Race and Medicine

Hi there,
I am one of those physicians that does not chart “race” as a description of a patient. In my area, there are too many patient of diverse backgrounds that just do not fit into any particular “race”. I will generally state my patient demographics as: “This is a 30-year old lady who presents with abdominal pain”. Most of my colleagues would present the same patient as:" This is a 30-year-old African-American female with abdominal pain" or “This is a 30-year-old Asian female with abdominal pain”. First of all, “female” is an adjective and not a noun so I never refer to anyone as a “male” or “female”. I use “gentleman” or “man” and “lady” or “woman”. Second, I may note ethnicity later in my history document if I feel that it is necessary to the care of the patient. For example, it might be worth knowing that a patient is of Greek ancestory if you are treating thalasemmia but this is probably not pertinent if you are treating cholecystitis.
Below is an interesting article from The Washington Post (my favorite newspaper). I thought it illustrated something that is pretty neat.
The Human Mirror
Gaze Into Nancy Burson’s ‘Race Machine’ and See the Similarities in Diversity
By Eileen Rivers
Washington Post Staff Writer
Saturday, December 3, 2005; C01


Miles Hawthorne scoots forward on a small stool and moves his face side to side before he snaps his picture. At the black console on the second floor of the American Visionary Art Museum, he tries to align his face with a grid that stares back at him from behind the glass-enclosed front of the machine, which looks like a minimalist version of a mall photo booth.
He clicks a mouse and a screen shows a grainy black-and-white picture of the 30-year-old student, who has olive skin, a long, rounded nose, large eyes and a full mouth.
Within seconds, the machine morphs his image, projecting color photos of how Hawthorne, who considers himself white, would look if he were Asian, black, Hispanic, East Indian and Middle Eastern. Hawthorne, a fine-arts major at Shepherd University in Shepherdstown, W.Va., says he sees a bit of himself in each picture.
That’s exactly what SoHo artist Nancy Burson was going for.
“The Human Race Machine,” created by Burson in 2000 for London’s Millennium Dome, is at the museum through September as part of an exhibit titled “Gender, Race and Class Do Not Equal Character,” which features works by local and national artists that explore perceptions of race, gender and class and their effects on social behavior.
The exhibit, which opened in October, has been popular, said Pete Hilsee, the museum’s director of communications. And Burson’s work has been one of its biggest draws.
The machine, the artist said, is based on one philosophy: that the similarities between people of various races far outweigh the differences. To Burson, who is white, there aren’t different races, just one – the human race, she said. The best way to show that, she thought, would be to give people the chance to manipulate their ethnicity and see themselves differently, even if only momentarily.
“It’s really interesting to step into somebody else’s shoes,” said Burson, 57. "It really gives you the experience, even if for a few seconds, to see who you could have been.
"Somebody [recently] said to me, ‘There’s no gene for race.’ And I said: ‘What? Why don’t we know that? Why isn’t this information out there?’ I thought the information was so huge and I still do, and I don’t think people understand that."
Hawthorne – who said he has a varied ethnic background that “often confuses people who try to categorize me by race” – said he had been waiting to glimpse the piece since he read about it two years ago.
“I thought it would give people, maybe especially of mixed race in their background, insight about other possibilities,” he said. "There’s a lot of people who fall in like an in-between category, what [might] be considered racial androgyny. I think people have a difficult time with that. What exactly are the rules that make up race? In the end, they don’t really mean anything."
On a recent weekday, more than 50 ninth- through 12th-graders from Century High School in Carroll County, which is predominantly white, lined up to use the machine during a field trip.
Nicole Diem, an art history, ceramics and drawing teacher at the school, said she believes the machine helped her students broaden their cultural and racial perspectives.
“I think that it gave them a much better understanding of a variety of cultures and how they can see themselves within that culture,” Diem said. "We live in rural Carroll County. There’s not a whole lot of variety."
Marwa Morsi, a 16-year-old junior in the school’s Arts, Humanities and Communications Academy, was taken by the machine’s promotion of unity. The deeper message of the race machine, said Morsi, who is of Middle Eastern descent, was that "everyone’s the same on the inside. It’s the outside that’s different."
Burson was commissioned to create the work by directors of the Millennium Dome, a series of interactive and mixed-media exhibits presented through 2000 in Greenwich, England, to celebrate the new millennium.
When they approached her in 1998, Burson was thrilled to be a part of the exhibit, but she did not know what she was going to present, she said.
Together, Burson and Zaha Hadid, a London-based architect and one of the program’s directors, brainstormed and came up with the race machine.
The machine’s mechanics are almost as complex as the philosophy behind it.
A digital camera takes a picture of your face. You then plot specific points – your eyes, nose and mouth – on a grid and then select a “race” (the machine categorizes the options as black, Asian, Hispanic, Indian, Middle Eastern or white). The machine blends your picture with a composite photograph of whatever ethnicity you have chosen.
The artistic process, Burson said, was sometimes a struggle.
When she started the project, she hired students from New York University, where Burson was an art professor from 1988 to 1994, to photograph people of various ethnicities.
Then Burson chose the “most representative photographs of each race” to develop composites, she said, adding that this process was the most difficult. She felt as if it went against the principles of nonjudgment and racial unity the machine was meant to represent, she said.
"I struggled with . . . ‘You know, everybody is beautiful to me. Now I have to decide what’s going to look better. What’s going to blend better. What composite can I arrive at that’s going to blend with everybody’s faces,’ " Burson recalled. "I felt like I was judging people on their appearance."
Her then-husband, David Kramlich, developed the computer software for the project. It took a year to pull it all together.
Burson’s race machines (several are in circulation) have toured museums, colleges and universities throughout the country. One machine is on permanent exhibit at the New York Hall of Science. The machine was featured in the PBS documentary “Race: The Power of an Illusion,” said Diane Thompson, office administrator of Wolfman Productions, the company that represents Burson’s project. The machine also appeared on an episode of the network’s "Egg, the Arts Show."
Over the past five years, the machine also has met with scrutiny.
One critic, Burson said, called it a throwback to 19th-century geneticist Sir Francis Galton’s theory of eugenics – which purports that intellectual ability and talent are passed down through race-related DNA.
The Galton comparison might have sprung from the fact that the geneticist, like Burson, used composite pictures of human

beings in his work.
But Burson said her motivation for creating composites was vastly different from Galton’s. Her goal is not to promote racial superiority, she said.
“When I first came to the art world and thought about what I wanted to do as an artist, there were three areas I was interested in,” Burson said. "How we perceive ourselves, how we perceive each other and how we perceive ourselves in the universe."
She started exploring that artistic philosophy in 1968, when she came up with the idea for “The Age Machine” – a computer-generated device for showing people their projected appearance as they age. Burson’s age machine – a model for her race machine – was ahead of its time in 1968.
Her first attempt at creating it was unsuccessful. She went to Experiments in Art and Technology – a New York group founded by arts innovator Robert Rauschenberg – and was told to come back in a few years when the technology needed to create such a machine might exist, Burson said.
“I’m not a scientist,” Burson said by phone from her Manhattan apartment. "I’m an artist and I come up with these ideas."
That idea – and the warping technology that Burson used and patented in 1981 – eventually garnered interest from the FBI, which bought the technology from Burson in the early 1980s to create “age-progressed” snapshots of missing children.
Burson continues to focus on ideas of perception in her latest works.
She has created a series of “Mankind” photographs – composite pictures based on world populations.
The works (each is of either a man or a woman) hang on opposite ends of a public atrium on Wall Street. Much like her race-machine composites, the 12-foot-high “Mankind” composites are made of dozens of photos of people from various races. But this composite “has more of an Asian look” because Asian ethnic groups dominate the world’s population, Burson said.
The idea for “Mankind” came from Ursula K. Le Guin’s novel “The Lathe of Heaven.” In the story, a man dreams about a world in which everyone is the same race.
After discovering that story, she explored the possibility of creating a piece that would illustrate how mankind would look if all races were blended into one.
“When you look inside of us, we’re all the same,” Burson said. "We’re all one."
© 2005 The Washington Post Company

I totally agree with you in describing someone only by race if it might affect a series of investigations or some other pertinent reason, but I didn’t understand the “female” vs “lady” concept. Could you explain how you view that?

I really have mixed feelings on this topic. In my therapy practices, I don’t include race as a descriptive in my reports, but if I saw it, I don’t think it would bother me. I guess in my field, there can be different vernacular and articulation styles that might considered a disorder (when it’s not) if one doesn’t take into account for race or even geographical location (e.g. Appalachian speech patterns vs. Cajun speech patterns). With the right clinician, it’s not a big deal, but with the wrong, impersonable, biased, etc. clinician it may affect the level of patient care.
Obviously, for a patient and doctor seeing each other face to face, race is for the most part apparent and probably doesn’t need to be included. But now telemedicine is becoming more popular (I even heard about a physician phone service for prescriptions for the uninsured?!?) maybe leaving out race could miss some pertinent health information that one race is prone to vs. another?
Someday when I make it into med school, I will be curious to see how this works in a strictly medical sense. My reports, I’m sure, are much different than what a hospital would reuqire.
I hate that race is such a big deal in our society, especially with our “PC” society. But then again, this is coming from a caucasian female. I’ve witnessed lots of injustice against other races, but really never felt it myself. Now sexism… that’s another story.
Also, as a side note, anyone with 2 X chromosomes and no Y chromosomes (or an XO) is female. Not all females are “ladies” (example: Gretchen Wilson. Love her, but she’s not a lady).

In my notes/dictations, I only mention race if it is specifically germaine to the reason(s) I am seeing the pt. And, as I am an anesthesiologist, I cannot even come up with a single reason it would apply; however, I reserve the right to do so should I deem it appropriate. A person’s race, ethnicity, background, socio-economic status, education, sexual orientation and so on should never affect or effect the quality of care I, or any other clinician, provides.

Regarding the gentleman & lady vs man or woman vs female or male - largely attributable to my “Southern” upbringing, I definitely tend to use gentleman & lady. It is simply a gesture of politeness & respect. However, I have no issues with using the other terms & have certainly done so myself.

And - not to correct Nat - but according to Merriam-Webster, both male & female may be correctly used as nouns.

From www.m-w.com

Main Entry: male

Pronunciation: mAl

Function: noun

Etymology: Middle English, from Anglo-French masle, male, adjective & noun, from Latin masculus – more at MASCULINE

1 a : a male person : a man or a boy b : an individual that produces small usually motile gametes (as spermatozoa or spermatozoids) which fertilize the eggs of a female

2 : a staminate plant

Although for many specialties this may play no role…in others it may be an important part of the HPI/PMH. If it is relevant I see no issue adding race or gender.

For an anesthesiologist, “red-haired fair-skinned” might be more applicable, right? (http://www.medscape.com/viewarticle/487261)

I think the general rule is that everything in the descriptive portion of the H+P should contribute in some way to the argument being made in the assessment and plan. It took me a long time to recognize that a medical presentation or write-up is an argument–a way of making a case for what to do next. So, as I see it, if I plan to spend some of the hospital’s money and staff time and the patient’s various medical and social risks that will result from sending their blood out for hemoglobin electrophoresis, then I should make an argument for why I’m doing it, and the fact that the patient is of African descent would be a reasonable part of that argument. But I would be even more convincing if I said the patient was of Afro-Haitian descent, or the child of Nigerian immigrants–that is, risk is not distributed equally by race. Even people of African descent from Haiti or Alabama would likely have differing risks for sickle cell disease–for instance, in a peds clinic I worked with a lot of Haitian immigrant patients, and I personally had two patients with hemoglobin SC, which my colleagues elsewhere in the city with lots of African-American patients had never seen. This is the result of many things: the places Haitians were kidnapped from in Africa had high gene frequencies of both S and C, there is an ongoing risk for malaria in Haiti, and there is a relative lack of European ancestry among most people in Haiti when compared to people of African descent whose ancestors were brought to the United States.

That’s all a long-winded way of saying that “race” is a messy and highly inexact stand-in for geographic origin, which is usually where the money is in terms of genetic risks. If we can get geographic origin nailed down, we should go for that; but if the patient’s family is from different places, has been in the New World a long time, and so on, then “race” is probably as specific as we can sometimes get. In terms of social risks–i.e., a patient is likely to be discriminated against if we send him down to the pharmacy with a prescription for morphine for his cancer pain–then racial terms like “black” would be the appropriate categories, since they predict the outcome of the intervention. The point is that these terms should be used for a purpose just like any other word in a presentation.

Though “male” and “female” can be nouns when describing mice or apes, and when used by physical anthropologists in describing human skeletons of unknown age, and while the dictionary reflects their general use in society, I agree strongly with Nat that I usually don’t like their use in the medical world.

When I hear this on the wards, it often comes from one of two different sources. One, exclusively with “female”, is almost always used by young male med students in an inappropriate migration of the kinda hip-hop quasi-respectful but subtly-demeaning usage of “female” as in “I didn’t necessarily want to sleep with every female I saw, but I wanted to improve my score” (http://www.findarticles.com/p/articles/mi_m1264/is_n12_v25/ai_16749848)–to which I feel like asking, are you auditioning for writing jobs for “Animal Planet”? And/or are you busy working on your future guest performance for a new Jay-Z single? Or, with either “male” or “female” this comes from a pseudoscientific language used for the purpose of inappropriate distancing, as in “This is a 50 year old male who presents with chest pain”–as if he was a kind of specimen ready to be pinned, mounted and sent off to cardiac cath. The importance of the category here is not that he produces spermatazoa for the fertilization of the female gamete. Replacing “male” with “man” quickly and quietly changes the emphasis: this is a person, not a biological object.

On the other side of the spectrum, “gentleman” and “lady” represent social categories of a different era and while I guess they’re OK for Sunday school pastors or vice-principals who are hoping to inspire more dignity in their charges, I find that their use in hospitals all too often either represents well-intended condescension to old people in the guise of respect (no 28 year old is described on the wards as a “gentleman” even if his pastor actually succeeded in making him into one) or a way of adding a bit of dry humor to deadpan descriptions of the derelict–as in “This is a 50 year old homeless gentleman who was brought by ambulance after being found yelling in the street with his pants off while also apparently being incontinent of urine and smelling of alcohol” and so on. Clearly “gentleman” is not being used in its original meaning here, and the usage is ultimately not a nice one. I admit I say this in a California/New England context: I suppose I would make an exception for a Southerner who really did call everyone ladies and gentlemen.

But still, I can’t help feeling that “man”, “woman”, “girl” and “boy” are reasonably descriptive for people in whom gender identity does not seem to be a question–why muck up these perfectly good and concise words with words like “lady” and “gentleman” that describe categories of old social hierarchy? (In the original, pre-Sunday-School meaning, they suggest that the person in question has avoided manual labor, has received a particular kind of education and belongs to a particular social class–a pretty specific meaning.)

(I suppose it’s worth noting, if I’m going to go on about this for this long, that “Male-to-female” or “Female-to-male” are the only exceptions I personally make to this rule, as they are the descriptors for transgender people used by medical professionals and transgender people alike.)

Sign me, “an older gentleman who was found in the library procrastinating while studying for his USMLE step 2 exam”–


  • megboo Said:

Also, as a side note, anyone with 2 X chromosomes and no Y chromosomes (or an XO) is female....

To procrastinate a little bit more with something I think is really important and interesting: your definition is actually less adequate than it might first seem. For instance, some women have XY chromosomes but have receptors for androgen hormones that don't respond to those hormones--which means they develop as very "female"-appearing women (although without a uterus or ovaries, and a usually shorter vagina that doesn't end at a cervix). Folks like this (there are a number of different syndromes like this that muddy up the gender divide) remind us that gender is more complex than genetics--and is actually kind of hard to pin down when you start getting down to the details. For instance--if "male" involves producing sperm, as in the second part of Dave's dictionary's definition above, is a man who doesn't produce sperm not "male" anymore? (Obviously if we describe "male" and "female" in terms of reproductive capacity a lot of people wouldn't have a gender.) If "female" is a pair of XX chromosomes, is a woman with XY and androgen insensitivity, or a single X (Turner syndrome) not "female"? And men with XXY (Klinefelter syndrome) require another addition to the definition. This isn't to be persnickety about med school stuff that you have yet to get to in your education, but just to say that gender is pretty complicated not only socially but biologically.

For an introduction to some of these syndromes see http://www.pbs.org/wgbh/nova/gender/spectrum.html and http://www.pbs.org/wgbh/nova/gender/textindex.html

and for an introduction to some of the intersex activists who are demanding changes to pediatricians' practices of gender assignment:


Which is all a far walk from Nat's original post except to say that just as race is not nearly as solid a set of categories as folks like to think, neither is gender.


I also use man/woman boy/girl and avoid male/female unless I’m using it as an adjective. Although I don’t object to it I’ve never found the need to state a race. I’ve used ethnicity only in the sense that at times I only know the patient’s country of origin without knowing the name of the language they speak. It’s easier to ask for the Chinese interpreter than the Mandarin, Cantonese, etc., since I don’t know enough about the differences between these languages even though the interpreter does not necessarily need to be from China.

The only one trouble I once had with the sex thing was an 18-year old on a pediatric surgery service. Calling him a boy didn’t seem right. But using the word “man” on a pediatric service just seems strange. I went with the neutral “18-year old” since his name was David and I don’t think his sex was going to be point of confusion to the rest of the care team.

  • efex101 Said:
Although for many specialties this may play no role...in others it may be an important part of the HPI/PMH. If it is relevant I see no issue adding race or gender.

I completely agree. While attending pathology conferences in Urological Oncology, not only did the attendings/residents ALWAYS mention race but it seems compeltely germaine for practice in this speciality.

  • joewright Said:
So, as I see it, if I plan to spend some of the hospital's money and staff time and the patient's various medical and social risks that will result from sending their blood out for hemoglobin electrophoresis, then I should make an argument for why I'm doing it, and the fact that the patient is of African descent would be a reasonable part of that argument.

But even in so called "obvious" cases involving race, you have to be careful and perhaps attempt to confirm your assumptions with the patient. For example, my medical family history includes cases of thallasemia (sp?) in EVERY generation, but not ONE case of sickle cell anemia.


My point was that not every female is a “lady”.

You seem rather snitty in your reply. Maybe that point was lost on you.

I’m sorry–I wasn’t trying to be snitty, and I did get your point. My point was that “female” isn’t as simple as chromosomes, and I think that the ways in which it’s more complex are interesting and challenging to “common-sense” ideas about how we describe or define people.


  • pathdr2b Said:

But even in so called "obvious" cases involving race, you have to be careful and perhaps attempt to confirm your assumptions with the patient. For example, my medical family history includes cases of thallasemia (sp?) in EVERY generation, but not ONE case of sickle cell anemia.

Absolutely--race or geography or any other demographic factors only predict association and probability--but almost never rule out a possibility or make a diagnosis. They only increase or decrease the ranking of that diagnosis in one's differential.

I think it is best to use "this is a patient with XY, XX, XO, XXY, whatever genotype that on "

  • megboo Said:

My point was that not every female is a "lady".

You seem rather snitty in your reply. Maybe that point was lost on you.

Sheesh. I certainly find myself internally passing judgment on my patients from time to time but I hope that I wouldn't verbally - or clinically - make a distinction between "lady" and "woman."

I find myself lapsing into "lady" every once in awhile when describing particular demographics. I'm pretty sure everyone around my noon conference table has used "little old lady" as an affectionate term to describe one of our elderly patients. And I've encountered very proper Southern gentlemen, often older and exceptionally dignified, who just naturally get referred to as "A 70-year-old gentleman with past medical history of .... "

We actually had an interesting discussion at noon rounds the other day about how to refer to a transgendered patient who is phenotypically male but has adopted a female presentation as she continues medical therapy, and anticipates surgical intervention, to complete the transgender process. I would definitely be opposed to applying some sort of genetic rule to refer to this person, who thinks of herself as a woman and wants to be regarded and treated as a woman.

And that actually brings me, finally, to my point: I think pretty much anyone is comfortable with being referred to as a "man" or a "woman." That's the way the bathroom doors are labelled and everyone generally figures it out, right? I don't particularly care to be referred to as a "female" because it sounds like you are referring to my parts rather than ME, and I suspect I'm not alone in that preference.

How 'bout if we refer to people in the way we think they'd want to be discussed?


who is going to post as much as possible today so I can see that nifty ticker reminding me of my fantastic vacation coming up!!!

Again, I refer back to my original post and my attempt at humor that must have been lost in this thread. My example of Gretchen Wilson being a female, but not a lady I thought would have referenced the humor. I guess not.

Anyhoo, when I write case notes I use female/male. Then again, my practice pretty much consists of children under 3 so I highly doubt I would have a transgender issue or woman/female/lady issue. If I came across a transgendered patient I’m not sure what I would write. Maybe ask the patient how they would like to be referred as or refer to my superior.

Maybe in my future case notes I should ask the parents if they prefer me to refer to their son as male vs. gentleman vs. sir vs. master vs. esquire vs. whatever role they have.

Nah, I’ll stick with male/female. I’ll worry about it when I have a transgendered or other genetic issue involved.

Man it is getting way too complicated for me…male/female sounds good.

  • efex101 Said:
Man it is getting way too complicated for me....male/female sounds good.

No shit! As an anesthesiologist - male v female v gentleman v lady RARELY has any impact. My notes are gleefully short & to the point -- pt in severe & progressing resp distress; emergent intubation & mech vent indicated - DONE!

Funny because as a Nurse I was FORCED to put down RACE, if not the review Nazis, Uh the review nurses would send you notes and if it continued a meeting with you and the director of nursing, crap like medicare will not pay us if the “Forms” are missing anything. Long live the Quality Review Nurses.