By Tue “Felix” Nguyen, Bahar Momin and Marie Vu

Diversity in Dermatology–

A Need for More Inclusivity

By Tue “Felix” Nguyen, Bahar Momin and Marie Vu

Diversity in medicine has been a long-standing issue. Recently, there has been a push toward more inclusivity and representation within different aspects of medicine. As our minority populations grow, the diversity gap between physicians and patients will widen. The United States (US) Census predicts that from 2016 to 2060, the Black population will increase by 41.1%, and the Hispanic population will increase by 93.5%.1 Much like how diverse our patient populations are in the US, the same degree of diversity should be reflected within the physician workforce. When taking into account the different subspecialties in medicine, dermatology is considered the second least diverse specialty — second to orthopedics.2

The lack of diversity within medical schools and the medical workforce stems from racial biases and systemic barriers that prevent minorities from seeking higher education. According to the AAMC 2018 physician data, the percentages of the active physician workforce who identify as Black and Hispanic are 5.0% and 5.8%, respectively, compared to 56.2% of physicians who identify as white.3 In dermatology, only 3% of dermatologists are Black, despite making up 13% of the US population. Similarly, about 4% of dermatologists are Hispanic, compared to 16% of the general population.4 These percentages of minority physicians are disproportionate compared to the minority populations in the US, with dermatology demonstrating a four-fold discrepancy between physicians and patients.

Racial-discordant patient-physician relationships describe how physicians often treat minority patients of different races, which indicate that physicians do not accurately reflect their patient populations.5 This phenomenon goes beyond needing more physical diversity and more cultural diversity. While incorporating cultural sensitivity workshops within the medical curriculum may help mitigate the adverse effects of racial-discordant patient-physician relationships, minority patients often express more comfort being treated by providers of the same race.6 Human medicine should not only focus on treating the disease but also on the patient — both in mind and body. Therefore, cultivating a more inclusive physician workforce improves cultural familiarity and awareness during the diagnostic and treatment process, which is paramount to treating patients holistically.

When considering diversity from the patient’s standpoint, there is a lack of textual and photographic representation of skin of color (SOC) within dermatologic educational resources.7 A study found that out of 1,123 compiled images depicting different skin diseases from various medical student resources, only 14.9% were of darker skin tones, which is again disproportionate to the actual proportion of minority groups within the US population.8 The lack of proper training in examining SOC proves challenging when attempting to accurately diagnose and treat various skin conditions in people of color (POC). Even the most seasoned dermatologists have more difficulty assessing certain skin conditions in darker skin tones that would be otherwise easier to diagnose in lighter skin tones. The higher melanin levels camouflage erythema or alter the appearance of skin lesions from what would be considered “textbook normal.” As a result, minority patients with deeper skin tones may have poorer treatment outcomes and prognoses due to misdiagnoses and delayed initiation of treatments.

So, what can be done? Some action items include: 1) Increasing underrepresented in medicine (UIM) medical students' exposure to the field of dermatology and their level of interest in it,4 2) Increasing the number of UIM students recruited into dermatology residency programs,4 3) Improving SOC education in medical training.

Increasing UIM student exposure to dermatology can be accomplished by early mentorship. Frequently, minority groups are marginalized and deprived of certain advantages such as finances and social capital, which perpetuates the diversity gap in medicine. The Skin of Color Society offers a mentorship program that connects medical students and young physicians to SOC experts to provide guidance, resources and SOC education. For underrepresented students in medicine, the American Academy of Dermatology (AAD) offers a onemonth mentorship program that students can use to work on publications, research or clinical work. These programs can encourage students to explore the dermatology field by providing a point of contact to help guide them through the application process and cultivate their passion for the specialty.

Many dermatology residency programs have begun to offer away rotation scholarships to UIM students. These scholarships provide funding to eligible students to help pay for shelter, transportation and food, mitigating the financial barriers many minority students face. In dermatology, students are encouraged to rotate through as many away rotations as possible to enrich their learning and build a professional network. Therefore, these support programs provide much-needed resources and opportunities to these groups readily available to the financially advantaged. Students can research whether or not a program offers rotation scholarships by accessing the program’s website or by contacting the program’s department. The UT Health Long School of Medicine’s Dermatology Interest Group will occasionally send out information regarding these programs to interested members.

Properly educating medical students and residents on treating dermatological conditions in SOC is a vital aspect of providing quality care to the diverse populations of San Antonio. Medical educational resources and curricula lack SOC representation for different skin diseases. To address this lack of representation, medical schools and residency programs can add SOC modules to train the next generation of physicians to handle the wide variety of cutaneous presentations. The UT Health San Antonio Long School of Medicine has been integrating more lectures into the preclinical curriculum to educate medical students about the different morphologic manifestations in SOC. In addition, local and national conferences hosted by the Texas Dermatological Society and the American Academy of Dermatology have incorporated lectures focused on treating SOC, indicating that SOC underrepresentation is recognized even at the national level. By exposing future healthcare providers to the diverse presentations of skin conditions, the misdiagnosis and underdiagnosis of patients with SOC can be minimized.

Diversity in dermatology is increasingly needed as minority populations continue to grow. Dermatology specializes in all hair, skin and nail conditions and should play a more prevalent role in the movement for more inclusivity and advocacy for these marginalized communities. Addressing the barriers that prevent many minorities from entering medicine will significantly close the diversity gap, improving our patients' therapeutic outcomes.

References 1. Vespa J., Medina L., Armstrong DM. Demographic Turning Points for the United States: Population Projections for 2020 to 2060.

United States Census Bureau. 2018 March; 7. 2. Akhiyat S, Cardwell L, Sokumbi O. Why dermatology is the second least diverse specialty in medicine: How did we get here?. Clin Dermatol. 2020;38(3):310-315. doi:10.1016/j.clindermatol.2020. 02.005 3. Figure 18. percentage of all active physicians by Race/ethnicity, 2018. AAMC. https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018. Published 2019. 4. Pritchett EN, Pandya AG, Ferguson NN, Hu S, Ortega-Loayza AG,

Lim HW. Diversity in dermatology: Roadmap for improvement. J

Am Acad Dermatol. 2018;79(2):337-341. doi:10.1016/j.jaad. 2018.04.003 5. Cooper LA, Neil R Powe. Disparities in Patient Experiences, Health

Care Processes, and Outcomes: The Role of Patient-Provider Racial,

Ethnic, and Language Concordance. The Commonwealth Fund. https://www.commonwealthfund.org/publications/fundreports/2004/jul/disparities-patient-experiences-health-careprocesses-and. 6. Hopkins Tanne J. Patients are more satisfied with care from doctors of same race. BMJ. 2002;325(7372):1057. 7. Ebede T, Papier A. Disparities in dermatology educational resources.

J Am Acad Dermatol. 2006;55(4):687-690. doi:10.1016/j.jaad. 2005.10.068 8. Perlman KL, Williams NM, Egbeto IA, Gao DX, Siddiquee N, Park

JH. Skin of color lacks representation in medical student resources:

A cross-sectional study. Int J Womens Dermatol. 2021;7(2):195196. Published 2021 Jan 8. doi:10.1016/j.ijwd.2020.12.018

Tue “Felix” Nguyen, Bahar Momin and Marie Vu are medical students interested in dermatology at the UT Health San Antonio Long School of Medicine. They all served as clinic coordinators for the local student-run dermatology free clinic.