Guidelines for the use of race, ethnicity and other cultural groups when teaching in the medical curriculum
The guidelines described below were adapted from recommendations developed by the Aquifer organization that develops widely used case-based learning modules, and are more fully described in a manuscript soon to be published in Academic Medicine (Krishnan, A., Rabinowitz, M., Ziminsky, A., Scott, S., Katherine C. Chretien, K.C., (2019), Addressing Race, Culture and Structural Inequality in Medical Education: A Guide for Revising Teaching Cases. Academic Medicine; In Press.)
- Minimize the use of race and ethnicity in a summary statement of a case. If a racial identifier is used in a case vignette (either in summary statement or in the social history), and is relevant to disease pathophysiology, it should be made clear in the teaching materials whether there is an epidemiologic association that is related to a genetic risk factor or is related to social or structural causes of racial health disparities, or both. References supporting the epidemiologic association should be provided as appropriate.
Example: Instead of describing a 12-year-old black male with clinical features suggestive of sickle cell disease in a case summary, describe a person with clinical features consistent with anemia who reports that he has sub-sarharan African ancestry. Provide data indicating frequency of sickle cell mutation in patients of differing ancestries and how racial appearance may not relate to genetic risk for sickle cell mutation in patients of African ancestry.
- Ensure that case scenarios that involve social or behavioral risk factors are not inferred from broad racial, cultural, and/or sexual/gender minority (LGBTQI) stereotypes. Also, avoid using behaviors as an adjective to describe the patient.
Example(s): If associating obesity rates with ethnic background and diet, include a description of potential structural causes of poor dietary behavior (e.g. Native Americans on reservations may have limited access to healthy foods). Scenarios of gay, lesbian, bisexual, and transgender individuals should not only be relevant to HIV or mental health cases. Instead of describing a “street person”, describe patient as someone who is currently homeless.
- Description of patient health beliefs or risk factors should be explicitly linked to an evidence-based description of patient cultural beliefs and/or structural/social determinants of health and do not re-inforce racial or cultural stereotypes.
Example: If describing a patient of Indian heritage with anemia and including questions about a vegan diet, it should be clear that this is related to the relative increased incidence of this dietary practice in this culture and an association with B12 deficiency. Furthermore, it should be emphasized that acquiring dietary history impacts clinical reasoning/differential diagnosis in all patients with signs/symptoms suggestive of anemia regardless of ethnic background.
- When using a complex clinical scenario, the treatment plan should include a plan to address social/structural determinants of health as relevant.
Example: If describing a non-English speaking patient from Vietnam with tuberculosis, could include a plan to have an interpreter present during the next office visit.
- Case vignettes should be reviewed for implicit bias. If appropriate, include examples of critical reflection and examples of addressing implicit bias among members of health care team.
Example: Case involves a transgender patient with a sexually transmitted infection. Provider in case discusses impact of bias against transgender patients and effects on receiving appropriate access to care.
- If racial or ethnic representation is included within case vignettes, the descriptions should include patients representing diverse racial, ethnic and sociodemographic groups that are representative of current US population.
Example: Pictures of dermatologic conditions should include patients with a diversity of skin colors.
Questions and Contact information
For questions about these guidelines, please contact:
Terry Kind, MD, MPH
Associate Dean for Clinical Education
Robert Jablonover, MD
Assistant Dean for Preclinical Education
Grace Henry, Ed.D.
Director, Office of Diversity and Inclusion
Definitions (adapted from Krishnan et al, Academic Medicine; In press)
Race, ethnicity, culture and minority identity.
Race has traditionally been defined as a “construct of human variability based on perceived differences in biology, physical appearance, and behavior”. However, this conception of race rests on the false premise that natural distinctions grounded in significant biological and behavioral differences can be drawn between groups. Race is a socially meaningful construct and is of limited biological significance.
The concept of ethnicity is an attempt to further differentiate societal or cultural groups and account for diversity within the population; however, like race, it carries its own historical, political, and social baggage. “Common threads that may tie one to an ethnic group include skin color, religion, language, customs, ancestry, and occupational or regional features. In addition, persons belonging to the same ethnic group share a unique history different from that of other ethnic groups. Usually a combination of these features identifies an ethnic group”.
“The concept of culture as distinct from race/ethnicity has been proposed as a better explanation for differences in health behavior and health outcomes. Culture is defined as integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Culture can be transmitted intergenerationally. Culture in the context of health behavior has been defined as “unique shared values, beliefs, and practices that are directly associated with a health-related behavior, indirectly associated with a behavior, or influence acceptance and adoption of the health education message”.
Importantly, knowing someone's ethnic identity or national origin does not reliably predict beliefs and attitudes. In most instances, the definition of culture is nebulous and imprecise. Inferring that certain health behaviors or outcomes differ by race, ethnicity, culture, may be misleading because they rarely account for the distinct differences within racial or ethnic groups or cultures.
The term minority refers to “a group of people who, because of their physical or cultural characteristics, are singled out from the others in the society in which they live for differential and unequal treatment, and who therefore regard themselves as objects of collective stigma and discrimination. The existence of a minority in a society implies the existence of a corresponding dominant group enjoying higher social status and greater privileges.” Characteristics that have been linked to minority group identity include sex, gender, sexual orientation, disability, ethnicity, nationality, race, language, culture, and religion. As a result, an individual who is a member of more than one defined minority group may be multiply stigmatized.
“Stereotypes are the belief that most members of a group have some characteristic. Some examples of stereotypes are the belief that women are nurturing or the belief that police officers like donuts. An explicit stereotype is the kind that you deliberately think about and report. An implicit stereotype is one that is relatively inaccessible to conscious awareness and/or control. Even if you say that men and women are equally good at math, it is possible that you associate math more strongly with men without being actively aware of it. In this case we would say that you have an implicit math + men stereotype”.
Social and structural determinants of health (SSDOH)
The hierarchical institutions, economic systems, policies, cultural norms, and infrastructural organization of our social world that directly/indirectly worsen health outcomes for some groups of people more than others. “A society’s social structure generates its specific patterns of SSDOH”.
Hoffman, K. M., Trawalter, S., Axt, J. R., & Oliver, M. N. (2016). Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), 4296-4301.
Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., & Banaji, M. R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of general internal medicine, 22(9), 1231-1238.
Heckler MM. Report of the Secretary's Task Force on Black & Minority Health. Washington, DC: U.S. Department of Health and Human Services; 1985. (Volume 1: Executive summary).
Nelson, A. (2002). Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the National Medical Association, 94(8), 666.
Krishnan, A., Rabinowitz, M., Ziminsky, A., Scott, S., Katherine C. Chretien, K.C., (2019), Addressing Race, Culture and Structural Inequality in Medical Education: A Guide for Revising Teaching Cases. Academic Medicine; In Press.