a greater risk of failure to Black race and Hispanic ethnicity, reducing the likelihood of those patients being offered the preferable option of a vaginal birth. But that changed in 2021 after major medical societies began to stop policies and practices that used race to ascertain disease risk.

In an accompanying press release Ebiere Okah, MD, assistant professor in the department of family medicine and community health at the University of Minnesota Medical School explained that the next step will be to find ways to challenge the belief that race is related to cultural values.

“Part of the solution lies in…acknowledging thew cultural diversity that exists within racial groups, and considering the ways in which structural factors create what we perceive to be culture,” she said.