Perceptions and Misperceptions of Skin Color

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Apr 15, 1995 - Gabriel Garcia Marquez. Love in the Time of Cholera. Submitted by: Lawrence N. Hill, MD. Department of State. Washington, DC 20521-6120.
PERSPECTIVE

Perceptions and Misperceptions of Skin Color Stephen H. Caldwell, MD, and Rebecca Popenoe, MA

• Case presentations are part of many clinicians' daily routines. The format for such presentations often involves stating the age, sex, and race of the patient in the opening description. However, although singleword racial labels such as "black" or "white" are of occasional help to the clinician, they are of limited diagnostic and therapeutic help in many routine cases. Because of their broad scope and lack of scientific clarity, these terms often poorly represent information—for example, about genetic risks and perceptions of disease—that they are supposed to convey. In many instances, they are superficial and potentially misleading terms that fail to serve the patient's medical needs. Demoting these terms from the opening line of routine case presentations shows a recognition of their limitations as scientific labels. Our patients will be better served by more detailed explorations of ethnicity, when germane, in the History of Present Illness or Social History sections of the case presentation in question. Ann Intern Med. 1995;122:614-617. From the University of Virginia, Charlottesville, Virginia. For current author addresses, see end of text.

1 he presentation of a case history has a traditional format that has evolved over centuries (1). In many institutions, medical students are routinely taught to begin their case presentations with a statement describing the age, sex, and "race" of the patient. In regions of the United States such as ours, where the population is predominantly of European-American or African-American descent, the description of race is often distilled down to "black" or "white." Thus, in our institution and in those with similar demographics, the fourth spoken word of many case presentations broadly describes the patient as black or white. Exactly when and how this form of introduction became common is unclear. French physician Louis Martinet (1795-1875) described the importance of stating "the name, sex, age, and occupation of the patient In some cases it becomes necessary to state the country or district from which the patient comes and the diseases which prevail there" (2). In the United States, the format of the opening line seems to have been established a priori in case reports in the early and mid-20th century. Since then, the actual utility or validity of these terms has seldom been discussed. We hope to show that the diagnostic and therapeutic utility of the terms "black" and "white" is limited. We contend that the use of these terms in the opening statements of routine, day-to-day case presentations implies that the terms have an importance and a scientific validity beyond their real merit. If 614

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ethnicity is thought to be pertinent to the case in question, the patient will be better served if the physician replaces these terms with more detailed comments in the History of Present Illness, the Social History, or the Physical Examination sections of the report. When broadly and routinely applied, as they often are, racial labels such as "black" and "white" can actually obscure an accurate appraisal of a patient's genetic and cultural backgrounds, both of which may significantly affect the patient's health risks and outcomes for various diseases. A similar argument may be made for other traditional racial terms, such as Hispanic, Asian, or Native American. Because most of our experience has been with patients of European-American and African-American descent, we focus primarily on this area.

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, a-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 a-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

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Table 1. Designation of Race in the Introductory Statements of Case Reports or Clinical Pathologic Conference Reports Published in Medical Journals* Journal

Type of Report

Racial Description Used in 1994

Case

Varied

No

Case

No

Varied

Case Case CPC

No Varied Yes

Gastroenterology

Case

Yes

Mayo Clinic Proceedings Medicine New England Journal of

Case Case

No Varied

Varied Varied No reports available No reports available No Varied

rvc

Nn

Nn

American Journal of Cardiology American Journal of Gastroenterology American Journal of the Medical Sciences Chest Circulation

A/fprlirinp

Racial Description Used in 1984

* The May or June issues of the journals were reviewed. Most issues had more than one case report; two issues had one clinical pathologic conference report each. CPC = clinical pathologic conference reports.

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 616

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. Acknowledgments: The authors thank Drs. Michael Rein, A. Sidney Barritt, Julia Popenoe, and Catherine Fisher for their suggestions and review of this manuscript and Ms. Kim Pennington for expert secretarial assistance. Requests for Reprints: Stephen H. Caldwell, University of Virginia Health Sciences Center, Division of Gastroenterology and Hepatology, Box 145, Charlottesville, VA 22908. Current Author Addresses: Dr. Caldwell: University of Virginia Health Sciences Center, Division of Gastroenterology and Hepatology, Box 145, Charlottesville, VA 22908. R. Popenoe: Carter G. Woodson Institute, University of Virginia, 1512 Jefferson Park Avenue, Charlottesville, VA 22903.

References 1. Stoeckle JD, Billings JA. A history of history-taking: the medical interview. J Gen Intern Med. 1987;2:119-27. 2. Walker HK. The origins of the history and physical examination. In: Walker HK, Hall DW, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworths; 1990:17. 3. Lok AS, Ghany MG, Gerber MA. A young woman with cirrhosis: autoimmune hepatitis vs. alpha 1-antitrypsin deficiency [Clinical Conference]. Hepatology. 1994;19:1302-6. 4. Wulfsberg EA, Hoffmann DE, Cohen MM. Alpha 1-antitrypsin deficiency. JAMA. 1994;271:217-22. 5. Molnar S. Human Variation: Races, Types, and Ethnic Groups. 2d ed. Englewood Cliffs, New Jersey: Prentice-Hall; 1983:128-46.

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6. Lewontin RD. Human Diversity. In: Nelson H, Jurmain R, eds. Introduction to Physical Anthropology. St. Paul: West Publishing; 1982:203. 7. Shipman P. The Evolution of Racism: Human Differences and the Use and Abuse of Science. New York: Simon and Schuster; 1994. 8. Boas F. The Mind of Primitive Man: A Course of Lectures Delivered before the Lowell Institute, Boston, Mass., and the National University of Mexico, 1910-1911. New York: Macmillan; 1911. 9. Gould SJ. The Mismeasure of Man. New York:W.W. Norton; 1981. 10. Pachter LM. Culture and clinical care. Folk illness beliefs and behaviors and their implications for health care delivery. JAMA. 1994;271:690-4.

11. Buckley TE. Unfixing race. The Virginia Magazine of History and Biography. 1994;102:349-80. 12. Haizlip ST. The Sweeter the Juice. New York: Simon and Schuster; 1994. 13. Shipman P. Facing racial differences together. The Chronicle of Higher Education. 3 Aug 1994;40:B-1. 14. Holmes SJ. Federal government is rethinking its system of racial classification. New York Times 1994 8 July. 15. Finucane TE, Carrese JA. Racial bias in presentation of cases. J Gen Intern Med. 1990;5:120-1.

Dr. Juvenal Urbino . . . arose at the crack of dawn, when he began to take his secret medicines: potassium bromide to raise his spirits, salicylates for the ache in his bones when it rained, ergosterol drops for vertigo, belladonna for sound sleep. He took something every hour, always in secret, because in his long life as a doctor and teacher he had always opposed prescribing palliatives for old age; it was easier for him to bear other people's pains than his own. In his pocket he always carried a little pad of camphor that he inhaled deeply when no one was watching to calm his fear of so many medicines mixed together.

Gabriel Garcia Marquez Love in the Time of Cholera Submitted by: Lawrence N. Hill, MD Department of State Washington, DC 20521-6120

Submissions from readers are welcomed. If the quotation is published, the sender's name will be acknowledged. Please include a complete citation, as done for any reference.—The Editors

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