Clinical practice guidelines are meant to streamline medical care, but many contain recommendations based on race that give white patients special treatment and require Black patients to get sicker before a doctor will help them, a new paper says.
The authors argue that, "Historic rationales for structural racism have hitchhiked into modern medicine."
The paper, published April 27 in Social Science & Medicine, examined the persistence of questionable racial categories in clinical practice guidelines, which provide a template for diagnosis and treatment supposedly based on objective research. The stamp of institutional approval means that racist guidelines can go unquestioned, and what doctors consider "optimal" treatment differs for patients of color — especially Black patients — and white patients.
The authors argue, "No [clinical practice guideline] should require that members of any racial group — particularly when that group is already medically underserved — exhibit symptoms of greater severity or duration than another group to receive the same treatment." And yet that is exactly what some guidelines do, as the researchers lay out in their paper.
In an email to The Academic Times, the authors described "the necessity of developing some systematic process" to evaluate the research informing contemporary clinical practice guidelines. Without this process, Ashley Rondini and Rachel Kowalsky said, guidelines that use "race as a proxy for biology" persist in a cycle that validates racist medicine and harms patients.
Gynecology may have the most famous anti-Black roots — James Marion Sims, the "father of modern gynecology," earned his distinction by performing experimental surgeries without anesthesia on 10 enslaved Black women. One woman, Anarcha, endured 30 operations. But more recent developments have less obvious racial implications, at least to many medical practitioners.
Rondini, an assistant professor of sociology at Franklin and Marshall College, and Kowalsky, an attending pediatrician at New York Presbyterian Hospital, wrote the paper based on previous research into the American Academy of Pediatrics' 2011 guideline for urinary tract infection testing in infants and children. They saw that Black babies and children need to show more severe symptoms before the American Academy of Pediatrics recommends testing for a UTI — meaning that non-Black children with UTIs get tested, diagnosed and treated for this common infection faster than Black children.
The UTI guideline was bizarre on its face — Kowalsky, a Latina and Jewish doctor in New York City treating a diverse patient population, "immediately questioned the racialization of the rule," Rondini said. Notably, untreated UTIs can increase the risk for hypertension and kidney failure, two conditions that Black people in the U.S. are already at greater risk of developing.
Moreover, when the researchers probed further, they found the racial distinctions in the guideline were based on unsound reasoning. The creators of the guideline didn't explain how patients were sorted into racial categories; they did not account for multiracial children; their data was contradictorily broken down into "white" and "non-white" girls but "Black" and "non-Black" boys; and "race was regarded in a way that implied that it could act as a proxy for biological, rather than socio-structural, factors," Rondini and Kowalsky said.
"We have been advocating for a change to the 2011 AAP [clinical practice guidelines] since 2014, but the argument has only recently begun to gain traction in the medical community," they said.
The authors' critique of this guideline led them to undertake a comprehensive literature review, and they realized that racialized guidelines — which are often racist guidelines — were prevalent. They cited Brown University professor Lundy Braun's work on reference value norms for pulmonary function tests, frequently used to assess conditions such as asthma or chronic obstructive pulmonary disease. Braun points out that the reference values for Black patients are about 15% lower than those for non-Black patients, effectively meaning that Black people have to be much sicker to get the level of care non-Black patients receive.
Braun published that work in 2014, but, Rondini said, "Nothing has changed. In fact, the algorithms that racialize the calculation of pulmonary function are programmed into the spirometric software that physicians use to interpret patient data and determine appropriate treatment." The spirometer cannot be activated without inputting the race of the person being tested, Braun reported.
There's a dire need for intervention, Rondini and Kowalsky said. "The issue here is that the medical literature that is treated as established knowledge may have been problematically conceptualized in relation to race," they said. As a result, researchers need to be aware that clinical practice guidelines can "inform and/or exacerbate inequities" — and should organize to resist it.
The paper, "'First do no harm': Clinical practice guidelines, mesolevel structural racism, and medicine's epistemological reckoning," published April 27 in Social Science & Medicine, was authored by Ashley C. Rondini, Franklin and Marshall College; and Rachel H. Kowalsky, New York Presbyterian Hospital – Weill Cornell Medicine.