Duke Medical Ethics Journal
Inequity In Dermatological Healthcare
By: Mariana Bouchan
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Skin diseases prevail in a world filled with medical innovation, leaving many with economic and social impacts. 1 in 10 individuals will most likely experience eczema during their lifespan [1]. Acne affects up to 50 million Americans yearly, causing significant puberty discomfort, and 1 in 5 Americans is estimated to develop skin cancer at some point [2]. Skin cancer and diseases have no border—they affect people of all races and demographics. However, there are alarming disparities in terms of treatment and diagnosis. Throughout history, minorities have been disproportionately represented in medicine. Minorities are not meant as patients and physicians, nor in research and innovations. It is critical for underserved communities to be represented in healthcare because it will bring us one step closer to better public health. Increased representation in the field of dermatology can lead to increased patient satisfaction and a more robust workforce. The lack of diversity in medicine, especially in dermatology, creates barriers that hinder overall global health. Diversity embraces different cultures, leading to a more open-minded society. Hence, it is essential to note marginalization and aim toward intervention methods as soon as possible.
What is Dermatology?
Dermatology is a medical specialty that focuses on health conditions regarding the skin, hair, nails, and membranes [3]. As the skin is the largest organ of the human body, people need equitable healthcare in the field. Dermatologists treat common conditions: acne, dermatitis, eczema, psoriasis, fungal infections, warts, and skin cancer. The practice of dermatology is critical to medicine, as skin cancer is the most common cancer in the United States. Exposure to harmful UV rays is inevitable; hence, it is essential for dermatology care to be equitable and available to all.
"Dermatology is the second least diverse specialty of medicine, thus alarmingly reflecting misrepresentation within the field."
Disparities in Dermatologists:
Disparities can be observed as early as in dermatology training. Dermatology is the second least diverse specialty of medicine, thus alarmingly reflecting misrepresentation within the field [4]. For instance, “African-American and Hispanic dermatologists comprised only 3% and 4.2% of all dermatologists in the United States, respectively” [4]. Such disparities can negatively influence the care of underrepresented minorities. Although race should not impact the quality of care from a physician, some patients may wish to seek service from physicians with similar customs or backgrounds. With such low representation, it is a given that seeking care from physicians with similar traditions can be incredibly difficult for URM individuals. One of the most significant barriers to the field of dermatology is education and the lack of mentorship. Socioeconomic factors and unfair biases further pose a challenge to minorities. The lack of diversity in the field often contributes to inequities in care among these ethnic groups. Furthermore, it limits perspectives and open-mindedness in medicine and may raise distrust in minorities. A significant goal of medicine is to increase overall public health; to do so, all cultures and backgrounds must be represented and acknowledged. With increased diversity in dermatology, there can be “a more rigorous learning environment, patients can have improved interactions with physicians from various backgrounds, institutions can appear more approachable and trustworthy when they include a workforce reflective of the community they serve, and those who have been purposefully excluded for many years can now be included” [7]. Increased diversity can increase healthcare access and encourage diversity in medicine.
Disparities in Dermatology patients:
Although around half of the US population includes people of color, minorities face various barriers to adequate dermatological care: access to insurance, proper diagnoses, language barriers, and representation. The broken process of holistic care for minorities allows the disease to manifest itself or remain untreated for years quickly. Racial biases harm the opportunities of minorities, especially in healthcare. In the past, access to dermatological care was seen as a “luxury” and thus limited to people of color. For this reason, there is little research regarding skin disease in people of color, and there are little to no images of people of color in educational literature. The lack of representation casts neglect on people of color, underserving their medical needs
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One significant way that minorities face inequity in dermatological care is skin tone. When it comes to skin color, minorities may face disadvantages such as “misconceptions regarding skin diseases in people of color, misdiagnosis due to insufficient training in diagnosing dermatological disease in skin of color, advanced presentation at time of diagnosis, and the lack of minority representation in dermatology” [5]. Darker skin colors can make it more difficult to diagnose disease, thus leading to the unexpected manifestation of illness. A significant contributor is the lack of instruction on ethnic skin disease. The dermatology curriculum focuses on Caucasian examples, neglecting how the condition looks on people of color. Researchers found that the percentage of skin-of-color images in dermatologic educational resources ranged from an alarming rate of 4-19% [5]. Thus, the lack of representation illustrates the neglect of adequate care toward people of color. Furthermore, the lack of education is a further barrier to proper skincare. Researchers have found that “blacks were less likely to believe that skin cancer is caused by lifestyle,18 yet we know that ultraviolet radiation exposure is the greatest risk factor for BCC in all skin types” [6]. Misconceptions about the symptoms of skin cancer can increase the risk of severe disease, along with the delay of intervention.
Intervention methods:
A significant barrier to equitable healthcare in dermatology is the lack of representation in the field and educational resources. To address this issue, medical schools should emphasize how skin disease manifests in various skin tones. Further research should also be on how to identify skin diseases on darker skin tones better. Without change, racial inequalities in health care will prevail, stopping society from moving towards better public health. Another intervention method is the spread of education to underserved communities. Increasing skin cancer awareness and debunking misconceptions can also aid a better future. Better education can lead to seeking care before it is too late, thus decreasing morbidity and mortality. Furthermore, increasing the representation of people of color in the dermatology workforce can reduce disparities. Medicine focuses on patient-physician relations. By
Review Editor: Kelly Ma
Design Editor: Priya Meesa
References
[1] Eczema stats. National Eczema Association. (2022, September 27). Retrieved November 12, 2022, from https://nationaleczema.org/research/eczema-facts/
[2] Skin cancer. American Academy of Dermatology. (n.d.). Retrieved November 12, 2022, from https://www.aad.org/media/stats-skin-cancer
[3] Smith, Y. (2019, February 26). What is dermatology? News. Retrieved November 12, 2022, from https://www.news-medical.net/health/What-is-Dermatology.aspx
[4] Akhiyat, S., Cardwell, L., & Sokumbi, O. (2020, February 19). Why dermatology is the second least diverse specialty in medicine: How did we get here? Clinics in Dermatology. Retrieved November 12, 2022, from https://www.sciencedirect.com/science/article/pii/S0738081X20300304
[5] Shango, K. H., Abdole, F. A., Gonzalez, S. M., Farshchian, M., & Moossavi, M. (2022, April 23). Reducing health disparities in dermatology medical students: CCID. Clinical, Cosmetic and Investigational Dermatology. Retrieved November 12, 2022, from https://www.dovepress.com/medical-student-confidence-in-diagnosis-of-dermatologic-diseases-in-sk-peer-reviewed-fulltext-article-CCID
[6] Bryn Mawr Communications. (n.d.). Health disparities and skin cancer in people of color. Practical Dermatology. Retrieved November 12, 2022, from https://practicaldermatology.com/articles/2019-apr/health-disparities-and-skin-cancer-in-people-of-color
[7] Perez, V., & Gohara, M. (2020, February 11). If you want to be it, it helps to see it: Examining the need for diversity in dermatology. International journal of women's dermatology. Retrieved November 12, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330424/
[8] Pathways: Inclusivity in Dermatology to increase number of Black, Latino, and Indigenous physicians in dermatology. Pathways: Inclusivity in dermatology to increase number of black, Latino, and indigenous physicians in dermatology. (n.d.). Retrieved November 12, 2022, from https://www.aad.org/news/pathways-inclusivity-in-dermatology-launch
increasing the representation of minorities, people of color will have facilitated relationships with physicians of their race. Mentorship programs and support chapters for pre-medical students will address this issue, leading to a more diverse field. Increasing diversity in dermatology is a dire need. Without resolving this issue, there will continue to be unequal access to healthcare, especially in underserved communities. “The American Academy of Dermatology (AAD), in collaboration with Johnson & Johnson Consumer Health* and the Janssen Pharmaceutical Companies of Johnson & Johnson** is launching “Pathways: Inclusivity in Dermatology” to increase the number of practicing dermatologists in the U.S. who are from the Black, Latino, and Indigenous communities, which are underrepresented minorities (URM) in medicine” [8]. Interventions like these will ultimately lead to more equity in terms of healthcare, which is the next step towards reaching equality both as a society and in medicine.