Exploring Residents’ Beliefs Regarding the Role of Race in Clinical Decision-Making: A Qualitative Study

ABSTRACT

Background Race has long been treated as a biological determinant in medicine, and many US faculty still reference it in clinical contexts. As the field shifts away from this model, the medical community faces the challenge of addressing how race shapes patients’ experiences and outcomes without reinforcing harmful practices. Internal medicine residents must navigate this transition amid conflicting guidance on incorporating race into clinical reasoning. Understanding how residents currently conceptualize and apply race in clinical contexts is essential to preparing them to deliver equitable, patient-centered care.

Objective To understand residents’ beliefs regarding race in clinical decision-making.

Methods We conducted a qualitative study using semistructured interviews with residents from 3 US internal medicine residency programs within a single institution between February and April 2023. Participants were recruited via email, presented with a clinical vignette, and asked about clinical management and the impact of race on their decisions. We conducted an inductive thematic analysis to identify emergent themes and interpreted the findings through Jean Piaget’s framework of cognitive conflict and learning.

Results Twenty-four residents completed the study. Three main themes emerged: (1) a persistent belief in race-based medicine where beliefs and clinical reasoning aligned around the idea of race as biological; (2) a disequilibrium defined by discrepancy between beliefs and clinical reasoning; and (3) a new equilibrium marked by alignment around race as a social construct and recognition of racism’s impact on individual health.

Conclusions Residents described dissonance between understanding race as a social construct and encountering clinical norms treating it as biological, revealing a process of questioning and reframing how race is used in clinical care.

Introduction

Race has long been a controversial concept in medicine. For years the medical community attributed biological differences to race. It is now well established that race is a social construct, with health outcomes more accurately understood as a reflection of social drivers of health. While data on race remains essential in research to understand health disparities, and while it is important to examine how race shapes clinical outcomes, using race as a proxy for genetic differences—known as race-based medicine—is an imprecise and oversimplified approach that reflects longstanding systemic biases in medicine.

Until recently, medical educators routinely encouraged medical students to explicitly mention race in clinical presentations,¹ and licensing examinations relied on race in question stems solidifying racial heuristics and the White normative body.^2,3 Clinical algorithms that reduce race to a limited set of discrete racial categories overlook the complexity of many patients’ ancestries, public identities (how people are perceived by others), and personal identities (how people perceive themselves).⁴ Many current medical educators were trained to view race as biological, and some continue to teach race-based medicine.

While the harms of race-based medicine are increasingly recognized, uncertainty remains about whether race should inform clinical decisions when it is used as a proxy for certain social and structural determinants of health.⁵ Research links structural racism to poor health outcomes, through social drivers of health⁶ and the psychological stress of racial discrimination.^7,8 Emerging evidence in epigenetics suggests that racism-related stress can affect gene expression across generations.^9,10 Some argue that using race—for example to screen Black-identifying patients earlier for prostate cancer—may mitigate harm.¹¹ Others caution that without explicitly connecting race to racism, such practices risk reinforcing racial essentialism and legitimizing biological conceptions of race.^12,13

Existing studies focused on how physicians, advanced practice clinicians, and nurses incorporate race into their decision-making suggest that reliance on race in medical decision-making is more common among physicians who tend to be older, have anxiety about decision-making in general, and lack awareness of institutional bias and racial privilege.^14-16 Recent work evaluating how medical schools are revamping curricula and how faculty perceive this shift suggests that while most faculty believe race is a social construct, this belief is not reflected in the preclinical curriculum.^17,18 This reveals a knowledge gap in understanding how residents’ beliefs and practices are changing during this time of transition.

This study examines residents’ beliefs about race in medicine in this evolving landscape as they shift from simplistic racial categorization to recognizing the impact of social factors—such as zip code, education, racism, and wealth—on health. By exploring residents’ current beliefs and clinical reasoning, we address a gap in the literature on how they understand and incorporate race in clinical scenarios, an essential step in ensuring they are prepared to provide equitable, patient-centered care to individuals from all backgrounds.

KEY POINTS

What Is Known

Residents can receive mixed guidance on how to incorporate race into clinical care.

What Is New

This qualitative study of 24 US internal medicine residents revealed 3 themes: (1) a persistent belief in race-based medicine where beliefs and clinical reasoning aligned around the idea of race as biological; (2) a disequilibrium defined by discrepancy between beliefs and clinical reasoning; and (3) a new equilibrium marked by alignment around race as a social construct and recognition of racism’s impact on individual health.

Bottom Line

Educational efforts should support residents through this cognitive conflict and help align teaching with modern concepts of race as a social determinant of health.

Methods

Study Design

We used thematic analysis to identify patterns and themes in residents’ beliefs and in the clinical reasoning they applied during case-based scenarios. This approach aligns with a post-positivist paradigm that acknowledges the existence of an objective reality while recognizing that researchers’ perspectives and participants’ social contexts influence the interpretation of data.

Setting and Participants

Medstar Graduate Medical Education has 3 internal medicine residency programs in the Washington, DC, Maryland region—Medstar Georgetown University Hospital, Medstar Washington Hospital Center, and Medstar Baltimore. We selected internal medicine residents, as this is a field heavily influenced by risk assessment, diagnostic algorithms, and medication selection, all areas that have traditionally relied on race-based associations.

Each residency program director sent a recruitment email to all residents in their program, followed by a reminder email to encourage participation. We reimbursed participants $50 for their time. Verbal consent was obtained prior to the interview. A total of 24 residents were interviewed between February and April 2023, at which point we determined that saturation had been reached.

Data Collection

We used one-on-one semistructured interviews incorporating a clinical vignette to better understand how and why residents factor race into clinical decision-making. The interview guide was based on the work of Shedra Snipes.¹⁹ We presented residents with a clinical vignette of a 57-year-old man of unknown race who presented to discuss hypertension, hyperlipidemia, and prostate cancer screening (online supplementary data). These clinical conditions were selected due to the history of race-based guidelines, diagnostic algorithms, and risk assessments associated with these conditions. A group of academic primary care physicians reviewed and edited the clinical vignette. Residents were asked questions about clinical management to understand how they incorporate race into clinical decision-making. We then asked explicitly about how race did (in this interview), does (in real-world practice), and should (belief) impact their clinical management of a patient. After the first 5 interviews were conducted, the principal investigator reviewed transcripts to ensure the prompts were appropriate to obtain the information desired and subsequently updated the interview guide.

Three first-year medical students (R.A., K.C.N., J.P.), who were unknown to the participants, conducted the interviews. Two of the 3 students had experience in conducting semistructured qualitative interviews. We conducted practice sessions for semistructured interviews, providing feedback to ensure consistency in data collection. Additionally, the principal investigator observed interviews during the first round and provided further feedback to refine the approach. The principal investigator interviewed residents who were from programs she was not affiliated with. Interviews were conducted via Zoom. Audio recordings were transcribed and then destroyed.

Data Analysis

We conducted an inductive thematic analysis²⁰ to identify emergent themes from our data, as this approach is well-suited for exploring complex, evolving beliefs without imposing predefined categories. This was followed by an application of Jean Piaget’s theoretical framework of cognitive conflict and learning. Piaget described cognitive conflict as a “psychological state involving a discrepancy between cognitive structures and experience,” or between incompatible cognitive structures competing for a single response.²¹ Using the sensitizing concept of Piaget’s theory, we identified categories within the data relating to the relationship between residents’ beliefs pertaining to how race affects health (cognitive constructs) and their behaviors (how they used race in clinic scenarios). We defined these categories as existing somewhere along a continuum, starting at an “old equilibrium” and progressing toward a “new equilibrium” to measure various degrees of belief and practices around race and racism.

All transcripts were redacted, uploaded into Dedoose (SocioCultural Research Consultants LLC) and analyzed by the research team. Each researcher reviewed 12 transcripts while the principal investigator reviewed all 24, such that each transcript was reviewed by 3 people. Each researcher completed open coding on their own, and then meetings were held to compile codes and identify themes. When areas of disagreement arose, an additional research team member reviewed the disputed data, and the group came to a consensus. Each team member individually applied the theoretical framework to the data. Data collection was concluded once saturation was reached for the concepts identified within the Piaget framework. We then met to share our proposed interpretation and worked together to construct our final framework.

Reflexivity

The team consisted of 4 first-year medical students (R.A., K.C.N., J.P., A.B.) and one academic attending physician (E.B.). A.B. did not conduct interviews but completed coding and data analysis. R.A. identifies as Asian. K.C.N. identifies as Native Hawaiian/Pacific Islander, Asian, and White. J.P. and E.S. identify as White, and A.B. identifies as African American. We tried to reflect on positionality throughout the analysis to acknowledge how identities may have shaped data gathered through the interview and how our experiences may shape data interpretation.

Ethical approval was granted by the Georgetown University Institutional Review Board.

Results

After approximately 20 interviews, we observed thematic redundancy and concluded data collection after 24 interviews. The 24 residents were evenly distributed across postgraduate year in training and gender. A slight majority of our residents (54%, 13 of 24) graduated from medical schools outside of the United States. The majority of participants were between the ages of 27 and 29 and graduated medical school between 2019 and 2020. Race and ethnicity were collected via open-ended questions, and we chose to collapse these data since many answered questions about race with ethnicity or country of origin (Table).

Table.

Demographics

Participants, N=24	n (%)
Gender identity
Woman	12 (50)
Man	12 (50)
Non-binary	0 (0)
Race/ethnicity
Black/African American	2 (8)
Asian	9 (38)
White	7 (29)
Middle Eastern/North African	4 (17)
Multiracial	1 (4)
Other	1 (4)
Year in training
PGY-1	7 (29)
PGY-2	8 (33)
PGY-3	9 (38)
Graduated from US-based medical school
Yes	10 (44)
No	14 (56)
Age
20-24	1 (4)
25-29	18 (75)
30-40	5 (21)

Abbreviation: PGY, postgraduate year.

We created a model depicting 3 main themes characterizing the relationship between beliefs and the clinical reasoning they applied during case-based scenarios (Figure): (1) an old equilibrium, where participants believed race was a reliable biological proxy and applied race-based clinical reasoning in case-based scenarios; (2) a disequilibrium, where competing concepts about the role of race existed or where beliefs and practices in clinical scenarios did not align; and (3) a new equilibrium, where race was understood as a social construct, the harmful health impacts of racism were acknowledged, and patients were treated as individuals with the specific health impacts of racism explored. We further divided the disequilibrium category into 2 subthemes: (1) discrepancy, where residents’ beliefs and clinical reasoning in case-based scenarios did not align, but no cognitive conflict was verbalized, and (2) internal conflict, where residents expressed internal conflict, recognizing cognitive dissonance (Figure).

Figure.

Relationship Between Beliefs and Clinical Reasoning in Case-Based Scenarios

The majority of transcripts were categorized into the disequilibrium theme with most of these falling into the internal conflict subtheme. Many transcripts reflected the old equilibrium with only a few being categorized into the new equilibrium theme.

Old Equilibrium

Many participants employed frameworks influenced by race-based medicine to define discrete biological categories and assumptions about cultural and social practices based on the race of a patient. This is often without an understanding of the complexity of one’s genetic ancestry. We saw this practice emerge from the data with subthemes like selecting pharmacotherapy based on the race of the patient, such as the following resident:

“At least from my understanding, if it’s a non-African American, you can start an ACE [angiotensin-converting enzyme inhibitor] and ARB [angiotensin receptor blocker] as first line, and then with African Americans, you start with thiazides and calcium channel blockers and then add on ACE and ARBs if you need a second agent.”

Many participants wanted to include race in the atherosclerotic cardiovascular disease risk (ASCVD) calculator during the clinical vignette and asked for the patient’s race during the interview. When explored, most did not understand why race was included or how it impacted risk:

“Possibly…some races have more risk of developing MIs, or atherosclerosis related problems…I’m trying to figure out if the calculator does change the ASCVD risk with African American. The risk is 8.5% compared to the White or other, where the risk is 9.4%, so it’s more. It gives a higher score in White population?”

Another subtheme prominent in this category was a heavy reliance on studies and guidelines that support race-based assessment and treatment:

“They’re based on hundreds and thousands of patients enrolled in studies. So, there’s a reason that they’re taking that into account…Obviously there are certain medications [that should be used in] African Americans with heart failure, [there are also] different recommendations further down the line in terms of goal directed medical therapy. I think it makes sense to pay attention to [these guidelines], because it’s all based off studies.”

When probed about how race factors into clinical care, these participants expressed belief in a genetic component to race while acknowledging the large impact of social drivers of health as they relate to race. We saw a conflation of race and genetic ancestry:

“I do believe genetics play a major role in many things including disease pathology, pathogenesis, disease progression, and response to treatment. So, if, genetically, a patient belongs to another race and their genes have been responding differently for each disease pathology or treatment…and evidence…proves that all these happen differently, then that’s the only way I believe that race changes management.”

Disequilibrium

This category was supported by subthemes highlighting conflicting messages about the role of race in the clinical context, as well as an acknowledgment of efforts to move away from race-based medicine.

Discrepancy:

Transcripts that fit the discrepancy category were characterized by residents who factored race into their clinical decision-making when reviewing the vignette, typically by asking about patient race when choosing an anti-hypertensive or assessing the risk of ASCVD or prostate cancer. However, when asked about how they think race should be factored into clinical decision-making these participants stated clearly that race does not impact their clinical management. This excerpt is from a resident who asked for the patient’s race during the clinical vignette and stated they would choose an anti-hypertensive based on the race of the patient: “It [race] should not make a big difference and change clinical decisions. That’s my personal point of view.”

Internal Conflict:

A considerable number of residents expressed internal conflict, recognizing the cognitive dissonance between their beliefs (cognitive constructs) and their clinical reasoning and practices in the case-based scenario (experiences). Some cited conflicting guidance from attendings and other teachers. One resident shared:

“I actually thought of this a couple of days ago in clinic, because I had this come up, and my attending says that the recommendations [for race-tailored anti-hypertensive pharmacotherapy] still stand. But I remember reading recently that there was some controversy. So, I’d have to do another dive into the literature myself.”

Others referred to the medical profession’s move away from race-based medicine, such as the following resident:

“So, I know that for hypertension in African Americans they are recommending more diuretics but we’re getting less inclined [towards] racially based medicine, so some preceptors do tell you to go more in line with that, others don’t really.”

Another resident revealed their distrust in race-based medicine: “There are studies [supporting race-based medicine] out there in any case. But they’re honestly being like, you know, disproven day by day.”

Some residents described more of a personal journey in understanding their cognitive conflict, such as: “I don’t know that I necessarily look at race when making a decision for a statin. However, the ASCVD … calculator does ask. So, I guess in a way it shapes every single decision that I make.” Another resident said, “I think that’s just because I was taught in medical school about these different types of antihypertensives. But… as I go further through my training, I realize that…maybe [race-based medicine] is not the best way to think about it.”

New Equilibrium

This category was characterized by a concordance in belief and practice with an understanding of race as a social construct that is dynamic and not associated with fixed social/cultural traits. This new equilibrium also recognized the importance of understanding the historical context of racism in medicine, while focusing on treating the individual rather than applying population level data to an individual patient indiscriminately.

“The extent that [race] should be considered…comes into how the individual I’m speaking with has interacted with the health care system and if that has led them to be more or less skeptical of the medical system…Because that would make me more inclined to spend more time trying to build a better therapeutic relationship with them, so that they would understand the recommendations that I’m making … for me, I don’t personally find compelling any evidence that suggests that the incidence of various diseases are affected by race so much as other social features like… someone’s overall income status.”

Discussion

In this article we investigated the contentions among internal medicine residents’ beliefs and the clinical reasoning they applied during case-based scenarios regarding the role of race in clinical decision-making. We found that many residents experienced conflict characterized by a discrepancy between their beliefs (cognitive constructs) and their behaviors (how they used race in clinical scenarios), with varying degrees of awareness. While some were unaware of these inconsistencies, others reflected on the discord between their beliefs and behaviors, questioning external influences that perpetuate outdated approaches. Surprisingly, many still viewed race as a biological construct, citing influences like guidelines, studies, and modeled behavior—a pattern more common among graduates from non-US medical schools, though our study was not designed to compare groups.

This data provides a framework for considering the various stages learners may experience when attempting to shift beliefs and clinical reasoning regarding complex topics like the construct of race and racism in their clinical training. As Piaget notes, this is a “process of equilibration” that is “fueled by conflict” through which cultural systems must grapple to shift and change.²¹ While medical institutions are beginning to question long-standing race-based approaches, our study highlights that efforts to teach updated models of clinical reasoning should be tailored to how individual trainees understand and engage with race in practice.

Our study aligns with previous research showing that while many faculty members acknowledge race as a social construct, their lectures do not consistently reflect this understanding.^17,18 Similarly, we found that, while residents recognize race as a social construct, their clinical reasoning in case-based scenarios often contradicts this view, reflecting deeper misunderstandings about how race and racism operate to uphold systemic inequities in medicine. Although understanding of race as a social construct and awareness of the harms of race-based medicine have evolved rapidly, behavioral change lags behind, partly due to the deep institutionalization of these beliefs within the culture of medical education and clinical care.²² This is often reinforced by outdated guidelines and faculty with ingrained beliefs and practices. Additionally, a flawed translational process between clinical research and practice neglects how the social implications of race influence outcomes—leading to interpretations that seem biologically based to those who do not critically examine them.

Some limitations of our study include that we interviewed residents from 3 distinct residencies but all within a single institution and a single specialty. A substantial proportion of those residents graduated from international medical schools, limiting national representativeness and warranting cautious generalization. Residents were reimbursed, potentially introducing socioeconomic and motivation biases. This study focuses only on how a patient’s identity as African American affects clinical management, overlooking the broader diversity of patients’ racial and ethnic identities. Finally, while we identified relationships between beliefs and clinical reasoning, these were inferred as participants’ behaviors in clinical practice were not observed.

Innovations have been proposed to help readers critically evaluate the role of race in clinical research such as a tool called the Critical Appraisal of Race in Medical Literature (CARMeL).²³ Guides are being published to help adopt anti-racist documentation practices and understand how these shape clinical encounters.²⁴ Efforts are needed to design and pilot targeted interventions that challenge residents’ beliefs and clinical reasoning regarding the role of race in clinical practice. These interventions should aim to integrate awareness of the historical harms of race-based medicine and foster critical reflection on when and why race may influence clinical decisions, aiming to advance anti-racist practices in medical education and health care more broadly.

Conclusions

Residents reported experiencing cognitive dissonance between their understanding of race as a social construct and its application in clinical context, where race was often treated as a biological construct. While some residents described specific moments of discomfort and reflection, others were unaware of the cognitive conflict. These findings outline common stages residents may encounter when confronting race in clinical decision-making.

Author Notes

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.

This work was previously presented as a short communication at the International Association for Health Professions Education (AMEE) Conference, August 24-28, 2024, Basel, Switzerland.

Editor’s Note

The online supplementary data contains the interview guide used in the study.