Dermatology Has A Race Problem. Meet One Of The Doctors Trying To Fix It

Imagine this. You develop a rash one day. Its itchy, painful and sore and you decide to visit a dermatologist to get it checked out. Most people wouldn’t even think twice about whether that dermatologist was confident that their medical training would qualify them to diagnose and treat that condition.

But Black people in the United States have every right to wonder this.

In a 2011 U.S. survey, almost half of dermatologists and dermatology residents reported that their medical training was inadequate to prepare them for diagnosing and treating conditions on Black skin.

“If those people didn’t feel comfortable treating melanoma, for example, a primary competency, we wouldn’t graduate them,” said Jenna Lester, MD, dermatologist and assistant professor in the University of California San Francisco (UCSF) dermatology department, talking about the survey. “What are we signaling to patients we care about when its acceptable for that percentage of people to graduate not feeling comfortable dealing with a large number of the population,” Lester added.

Lester explains that the issues are complex and far-reaching, but part of it is the distinct lack of pictures of skin conditions on darker skin during medical school education and in residency.

“I remember in residency hearing someone say ‘this would look different in darker skin,’ but never showing us a photo to show us what this would look like. To me it was problematic to say ‘this would be different,’ but I don’t have a way of showing you what that difference would look like,” said Lester.

A 2018 study showed that only 4.5% of pictures in four major general medicine textbooks featured dark skin, a huge under-representation considering 13.4% of people in the U.S. are Black according to the 2019 census.

“Even photographs in grand rounds, from invited speakers or from people within the department – even these lectures don’t have a diverse group of photos that are used, we are just reinforcing that concept over and over,” said Lester.

This lack of representation is not just confined to medical textbooks either. With the recent Covid-19 pandemic, one of the more unusual reported symptoms has been ‘Covid toes,’ where some people see inflammation and reddening of their toes.

“Potentially, people are unaware of what these skin findings look like in the very people who are most negatively impacted by this condition – those who are hospitalized at the highest rates, the people who die at the highest rates,” said Lester.

Although there are now efforts ongoing to collect more cases and pictures of the condition in diverse skin tones, at the start of the pandemic, almost all of the emerging research and academic papers coming out with pictures of Covid toes featured exclusively white skin.

“In these situations, my role as a dermatologist is as part of the medical team, supportive of other doctors who are dealing with other organ systems, but also trying to figure out what ways we as dermatologists can impact someone’s overall quality of life or survival. I can’t really do this if i’m faced with a disease that’s killing people, but I don’t even currently have a way of teaching people what this looks like in all different skin tones,” said Lester.

People with darker skin tones tend to have worse outcomes for many dermatological conditions including skin cancer. To try and address this, Lester started a clinic at UCSF, specifically to cater for patients with skin of color.

“Anecdotally from what I’ve heard from patients and referring providers, its been a pretty powerful experience. There’s been such a need for this service in this area for so long, people are happy with it,” said Lester.

The clinic is one of only a few in the country that specifically cater to people with darker skin, including one at Mount Sinai in New York.

“When you have a field in medicine that for so long has excluded people, intentionally or unintentionally, its important to create a place that signals to them in a very obvious way “you are welcome here,” said Lester.

A small study from last year published in JAMA Dermatology found that Black patients seen at a specialized skin of color clinic reported a higher satisfaction with their care, compared to previous experiences at non-specialized clinics.

“I think my ultimate goal would be that clinics like this wouldn’t need to exist and that all patients would feel welcome in any clinical setting, with all dermatologists having the skills to diagnose and treat all patients, but this isn’t the case right now.  Until there is evidence that it is no longer needed, I plan to provide this service,” said Lester.

Dermatology is the second least diverse medical specialty after orthopedic surgery. Only 9% of dermatologists in the United States are Black, Indigenous or Latinx. So how can these deep-seated and persistent issues, which clearly affect patient care be changed?

“Changing the representation of photographs in textbooks is a start, but when you have under-representation of certain skin tones in textbooks, but they are over-represented in pictures of sexually transmitted infections, this causes you to think about people in a certain way,” said Lester.

Lester plans to formally study how her skin of color clinic affects patient care and the perception of their care, but knows that more needs to be done on a wider scale to make dermatology more accessible for Black patients and physicians.

“We really need to begin as a medical community to grapple with the racist structures that exist within our clinics our academic institutions within our larger society that set some of these things up to be the norm. We can change the photographs, but there needs to be a bigger structural dismantling,” said Lester.