Swayed by Stereotypes

Thursday, December 1, 2016

“Mr. Hayward is a 45-year-old African-American male with hypertension who presents with dyspnea on exertion…”

Patient narratives like the one above traditionally open with a mention of race.

That has begun to change, however, as UCSF and peer institutions move to discourage this practice—in some cases as early as in the first months of medical school.

The newly launched Bridges curriculum has already educated first-year students on this issue during a weeklong orientation called “Differences Matter” and through longitudinal lectures by Vice Dean Catherine Lucey.

The aim is to reduce the clinical influence of stereotypes, or overly simplified beliefs about a group of people with a shared characteristic. Stereotypes, we learn, can lead us to ignore pertinent clues, make erroneous diagnoses, and reinforce health disparities.

While Mr. Hayward is a black adult, and while half of black adults in the United States have some form of cardiovascular disease, we should not jump to this diagnosis based on race and a couple of corroborating details.

Rather we are encouraged to conduct nuanced inquiry into all aspects of a patient presentation. Excluding racial descriptors from our report helps us stave off stereotypes and achieve this goal.

Illness Scripts

As first-year students, we also learn from Dean Lucey that the diagnostic process relies on the use of illness scripts.

Illness scripts are mental summaries of how diseases present in terms of their symptoms, epidemiology, and temporality. After comparing these scripts to the patient presentation, we diagnose the illness that matches best.

The challenge is that the same illness can present in various ways and various illnesses can present in the same way.

Such nonspecificity requires the use of a diagnostic heuristic, leading our educators to counsel that “when you hear hoofbeats, think of horses not zebras.”

In literal terms, this aphorism suggests that we not only picture the typical way an illness presents but also prioritize commonplace illnesses over the rare or obscure.

As we juxtapose our education on racial descriptors and illness scripts, however, we are left with puzzling advice.

When should we guard against stereotypes to foster a comprehensive investigation, and when should we mobilize them to narrow our differential diagnosis?

LGBT Health

“Do you have sex with men, women, or both?”

At the same time that race has taken a backseat in patient narratives, LGBT issues have come to the fore. UCSF and peer institutions now recommend that we ask patients the above question so as to promote LGBT-sensitive care.

But if our discussion on race is any indication, this recommendation merits closer scrutiny.

Does learning that our patient is LGBT promote comprehensive inquiry, or does it evoke counterproductive stereotypes?

The most obvious clinical outcome of the suggested approach is that in realizing our patient is a gay male, we heighten our suspicion for sexually transmitted diseases (STDs).

Yet a gay male in a monogamous relationship could have relatively low risk compared to a straight male with daily encounters.

Of greater utility would thus be to ask about multiple partners. Indeed, regardless of sexual orientation, partner plurality is a significant risk factor for STDs.

Like racial descriptors, it seems then that—at least regarding some illnesses—sexual orientation does little more than lead us astray.

That is not to say that race and sexual orientation have no place in the clinical setting. And herein lies my view on when to use stereotypes:

For diseases with causal pathways that remain poorly understood, it is possible that labels—and the stereotypes they invite—may allow for the best prediction of risk.

But if other information would lead to a similar assessment of risk or an identical course of care, steering clear of labels would be the preferable approach.