Patient’s Medical History: Should the Description of Race and Ethnicity be Forbidden?
There is concern that I and others who teach medical students to take a medical history and perform a physical examination have been teaching the wrong way. We have always been teaching the student to start off the history with, as an example, “The patient is a 35 year old Hispanic married male carpenter who…”
Wrong!!
We are now told by those who know: writing Hispanic may be discriminatory and also used as a stereotype (and the same goes for black, African-American, Asian and so on). Not only that but these days the word "married" is inconsequential in terms of making a diagnosis. How about the word “carpenter”? It might be used as a stereotype and be discriminatory. How about age? Can be used to discriminate and stereotype? "Male" or "female"--too biological not humanistic--"man" and "woman" is better.
The argument against writing the race or ethnicity as identifying elements is that also these days most physicians may not know “who is what”? And the argument is there is such a mixture of race, cultural backgrounds or religions that simply the appearance of the patient may not be definitive. If the patient is asked specifically about what race they represent in order to identify a related disease (and most doctors rarely if ever directly ask such a question), the patient’s response may not be clinically relevant if one realizes the genetic complexity of every named race.
So this is the issue: should our teaching be changed and the example introductory line for a medical history begin “The patient is an adult man who..” ?
To read more about this issue:
"Misuse of Race in Medical Diagnosis" by Richard S. Garcia in “The Chronicle of Higher Education".
University of California San Francisco Medical School Statement regarding the Use of Race and Ethnic Identifiers 2006.
Write us here what is your opinion of the writing of race and ethnicity as identification of a patient in the patient’s own medical record. ..Maurice.
posted by Maurice Bernstein, M.D. @ 12:25:00 PM
7 comments
7 Comments:
Hey Dr. B--
Do I detect a hint of defensiveness in your post?
I wasn't able to link to the UCSF statement, but Dr. Garcia's points are well-taken. I don't want to put words into his mouth, but it seems that he's pointing out one mental trap into which all doctors can fall: allowing certain assumptions to crowd out possibilities in terms of a diagnosis (or of management). His anecdote about the ER physician dismissing the headache of the "14 year-old black male" and missing an intracranial mass is perhaps his best example of how such racial, ethnic, and social "tags" can serve to bias a clinician with potentially disastrous outcomes for the patient.
For my part, however, I prefer more skepticism rather than less information. Once I had to admit a homeless guy who used to drink a staggering amount on a daily basis for "mental status changes." The ER, who apologized in advance for making me have to tend to such a character, billed it to me as a soft admit to "let him dry out overnight." He had been in the ER for something like 7 hours and only had an alcohol level of around 200, which for him was definitely on the lower side of things. I hope I don't sound too self-congratulatory when I tell you that something seemed amiss, didn't match the pattern of all his previous ER visits, which were extensive, so I told the nurse to throw him in the scanner. It raised some eyebrows that I was wasting such resources on just another drunk, but their eyebrows went even higher when the images clearly showed that he had a fairly large subdural bleed, and we shipped him off to a neurosurgeon. The take-home point to me was not that I didn't want to know that he was a drunk, but rather that such information didn't override the rest of the clinical picture. The ER diagnosis ("drunk") didn't seem to match all the available information, so I got the scan.
In terms of histories, my own practice is generally not to include any tag other than age in the opener (e.g. "a 45 yo male"), and then put what descriptors I think are relevant into the social history. In your example, for instance, being a carpenter to me would be something quite relevant given occupational exposures or hazards. "Married" is definitely not helpful if all one wants to know is sexual history, though I usually say if someone is living with their spouse and/or kids; defining a "race" to me has occasional value but is usually pretty limited. So for me it comes down not to whether the information should be there, but instead to what the clinician chooses to do with that information and how much importance to assign to it.
Billy, first I want to thank you for your view of the issue. And yes, I am perhaps from the "old school" that finds merit and not discrimination nor stereotyping in that opening line identifier. I look at it as a beginning for the physician or nurse or other healthcare attendant to the patient to gain a bit of a humanistic picture of the patient with whom they will be involved. Yes, it is always possible that the picture is not quite the perfect image of the patient but no chart recording whether in the first line nor in the Past History section may truthfully represent the way the patient him/herself would have described themselves if they would have written the description themselves. How the image is described are expressions of the writer physician and not the subject.
I teach my medical students that what they write in the history and physical is not the end-all in the description of the patient or the clinical condition nor of the differential diagnosis. More detail and information may be coming and this information will make up part of the progress notes which are later written. It's only a beginning.
My argument with all this concern about the first line is if it is acceptable to put all this identifying information elsewhere in the history or physical, what is so special about the introductory first line. No thoughtful physician is going to jump to a conclusion about the patient by reading only the first line.
Billy, please let me know specifically what trouble you are having accessing the UCSF white paper. You should be going directly to my Google website and downloading a Microsoft Word document. ..Maurice.
Dr. B.,
Admittedly, I am an engineer, not a physician. That said, I think there are a couple of dangers in putting too much information in the first line of the history, and both are related to human nature.
The first is the possibility the physician reading the history might take the "Reader's Digest Condensed Version" approach, assume they have the basics of what they need to know, and gloss over detailed information that might be pertinent.
The second is the human tendency, intentional or not, to stereotype people based on, among other things, behaviors or socioeconomic status. Billy's example with the "drunk" is an excellent one.
I think Billy makes an excellent point - keep the opening line to the very basics. Age and gender are important if for no other reason than they help someone identify they're talking to the right patient. Beyond that, any additional pertinent information can be included in the appropriate section.
Again from an engineering standpoint, a clean, concise and well organized report is much faster and easier to read. I suspect that initially med students tend to be overly verbose and include way too much information, fearing that if they don't they might miss something. It happens in other professions too. The good thing is that as they gain experience, they learn what information is pertinent.
Dr. B., I'm not able to open the file either. When I researched the reason, it was because my Office program is earlier than
2007. You can get a 60 day free trial "compatibility pack" from Microsoft to remedy this, but after that it costs $149 for the full 2007 version.
The original document file extention (.doc) is being phased out, being replaced by (.docx) which is the extension that your document has.
http://office.microsoft.com/en-us/word/HA100444731033.aspx
Emily
Emily, thank you for the information regarding the UCSF file. Since I think it is important for visitors to read how UCSF Med School has changed how they want the students to be taught regarding recording patient's race/ethnicity, I will see if I can convert the file to a pre-2007 .doc. ..Maurice.
OK..everybody try again. I converted the UCSF paper to a .doc file.. and if you have the "old" Microsoft Word, you should be able to access the file now. Let me know if you still have problems. ..Maurice.
Answered on my blog. (Sorry; slow blogging day.) Here's the essence:
I'm going to come down on the side of more information in the opening statement rather than less. I'd love to hear something like, "58-year-old married female secretary who just dropped her last child off at college and started art lessons last week..." and here's why. It has to do with this quote from Sir William Osler:
"The good physician treats the disease; the great physician treats the patient who has the disease."
The more I know about the patient who has the disease, the better job I will be able to do caring for that patient. How better to get to know the patient than to describe him or her as fully as possible right from the start of the encounter. For those who worry about stereotyping, allow me to offer the following suggestion: ask the patient to describe him or herself, and then include the response in the opening statement.
I don't treat diseases. I treat people, and because every person is different, I think it is better to err on the side of more description rather than less.
Post a Comment
<< Home