Black patients treated at an academic medical center were more likely to have their race documented in the first line of their patient history compared with white patients, researchers report in an article published online January 11 in JAMA Internal Medicine. The team also found that attending physicians were more than twice as likely to document race as newly minted resident physicians.
Prior to the study, the researchers had anecdotally noticed worrying trends and decided to dig into patient medical records to gauge the degree of racial bias in clinician documentation, first author Jessica R. Balderston, MD, Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, told Medscape Medical News.
The team analyzed details for 1200 patients treated between January 1, 2018 through December 31, 2019 and whose electronic health record included a diagnosis of breast cancer, sickle cell disease with crisis, status epilepticus, hypertensive emergency, pneumonia, or motor vehicle collision. They queried records to identify the first 200 consecutive adults with each diagnosis.
“Race was documented in the history of present illness in 323 patients (26.9%), including 257 of 777 Black individuals (33.1%) and 63 of 384 White individuals (16.4%) (P < .001),” write Balderston and colleagues. “After adjusting for other factors, Black patients had higher odds of having race documented (adjusted odds ratio, 1.57; 95% CI, 1.11 – 2.25, compared with White patients), and Black clinicians were less likely than White clinicians to document the patient’s race.”
At registration, patients’ race is captured by staff and often is documented in other parts of the notes such as the social history, which describes employment, where a person lives, and with whom he or she lives — powerful data that can help with detailed analysis later. The first line of the patient history, however, represents the clinician’s first impression of the patient.
“This is really looking at whether it needs to be in such a prominent position that it’s framing the context of the patient being there. If it’s not relevant, why is it there? The practice in putting it in such a prominent position is what we found to be biased,” Balderston told Medscape Medical News.
Balderston did, she acknowledged, encounter pushback when she presented the group’s findings during a recent conference. A young resident in the audience countered that they are taught to mention race, so how could that be racist?
“When you’re told to mention race every time, that’s fine. When you only mention Black people and you don’t mention White people that’s biased. It’s that simple,” Balderston replied at the conference.
The team’s findings raise “the question of whether basic medical practices, such as how patients are characterized in the first line of the [history of present illness], invite stereotypes and bias into clinical judgment,” according to a companion commentary.
While acknowledging that additional research is needed at multiple sites, Balderston points to the potential of using their single-site findings as a teaching tool. “This was something we could identify as strong evidence of racial bias. And every time we confront that and acknowledge it, it gives us another opportunity to try to fix it and try to do better,” she adds.
Jesse C. Ikeme, M.D., a resident physician in internal medicine at the University of California, San Francisco, and the commentary’s lead author, told Medscape Medical News that process improvements could take the form of more consistent communication and expectation-setting on the wards, thoughtful educational materials, and published case presentations.
“Second, critically examining the complex interactions between race and medicine should be as essential a part of the medical curriculum as commonly taught associations between race and specific diseases,” he added via email.
Funding for research described in this story was provided by the National Institutes of Health. Study author Gregory Golladay, MD, disclosed funding from OrthoSensor Inc, KCI Inc, and Cerus.
Diedtra Henderson is a freelance journalist based in Washington, D.C. She has previously written for the Boston Globe, The Associated Press, the Denver Post, the Seattle Times, and the Miami Herald. Follow her on Twitter: @dee_henderson