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Editor's Note
January 11, 2021

Reappraising Medical Syntax—Does Race Belong in the First Line of the Patient History?

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco
  • 2Editorial Fellow, JAMA Internal Medicine
  • 3Division of Research, Kaiser Permanente Northern California, Oakland
  • 4Associate Editor, JAMA Internal Medicine
JAMA Intern Med. Published online January 11, 2021. doi:10.1001/jamainternmed.2020.5789

In the midst of the resurgent movement for racial justice, physicians and health care institutions should carefully look within for potential sources of racial and ethnic health disparities. In this issue of JAMA Internal Medicine, Balderston et al1 report on differential documentation of race in the first line of the history of present illness (HPI). In 1200 admissions to an academic medical center in Richmond, Virginia, 33% of Black patients had their race documented in the first line of their admission note compared with 17% of White patients (adjusted odds ratio, 1.57; 95% CI, 1.11-2.25). Black clinicians had 58% lower odds of documenting race than White clinicians (adjusted odds ratio, 0.42; 95% CI, 0.20-0.80), and attending physicians had 2.37 times greater odds of documenting race than resident physicians (95% CI, 1.73-3.27) in adjusted analyses.

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    2 Comments for this article
    Racial References
    George Dyck, M.D. | University of Kansas School of Medicine
    For years before my retirement from active medical school teaching twenty years ago I objected to the reference to race in the first line of the patient history. It is an unfortunate holdover that reinforces implicit racism. Of course reference to race is an appropriate part of the social history, because it is a social construct often important to note in our present society and in my field of psychiatry. But it has no purpose in the first line of the history other than to reinforce racial stereotypes.

    George Dyck, MD
    Emeritus Professor, University of Kansas
    Being colorblind is a missed opportunity.
    Marla Gorosh, MD, FACH | Henry Ford Health System, Academy on Communication in Health Care
    As I teach unconscious bias to all members of our healthcare team, I teach that as a white primary care doctor, I have made it a point to ask patients if they would like me to identify them by race in the clinic note. We are usually looking at the EHR together as I type the first line of my note. I ask how they describe themselves and what terms they may want to use, Black v African American, if any. I have noted that recognizing people’s racial (or ethnic) identity is not only important to them but also important to me as a trigger to check my unconscious biases. When I notice one’s race it reinforces for me that I may have to “take this person’s care under my wing” as I refer them to specialists in the healthcare system where they may need extra support for the systemic or personal barriers they may encounter. There are times I have expressed my intention to be their steward through their healthcare journey specifically because of unconscious bias or systemic barriers. This brief interaction which usually occurs at our first meeting allows for them to agree or not to having their race mentioned in the HPI. I have been able to learn how they see the use of this language as being helpful or not. I feel I can be transparent while also expressing my intention to partner as an ally. The partnership remains whether the note includes their race or not.