Derm Topics

Patient Buzz: Skin Bias in Dermatology

The New York Times is one of several major publications that have recently covered skin bias in dermatology. Is this coverage helpful or hurtful to the specialty? How can individual dermatologists make a difference in reducing disparities in care?

For their take, I reached out to Tiffany T. Mayo, MD, assistant professor of dermatology at the University of Alabama at Birmingham, and Theodore Rosen, MD, professor of dermatology at Baylor College of Medicine and chief of dermatology service at the Michael E. DeBakey Veterans Affairs Medical Center.

Do you think the recent coverage of skin bias in dermatology will lead patients of color to distrust dermatologists?

Dr. Mayo: No, I do not think the NYT article will lead patients of color to distrust dermatologists. Many patients of color are already skeptical of dermatologists who do not share their skin tone or hair texture, and this article reinforces how they already feel. The NYT article resounds more with physicians than patients of color and may be an opportunity for dermatologists, and the field of medicine in general, to be intentional about inclusivity and work toward mending the distrust in patients of color.

Dr. Rosen: Though the NYT article may, in fact, lead some people of color to distrust a dermatologist who does not share their skin tone, I believe that, for the most part, that distrust may be overstated and somewhat unjustified. 

While the NYT article has an element of truth and uses isolated cases to support its premise, I think that the situation is depicted as much more dire than it actually is. I published the first significant textbook devoted to disease in skin of color, “Atlas of Black Dermatology,” in 1981. Subsequent to that, other, more comprehensive textbooks have been published. Many of our major dermatological journals have run an entire issue related to skin of color, often more than once. So, it’s not like there haven’t been appropriate, well-illustrated educational resources available for at least the last 40 years.

Trainees learn as much, and probably more, from their clinical experiences as compared to textbook reading. You simply can’t be trained in a program like ours at Baylor College of Medicine, in Houston, Texas, without being exposed to a rainbow of skin colors and diverse cultural backgrounds. Our trainees see pretty much every skin disease in almost every ethnic group imaginable during their formative years. So, if pityriasis rosea isn’t depicted in dark skin in some standard textbook, the residents will certainly see it – in the flesh – while in training for three years. That training should stay with them for the remainder of their professional lives. There may, indeed, be some training programs that draw predominantly from a nearly monomorphous Caucasian population, but most training programs are located in or near large metropolitan areas which will ensure exposure to a variety of disorders in a multitude of skin colors.

How should dermatologists, and white dermatologists in particular, respond to patient concerns about skin bias in dermatology?

Dr. Mayo: Though skin of color images are lacking, most dermatologists see a fair amount of skin of color during training and feel comfortable treating ethnic skin. Dermatologists should be empathetic to patient concerns but elaborate on their experience in managing the patient’s condition, highlighting specific treatment modifications to address the patient’s skin or hair type. For instance, addressing hyperpigmentation when treating acne or discussing scalp treatment modifications based on hair washing frequency/styling method will provide reassurance for the patient.

Dr. Rosen: Honesty is always the best policy. I remember one of my Black patients, during her first visit, bluntly asked me if I felt confident in my skills at handling her medical and cosmetic concerns. I told her straight up that I had no problem doing so. She then posed an interesting question: what percentage of my patient pool was drawn from skin of color? She was shocked when I told her that it was about 50%. I do think that every dermatologist should have these statistics available for patients who might want to know them.

For any dermatologist who actually does not feel comfortable with skin of color, be willing to admit that to a patient who asks. And, it is that professional’s ethical personal responsibility to enhance their skill at diagnosis and treatment in non-Caucasian skin. How can they accomplish that? By attending conference sessions or entire symposia and/or read one of the various textbooks devoted precisely to this subject.

What can individual dermatologists do to help solve the problem of skin bias?

Dr. Mayo: As dermatologists, we can help address the problem of skin bias by acknowledging the problem, increasing education, including lectures, on skin of color for ourselves and trainees, and advocating for increasing skin of color representation among dermatologists. Individual dermatologists can increase their expertise by self-educating through society resources, journal articles, lectures, and text books dedicated to skin of color.

Dr. Rosen: We certainly also need more diversity among the dermatological workforce. But it’s really important that ANYONE who hangs out their shingle (these days more likely joins a multispecialty clinic) and purports to offer expert medical skin care be well versed in the nuances of caring for skin of color.

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