Drawing from critical race theory,1 race-conscious medicine calls for attention to racism rather than race as a determinant of illness and health.2 Medicine has progressed toward race consciousness by recognizing racist practices in prevailing estimations of kidney function and responding to activist calls for the removal of race from the equation,3 removing race as a risk factor for vaginal birth after Cesarean delivery4 and pediatric urinary tract infections,5 and promoting policy reforms to advance racial justice and health equity.6 Racialized health inequities persist because of how structural racism shapes discriminatory policies and actions of individuals to harm the health of racially oppressed groups (ie, groups that have been systematically denied services and power by laws and policies).7 In pediatrics, these inequities are especially pronounced across birth weight, asthma, diabetes, justice involvement, and firearm injury.8,11 As discussions shift from race to racism, questions remain on how to implement race-conscious medicine in clinical practice.

In this article, we respond to the need for practicable tools by introducing the PLAN acronym (Pay attention, Listen to patient narratives, Advocate for equitable outcomes, and Name racist institutions and structures; Table 1) as a method to mitigate racialized health inequities in pediatric medicine. We present 2 real cases in which racialized care biases emerged and consider how the PLAN approach can promote racial justice and health equity.

TABLE 1

The PLAN Acronym for Race-Conscious Pediatric Care

AcronymExplanationExample
ay attention. Notice racialized power hierarchies. Recognize who wields power over whom. Identify sources of potential harm. On rounds, look out for which patients are discussed most thoroughly and which are glossed over. 
isten to patient narratives. Respect the patient’s autonomy and honor their knowledge of their own body and experience. If an encounter with a patient felt unfairly rushed, make time to hear out that patient and their family. 
dvocate for equitable outcomes. Speak up and intervene in instances in which bias and inequity may harm patient care. When a care decision disregards a patient’s life circumstances (or their experience of racism), call for a pause and a new plan that centers justice. 
ame racist systems. Reform the power systems and cultural norms that enabled the racialized harm. Implement policy changes like providing community care companions12 or patient navigators13 to mitigate medical racism. 
AcronymExplanationExample
ay attention. Notice racialized power hierarchies. Recognize who wields power over whom. Identify sources of potential harm. On rounds, look out for which patients are discussed most thoroughly and which are glossed over. 
isten to patient narratives. Respect the patient’s autonomy and honor their knowledge of their own body and experience. If an encounter with a patient felt unfairly rushed, make time to hear out that patient and their family. 
dvocate for equitable outcomes. Speak up and intervene in instances in which bias and inequity may harm patient care. When a care decision disregards a patient’s life circumstances (or their experience of racism), call for a pause and a new plan that centers justice. 
ame racist systems. Reform the power systems and cultural norms that enabled the racialized harm. Implement policy changes like providing community care companions12 or patient navigators13 to mitigate medical racism. 

Baby G was born full-term via an uncomplicated, spontaneous vaginal delivery to a multiparous Pashto-speaking mother. After a standard hospital stay, the pediatrics team discharged him with a follow-up the next day at the refugee clinic in which his parents received care. At the clinic, Baby G met the criteria for phototherapy and was admitted to the NICU. He underwent extensive testing for hemolytic and infectious processes, which all returned normal results. Because of Baby G’s Middle Eastern heritage, he was considered at an increased risk for α-thalassemia, despite a peripheral smear, haptoglobin, and lactate dehydrogenase that suggested against the diagnosis; the full newborn screen had not yet resulted. Unclear concerns for consanguinity arose, exacerbated by Baby G’s father, who provided the history, speaking a language other than English, and the team consulted genetics to evaluate homozygous recessive conditions that could cause severe neonatal hyperbilirubinemia of otherwise unknown etiology. Baby G completed extended genetic analyses and microarray panels. Ultimately, Baby G responded well to treatment and was discharged after 4 days with follow-ups at the refugee clinic and with genetics.

It is not immediately apparent that medical harm occurred in the care of Baby G; however, this case reveals multiple ways in which race-based medicine and biases interfered with optimal care and how the PLAN strategy can promote equity.

The early recognition of patient-provider dynamics would have alerted a concerned observer to clear communication issues and the underuse of an interpreter. For example, Baby G’s mother often spent hours curled in the chair in the corner of Baby G’s room. When staff told her, in English, that she could go home, she appeared confused and upset. Noticing this confusion could have triggered the need for an interpreter in every communication with Baby G’s family, from personal support to clinical decision-making.

Later in the admission, when an interpreter was introduced, Baby G’s parents quickly clarified that they were not cousins. Although they belonged to the same broad kinship tree (they calculated that they are roughly fifth cousins), their relationship would not increase the risk of Baby G carrying any homozygous recessive condition. Also, on further elicitation of family history, the parents shared that Baby G’s older sibling also required phototherapy briefly after birth, responded well, and had developed normally since, without any concern for an underlying genetic condition. Consistent access to language services might have uncovered this history earlier in the admission and prevented unnecessary workup.

In this case, advocacy would have involved calling for the immediate and consistent use of a Pashto interpreter to facilitate all communication with Baby G’s family. This would have prevented confusion and assumptions that Baby G possessed a recessive disorder because of his race or his parents’ nationality or presumed culture.

Multiple barriers exist to the effective use of interpreters for patients and families who speak a language other than English, including logistical, financial, and educational,14 and a recent multicenter prospective cohort study revealed that, even in the presence of in-person and video interpreters, children of parents who spoke a language other than English had 2.1 greater odds of an adverse event during hospitalization.15 In addition, although the updated guidelines for neonatal hyperbilirubinemia advocate against the use of race as a risk factor,16 the guidelines encourage the consideration of “genetic ancestry,” which is an improvement; however, it may be imprecise and a false proxy for race.17,18 In Baby G’s case, the use of interpreters to elicit a thorough family history would have revealed a race-conscious approach and informed a broad differential diagnosis rather than inappropriately ordering excessive laboratory tests predicated on a race-based, inaccurate belief of consanguineous genetic etiology. Reforming these systems might involve ensuring interpreter service capacity meets patient needs and implementing required training on Team Strategies and Tools to Enhance Performance and Patient Safety, an evidence-based protocol for improving outcomes for patients who prefer languages other than English recommended by the Agency for Healthcare Research and Quality.19 

Tanae came to the community emergency department with agonal respirations and bradycardia with her distraught young mother. Tanae was a nondysmorphic Black child whose weight was less than the second percentile. She was hypotonic and had a gastrostomy tube. Tanae was taken immediately to the code room while the mother tried to explain her child’s genetic disorder to the emergency department staff. Notably, this event occurred before universal access to electronic medical records. The child’s pediatric specialist was working outside the continental United States. Despite resuscitation attempts, the child did not survive. The mother was shocked and further distressed after receiving a call from Child Protective Services the following day.

Careful observation of the child would have revealed she was well-cared-for; her skin was intact, without decubiti or skin breakdown despite her low tone and limited movement, and the mother was knowledgeable and brought Tanae’s medication with her. The mother’s affect was appropriate for the situation, as she explained, through tears, the circumstances leading up to the emergency department visit. Many rare neurogenetic disorders are described and illustrated in medical textbooks in white children, which may implicitly deter pediatricians from considering neurodegenerative disorders in Black children.20 

It is frequently difficult for the emergency response leader to obtain a complete history in a code situation. Other health care team members can obtain the complete history from the patient’s family, review available details, including patient medications, and access collateral information from other pediatric providers as necessary.

Recognizing the mother’s knowledge of the child’s condition and reviewing medications may have avoided the protective services call. Understanding the terminal status of the child may have prompted a decision to provide social work services and bereavement counseling for the family, reducing the harm of family policing through a protective services interrogation.

Studies reveal an increased likelihood of reporting and evaluating suspected cases of child abuse and neglect if the patient is Black, with a higher likelihood of unsubstantiated conclusions.21,22 Importantly, racism not only results in the overreporting of Black and Native American children but also the underreporting of white children, resulting in an estimated 4 of 5 preventable deaths among white children due to reinjury.21,22 Early universal access to bereavement and psychological services may support families and reduce harm after unsuccessful code experiences.

Race-conscious pediatric care attends racial power dynamics across medical systems, pediatric care providers, patients, and parents. This means centering patient autonomy, intervening in racist behaviors, and identifying systemic improvements to promote health equity and eliminate health disparities. Pediatric providers should feel empowered to recognize when circumstances favor the racially advantaged (ie, white or white-adjacent) over the racially minoritized (eg, Black, Latinx) and take direct action. Language like “I’m worried that this decision could hurt this patient in ways we didn’t anticipate, and I would like to try this alternative. I see this as a racial justice issue” or “I noticed that Patient A received this care benefit, but Patient B didn’t, and I think Patient B qualifies as well. To ensure care parity, I am going to place the referral for Patient B” can promote equitable outcomes. To achieve systemic change, clinicians must advocate for policy reforms with academic program directors, health care administrators, clinical societies, and legislators. As antiracist task forces, speaker series, and reading groups continue to increase awareness of the harmful outcomes of race-based practices, we must ensure that the pediatric training, teaching, textbooks, and workforce engage clear models to implement race-conscious medicine.

Drs Cerdeña and Plaisime conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript; Drs Belcher and Wright critically reviewed and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

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