Our study suggests that at present, physicians are faced with conflicting streams of information about the correlation of race and human genetic variation. Our findings indicate that race in the clinical setting is a confusing and poorly defined construct. While most physicians believed patients’ race had important clinical implications, no consensus emerged regarding why race was useful in the clinical encounter. This wide variation in physicians’ attitudes suggests that patients may be treated differently depending on their physicians’ views of what “race” means or represents. Furthermore, some physicians expressed discomfort with explicitly talking with patients about their race and how the physician was incorporating the patient's race into their clinical recommendations. Increasing physicians’ ability to discuss ancestry, race, and ethnicity with patients in the examination room could help make physicians’ clinical decision-making more transparent to patients and enhance patient satisfaction.
Physicians were reticent to make the connection between race, genetics, and disease, due to the skepticism that a patient's race is a sufficient proxy for capturing genetic variation at the individual level. Physicians had high hopes for the future and foresaw genetics superseding race in clinical medicine. Their excitement was tempered by concerns about the potential for genetic discrimination and loss of privacy.30,31
Nonetheless, this excitement and anticipation regarding genomic medicine suggests that physicians will be a potentially receptive audience for genetics education. Interestingly, most of the physicians did not feel that genetics was particularly relevant to their current practices. While physicians’ enthusiasm about the future potential of genomic medicine suggests their interest for genetics education, targeting genetics education towards topics with high clinical relevance will be critical to engaging practicing physicians and increasing their knowledge of genetics.32-34
Although we hypothesized that differences might exist in black and white physicians’ attitudes regarding race, genetics, and clinical decision-making, the physicians in our study were much more similar than different. These similarities may reflect the powerful role that medical training and socialization plays in the development of health professionals’ attitudes. However, during the focus groups, the black physicians discussed social determinants of health and racism with ease, while the white physicians expressed more discomfort with discussing race particularly with patients in the exam room. The differences in identified themes may reflect a difference in the role race plays in the everyday lives of blacks and whites in the United States.35
Nonetheless, the shared beliefs among white and black doctors presents common ground for a much-needed discussion within the medical profession about race and its application to our developing knowledge of human genetic variation.
Our study has several limitations. Qualitative research is ideal for exploring complex themes such as those presented in this paper, but cannot determine the proportion of physicians that hold any given attitude. Also, there is the potential for selection bias. We did not use a random sampling strategy and physicians who responded may have had unique interests, experiences, or networks that led to their participation in the study. Because participants were limited to a relatively small sample of black and white general internists, with an overrepresentation of academic internists, and internists from major metropolitan geographic areas the perspectives from these 10 focus groups may not be generalizable to all physicians. Another potential limitation is the possibility of response bias. Physicians may have been uncomfortable sharing their true opinions and may have responded to questions in ways that would enhance social desirability among their peers. We sought to minimize the likelihood of this type of bias in several ways: 1) by keeping the groups reasonably homogenous with regard to race and professional training; 2) by using race-concordant primary care physician moderators with no particular expertise in genetic research; 3) by using standard focus group moderation techniques to ensure participants felt comfortable sharing their opinions, and 4) by holding the groups in neutral locations.
Despite these limitations, the study makes several important contributions. The study offers a window into the perspectives of primary care physicians on the intersection of race and genetics in clinical decision-making. The physicians articulated some of the ambiguity and growing controversy over the appropriateness of using racial categories in clinical practice.13,36
As with the rest of the medical/scientific community, the physicians did not come to a clear set of conclusions but did underscore the need for continued dialogue and education. They also grappled with the three-way links among race, genetics and disease in ways reminiscent of the contemporary debates on the biological bases of race.18,19
Physicians in our study attempted to strike a balance between the emerging knowledge on race and genetics, with the knowledge of social and environmental determinates of disease.20,21
The physicians’ enthusiasm for the future of genomic medicine suggests a readiness to embrace the emerging developments in genetics that are expected to have a profound impact on health and health care.32,34
The field of genetics and genomics is evolving, and we are learning new information regarding genetic variation and risk for disease.37
There is a great need for multidisciplinary research that will increase understanding of the genetic and environmental components of disease.38,39
This research will aid in the translation of genomic knowledge into clinical practice. Will a patient's race have more or less clinical utility in the genome era? As our knowledge grows, race may have less relevance in decisions that are based primarily on biochemical or physiologic processes, which may be better guided by genomic information. However, as long as social inequities and cultural differences exist, race is likely to matter in healthcare for a very long time.
Only with a better understanding of social and environmental determinants of health and their interaction with genetics will we be able to begin to unravel the causes of some of the racial and ethnic health disparities in the United States.40
Physicians must perform a balancing act as they obtain clinical information, including race, to guide their treatment of patients. In the future, genetic information will play a larger role in guiding these decisions. We are entering the genomic era of medicine, a time of great promise to develop new diagnostics tools and drug therapies for common diseases. The challenge will be to ensure that genomic medicine will improve the care of all patients regardless of their racial or ethnic identity.