By Nada Elbuluk, MD, MSc
There has been a longstanding need to improve medical care for people of color. The Black Lives Matter movement and events of the past 18 months have brought a heightened awareness of systemic injustices across our society, including in the medical system. Conversations about racial disparities are ongoing, but the healthcare industry needs to go beyond awareness – we need better answers and solutions to these issues.
Diversity among providers and staff is important. We also must make sure our environment is inclusive and that we have culturally competent providers who can deliver equitable care for all our patients.
People of color and individuals from underserved communities tend to experience poorer health outcomes from delayed detection and undertreatment, resulting in increased morbidity and mortality. To properly address these disparities, we must examine our infrastructure and healthcare delivery systems to understand what factors contribute to these inequities and begin to make measurable and impactful changes.
Many medical schools, as well as physician extender schools, are adding bias awareness and cultural competency training to their curricula. Hospital systems are also looking at how they can incorporate this training for those who are already practicing, so that active clinicians and other healthcare providers can become aware of their own biases.
Cognitive biases in medicine can have significant implications on healthcare outcomes. In addition to unconscious bias (also known as implicit bias) and conscious bias, there are other biases to be aware of:
- Representative bias. Diseases may look very different on darker and lighter skin colors, and if an individual has been trained primarily on lighter skin phototypes, they may fall victim to representative bias and miss a diagnosis in a person with darker skin.
- Premature closure. One can make a quick judgment or diagnosis based on what is salient or familiar to them rather than going through a comprehensive thought process that considers the patient’s unique background and presentation. As a result, a clinician may end up closing their decision-making too early in the diagnostic process and potentially make the wrong diagnostic and treatment decisions which can have various implications.
It is essential to provide medical knowledge that can reduce biases toward skin of color. This education should start in medical school, as it lays the groundwork for how clinicians will practice throughout their careers.
This can be achieved by ensuring that skin of color is adequately and appropriately represented in educational materials. Training clinicians to recognize how skin conditions present on darker skin colors is key to reducing healthcare disparities, yet professional resources often do not sufficiently represent people with deeply pigmented skin.
A JAAD study analyzed the images found in print and digital educational resources. Of the 15,445 images studied, only 19.5% depicted darker skin. There are potentially life-threatening diseases that can present with skin changes that are more subtle in darker skin colors. Moreover, many dermatology textbooks and atlases often fail to adequately depict conditions across the spectrum of severity in people of color. When students don’t have access to diverse training materials, they can miss these diagnoses in dark skin, contributing to poorer outcomes. Our educational institutions should be purposeful in education and training related to skin of color and providing comprehensive tools so that all clinicians are comfortable identifying and treating disease in all skin types.
Resources to enhance pattern-recognition skills in the exam room should also be made available—not a separate atlas of dark skin but one tool to handle all skin colors. Using a reference tool at the point of care can better equip students, trainees, physicians, and physician extenders with the knowledge to better identify diseases accurately. The right decision support tools can help teachclinical reasoning skills and provide access to information at the bedside.
There are also multiple organizations and initiatives aimed at improving health equity. Project IMPACT, is one such initiative, which was born out of the desire to address issues of health equity beginning with disparities in medical education and the downstream effect they have on misdiagnosis and increased disease burden and mortality for people of color. The global initiative boasts a comprehensive and updated repository of clinical imagery, research articles, landmark textbooks, and more as it relates to improving healthcare for skin of color.
The individual organizations that are Project IMPACT collaborators are also doing important work to improve health equity. The New England Journal of Medicine (NEJM) has a dedicated online webpage covering topics related to Race and Medicine. It features a collection of editorials, interviews, research and more as part of its commitment to educate the medical community about systemic racism and improve the lives of BIPOC patients. NEJM Group also co-sponsored, along with the Skin of Color Society and VisualDx, “The Impact of Skin Color and Ethnicity on Clinical Diagnosis and Research,” a four-part webinar series in which clinical experts, thought leaders, and advocates discussed issues of health disparities, structural racism, and medicine while examining specific dermatologic diseases.
Additionally, The American Academy of Dermatology Association shares information and guidance to improve diagnostic accuracy of skin cancer on pigmented skin, helping to fill a major knowledge gap in the medical community that leads to significant disparities. Skin of Color Society also provides resources for physicians to educate patients on dermatological conditions, especially differences in conditions on pigmented skin in skin of color in order to further patient knowledge and empower them in their healthcare experience.
Improving healthcare outcomes for people of color is imperative, and meaningful change will not be possible without actively reducing bias and bridging gaps of knowledge in medical education.