By PHUOC LE, MD and SAM APTEKAR
Fifteen years ago, as a medical student, I learned a terrifying lesson about blindly using race-based medicine. I was taking care of Mr. Smith, a thin man in his late 60s, who entered the hospital with severe back pain and a fever. As the student on the hospital team, I spent over an hour interviewing him, asking relevant questions about his medical and social history, the medications he took, and the details of his symptoms. I learned Mr. Smith was a veteran who ran into tough times that left him chronically homeless, uninsured, and suffering from hypertension and diabetes. I performed a complete physical exam, paying particularly close attention to his back. Upon reviewing his blood tests and kidney function, I read the computer’s report: “normal.”
I felt confident as I presented Mr. Smith’s treatment plan to my attending physician: I recommended a CT scan, ibuprofen for pain, blood pressure lowering medication, and an antibiotic. My attending listened quietly, reviewed the labs herself, and then firmly corrected every aspect of my treatment proposal. “His kidney function is NOT normal. What you want to do for him can further damage his kidneys. The lab reported his creatinine as ‘normal’ because it has an algorithm that makes faulty assumptions based on race.” Mr. Smith, according to the medical record, was African American.
I almost harmed Mr. Smith because I hadn’t realized that the exact same creatinine level (the key metric for kidney function) yields two different reports based on whether you’re African American or not. The logic goes that because black people supposedly have higher muscle mass on average, healthy creatinine levels for those who check the “black” box is different from those who check other boxes. Physicians around the country continue to rely on this metric even when the black patient is thin, like Mr. Smith. This example of race-based creatinine levels to determine kidney function is a symptom of race-based medicine in general: (poorly defined) racial categories are often used as proxies to explain discrepancies in health outcomes by race, which is a potentially dangerous analysis. Mr. Smith’s case forced me to consider why race-based medicine is problematic and where our attention as healthcare providers should be directed instead.
What is certain is that health inequities persist along racial lines. African Americans and Hispanics have higher rates of diabetes, hypertension, and heart disease than other groups (Figure 1). American Indians and Alaskan Natives are 2.1 times as likely to be diagnosed with diabetes as white individuals and the prevalence of obesity in this population is higher than any other group. While it would be convenient to attribute these disparities to genetic difference, this is simply not the case.