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There is little to no information on whether race should be considered in the exam room by those who care for and treat patients. How primary care physicians understand the relationship between genes, race and drugs has the potential to influence both individual care and racial and ethnic health disparities.
To describe physicians’ use of race-based therapies, with specific attention to the case of BiDil (isosorbide dinitrate/hydralazine), the first drug approved by the FDA for a race-specific indication, and angiotensin-converting enzyme (ace) inhibitors in their black and white patients.
Qualitative study involving 10 focus groups with 90 general internists.
Black and white general internists recruited from community and academic internal medicine practices participated in the focus groups.Of the participants 64% were less than 45 years of age, and 73% were male.
The focus groups were transcribed verbatim, and the data were analyzed using template analysis.
There was a range of opinions relating to the practice of race-based therapies. Physicians who were supportive of race-based therapies cited several potential benefits including motivating patients to comply with medical therapy and promoting changes in health behaviors by creating the perception that the medication and therapies were tailored specifically for them. Physicians acknowledged that in clinical practice some medications vary in their effectiveness across different racial groups, with some physicians citing the example of ace inhibitors. However, physicians voiced concern that black patients who could benefit from ace inhibitors may not be receiving them. They were also wary that the category of race reflected meaningful differences on a genetic level. In the case of BiDil, physicians were vocal in their concern that commercial interests were the primary impetus behind its creation.
Primary care physicians’ opinions regarding race-based therapy reveal a nuanced understanding of race-based therapies and a wariness of their use by physicians.
Personalized medicine—in which treatments are based on an individual’s or group’s genetic make-up—has been envisioned as an important medical advancement.1,2 Yet the clinical application of such technology has been limited, in part due to its slow translation into clinical practice.3,4 One proposed avenue to realizing the promise of personalized medicine is through race-based prescribing, i.e., using racial identification to predict drug response.1,5,6 There is little to no information on the attitudes of primary care physicians regarding the relationship, if any, between race and drug response or regarding physicians’ attitudes about race-based prescribing.
How primary care physicians understand the relationship among genes, race and personalized medicine has the potential to influence both individual care and racial and ethnic health-care disparities. To better understand primary care physicians’ perspectives, we conducted a series of ten race-concordant focus groups with black and white physicians. The research questions for these analyses were: (1) how do physicians describe the use of race-based therapies in general and specifically the use of BiDil5 (the first drug approved by the FDA for a race-specific indication to treat heart failure in self-identified black patients7) and ace inhibitors in their black and white patients? (2) How do physicians characterize the implications of race-based therapies?
The data used in the analysis are part of a larger study with the objective of developing a survey instrument for measuring physicians’ knowledge and beliefs on biological and genetic differences based upon their patients’ race and ethnicity.8 This paper will focus on the physicians' discussions regarding race-based therapies. The Discussion Guide is available from the author upon request.
We conducted ten focus groups in five geographic areas between October 2005 and March 2006. Five of the groups were made up of self-identified black physicians, and the other 5 groups consisted of self-identified white physicians with an average of 9 participants per group (range 7–12). Physicians that participated in the focus group received $250.00. The two facilitators were general internists with experience moderating focus groups, members of the research team, and were the same race as their participants. Study sites were selected to reflect a range of geographical regions and included the following cities: Atlanta, Baltimore, Detroit, Los Angeles, and Philadelphia.
We sent invitational letters to general internists listed in the American Medical Association Physician Masterfile Database and faculty lists from the Department of Medicine at the medical schools in each metropolitan area. We used snowball sampling to recruit additional black physicians to participate in the study due to small number of black physicians practicing in the US. Eligible physicians were board-certified/board-eligible in Internal Medicine.
The focus groups were transcribed verbatim, and the data were analyzed using template analysis. 9–11 A core team of researchers created an initial code list based on two pilot groups in Washington, DC, and a priori hypotheses about themes expected to be relevant in the analysis. Two team members independently coded all the focus groups. The entire research team resolved any inconsistencies between the two coders to create a final dataset for analyses. The pilot groups were re-coded with the final code list. We analyzed all themes pertaining to race-specific or race-targeted drugs.
A total of 90 physicians participated in the focus groups (Table 1). Analysis revealed a spectrum of opinions relating to the practice of race-based pharmaceutical treatment, but there were no consistent differences in opinions between black and white focus groups. Physicians expressed both positive and negative attitudes towards race-based therapies (Table 2).
Physicians discussed several positive aspects of using a patient’s race to tailor prescribing. Several groups reported that some medications varied in their effectiveness across different racial groups, with many physicians citing the example of ace inhibitors. The majority of the groups voiced an opinion that black patients with hypertension do not respond to ace inhibitors to the same extent that white patients respond to the drug. One proposed mechanism for the observed differential effect of ace inhibitors between racial groups was suggested to be differences at the genetic level. Several physicians admitted they were less likely to start black patients on an ace inhibitor as first-line treatment of hypertension in the absence of a compelling reason such as proteinuria.
Physicians who were supportive of race-based therapies hypothesized that a race-specific drug may motivate patients to comply with medical therapy and promote changes in health behaviors by creating the perception that the medication is tailored specifically for them.
Physicians also expressed negative attitudes towards the practice of prescribing medicines based on race. Although both black and white physicians reported that hypertensive whites respond better to ace inhibitors as compared to hypertensive blacks, physicians often recognized the potential renoprotective effects and post myocardial infarction benefits of ace inhibitors in black patients and voiced concern that black patients who may benefit from ace inhibitors may not be receiving them.
Concerns of race-based prescribing focused around skepticism of the underlying premise of race-based therapies. Many physicians voiced concern that prescribing medications based on race presumes that some inherent patient factor influencing drug responses differs in meaningful ways by racial group. They were wary that the category of race would be able to capture differences at the genetic level.
The physicians’ skepticism of race-based therapies was based, in part, on their belief that the link between race and genetics is inexact because racial inter-mixing has resulted in a sharing of clinically meaningful genotypes. Instead of using race as a placeholder for genetic variation, physicians advocated examining the genetic polymorphism that may account for differential responses to drug therapy.
Both white and black physicians voiced concern about the medical and social implications of race-based therapies. Many discussed the idea of a “slippery slope” with race-based medicine giving legitimacy to the notion of distinct genetic differences between racial groups. Another drawback expressed in the focus groups was the possibility that race-based therapies’ focus on purported biologic differences between racial groups might be used to undermine society’s responsibilities to resolve health disparities.
While there was a range of attitudes about race-based therapies in general, physician attitudes toward BiDil were significantly more critical. Black and white physicians cited market forces as the primary impetus behind its creation. Physicians overwhelmingly voiced concern that commercial considerations shaped the development of the first drug approved for a race-specific indication. Most physicians did not feel that BiDil represented the future direction of race-based therapies.
The attitudes of primary care physicians are important factors in the debate over race-based pharmaceutical treatments. A concern voiced by researchers in this area is that physicians are unaware of the nuances of these debates and could simply become uncritical consumers of the race-based therapeutics marketed to them.12–15 Our study, the first to our knowledge to investigate primary care physicians’ opinions regarding race-based therapy, reveals a nuanced understanding of race-based therapies and a wariness of their use by physicians.
Both black and white physicians in our focus groups reported being skeptical about the underlying premise of race-based therapies and uncertain that physicians could use race to identify patients who would be the most likely to benefit from a drug. In general, the physicians included in these focus groups did not believe that race was an adequate proxy for genetic variation in populations, with many citing the “mixing” of racial groups. Physicians’ appreciation of the challenges of applying race-based therapies in the exam room means physicians are not likely to be uncritical acceptors of race-based drugs that are marketed to them.
Many physicians expressed dismay at what they perceived to be the primary aim of race-specific pharmaceutical trials, namely to get physicians’ attention for marketing purposes. Future medications that capitalize on single race-based clinical trials may be met with resistance in the medical community in large part due to their concerns of the underlying premise of drugs designed for specific racial groups, i.e., that race is a good proxy for predicting drug response.
The black and white physicians in these focus groups shared largely similar attitudes across the key themes. One possibility for the apparent homogeneity could be that all the participating physicians received an US medical education and trained in US residency programs. Another is that our sample was not large or diverse enough to detect differences between the black and white focus groups. Future studies including a large representative sample of physicians should be conducted to confirm our findings.
Our study has a number of limitations. First, we studied a group of internal medicine physicians who may not be representative of all primary care physicians. Many of the black physicians in particular were recruited through snow-ball sampling due to the low number of black physicians practicing in the US. Black physicians in some geographic areas in our study suggested black colleagues to contact for the study. Snow-ball sampling may lead to biases due to nonrandom selection procedures.16 Second, physicians were recruited from racially diverse cities. Physicians who practice in diverse settings may be more aware of the complexity of race-based prescribing than those practicing in homogenous environments. Third, the study revealed a multitude of perspectives and diverse experiences but did not lend itself to making generalizations. A large nationally representative study of physicians is the next step in this research.
In summary, we found that primary care physicians, who are on the forefront of providing care to racially and ethnically diverse patient populations, are not uncritical consumers of race-based therapies. Physicians share a complex understanding of the issues involved in the ongoing debate over race, genetics and medicine in the larger scientific community. The continued study of race and medicine is essential to help inform physicians of the appropriateness of using race in treatment decisions.
This research was supported in part by the Intramural Research Program of the National Human Genome Research Institute, National Institutes of Health. Writing and data analysis support was provided in part by Health Service Research and Development (HSR&D) MD Postdoctoral Fellowship Research TPM 61-028. This paper was presented at the SGIM National Meeting, Washington, DC, 2007. The content is solely the responsibility of the authors and does not represent any position or policy of the National Human Genome Research Institute, National Institutes of Health or Department of Health and Human Services.
Conflict of Interest None disclosed.
Sources of Funding
This research was supported in part by the Intramural Research Program of the National Human Genome Research Institute, National Institutes of Health. Writing and data analysis support was provided in part by Health Service Research and Development (HSR&D) MD Postdoctoral Fellowship Research TPM 61-028.