“53 year-old black male,” the medical student begins his presentation of the patient’s case. “53 year-old man,” I correct him. It’s not his fault, we are taught to do this in medical school. We are taught to refer to people as “male ” or “female,” but every time I hear someone say that I think of my medical school professor adding “person.” As in “male person,” or better yet, man. Not a specimen of the male of the species, but a human man.
The specification of the race has also been traditionally taught to medical students, though the practice has become increasingly controversial. The justification for placing race so centrally in the presentation is that the prevalence of certain diseases varies among different races. While this assertion is undeniable when it comes to presenting the age of the patient, increasing age being a risk factor for nearly everything that befalls people, the scientific basis for mentioning race is far from established. Specifically, there is no race “gene,” and even the genetic analyses that so neatly put us in categories of being 73% European and 12% African and 15% Martian rely on the observation that certain variations in the genetic code appear more frequently among certain ethnicities. These variations, SNPs, are not markers of a particular race though, and indeed appear in all races.
Race is not a biological construct, it is a social one . But, like other social constructs, it may still have a huge impact on a person’s health. Money, for example, is a social construct too and we are all well-aware of the beneficial effects on health that come with increased socioeconomic status. In medicine we are taught that certain diseases are more prevalent in certain races. These observations may be due to factors that are genetic, or environmental, or both. “If you mention that the patient is Caucasian, and you know about migration patterns of Northern Europeans and increased prevalence of multiple sclerosis and you practice in Minnesota, then perhaps it helps,” a Ph.D. sociologist lecturing on the topic observed. “But if you’re in Texas, then it’s irrelevant.” He was kindly pointing out to a room full of doctors what we do not know: we know nothing about migration patterns of anybody over time. In my own field, it has been observed that sarcoidosis, an inflammatory lung disease of unknown cause, is more prevalent in African-Americans. But nearly everyone I have diagnosed with sarcoidosis since coming to Salt Lake City is Caucasian. Mentioning race doesn’t help me. And it certainly doesn’t help me enough to justify the prominence in the presentation.
“What’s the harm” one might ask, “in presenting patients this way?” We don’t want to be put in a box, none of us do. Mentioning the race early in the presentation may increase the likelihood of bias. Even mentioning the sex can bias us. We are more likely to perceive chest pain in a man as a serious problem while dismissing the same complaints of a woman, even though heart disease is the top killer of both men and women.
Nobody wants to be put in a box. I think of our 70-year-old neighbor who complained that after her hair turned gray her doctors acted like she didn’t understand anything. I think of the woman with a speech impediment whose primary care doctor had put in all caps on the front of her chart “NORMAL INTELLIGENCE.” I think of the Catholic patients who actually do want birth control, and of the Jewish friends who eat pork, of the Hispanic friends who are not “from Mexico,” the Muslim women who have no problem being examined by male physicians, because, indeed, most of the physicians in their country are men. We can be categorized by our age, sex, race, occupation, place of birth, income, education, health insurance status, and a lot of other variables, that taken together paint a picture of who we are. But none of us is pleased to be reduced to a stereotype based on those characteristics. Being ignorant of someone’s culture and finding non-condescending ways to ask relevant questions is, I find, far preferable to trading on superficial stereotypes of that presumed culture. As medical schools seek to integrate cultural sensitivity into the medical school curriculum I still think our best approach as doctors is simply to see, and treat, people as individuals.