The Construction and Meaning of Race Within Hypertension Guidelines: A Systematic Scoping Review.

BACKGROUND: Professional society guidelines are evidence-based recommendations intended to promote standardized care and improve health outcomes. Amid increased recognition of the role racism plays in shaping inequitable healthcare delivery, many researchers and practitioners have critiqued existing guidelines, particularly those that include race-based recommendations. Critiques highlight how racism influences the evidence that guidelines are based on and its interpretation. However, few have used a systematic methodology to examine race-based recommendations. This review examines hypertension guidelines, a condition affecting nearly half of all adults in the United States (US), to understand how guidelines reference and develop recommendations related to race. METHODS: A systematic scoping review of all professional guidelines on the management of essential hypertension published between 1977 and 2022 to examine the use and meaning of race categories. RESULTS: Of the 37 guidelines that met the inclusion criteria, we identified a total of 990 mentions of race categories. Black and African/African American were the predominant race categories referred to in guidelines (n = 409). Guideline authors used race in five key domains: describing the prevalence or etiology of hypertension; characterizing prior hypertension studies; describing hypertension interventions; social risk and social determinants of health; the complexity of race. Guideline authors largely used race categories as biological rather than social constructions. None of the guidelines discussed racism and the role it plays in perpetuating hypertension inequities. DISCUSSION: Hypertension guidelines largely refer to race as a distinct and natural category rather than confront the longstanding history of racism within and beyond the medical system. Normalizing race as a biological rather than social construct fails to address racism as a key determinant driving inequities in cardiovascular health. These changes are necessary to produce meaningful structural solutions that advance equity in hypertension education, research, and care delivery.

Antiracism in Action: Development and Outcomes of a Mentorship Program for Premedical Students Who Are Underrepresented or Historically Excluded in Medicine.

INTRODUCTION: Black, Latinx, and Native American and Alaska Native people are underrepresented in medicine. The increasingly competitive medical school application process poses challenges for students who are underrepresented in medicine or historically excluded from medicine (UIM/HEM). The University of California, San Francisco-University of California, Berkeley (UCSF-UCB) White Coats for Black Lives Mentorship Program provides a novel and antiracist approach to mentorship for these premedical students. METHODS: The program recruited UIM/HEM premedical and medical students through a survey advertised by email, on the program's website, social media, and by word of mouth. The program paired students primarily with race-concordant mentors, all of whom were UCSF medical students. From October 2020 to June 2021, program mentees engaged in skills-building seminars based on an antiracism framework and received support for preparing medical school applications. The program administered preprogram and postprogram surveys to mentees, which were analyzed via quantitative and qualitative methods. RESULTS: Sixty-five premedical mentees and 56 medical student mentors participated in the program. The preprogram survey received 60 responses (92.3% response rate), and the postprogram survey received 48 responses (73.8% response rate). In the preprogram survey, 85.0% of mentees indicated that MCAT scores served as a barrier "a great deal" or "a lot," 80.0% indicated lack of faculty mentorship, and 76.7% indicated financial considerations. Factors that improved most from preprogram to postprogram were personal statement writing (33.8 percentage-point improvement, P < .001), peer mentorship (24.2 percentage-point improvement, P = .01), and knowledge of medical school application timeline (23.3% percentage-point improvement, P = .01). CONCLUSION: The mentorship program improved student confidence in various factors influencing the preparation of medical school applications and offered access to skills-building resources that mitigated existing structural barriers.

Tilting the Scale: Current Provider Perspectives and Practices on Breastfeeding with HIV in the United States.

The risk of vertical transmission from breastfeeding with HIV (BFHIV) has been found to be very low in optimal scenarios with sustained maternal viral suppression during pregnancy and postpartum. Medical providers must account for the risk of this serious adverse event alongside parental autonomy, breastfeeding benefits, and patient values. To assess provider practices, comfort, and challenges with BFHIV, an online mixed-method survey was sent to breastfeeding and HIV provider listservs from June to July 2021. The target population was US medical professionals from diverse practice settings with experience in clinical issues associated with BFHIV, including physicians, advanced practice providers, nurses, and lactation consultants. Data analysis utilized nonparametric hypothesis testing, ordinal regression, and reflexive thematic analysis. Most providers reported counseling pregnant people with HIV on infant feeding choices, but fewer specifically endorsed counseling about breastfeeding. Of 84 unique institutions identified by 100 included respondents, 10% had an institutional protocol supporting BFHIV. Institutional protocols were associated with higher degrees of provider comfort with BFHIV in optimal scenario clinical vignettes. Providers perceived that White patients faced fewer BFHIV barriers than patients with other racial identities. Discomfort balancing the goals to protect infants from infection risk and support the parent's role in infant feeding decisions was a key theme in free text responses; this manifested in a spectrum of management styles ranging from patient's informed choice to paternalism. This study highlights the tension providers navigate regarding BFHIV discussions, calling for patient care guidelines and protocols grounded in risk reduction and respect of patient autonomy.

Toward the elimination of race-based medicine: replace race with racism as preeclampsia risk factor.

Pregnancy-related morbidity and mortality continue to disproportionately affect birthing people who identify as Black. The use of race-based risk factors in medicine exacerbates racial health inequities by insinuating a false conflation that fails to consider the underlying impact of racism. As we work toward health equity, we must remove race as a risk factor in our guidelines to address disparities due to racism. This includes the most recent US Preventive Services Taskforce, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine guidelines for aspirin prophylaxis in preeclampsia, where the risk factor for "Black race" should be replaced with "anti-Black racism." In this commentary, we reviewed the evidence that supports race as a sociopolitical construct and the health impacts of racism. We presented a call to action to remove racial determination in the guidelines for aspirin prophylaxis in preeclampsia and more broadly in our practice of medicine.

Why Professionalism Demands Abolition of Carceral Approaches to Patients' Nonadherence Behaviors.

Some clinicians' and organizations' considerations of how a patient's prior adherence to health recommendations should influence that patient's candidacy for a current intervention express structural racism and carceral bias. When clinical judgment is influenced by racism and carceral logic, patients of color are at risk of having their health services delivered by clinicians in ways that are inappropriately interrogative, aggressive, or punitive. This commentary on a case suggests how an abolitionist approach can help clinicians orient themselves affectively to patients whose health behaviors express or have expressed nonadherence. This article argues that an abolitionist approach is key to facilitating clinicians' understandings of root causes of many patients' nonadherence behaviors and that an abolitionist approach is needed to express basic health professionalism and promote just, antiracist, patient-centered practice.

Algunos médicos y organizaciones opinan que la adhesión previa de un paciente a las recomendaciones de salud debería influir en su candidatura para una intervención actual, lo que expresa el racismo estructural y los prejuicios carcelarios. Cuando el racismo y la lógica carcelaria influyen en el juicio clínico, los pacientes de color corren el riesgo de que los médicos les presten servicios de salud que sean inadecuadamente inquisitivos, agresivos o punitivos. Este comentario sobre un caso sugiere cómo un enfoque abolicionista puede ayudar a los médicos en la orientación afectiva de los pacientes cuyos comportamientos de salud expresan o han expresado no adhesión. Este artículo sostiene que un enfoque abolicionista es clave para facilitar que los médicos comprendan las causas fundamentales de los comportamientos de no adhesión de muchos pacientes y que es necesario un enfoque abolicionista para expresar la profesionalidad sanitaria básica y promover una práctica justa, antirracista y centrada en el paciente.

Providing Patient-Centered Perinatal Care for Transgender Men and Gender-Diverse Individuals: A Collaborative Multidisciplinary Team Approach.

BACKGROUND: Little is documented about the experiences of pregnancy for transgender and gender-diverse individuals. There is scant clinical guidance for providing prepregnancy, prenatal, intrapartum, and postpartum care to transgender and gender-diverse people who desire pregnancy. CASE: Our team provided perinatal care to a 20-year-old transgender man, which prompted collaborative advocacy for health care systems change to create gender-affirming patient experiences in the perinatal health care setting. CONCLUSION: Systems-level and interpersonal-level interventions were adopted to create gender-affirming and inclusive care in and around pregnancy. Basic practices to mitigate stigma and promote gender-affirming care include staff trainings and query and use of appropriate name and pronouns in patient interactions and medical documentation. Various factors are important to consider regarding testosterone therapy for transgender individuals desiring pregnancy.