Dermatology is the 2nd-least-diverse medical specialty. How do we move toward equity?

The overwhelming number of fatalities from COVID-19’s devastating affect on communities of color has spurred those in the field of health care to examine racial disparities that have long pervaded nearly every aspect of medicine, from bias in kidney testing to the increase of  maternal mortality in Black women.

Dermatology was ranked as the second-least-diverse medical specialty in 2020 according to a Clinics in Dermatology review. Lack of mentorship, decreased awareness of the specialty during medical school, socioeconomic barriers associated with the application process and implicit bias during resident selection were the four main causes of the diversity gap, another Clinics in Dermatology study found.

The diversity problem directly affects the quality of care, a feature in Practical Dermatology states: The dearth of dermatologists from groups that are underrepresented in medicine means there are fewer who might be familiar with how skin disease presents in patients from those groups.

Dermatology professionals have begun to call out the discrepancies in health outcomes in order to shed light on vast disparities in care, both in the field and within health care and society as a whole. “The need for true change has been evident for far too long amongst marginalized communities of color,” says Misty Eleryan, MD, Micrographic Surgery and Dermatologic Oncology fellow in the Division of Dermatology at UCLA.

“Now we have the attention of everyone,” she adds, making reference to the protests against police violence and racial injustice in the summer of 2020.

Dr. Eleryan and Jenny Kim, MD, PhD, professor of clinical medicine/dermatology at the David Geffen School of Medicine at UCLA, along with other colleagues and trainees, co-founded an Equity, Diversity and Inclusion committee within the Division of Dermatology to find solutions for the field.

 “I have recognized that inequities in medicine lead to biases that have allowed more opportunities for one group versus those who are underrepresented in medicine and I would like to be an ally,” Dr. Kim says. “We can't be passive, if we want changes to take effect. There has to be purposeful action.”

The Dermatology EDI Committee has set five goals: 

  • Foster a more inclusive and diverse climate. The Division is launching implicit bias training that also will become embedded in recruiting efforts.
  • Demonstrate EDI linguistically and visually by updating the division website text and images to reflect the diversity and expertise of faculty, staff, trainees, students and patients. The site also will highlight patient, staff, trainee and faculty stories.
  • Develop a holistic review process for upcoming generations of students and trainees by promoting characteristics other than high scoring metrics to bring in well-rounded candidates of all backgrounds. Dr. Kim says she aims to more closely “examine the road traveled by applicants,” to provide more opportunities.
  • Revamp curricula and bring in speakers that offer a span of perspectives and knowledge, from dermatology disease to health disparities.
  • Enhance intellectual development in the form of career development and research projects that relate to health disparities and health equity.

A priority for Dr. Kim and her team are to familiarize themselves with skin and hair conditions that affect all groups of people.

“In dermatology, many of us are beginning to put a spotlight on inequities that exist within our specialty, one of the most important being the lack of representation of darker skin in our textbooks,” Dr. Eleryan says. “Dermatology is a visual field so a lot of our resident education is centered around Kodachromes, which are digital images depicting certain skin diseases.”

In an analysis from the Journal of American Academy of Dermatology of more than 7,000 images reviewed from major dermatology textbooks, an average of 80% of dermatologic diseases were depicted on only fair skin.

Dr. Eleryan says many were shocked by the finding.

“Just imagine what message is being sent to trainees when you are only exposed to certain skin tones,” she says. “Not only that, but much of our clinical diagnoses are made based on the education from these textbooks. This is why it is important to have better representation and inclusivity of ALL skin tones.”

Many common skin diseases present differently on various skin tones. Dr. Eleryan says if trainees are not taught this at an early stage of their careers, they risk misdiagnosing patients with darker skin and prolonging definitive diagnoses.

Dr. Eleryan has been motivated to address this major disparity in dermatology – and developed an all-inclusive dermatology color atlas during her second year as a resident. “This is just a start because we need all medical educators to commit to including all skin tones within their lectures.”

Dr. Kim says she and her colleagues want be able to show patients that through the common problems they face, “we are able to be there for them and take care of them, not only physically, but also emotionally.

“Dermatology has such visible conditions, which really affects people's well-being,” she says.

Amy Vandiver, MD, PhD, third-year resident and STAR Fellow, focuses on a patient population experiencing unique skin challenges – geriatric patients.

“I don’t think people realize how central skin is to getting old,” Dr. Vandiver says. “As we age, there is a significant decline in the skin’s ability to act as a barrier, which predisposes us to dryness itching, rashes and infections. This really impacts elderly people’s quality of life and how they age systemically.”

Dr. Vandiver says, like Dr. Kim, what she loves about dermatology is the ability to make a big difference in people’s lives and well-being.

“We have such a small window (of time) to address things that may seem small to the rest of us, but they are central to how people experience the world on a daily basis. For example, if every time you bump yourself, you bruise and bleed, that’s going to impact how you experience life.”

In her own life, she witnessed how her grandparents’ care wasn’t being tailored to their needs.

“People were frustrated with them and weren’t really appreciating what full lives they’ve had,” she says. “As a medical professional, we must find ways to restore autonomy and treat elderly patients with the kind of respect that they deserve.”

Dr. Vandiver emphasizes that by focusing on whole patient health in specialized care such as dermatology, health care professionals can be better allies to patients from marginalized backgrounds and stigmatized identities and conditions.

“I went into medicine to improve patients’ quality of life and improve their lives when they need it,” she says. Through her training, however, she’s seen how the field of dermatology hasn’t always been so accessible for patients with limited insurance and resources.

“I think that’s what’s really motivated me to become more involved with the EDI work – to see what we can do to address that,” she says.

Through increased mentorship, anti-bias training, education, and awareness, Dr. Kim is optimistic both dermatologists and patients will benefit.

She says she hopes medical professionals can be “more aware and passionate about how we can all do our individual parts to change things for the better.

“I'm really hopeful that when we feel this passion, we can make real change.”

Related:

The science of treating the inequalities that make us sick

How UCLA Health’s Black Leadership Coalition rallied to launch a new health equity initiative

Improving health through film for patients with HIV and histories of trauma


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