Three Strategies to Boost Skin of Color Representation in Medical Schools

Data shows that people of color (POC) throughout the United States experience higher rates of morbidity and mortality across a wide range of health conditions compared to their White counterparts¹. Disparities pervade every area of medicine, and dermatology is no exception. Textbooks, research, and clinical training have disproportionately shown skin disease on White patients, often leading to a later diagnosis, worse prognosis, and poorer health outcomes for POC². While the formal curriculum emphasizes an equal standard of care for all patients, this objective is undermined by unequal representation in graduate medical education and beyond³. Below are three ways medical schools can improve skin of color (SOC) representation in both preclinical and clinical course materials so that physicians are better prepared to treat POC.

#1. Increase Access To SOC Resources

Better access to SOC resources in medical programs would provide students with the tools to learn how different diseases manifest on diverse skin tones. According to an article published in the Journal of American Academy of Dermatology (JAAD), top resources for SOC images include:

• JAAD Case Reports
• Journal of Drugs in Dermatology
• Cutis
• Dermatologic Societies AAD
• Skin of Color Society
• VisualDx
• Skin Deep

These resources were chosen “based on accessibility, number, and proportion of SOC images within the section (50% or more), covering a broad spectrum of conditions⁴.” Many of these resources are free, have open access, or include a subscription that can be integrated into many institutions.

Medical programs should prioritize access to these resources and increase awareness among students and faculty members so they can be utilized within the curriculum itself or as third-party resources.

Studies found that the representation of race in lecture slides does not reflect the racial demographics of the U.S. population, with images predominantly showing White skin².

Lecturers should prioritize the inclusion of medical images showing both light and dark skin wherever possible.

Many of the resources mentioned above make it simple for educators to include SOC images in their lectures and cite their source. Additionally, side by side images of the same disease on lighter skin and darker skin can emphasize the different characteristics across skin tones. Learning objectives can also prioritize discussing these key differences so that students become more comfortable recognizing these conditions in POC⁵.

To track progression, faculty should gain feedback from students via end-of-course evaluations. This would allow the school to measure effectiveness of the skin tone diversity in their curriculum and hold faculty members accountable for inclusive teaching practices. One example of a statement that can be used in the evaluation is: “The course provided exposure to images of skin conditions on diverse skin tones.” Students can rank their agreement with these statements on a five-point scale ranging from strongly disagree to strongly agree.

A similar format had positive results in an intervention study to increase SOC representation in a pre-clerkship dermatology course⁵. These evaluations can be extended to any course that includes disease manifestations on the skin. Students can also have the option to leave comments or suggestions for faculty members, providing specific ways to improve representation.

In closing, these are three specific ways that medical institutions can prioritize diversity and inclusion in their curriculum. To reduce the disparities in medicine, change must happen individual and systemic levels. The underrepresentation of POC in the curriculum is doing a huge disservice to the diverse patient population in our country. From day one of medical school, images and case scenarios should be inclusive of all racial and ethnic backgrounds, ensuring that when students graduate, they feel comfortable identifying skin conditions on any patient who needs their care.

References

1. Feagin, Joe, and Zinobia Bennefield. “Systemic racism and U.S. health care.” Social science & medicine (1982) vol. 103 (2014): 7-14. doi:10.1016/j.socscimed.2013.09.006
2. Louie, Patricia, and Rima Wilkes. “Representations of race and skin tone in medical textbook imagery.” Social science & medicine (1982) vol. 202 (2018): 38-42. doi:10.1016/j.socscimed.2018.02.023
3. Karnieli-Miller, Orit et al. “Which experiences in the hidden curriculum teach students about professionalism?.” Academic medicine : journal of the Association of American Medical Colleges vol. 86,3 (2011): 369-77. doi:10.1097/ACM.0b013e3182087d15
4. Chang, Michelle J, and Shari R Lipner. “Resources for skin of color images.” Journal of the American Academy of Dermatology vol. 84,6 (2021): e275-e277. doi:10.1016/j.jaad.2021.01.040
5. Yousuf, Yusef, and Jaime C Yu. “Improving Representation of Skin of Color in a Medical School Preclerkship Dermatology Curriculum.” Medical science educator vol. 32,1 27-30. 30 Nov. 2021, doi:10.1007/s40670-021-01473-x