The Problem
For a decade, pediatricians across America followed a clinical practice guideline that explicitly used race to determine whether to obtain a catheterized urine specimen – the gold standard in diagnostic care – for suspected urinary tract infections (UTI) in infants and toddlers. The American Academy of Pediatrics’ UTI guideline, published in 2011 and reaffirmed in 2016, included race as a risk factor in these clinical decisions. This practice effectively created different standards of care for Black children, resulting in a lower likelihood of them being diagnosed and treated for UTIs. In 2020, AAP members raised serious concerns about this guideline, noting that the guideline conflated race, a social construct, with biological risk factors for UTIs.
The Response
The AAP’s response was swift and comprehensive. In 2021, the Academy retired the guideline, acknowledging that race likely served as a proxy for unmeasured social and structural factors rather than biological predisposition.
But they didn’t stop there.
Recognizing that the UTI guideline represented a broader problem, the AAP Board Committee on Equity championed a policy statement in 2022 mandating the systematic review of all AAP guidance documents for race-based approaches. This policy committed the Academy to “deconstruct, revise, or retire” any guidelines inappropriately using race in clinical decision-making.
The Discovery
With support from the Doris Duke Foundation, the AAP assembled a team of health equity researchers to examine their entire catalog of clinical guidance. The findings were sobering: bias was “broadly embedded in practice guidance,” with overt racial algorithms representing just the tip of the iceberg. The review revealed how institutional protocols, clinical pathways, and electronic health record tools were perpetuating these biases at scale.
The Impact
The retired UTI guideline had influenced care for one of the most common pediatric complaints – fever. By addressing this single guideline, the AAP began dismantling a system that had normalized differential treatment for Black and white children.
Lessons for Medical Societies
- Member advocacy matters: Front-line clinicians and researchers can catalyze institutional change
- Single examples illuminate systemic issues: One problematic guideline may signal the need for a broader focus
- Guideline retirement isn’t enough: Organizations must examine how such guidelines were created and build robust processes to avoid future inappropriate use of race
- Dr. Joseph Wright, Chief Health Equity Officer at the AAP, emphasizes that sustainable change requires a focus on three main areas: discovery and evidence generation, policy implementation, and changing clinical practice via education.
Call to Action for Specialty Societies
Every medical society should ask: Which of our guidelines might be perpetuating inequity? The AAP’s experience shows that confronting this question, though uncomfortable, is essential for delivering equitable care to all patients.