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Prominent dermatologists detail how a biased literature, a lack of education, accessibility issues, and historical wrongdoings have all influenced the study of skin of color.
The pursuit of equality is never-ending, especially as it relates to medicine.
In fact, it can be argued that this is the nature of medicine; ideally, stakeholders are always striving to create a better health care system that nurtures and informs vulnerable and diverse communities, contributing to a larger and healthier global community in the process.
This is the idealistic portrayal of health care, but it is not the most realistic portrayal, currently.
Without discounting the advancements made in the history of medicine as they relate to racial equality—of which there are a myriad of examples—the scientific community is mired in the same complications that pervade all forms of progress in society, whether it’s related to culture, politics, education, and more.
As such, the topic of racial disparities in health care is evergreen; there will always be opportunities to discuss these issues, and there will always be opportunities to fix these issues. Dermatology is only one of many fields addressing unique challenges and opportunities in the pursuit of equitable care.
Raj Chovatiya, MD, PhD, Assistant Professor at the Department of Dermatology, Northwestern University Feinberg School of Medicine talked to HCPLive about the intrinsic and extrinsic factors that drive the differences in dermatologic diseases and care.
“Some of the differences that we see in (dermatological care) can be explained by genes, proteins, cells, pigment, and the immune system,” Chovatiya said. “But a lot of the differences that drive many of the social constructs underlying the concepts of race, ethnicity, education, housing, access to health care, income geography, a lot of this really underlies many of the differences that we see across dermatology and skin of color.”
In this iteration of This Year in Medicine 2021, Chovatiya, along with Nanette B. Silverberg, MD, Chief of Pediatric Dermatology for Mount Sinai Health System and Member of Society for Pediatric Dermatology, discuss the intricacies of racial inequality in dermatology care, as well as what clinicians and patients alike can do to enact change.
“While we were perhaps trying to be inclusive and not necessarily mentioned race and color in older studies, now we want to be mindful to include it, and to discuss it in a positive, proactive way that provides patients and physicians with good information, but also to remove some of the biases of the past. And to help also create more natural inclusiveness,” Silverberg said.
Facilitating change in the dermatology begins with education.
The best doctors and dermatology experts have always known how crucial it is for a patient to understand their condition just as intimately as the they do. However, in recent years, the idea of what is known about skin of color in the dermatology field has been challenged.
“You've seen a lot of studies start to come out that are suggesting that with a lot of our educational materials, we're not really looking at photographs of dermatologic presentations across diverse skin types, we really don't have that much data on treatment outcomes across diverse skin types, (and) understanding of if there are differences in longitudinal course disease across different skin types as well,” Chovatiya said.
Though there has always been a need for more studies specifically designed to evaluate skin of color, the issue of representation in broader investigations remains.
Simply put, the study of dermatology is not truly complete without a diverse patient population, as dermatological conditions can affect patients differently depending on their skin type.
Erythema, for example, presents differently across darker and lighter skin types, as do lesions and certain hair disorders. However, patients and clinicians might not be aware of these differences due to limitations in current data.
“When we educate physicians, and that includes dermatologist and also medical students and sub-specialists or even primary care doctors, we're often using resources that are older, that have mostly patients who are white depicted, and that has limited some of the education,” Silverberg said.
As such, it’s important to discuss improved inclusion in research and education shaping the specialty, Silverberg added.
“It's wonderful that there's really so much interest in it now, but there have been so many physicians who are truly dedicated to the topic in the past few decades that have really helped bring it to the forefront,” she said.
Hearteningly, the dermatology field is replete with experts such as Silverberg and Chovatiya who are motivated to improve the quality of life of their patients.
That said, concern regarding education and access for patients of color is still warranted, as both doctors would suggest. Providers are often seeking news ways in which they can educate patients about what to expect from their disease process, in addition to the newest treatments and therapeutic options.
“I think we often focus on making the best medication possible the best treatment plan possible,” Chovatiya said. “But at the end of the day, unless you can actually implement it, and get people using it and get people seeing their health care providers, none of it's going to make any difference.”
Chovatiya added that patients with skin of color, especially in regard to Black and African American populations, a shortage of availabilities to specialist care has been recorded in recent studies.
As such, there is often a delay in diagnosis in these patient populations, which can result in an increase in the severity of presentation, worsen symptoms and burden, and even affect treatment outcomes.
There’s an urgency to the subject of racial equality in medicine, and rightfully so. The issue of accessibility to dermatological treatments and therapies for people with skin of color is a contemporary one.
Luckily, there are a multitude of contemporary solutions. For instance, both Chovatiya and Silverberg observed a renewed interest in telemedicine and telehealth in recent years, undoubtedly brought on by the COVID-19 pandemic.
“That's one of the things I hope is going to continue over the course the next decade,” Chovatiya said. “I can really see it becoming a tool where you can catch people that are maybe not able to get into clinic in a timely fashion, maybe it's difficult for them because they work and they can't really get the transportation, to be able to get the same level of care as everybody else.”
HCPLive has reported on this phenomenon several times in the past year.
One such study from the University of Chicago featured several pediatric group visits in which families of color affected by pediatric vitiligo could discuss their experiences living with the disease. The meetings were held via Zoom, with 79% of parents stating they would attend more sessions.
Investigators of that particular study also spoke of the need to increase access to telemedicine in several different communities.
Regarding in-person care, a myriad of specialized care options is available for patients of color, which also include pediatric populations as well.
“I had the special opportunity to work on as an editor of a textbook, Pediatric Skin of Color, about 5 years ago, and we had a core group of American Physicians, (and) international physicians who specialized and understood skin of color well,” Silverberg said. “So, I think that people can find specialized positions, (and) they can look for practitioners who focus on skin of color through their websites or looking for skin of color centers.”
Specialist care in dermatology has only become more prevalent in recent years, as has the desire by some patients with skin of color to be treated by doctors and dermatologists of the same race or ethnicity.
“I think that in my personal practice, something that surprised and impressed me the first couple of years of training was how important it was for patients to really form that type of personal connection outside of their condition itself based on shared culture, shared language, ethnicity, race,” Chovatiya said.
There are, of course, historical implications with some of these decisions, as Silverberg referenced in her interview with HCPLive. Not only are medical abuses such as the Tuskegee Syphilis Study well known—predominantly referenced as the “Tuskegee Experiments”—but they have also been hugely influential in how some patients view medicine.
Trust is as vitally important as accessibility, perhaps now more than ever.
Patients with skin of color need to know that they are being treated with the utmost care by providers regardless of either party’s race or ethnicity. At the same time, providers need to treat patients with skin of color as individuals without disregarding the context for which these patients are being treated.
“Patients want to really be able to relate to a provider who understands their experience, who understands the unique nature of their skin understand the unique nature of their disease presentation,” Chovatiya said. “So it's part of a bigger picture of revising our language and thinking about what is normal, what is not normal, what is classic, what is not classic, opening our minds, broadening our perspective and really putting that information out there or just uncovering it if it hasn't really been studied yet—to really understand just how things are different across diverse skin types, as opposed to trying to lump things into what's typical.”