Representation in Education: How Diversity in Clinical Images Can Reduce Healthcare Disparities

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By Nada Elbuluk, MD

It is our ethical and moral obligation as physicians to provide health equity to all patients. Despite knowing this, medicine has historically fallen short. For far too long patients with pigmented skin have been marginalized and have faced worse healthcare outcomes than their peers with lighter skin colors. When it comes to skin cancer, for example, statistics show that the morbidity and mortality of melanoma and non-melanoma skin cancers are disproportionately higher among African Americans and Hispanics. The estimated five-year melanoma survival rate for Black patients is only 70% compared to 94% for whites.

Healthcare disparities and a lack of health equity are complex problems that require multifaceted solutions. One tangible way we can start to address some of these issues is through medical education, more specifically, medical images. By ensuring that medical training includes a diverse set of clinical images that is representative of our national and global populations, we can begin to improve diagnostic accuracy, which has downstream implications in improving healthcare outcomes—particularly for patients of color. 

When it comes to skin of color, there are two categories in which we can improve education. The first category deals with conditions that affect people of all skin types and ethnicities but look different depending on the patient’s skin tone. Take Lyme disease, for example. Most clinicians know to look for the classic presentation of an erythematous targetoid patch, but how does that present in dark skin? It can often appear violaceous to brown with less obvious demarcation of the central bull’s eye or targetoid appearance that healthcare providers are trained to look for. Without this training, providers can fall prey to representative bias in which they miss diagnoses because the patient fails to show the “classic” presentation of a condition, which traditionally has been taught in lighter skin types. The implications of these missed diagnoses can have significant consequences on disease burden as well as patient morbidity and mortality.  

Beyond recognizing disease presentations in darker skin, the second equally important category that healthcare providers must familiarize themselves with are conditions that disproportionately affect skin of color populations, such as keloids and pseudofolliculitis barbae.

The problem we are now facing is that professional resources often do not adequately prepare medical students and other healthcare providers for making diagnoses in skin of color. Medical textbooks and atlases have traditionally underrepresented presentations of disease in people of color. According to a recent study in JAAD, only 19.5% of the images used in medical school and dermatological training represent dark skin. 

The bottom line is if medical education is primarily training future clinicians to detect conditions in one skin type, race, or ethnicity then we are failing to adequately prepare them to take care of a global population. Lack of adequate training can result in misdiagnosis, underdiagnosis, and undertreatment in people of color. 

This is not health equity.

To rely solely on dark skin dermatology textbooks and atlases to address this inequity is also no longer acceptable. While these are valuable and important resources, they do not solve the problem that skin of color images are largely underrepresented in primary medical resources. 

So, what can we do? We can seek out materials that represent the full spectrum of human disease across skin types including variation in color, morphology, and presentation and also work to ensure that these materials are a required part of medical school and residency educational curriculums. This same rule applies beyond medical school: Nurses, physician assistants, nurse practitioners, and patient-facing providers across the board need to be trained in skin of color. We all need to know the importance of recognizing skin conditions in patients with darker skin pigmentation. 

Biases are present in all facets of life—not just in medicine. And while it takes time to examine where injustices lie and then make actionable changes, the task of reducing bias is not insurmountable. Improving access to diverse images through medical education and training is just one piece of the puzzle that can help bring us one step closer to reaching the healthcare equity that providers strive for and that all patients deserve.

Nada Elbuluk, MD, a board-certified dermatologist, is Director of Clinical Impact at VisualDx and an Associate Professor of dermatology at the University of Southern California. 

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