Mixed Race Studies

If doctors and clinical educators rigorously analyze algorithms that include race correction, they can judge, with fresh eyes, whether the use of race or ethnicity is appropriate. In many cases, this appraisal will require further research into the complex interactions among ancestry, race, racism, socioeconomic status, and environment. Much of the burden of this work falls on the researchers who propose race adjustment and on the institutions (e.g., professional societies, clinical laboratories) that endorse and implement clinical algorithms. But clinicians can be thoughtful and deliberate users. They can discern whether the correction is likely to relieve or exacerbate inequities. If the latter, then clinicians should examine whether the correction is warranted. Some tools, including eGFR and the VBAC calculator, have already been challenged; clinicians have advocated successfully for their institutions to remove the adjustment for race.^43,44 Other algorithms may succumb to similar scrutiny.⁴⁵ A full reckoning will require medical specialties to critically appraise their tools and revise them when indicated.

Darshali A. Vyas, Leo G. Eisenstein, and David S. Jones, “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms,” The New England Journal of Medicine, Volume 2020, Number 383, 882. https://dx.doi.org/10.1056/NEJMms2004740.

Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms

The New England Journal of Medicine
Volume 2020, Number 383
pages 874-882
2020-08-27 (published on 2020-06-17, at NEJM.org.)
DOI: 10.1056/NEJMms2004740

Darshali A. Vyas, M.D., Resident Physician
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
Harvard University, Cambridge, Massachusetts

Leo G. Eisenstein, M.D., Resident Physician
New York University Langone Medical Center, New York, New York

David S. Jones, M.D., Ph.D., A. Bernard Ackerman Professor of the Culture of Medicine
Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts

Physicians still lack consensus on the meaning of race. When the Journal took up the topic in 2003 with a debate about the role of race in medicine, one side argued that racial and ethnic categories reflected underlying population genetics and could be clinically useful.¹ Others held that any small benefit was outweighed by potential harms that arose from the long, rotten history of racism in medicine.² Weighing the two sides, the accompanying Perspective article concluded that though the concept of race was “fraught with sensitivities and fueled by past abuses and the potential for future abuses,” race-based medicine still had potential: “it seems unwise to abandon the practice of recording race when we have barely begun to understand the architecture of the human genome.”³

The next year, a randomized trial showed that a combination of hydralazine and isosorbide dinitrate reduced mortality due to heart failure among patients who identified themselves as black. The Food and Drug Administration granted a race-specific indication for that product, BiDil, in 2005.⁴ Even though BiDil’s ultimate commercial failure cast doubt on race-based medicine, it did not lay the approach to rest. Prominent geneticists have repeatedly called on physicians to take race seriously,^5,6 while distinguished social scientists vehemently contest these calls.^7,8

Our understanding of race and human genetics has advanced considerably since 2003, yet these insights have not led to clear guidelines on the use of race in medicine. The result is ongoing conflict between the latest insights from population genetics and the clinical implementation of race. For example, despite mounting evidence that race is not a reliable proxy for genetic difference, the belief that it is has become embedded, sometimes insidiously, within medical practice. One subtle insertion of race into medicine involves diagnostic algorithms and practice guidelines that adjust or “correct” their outputs on the basis of a patient’s race or ethnicity. Physicians use these algorithms to individualize risk assessment and guide clinical decisions. By embedding race into the basic data and decisions of health care, these algorithms propagate race-based medicine. Many of these race-adjusted algorithms guide decisions in ways that may direct more attention or resources to white patients than to members of racial and ethnic minorities…

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