Abstract
Introduction
Medical education utilizes standard clinical practice and recommends clinical algorithms to inform trainee curricula. The use of race and ethnicity as a medical screening tool impacts medical outcomes by associating race with genetics without considering that race incorporates social, economic, and cultural variables that influence outcomes.
Methods
To evaluate underlying factors contributing to differences in hypertension prevalence, control, and treatment recommendations across race/ethnicities, a 2-week elective course was developed for third- and fourth-year medical students. In this elective course, students performed self-directed literature-based research on hypertension health disparities. We then developed three videos that addressed the racial/ethnic impact on hypertension prevalence and control and incorporated the students’ research findings. The videos were presented at a lunch-and-learn session, open to medical students and health professionals, that was focused on healthcare inequities in hypertension. Pre- and post-session survey data was collected to assess how the discussion changed participant knowledge and impressions of the role race plays in hypertension prevalence, control, and treatment.
Results
Survey results denoted that 100% of lunch-and-learn participants increased their understanding of the impact of health inequities on hypertension. Overall, there were significant differences in knowledge gained and understanding of health disparities that influence hypertension treatment across participants from all genders and racial or ethnic groups. Notably, pre-session survey results indicated that participants tended to agree that treatment guidelines incorporating race improve equity in the treatment of hypertension whereas post-session results showed that participants were less likely to agree with this assertion.
Conclusions
Developing educational opportunities to discuss health inequities can influence perceptions of patient care.
Keywords: Hypertension, Medical education, Health disparity, Health equity, Race, Ethnicity
Introduction
Contrary to the commonly held misconception that race is a biological category, race cannot be determined genetically [1, 2]. Although racial groups share some degree of ancestral and geographical origins, there is greater genetic diversity within racial groups than across racial groups [3]. Furthermore, a person’s racial identity may reflect only a subset of that individual’s geographical origins. As the epidemiology of various diseases has been evaluated, race has been included with sex and age as a potential risk factor resulting in a number of race-adjusted clinical algorithms including the calculation of glomerular filtration rate in staging chronic kidney disease [4, 5], calculating coronary heart disease risk [6], calculating breast cancer risk [7, 8], and interpretation of pulmonary function tests [9, 10]. This has propagated the belief that race is a biological risk factor for certain diseases. One problem with this perception is that race encompasses nongenetic factors such as social, economic, cultural, environmental, and psychological variables that themselves can impact disease risk [11–13]. Further, the utilization of race-adjusted clinical algorithms has been shown not only to reinforce biases, but in some cases to be harmful to patients and perpetuate healthcare disparities [14, 15]. Medical education is tasked with teaching accepted medical practice to students yet changes in clinical recommendations and clinician practice that reflect our evolving understanding of race and its relationship with biological and social impacts can take time.
As race-specific clinical recommendations have begun to be scrutinized, race and ethnicity are changing from being taught as independent risk factors for disease to discussions of underlying variables impacting racial and ethnic differences in disease prevalence and response to treatment [16]. For example, it has been standard to teach that the use of angiotensin-converting enzyme (ACE) inhibitors was less effective for Black patients when used as initial monotherapy to treat hypertension [17]. The 2017 American College of Cardiology (ACC) and the American Heart Association (AHA) hypertension guidelines recommend the use of a thiazide-type diuretic or calcium channel blocker as first-line monotherapy to treat hypertension in Black patients. This differs from the recommendation for the non-Black population which includes the option of an ACE inhibitor or angiotensin receptor blocker (ARB) [18]. While findings from studies using ACE inhibitors or ARBs as monotherapy in Black patients are somewhat conflicting, most studies suggest use of ACE inhibitors and ARB agents in combination with thiazides or calcium channel blockers (CCBs) is effective for Black individuals and their use as combined therapy is common practice [19, 20]. The race-based recommendations for hypertension treatment have the potential to negatively impact heath equity by reducing access to ACE inhibitors and ARBs in Black patients. Additionally, the existence of the recommendation in the absence of clear results from large-scale rigorous studies testing these assertions perpetuates the misconception that there is a genetic distinction between Black and non-Black patients that underlies the variability in physiological responses to different treatments.
Recognizing non-genetic factors impacting a patient’s disease risks, ability to obtain medical care, and adherence to recommendations has the potential to enable more direct and effective approaches to address areas of health inequity and disparities. For example, living in areas with limited access to grocery stores has been associated with an increased risk of hypertension, diabetes, heart disease, stroke, and chronic kidney disease [21]. Certain health behaviors, such as alcohol use, have a greater negative impact on those with a lower socioeconomic status [22]. Low socioeconomic status can also lead to living and working in neighborhoods with higher environmental exposures that increase risks for asthma, lung cancer, and other respiratory conditions [23]. Children in neighborhoods with a low Child Opportunity Index, reflecting 29 neighborhood attributes impacting a child’s development and outcome, have poorer physical and mental health status [24]. Many non-genetic factors contributing to health disparities are associated with multidimensional poverty with a greater impact on minoritized individuals [25].
The purpose of the present study is to evaluate the potential outcomes of engaging medical students and medical professionals in discussions about how race and ethnicity are used to inform medical treatment. Using the paradigm of differential recommendations for hypertension as a teaching topic, a 2-week elective course was designed that allowed students to perform a literature review on health disparities of hypertension treatment. The information gathered during this elective was then collated and used to generate a set of instructional videos to educate the clinical community, in particular medical students, on the complexity of the underlying factors impacting differences in hypertension prevalence and treatment across races and ethnicities. The videos were presented at a lunch-and-learn discussion forum and participants were surveyed for their existing knowledge of hypertension prevalence and treatment as well as the impact of the lunch-and-learn session on their attitudes toward hypertension-related health disparities. The potential long-term benefits of this learning platform are (1) promoting an atmosphere of open communication to address issues of health inequities and (2) promoting a culture of exploring the basis of recommended medical practices, particularly those that may contribute to health inequities.
Methods
Participants
A total of four third- and fourth-year medical students participated in the elective course. The lunch-and-learn was open to medical students years 1–4 and was advertised to the broader Indiana University medical community. While the majority of lunch-and-learn participants were medical students, other members of the medical professional community were part of the participant group and are reflected in the participant demographics (Table 1). Three of the five racial categories defined by the United States government (American Indian/Alaskan Native, Asian, Black, Native Hawaiian/Pacific Islander, and White) were represented. Hispanic is classified as an ethnicity by the United States government. A total of 32 participants attended the lunch-and-learn session and consented to participate in the lunch-and-learn survey.
Table 1.
Demographics of lunch-and-learn survey participants
| N | Percent | |
|---|---|---|
| Gender: | ||
| Male | 14 | 44% |
| Female | 18 | 56% |
| Race/ethnicity: | ||
| White | 11 | 34% |
| Black | 8 | 25% |
| Asian | 9 | 28% |
| Hispanic | 3 | 9% |
| Prefer not to say | 1 | 3% |
| Professional stage: | ||
| MS 1 | 4 | 13% |
| MS 2 | 21 | 66% |
| MS 3 | 2 | 6% |
| MS 4 | 1 | 3% |
| Clinical faculty | 1 | 3% |
| Health professional | 1 | 3% |
Development of Elective
A 2-week elective was created in which students explored clinical algorithms and treatment recommendations that were based on race or ethnicity, specifically looking at hypertension. In the first week, students read a set of pre-selected foundational papers focused on racial disparities in healthcare. They then focused on racial disparities in patients with hypertension and identified a contributing social, cultural, or genetic factor. Students then performed a literature review and wrote a summary of their findings. After discussion, students compiled their findings into a presentation. Course learning objectives included providing justification for clinical recommendations; identifying factors impacting clinical recommendations that include race or ethnicity distinctions; explaining the impact of using race or ethnicity as a basis for clinical decision-making; and analyzing and synthesizing information from the research literature to understand clinical recommendations.
Development of Videos and Presentation at Lunch-and-Learn
Three educational videos were developed by the authors and professionally prepared. The first video was 5 min in length and focused on hypertension consequences, prevalence, and control via lifestyle modifications and treatment (Video 1 :Hypertension Prevalence and Control) The second video, 6.5 min, introduced race in terms of how it is defined and assigned and then reviewed hypertension prevalence and control across racial groups along with recommended treatments and the impact of race (Video 2: Race and Hypertension). The final video was 8.5 min in length and discussed social, economic, and cultural factors underlying hypertension and incorporated the research topics from the elective students’ projects (Video 3: Addressing Hypertension Disparities).
The lunch-and-learn session was a 1-h session. Participants were divided into groups of 3–6. A pre-session survey was distributed at the start of the session. The session began with four questions using an anonymous audience-response polling application. Polling questions can be found in Table 2. Participants were asked four questions about hypertension definition, consequence, prevalence, and control. The first video was then played. Groups were then provided with two questions for table discussion: (1) What underlies the high percentage of hypertension and uncontrolled hypertension? And (2) what are barriers to controlling hypertension? The goal of this discussion was for groups to identify underlying risk factors that impact all individuals. After a brief read-out from groups, a second set of polling questions was completed focusing on prevalence and control across different races and ethnicities, specifically Hispanic, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White individuals. These designations were chosen to match data from the National Center for Health Statistics, Centers for Disease Control and Prevention [26]. The second video focused on how race is identified and the influence of race on hypertension was shown. Groups were then provided with two questions for table discussion: (1) What are potential consequences of using race to treat hypertension? And (2) what factors may underlie racial differences in hypertension/uncontrolled hypertension? The goal of this discussion was for groups to consider social determinants of health. After a brief read-out from groups, the final video was played focusing on factors underlying these racial differences. Participants were then invited to share final thoughts and impressions. Post-session surveys were distributed during the final video.
Table 2.
Pre-learning knowledge assessment (polling questions)
| Questions | % Correct |
|---|---|
| Segment 1: (General knowledge about hypertension) | |
| Q1: How is hypertension currently defined? | |
| Answer: Blood pressure at or above 130/80 mm Hg | 63% |
| Q2: For which of the leading causes of US deaths (2021) is hypertension a risk factor? | |
| Answer: Heart disease | 99% |
| Answer: Stroke (cardiovascular disease) | |
| Q3: What is the prevalence of hypertension in US adults? | |
| Answer: 50% | 36% |
| Q4: Approximately what percentage of those with hypertension have controlled it (BP<130/80 mm Hg) through lifestyle modification or medication? | |
| Answer: 25% | 22% |
| Segment 2: (General knowledge about health disparities in hypertension) | |
| Q1: What differences are there when looking at prevalence of hypertension across race or ethnicities? | |
| Answer: Non-Hispanic Black>Non-Hispanic White>Non-Hispanic Asian>Hispanic | 8% |
| Q2: What differences are there when looking at prevalence of hypertension across race or ethnicities when considering uncontrolled blood pressure >140/90 mm Hg in patients treated with medication? | |
| Answer: Non-Hispanic Black>Non-Hispanic Asian>Non-Hispanic White>Hispanic | 13% |
| Q3: What are the recommendations for monotherapy treatment of hypertension in Black patients according to the 2017 ACC/AHA guidelines? | |
| Answer: Inclusion of a thiazide-type diuretic or calcium channel blocker | 54% |
Analysis of Pre-Post Session Surveys/Statistics
Survey results were analyzed using descriptive methods. A 5-point Likert scale was used for each question with 1 being agree completely; 2, agree somewhat; 3, neither agree or disagree; 4, disagree somewhat; and 5, disagree completely. The mean score was determined based on the total number of participants per group. The Mann-Whitey U-test was used to compare pre- and post-session survey results and a p-value<0.05 was considered significant. GraphPad Prism software was used for data visualization and statistical analysis.
Results
Medical Student Elective
During the 2-week Healthcare Inequities in Clinical Algorithms and Treatments (HICATS) elective, students identified and researched potential factors contributing to differences in the prevalence and control of hypertension across racial and ethnic groups. One project focused on adherence to recommendations to use race when choosing initial monotherapy for hypertension as well as comparing hypertension prevalence among US-born and foreign-born Black individuals. Another project reviewed differences in nitric oxide availability and the influence of diet and exercise in Black vs White individuals. A third project reviewed the impact of incarceration and solitary confinement on the incidence of hypertension. The final project explored pre-eclampsia, particularly the impact of prenatal and postpartum care across racial and ethnic groups. Findings from the four elective projects were incorporated into the third video and helped inform the lunch-and-learn discussion.
Pre-learning Knowledge Assessment
At the start of the lunch-and-learn session, participants were asked to participate in an interactive multiple-choice polling survey to assess their overall knowledge about hypertension as well as health disparities in hypertension. Results showed that there was a high level of variability in knowledge about these topic areas (Table 2). Almost all participants (99%) responded correctly that hypertension is a risk factor for the leading causes of death in the United States: heart disease and stroke. However, participants were less knowledgeable about what is the prevalence of hypertension (36% answered correctly) and what is the percentage of individuals who have hypertension controlled through lifestyle modifications or medications (22% answered correctly). Only 8% of participants answered correctly that the prevalence of hypertension is highest in the non-Hispanic Black population when asked about differences in hypertension across races or ethnicities. Similarly, only 13% answered correctly when asked what the differences in controlled hypertension across races or ethnicity are; however, 54% of participants answered correctly that the 2017 ACC/AHA recommendation for non-Hispanic Black patients for hypertension indicates including a thiazide-type diuretic or calcium channel blocker.
Survey Results
Participants attending the lunch-and-learn were asked to complete a pre-session survey and post-session survey containing the same questions (Table 3). Responses were tabulated according to gender as well as self-identified race or ethnicity of participants. While participants were allowed to choose multiple categories for race and ethnicity, all participants only chose one category. Participants self-identified into one of four racial/ethnic groups (Asian, Black, Hispanic, and White; Table 1). Responses were compared between pre-session and post-session responses with 1 representing agree completely, 2 agree somewhat, 3 neither agree nor disagree, 4 disagree somewhat, and 5 disagree completely. There were significant changes in responses between pre-session responses and post-session responses for questions 1–5, which assessed knowledge for understanding hypertension treatment. Participants indicated they were more knowledgeable after participating in the lunch-and-learn, on average agreeing somewhat or completely. However, for questions 6–9, which focused on the use of race and ethnicity in treatment recommendations, responses indicated that participants neither agreed nor disagreed with the appropriateness or positive impact on health equity of using race or ethnicity to guide treatment.
Table 3.
Pre- and post-session comparison. 5-point Likert scale was used for each question with 1 being agree completely; 2, agree somewhat; 3, neither agree or disagree; 4, disagree somewhat; and 5, disagree completely
| Mean | (SD) | Mean | (SD) | Overall pre- vs. post- | |
|---|---|---|---|---|---|
| N=29 | N=32 | ||||
| PRE | POST | p-value | |||
| Q1: I am confident regarding my knowledge of current hypertension treatment recommendations | 3.19 | (0.53) | 1.71 | (0.17) | 0.0286 |
| Q2: I am confident regarding my understanding of the rates of successfully controlling hypertension with lifestyle modifications and medicine. | 3.19 | (0.63) | 1.82 | (0.36) | 0.0571 |
| Q3: I am confident regarding my understanding of the rates of successfully controlling hypertension with pharmacological interventions. | 3.47 | (0.62) | 1.65 | (0.17) | 0.0286 |
| Q4: I am aware of how race is taken into consideration in current hypertension treatment recommendations. | 2.64 | (0.74) | 1.61 | (0.17) | 0.0286 |
| Q5: American College of Cardiology and American Heart Association treatment recommendations guided by race are commonly followed by physicians in the US. | 3.07 | (0.40) | 2.15 | (0.49) | 0.0286 |
| Q6: It is appropriate to use a person’s race or ethnicity to help guide initial treatment choice for hypertension. | 2.84 | (0.57) | 3.20 | (0.62) | 0.4857 |
| Q7: Treatment guidelines incorporating race or ethnicity are based on scientific studies that evaluate genetics | 3.10 | (0.40) | 3.36 | (0.59) | 0.4857 |
| Q8: Treatment guidelines incorporating race or ethnicity are based on scientific studies that evaluate lifestyle and/or environmental factors. | 2.93 | (0.46) | 3.20 | (0.25) | >0.9999 |
| Q9: Treatment guidelines incorporating race or ethnicity improve equity in the treatment of hypertension | 2.68 | (0.49) | 3.25 | (0.32) | 0.2000 |
When we compared pre-session survey and post-session survey responses by gender, the results for both females and male were consistent with the results for the overall group (Table 4). For questions 1–5 of the survey, there was a strong shift from somewhat disagree to agree in both female and male participants, indicating participants were more knowledgeable after the lunch-and-learn session. For questions 6–9, there was no significant difference between pre- and post-session responses in either female or male participants, with average response near neutral at the start of the session and trending slightly towards disagree after the session. There was good concordance between genders with males trending slightly more with agree pre-session and slightly more with disagree post-session for questions 6–8.
Table 4.
Pre- and post-session survey responses by gender. 5-point Likert scale was used for each question with 1 being agree completely; 2, agree somewhat; 3, neither agree or disagree; 4, disagree somewhat; and 5, disagree completely
| PRE | POST | |||
|---|---|---|---|---|
| FEMALE | MALE | FEMALE | MALE | |
| N=15 | N=14 | N=18 | N=14 | |
| Q1: Knowledge of treatment recommendations | 3.20 | 3.07 | 1.72 | 1.79 |
| Q2: Knowledge of success of lifestyle or medicine | 3.27 | 3.50 | 1.83 | 1.57 |
| Q3: Knowledge of success with medicine | 3.21 | 3.71 | 1.72 | 1.50 |
| Q4: Knowledge of recommendations incorporating race | 2.71 | 3.14 | 1.78 | 1.43 |
| Q5: Adherence to recommendations by physicians | 2.86 | 3.07 | 1.94 | 2.00 |
| Q6: Appropriate to use race | 3.00 | 2.50 | 3.00 | 3.07 |
| Q7: Genetic evidence for guidelines | 3.21 | 2.93 | 3.11 | 3.57 |
| Q8: Evidence for lifestyle/environmental factors | 3.00 | 2.79 | 3.00 | 3.29 |
| Q9: Incorporation of race/ethnicity improves equity | 2.57 | 2.64 | 3.11 | 3.07 |
When we compared pre-session and post-session responses by race and ethnicity, more varied results were seen (Table 5). When considering the overall trend for questions 1–5, all participants regardless of race or ethnicity mostly reflected the overall trend shown in Table 3. All groups indicated greater confidence in knowledge after the session. Only slight differences were seen when considering confidence in knowledge before the session across races and ethnicity.
Table 5.
Pre- and post-session survey responses by race/ethnicity. 5-point Likert scale was used for each question with 1 being agree completely; 2, agree somewhat; 3, neither agree or disagree; 4, disagree somewhat; and 5, disagree completely
| PRE | POST | |||||||
|---|---|---|---|---|---|---|---|---|
| WHITE | BLACK | HISPANIC | ASIAN | WHITE | BLACK | HISPANIC | ASIAN | |
| N=11 | N=7 | N=3 | N=8 | N=11 | N=8 | N=3 | N=9 | |
| Q1: Knowledge of treatment recommendations | 3.00 | 2.43 | 3.67 | 3.38 | 1.91 | 1.50 | 1.67 | 1.78 |
| Q2: Knowledge of success of lifestyle or medicine | 3.45 | 3.14 | 2.33 | 3.50 | 1.55 | 1.63 | 2.33 | 1.78 |
| Q3: Knowledge of success with medicine | 3.45 | 2.86 | 4.33 | 3.25 | 1.55 | 1.50 | 1.67 | 1.89 |
| Q4: Knowledge of recommendations incorporating race | 3.18 | 2.00 | 2.00 | 3.38 | 1.64 | 1.38 | 1.67 | 1.78 |
| Q5: Adherence to recommendations by physicians | 2.64 | 2.86 | 3.67 | 2.88 | 1.55 | 2.38 | 2.67 | 2.00 |
| Q6: Appropriate to use race | 2.36 | 2.71 | 3.67 | 2.63 | 3.18 | 2.50 | 4.00 | 3.11 |
| Q7: Genetic evidence for guidelines | 2.73 | 3.00 | 3.67 | 3.00 | 4.00 | 3.13 | 3.67 | 2.67 |
| Q8: Evidence for lifestyle/environmental factors | 2.27 | 3.00 | 3.33 | 3.13 | 3.45 | 3.13 | 3.33 | 2.89 |
| Q9: Incorporation of race/ethnicity improves equity | 2.18 | 2.71 | 3.33 | 2.50 | 3.18 | 3.25 | 3.67 | 2.89 |
For questions 6–9, there was less consistency in responses across racial and ethnic groups. When asked about appropriateness of using race or ethnicity in guiding initial treatment (question 6), Asian and White participants agreed pre-session with slight trend towards disagreement post-session. Black participants remained unchanged, slightly agreeing that race/ethnicity should be used as a guideline, while Hispanic participants disagreed somewhat pre-session and more strongly post-session. When asked about evidence supporting treatment guidelines based on race and ethnicity (questions 7 and 8), Hispanic and Black participants showed little change pre- and post-session. White participants showed more of a trend towards disagreeing post-session that treatment guidelines are based on scientific studies evaluating genetics (question 7) or lifestyle and/or environmental factors (question 8). When asked about whether incorporating race or ethnicity into treatment guidelines improved equity in the treatment of hypertension (question 9), Black and White participants showed some agreement pre-session but moved towards disagreeing after the session. Interestingly, in both the pre- and post-session responses, Hispanic participants disagreed whereas Asian participants agreed.
Discussion
As our understanding of biological and social factors of disease evolves, the medical field’s perspective of race is changing. Race is now defined more as a social construct, rather than a biological or genetic risk factor around which treatment plans are structured. In part, this is due to improved understanding of genetic heterogeneity among racial groups, with recent studies demonstrating that racial classifications exist separately from true genetic differences between peoples [11]. Despite the fundamental heterogeneity among racial groups, race is often used as a surrogate for genetic and non-genetic factors that impact differences in healthcare outcomes between groups [1]. This approach conflates race and genetics, resulting in the propagation of a belief that there are biological differences that stem from race which drive healthcare outcomes, despite there being no evidence for such differences.
Race is not defined by genomics or objective ancestry but is rather an ambiguous category that incorporates culture, environment, and individual self-identification [3, 27]. The process of assigning people into racial groups is ultimately subjective and does not account for factors such as multiple ancestry, with individuals assigning race based on their own personal beliefs. In clinical settings, patient race may be determined by self-identification or based on observation by clinical staff, particularly in older studies. In many instances, this decision influences healthcare decision-making [28, 29]. Using race as a factor to inform treatment depends on the presumption that all individuals in a racial category experience the same stressors and social determinants of health. Factors such as life adversity, psychosocial stress of experiencing racism, and limited access to healthcare are often experienced in minoritized groups and have significant impact on healthcare outcomes [30]. However, these risk factors are not limited by race and ethnicity, nor are they experienced universally within those categories. Therefore, it is critical for clinicians to look beyond race or ethnicity and focus on the individual’s lived experiences to structure appropriate treatment plans.
In the current study, we attempted to engage learners in assessing the value of the evidence underlying the use of race and ethnicity when evaluating hypertension prevalence, control, and treatment. Further, we used findings from the students’ projects in educational materials that were the basis for discussions on factors impacting health inequities. We evaluated changes in knowledge and attitudes among participants after viewing the videos and engaging in directed discussion aimed at producing a stepwise conversation from basic health impact and prevalence of hypertension to differences in hypertension prevalence and control among different racial and ethnic groups to various factors that may underlie the differences.
When we evaluated our knowledge questions looking at treatment of hypertension and recommendations based on race, participants reported an increase in understanding and awareness after the session. This was true across racial/ethnic groups and gender. It was not surprising that most participants somewhat disagreed that they were confident in their knowledge about hypertension before the start of the session. Nearly 85% of the participants were at the beginning of their first or second year of medical school and had not yet taken courses in which hypertension was covered in depth. We also expected that they would gain knowledge during the session since the educational videos were designed to provide a baseline of knowledge.
Views on the scientific basis and impact on health equity of using race and ethnicity in treatment guidelines showed little change on the post-session survey compared with the pre-session survey. Average responses at the start of the session were near neutral on the agree side and were near neutral on the disagree side at the end of the session. This may reflect the complexity of the topic: specific racial and ethnic groups can have an increased likelihood of life experiences that negatively impact risks and prognoses associated with hypertension. Ignoring race and ethnicity could result in overlooking vulnerabilities and missed opportunities to decrease health inequity. Discussing the impact of these experiences on health outcomes can increase awareness and potentially influence changes at the individual, interpersonal, organizational, community, and public policy levels [31]. On the other hand, these life experiences are not exclusive to any racial or ethnic group nor are they experienced universally within a racial or ethnic group. Thus, the use of race and ethnicity may provide an opportunity to discuss social, economic, cultural, environmental, and psychological factors for which a patient may be at an increased risk. It is in this context that the students in our elective reviewed studies reporting differences across racial and ethnic groups related to hypertension. By initially tasking students to review a set of papers discussing race and ethnicity in the context of healthcare, we began the elective better understanding the limitations of interpreting individual differences as genetic risk factors. Students then used this approach when researching topics related to race, ethnicity, and hypertension. Our educational videos and lunch-and-learn sequence took a similar approach in first acknowledging that there are differences in hypertension prevalence and control across races/ethnicities and then exploring non-genetic, and thus modifiable, factors that could impact these differences. Our directed discussion allowed for an open exchange of ideas and experiences.
Conclusions
The way race and ethnicity are used in medicine has the potential to significantly impact healthcare outcomes, especially in the treatment of hypertension. Treatment of hypertension requires physicians to examine a patient’s modifiable and non-modifiable risk factors, with the goal of developing an individualized treatment plan that addresses those factors. Modifiable risk factors, such as smoking, and non-modifiable risk factors, such as family history, are independent of a patient’s race or ethnicity and can significantly alter the course of treatment. Race and ethnicity can contribute to social, economic, cultural, environmental, and psychological risk factors, some of which are modifiable at an individual level while others require interventions from a healthcare system or public policy changes. Our results found that, although medical students and professionals have limited understanding of how race or ethnicity is used to inform the medical treatment of hypertension, these participants were receptive to learning more about this topic to provide better care. Like hypertension, there are many disorders in which there are differences across racial and ethnic groups in prevalence, control, and outcome. The educational approach described here can be utilized to explore underlying factors impacting these differences and to launch wider discussions. This study was limited by small sample size and its qualitative nature.
Funding
This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $19.8 million with 10% financed with nongovernmental sources.
Declarations
Disclaimer
The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.
Ethics Approval
This study received approval through Indiana University School of Medicine’s Institutional Review Board under IRB #19685.
Consent to Participate
All participants were provided an informed consent statement and participation was voluntary. Data collected was anonymized.
Consent for Publication
All authors consent to publication of this original work.
Competing Interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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