How I Teach Racial Categorization in Reference Equations Used to Interpret Spirometry

Race has been used in medical algorithms, including reference equations for spirometry, following the assumption that race is a biological concept due to the finding that Black American and Asian populations have lower lung function (i.e., forced expiratory volume in 1 second and forced vital capacity) than White populations. Recognizing that race is a social construct and its use in medical algorithms may contribute to health disparities, this practice has been questioned. This inquiry, combined with recent evidence, led the American Thoracic Society to recommend using race-neutral reference equations for spirometry in 2023. In this article, we share our approach to teaching spirometry interpretation, focusing on the factors that determine lung function and the effects of using race-based or race-neutral reference equations. We explicitly define race as a social construct and review the likely reasons for the differences in lung function found between racial groups. We use an interactive and case-based approach to facilitate learning. As part of our interactive approach, we incorporate strategies to enhance psychological safety for the learners. This is particularly important for this topic because discussions of race and health inequities can be contentious and uncomfortable and have the potential to exacerbate the difficulties faced by learners from groups that are underrepresented in medicine. Our approach is intended for a small group of graduate medical learners and could be presented during formal didactic instruction or informally during clinical teaching.