Under‐representation of skin of colour in dermatology images: not just an educational issue

Healthcare disparities are regrettably familiar: black people are 50% more likely to die from heart attacks or stroke than white people; residents of rural areas of the U.S.A. have higher prevalence of chronic obstructive pulmonary disease and Mexican‐American adults with hypertension are less likely to have controlled blood pressure.1 An especially troubling healthcare disparity for our specialty is dermatologists’ suboptimal familiarity with diagnosing skin disease in skin of colour. In one study, 47% of dermatologists felt that their training was inadequate to diagnose skin disease in skin of colour.1 One of the authors (J.C.L.), witnessed this situation leading to suboptimal care – a patient with a rash that was subsequently diagnosed as toxic epidermal necrolysis waited in the emergency room for several hours because the ‘characteristic’ redness that dermatologists seek to make the diagnosis can be subtle in skin of colour. Unfamiliarity with darker skin may have contributed to the delay in diagnosis and treatment for this patient. This example of care disparity is arresting but not rare. Many dermatologists can recall similar situations where visual diagnosis was debated or delayed, until a biopsy revealed a common disorder that presented in a way that was not ‘classic’ because of the patient's darker skin. Why might dermatologists feel ill‐equipped to diagnose certain skin diseases in persons of colour? Past studies have documented that teaching images disproportionately depict white skin.2 To learn whether this disparity still exists, we trained three independent image reviewers who categorized photos from two common textbooks and a frequently used teaching set. Of the 5026 images we reviewed, the proportion of images depicting skin of colour was estimated to be 22–32% in textbooks and 21–38% in the teaching set. However, for images of sexually transmitted infections (STIs), the proportion of skin of colour varied from 47% to 58%, compared with 28% for images of infections that were not STIs. Thus, the depiction of skin of colour in our teaching images remains imbalanced. Similarly, in one survey, only 25·4% of dermatology trainees and 19·5% of programme directors of dermatology residencies approved by the Accreditation Council for Graduate Medical Education reported having lectures by an expert that were specific to skin of colour.3 These discrepancies, as noted by others,2 can affect the quality of our care by failing to expose physicians in our specialty to a diverse range of clinical appearances. We are not teaching (and possibly not learning) skin of colour.2 However, we believe that imbalance in the depiction of skin of colour in teaching images can have deeper and broader effects than simply missed educational opportunities. Firstly, suboptimal comfort with diagnosing and caring for patients of colour can affect the physician–patient relationship. Within communities of colour, there is a legacy of mistrust in the medical system, which we strengthen when we are unsure. If we are not confident in our diagnostic abilities in skin of colour, we may hesitate when faced with common diagnoses. Uncertainty in clinical diagnosis can contribute to disparities in powerful but subtle ways:4 if there is a dearth of taught material, then stereotypes may dominate. In this way, our lack of diversity in images and over‐representation of certain diseases can contribute to disparities. Secondly, the lack of visual representation of all types of skin in our common teaching texts can affect our trainees. For trainees of colour it can be conflicting to work in a system in which their race is overlooked or presented in a distorted way. This conflict could contribute to decreased job satisfaction and burnout, precisely at a time when leaders are calling for more diversity in our field. Finally, this imbalance in conventional dermatology images can affect the integrity of our field. The content of our teaching materials reflects what we value. Without balanced representation of skin of colour in our teaching, our specialty has a narrowed scope of practice and limited impact. An important step forward is naming this disparity and its consequences as a more serious issue than a lost educational opportunity. Most diagnoses should have representative photos in a broad spectrum of skin colours. We should consider over‐representation of skin of colour, as we often lack the opportunity to see actual patients, making teaching images more important. There are full textbooks5,6,7 and digital resources (https://www.visualdx.com/visualdx/7/) with images of skin of colour, so these photos already exist. We should involve more experts in skin of colour in the authorship of commonly used textbooks. To expand our databases of existing photos, we should also actively photograph common dermatoses in skin of colour. By 2060, 47% of Americans will have nonwhite skin.1 The visual images from which we teach and learn must reflect this diversity; our patients, trainees and our specialty deserve nothing less. We are indebted to Jose Cortez, Morgan Cronin, Anelah McGinness and Eleni Linos for their assistance with this project. They were not compensated for their contributions. None to declare.