Case Presentations

Several examples will serve to illustrate the superficiality of racial divisions in day-to-day medical parlance. Recently, a 24-year-old "white" female presented in our clinic with, among other problems, -thalassemia trait. A thorough social history later revealed that one of the patient's parents was of Mediterranean ancestry, a point obscured by the patient's married name and fair complexion and the clinician's use of the label "white." Similarly, a middle-aged, "white" male presented with recurring fever and abdominal pain. He was eventually diagnosed with familial Mediterranean fever. A careful social history revealed the patient's Greek ancestry. In short, the term "white" encompasses a diversity of genetic backgrounds that the term poorly represents.

The label "black" may also be misleading in predicting diagnoses among African-American patients. Although we are not aware of any studies of specific prevalences, autoimmune hepatitis is perceived to be more common in patients of European descent than in others, and indeed it may be more common because it is associated with inherited histocompatibility antigens. However, we have encountered the disorder not infrequently in patients of African-American descent. A recent published case report described a "black" female with autoimmune hepatitis and a poor response to steroid therapy that may have been due to carriage of -1-antitrypsin [3], which has also been reported to occur less frequently in patients of African descent [4]. As in the cases of "white" patients mentioned above, the notation "black" in the opening description of this patient was potentially misleading if her diagnoses were to be based on suspected prevalences. The authors of the report were obviously unimpressed with the likelihood of either disorder based on the patient's stated race, and they rightly pressed ahead to arrive at their diagnosis.

Race and Ethnicity

The terms "race" and "ethnicity" are often used interchangeably, but they are in fact far from synonymous: "Race" refers to differences of biology, "ethnicity" to differences of culture and geographic origin. We contend that ethnic differences, rather than distinctions between black and white, more accurately convey information potentially relevant to a particular case. For instance, a Kenyan, a Haitian, and an African-American would be considered racially identical—"black"—according to current practice, but they do not share nutritional habits, attitudes and beliefs about medical care, or even biological inheritance.

Webster's Dictionary defines race as "any of the major biological divisions of mankind, distinguished by color and texture of hair, color of skin and eyes, stature, bodily proportions, etc." But are the crucial differences among human beings really those of superficial appearance? Is it scientifically justified to assume that these outer traits indicate inner biological differences among humans?

By using the terms "black" and "white," the medical community purports to refer to real biological divisions within our species, and yet a closer look at the data shows that these divisions do not fall as neatly as our terms for skin color suggest. For instance, persons from Papua New Guinea, although "black"-skinned, are genetically more closely related to Asians than to "black" Africans.

In addition, numerous studies [5] of human physical variation within populations show that traits that are often lumped together as definitive of a race do not in fact vary as a group. When population geneticist Richard Lewontin measured the degree of population differences in gene frequencies for 17 polymorphic traits, he found that only 6.3% of all variation could be accounted for at the level of major geographic race [6]. The visible characteristics of "race" were unreliable indicators of genotypic variation.

This is not to argue that regional genetic variation does not exist. As Pat Shipman has recently pointed out [7], the fact that the lines of classification are so difficult to draw and necessarily so imprecise (one reason for this is constant mating across established group lines) does not refute the existence of regional variants of our species. Future researchers could explore more medically relevant differences among groups of Homo sapiens that have occupied different regions over time. At the present stage of knowledge, however, the division of the world's population into perceived races lacks scientific clarity and legitimacy.

Anthropologists have long recognized that the racial lines drawn by a society are cultural rather than scientific constructions [8, 9]. Within the international medical community, therefore, racial divisions may not even be perceived in the same way. What is black to someone from the United States, for example, may be white to a Brazilian or a Caribbean Islander. The terms "black" and "white" say more about how U.S. society has been structured than about medically relevant, biological realities.

Webster's Dictionary defines the term "ethnic" as "designating or of any of the basic divisions or groups of mankind, as distinguished by customs, characteristics, language, etc." Social scientists accept "ethnicity" as a term that refers to the cultural distinctions that persons make themselves—their identities. Reductionist racial labels often obscure rather than illuminate ethnic differences. Ideas about medical care, nutrition, and disease that bear on treatment are better provided by giving information about ethnic identity and background in the Social History section of the case presentation.

The medical community is increasingly aware of the ways in which cultural practices influence a person's health [10]. The various persons grouped as black and white, however, are often widely divergent in beliefs, habits, reactions to illnesses, and perceptions of the medical community. The terms "black" and "white" do not impart the type of information implied by their continued use in the introductions to routine case presentations.

Genetic Background of the U.S. Population

In the United States, 350 years of interaction has led to considerable mixing between persons of various geographic origins [11]. Although the evidence of such diverse ancestry is at least implicitly acknowledged in the African-American community by attention to gradations of skin color, it is less frequently acknowledged that many "whites" have African and other non-"white" ancestors. However, a recent highly acclaimed autobiography by Shirlee Taylor Haizlip [12], a "black" woman, calls attention to the prevalence of such cases. Haizlip recounts her discovery of her own "white" relatives who had split off from the "black" side of her family a generation earlier. As for the African-American population in the United States, geneticist Luigi Cavalli-Sforza [13] has estimated that 30% of their genes derive from "white" sources.

These facts suggest that the traditional racial divisions used in the United States are of questionable utility and accuracy. This issue has recently earned the attention of U.S. government demographers. According to news accounts [14], the current official categories used in the U.S. Census and other documents are presently being reviewed by the Office of Information and Regulatory Affairs in the Office of Management and Budget. The debate within the government treats issues of ethnic and racial identity that are beyond the scope of this paper, but it supports our contention that the use of racial labels is burdened by inaccuracies. This seems especially true at the level of the routine case presentation.

Does Bias Become an Issue?

Numerous reports about the course and optimal treatment of many diseases have been based on perceived racial groupings. We do not dispute that racial or ethnic categories sometimes have important epidemiologic implications. However, the division into "black" and "white" in routine, day-to-day presentations is often irrelevant and potentially misleading.

Do these terms engender bias? One study [15], which examined the way in which "black" and "white" patients are presented at morning report, suggests that they do. Black patients were far more likely than whites to be identified by a racial label, and yet that label was considered relevant in only 2 of 18 cases. The authors perceived the presentations of black patients to be unflattering more often than the presentations of white patients.

To the extent that the terms "black" and "white" often needlessly separate persons in a clinical setting, their use may sometimes be construed as pejorative, whether this is intended or not. In most cases, racial monikers simply represent a long-followed tradition. We submit that many clinicians who work in settings in which these terms are routinely used may be surprised at their own reactions when the terms are deleted from day-to-day presentations.

Published Case Reports and Current Practice

Although our emphasis is on the routine "workday" oral case presentation, we reviewed case reports or clinical pathological conference reports from current and past issues of nine medical journals to assess the ways in which these reports have been presented over the past 10 years. Overall, most of the journals varied considerably in their use of racial labels in the opening lines of case reports. In general, this seemed to be less the result of editorial policy than of individual authors' styles (Table 1).

In addition, we informally surveyed the clerkship directors of 48 U.S. medical schools using a brief written questionnaire that asked specifically whether medical students were taught by oral or written example to use the terms "black" or "white" in the introductory statements of routine case presentations. Four responses were possible ("yes," "no," "variable," and "don't know") and allowance was made for qualifying comments.

Thirty-seven (77%) clerkship directors responded (7 from the Northeast, 15 from the South, 12 from the Midwest, and 3 from the West). Twenty-two of the 37 (59%) answered "yes" and 12 (32%) answered "variable." Only one answered "no," and he added that students are expressly taught to not use the terms unless they think them relevant. Two directors answered "don't know," and one commented that much of the teaching on this issue occurs by "osmosis" from the resident housestaff to the students.

Many of those who responded with "yes" or "variable" also commented that this practice is taught to students passively, by the oral example of residents. Thus, as experience with residents and clinicians from numerous medical schools might suggest, describing race in the opening line seems to be common in U.S. medical schools. This practice is either passed along as oral tradition or formally taught. We could not detect a significant regional variation in this small survey (6 of 7 directors from the Northeast and 9 of 15 directors from the South answered "yes" and the remainder from these regions answered "variable" or "don't know").

Conclusions

Most physicians would agree that both the genetic constitution and the cultural background of a person predisposes him or her to various diseases and may modulate responses to certain therapies. An accurate social history can, in many cases, provide invaluable information about a patient's ethnic background and possible risks for certain diseases. However, labels such as "black" or "white" in the opening line of case histories poorly represent this important information. The same may be said of other broad, superficial terms, such as Hispanic or Asian, that inadequately address attributes that should be dealt with in a more meaningful way when thought to be pertinent to patient care.

In many routine cases, such terminology serves as little more than a "jog" to the memory of busy clinicians. The costs, however, may be to engender the perception of bias, to miss clinically relevant information, and to assume the presence or absence of genetic or cultural factors that, in fact, may or may not be present. Demoting these labels from the opening line of our day-to-day presentations shows a recognition of their limitations as scientific terms and a commitment to representing pertinent ethnic variations in an accurate, relevant, and ultimately more helpful manner.