Improving skin of colour representation in derm education
Studies show efforts to increase skin of colour representation in dermatology education materials and curricula are progressing, but more work is needed (1,730 words, 9 minutes)
There is a lack of representation of skin of colour in dermatology textbooks and medical school curricula that is affecting the ability of physicians to treat darker-skinned patients effectively, said Nickoo Merati, a fourth-year medical student at McGill University in Montreal, during the 7th annual Skin Spectrum Summit on Nov. 6.
As part of her talk, Merati explained how in 2020, she and other Canadian students approached the undergraduate medical education committee at McGill to collaborate on an anti-racist review of the school’s entire pre-clerkship curriculum. The study included all blocks, but the dermatology component was identified as a priority, she said.
Merati explained that the review was conducted by two independent blinded reviewers—with a third reviewer to resolve discrepancies—who went through the 70 hours of lecture material on dermatology. The reviewers noted if only pictures of white skin were used, or if descriptions were based solely on white skin. They also noted if dark skin was overrepresented for specific conditions such as STDs.
She said that this project was used to update the curriculum and course materials of the dermatology program at McGill and is now being used with first-year medical students. The review is underway for other blocks, including cardiology and gynecology, she said. Merati said that she and the other medical students who initiated the review are also currently doing a research project to evaluate the whole process, which can then be shared with other medical schools.
Also, to help detail the limitations in existing educational materials, Merati cited an article from 2020 in Stat, a U.S. health news website, titled “Dermatology Faces a Reckoning: Lack of Darker Skin in Textbooks and Journals Harms Care for Patients of Colour.”
“This article highlights that in dermatology, where images are critical for diagnoses, the lack of images of darker skin poses a roadblock to proper treatment and medical education, underscoring the fact that we need a diversity of images,” said Merati.
She also cited a study by Dr. Jules Lipoff and colleagues (J Am Acad Dermatol Jan. 2021; 84(1):194-196) that looked at skin of colour representation in commonly used dermatology textbooks, including Bolognia's Dermatology and Fitzpatrick's Colour Atlas.
Findings from that study include:
Only 4% to 18% of the images in the texts represented skin of colour
Representation of common conditions in skin of colour was limited—half the texts had no images of acne in darker skin
Dark skin was over-represented in depictions of sexually transmitted infections, such as syphilis
Merati also described research by medical students at the University of Ottawa who conducted an environmental scan of all 17 medical schools in Canada regarding skin of colour representation in dermatology teachings. Their findings, published online in J Cutan Med Surg (Sept. 9, 2021; 12034754211045377), found that in the academic year starting in 2019, only five of the schools had representation. In the following academic year, this had increased to 14 of 17. She said the students also found that in 2019, less than one-quarter of dermatology lectures presented phototypes of darker skin. In 2020, that had increased to three-quarters.
“This highlights an improvement from the 2019 to 2020 years, most likely due to the increased advocacy surrounding the Black Lives Matter movement,” said Merati. “But there is still room for improvement. This is not yet all schools, and this is not yet all dermatology lectures.”
Bottom Line: Skin of colour is underrepresented in commonly used dermatological textbooks and in medical school curricula, making it harder to know how to treat darker-skinned patients. Activist movements such as Black Lives Matter may have helped bring more attention to these issues, but there is still much work to be done.
From the literature on ethnodermatology education
Improving the representation of skin of colour in a medical school pre-clerkship dermatology curriculum
This article, from the Faculty of Medicine and Dentistry at the University of Calgary in Edmonton, describes a project to improve the representation of skin of colour in a pre-clerkship dermatology medical school curriculum. The people behind the project used a constructivist approach, adding images and discussion points on skin diseases in persons of colour into existing teaching sessions.
The authors report that student evaluations of the changes showed a strong agreement with the idea that the project improved exposure to images of dark skin and improved the students’ comfort in identifying skin conditions in persons of colour.
Altmetric analysis of skin of colour articles: A cross-sectional study
To investigate online attention to research articles on skin of colour (SOC), as well as publication trends for these articles, the authors of this paper searched records from the science data company Altmetric.
They extracted data on media outlets, citations, page views, journal impact factors and the Altmetric attention score (AAS).
Their sample ended up including 425 articles published in 114 journals. The included articles had on average an AAS of 13 (0-423), 42 citations (0-1,214), and 2,728 page views (7-15,000).
Between the first half of the study period (1993-2006) and the second half (2007-2021), there was a 7.8-fold increase in the number of SOC articles published. The total number of SOC articles increased by 57% from the years 2011-2015 to 2016-2020.
The authors found that AAS correlated well with citations, page views, and impact factors.
Of the 50 articles with the highest AAS, 37 were published between 2016 and 2021. The top four AAS articles focused on SOC representation in educational resources.
The authors conclude that it is promising that more SOC articles are being published in recent years and are gathering more attention. However, they note SOC articles remain less frequently read than other dermatology articles.
Leveraging artificial intelligence to improve the diversity of dermatological skin colour pathology: Protocol for an algorithm development and validation study
The authors of this paper write that advances in deep learning artificial intelligence (AI) could be used to reduce inequalities in skin cancer prognoses and survival rates if the skin types represented in image libraries used to train them could be more diversified.
They intend to try and address the shortage of images of dark skin in dermatology image libraries by having an AI system artificially generate images that combine existing images of skin cancer lesions in light skin with images of lesion-free darker skin types.
Evaluators with a range of medical backgrounds, experience and training will be asked to evaluate whether the images appear artificial. A sub-panel of dermatologists will determine the accuracy of the disease presentation.
If this process produces useful synthetic images of skin cancer in dark skin, the authors will then use the images in the training of an AI early detection model for skin cancer.
Misconceptions of photoprotection in skin of colour
The authors of this paper note that recommendations for photoprotection based on skin type released by medical societies and the U.S. Food and Drug Administration have been evolving along with the knowledge base. However, misconceptions remain about skin damage related to sunlight and the benefits of photoprotection, particularly among people with darker skin types. Both patients and physicians still hold these misconceptions.
To try and address these misconceptions, this review summarizes currently available evidence of the impact of both UV and visible wavelengths and the low utilization of photoprotection measures among people with skin of colour. The authors write that their goal is to provide recommendations to help educate patients.
VIDEO: Identifying blemishes in skin of colour education—Elizabeth Dominguez, 2022
At the intersection of skin and society
A project from the Department of Geography at the University of Victoria (UVic) in Victoria, B.C. is supporting communities in Tanzania and Canada in documenting efforts to have Indigenous people lead decision-making regarding natural resources.
A news report from the university says this project illustrates how partnerships can advance the United Nations Sustainable Development Goals and the UN Declaration on the Rights of Indigenous Peoples.
The news report notes that UVic geography grad student Kate Herchak’s thesis work is a crucial part of a larger UVic geography research project on the international collaboration. Herchak is Inuk on her father’s side from Kuujjuaq, Que. She has conducted research with Maasai youth exploring how youth maintain cultural connections and knowledge despite increasing pressure to relocate to larger cities, according to the article.
In Tanzania, the Enguserosambu Forest Trust (EFT) is a community forest management body mandated to draw upon cultural traditions in its operations. The article notes that UVic researchers say the EFT offers a model that can be applied to other communities and that they plan to use community-driven, participatory research methods to increase the capacity of the participating Indigenous communities in Tanzania and Canada, particularly the Loita Maasai and the Carcross/Tagish First Nation of the Yukon.
As part of the UVic project, for several weeks in summer 2022, Tanzanian youth will use photography and video equipment to record and explain how they and their peers maintain connections with their own culture and traditions, gathering information and knowledge.
This is one part of a two-year Indigenous Knowledge Bridging of Land and Water Stewardship in Tanzania and Canada project. The project is funded by the Social Science and Humanities Research Council (SSHRC), an agency which works to access and mobilize Indigenous-led knowledge that will enhance land and water governance and self-determination for Indigenous Peoples in both countries, while also increasing research capacity.
“Indigenous people have always been experts in international development, and part of this work is recognizing all this knowledge that Indigenous people have,” Herchak said in the article. “This presents a special opportunity for Indigenous youth to be partners in research and to push the narrative on the role of youth within Indigenous economics, and what the parallels are that we can learn from.”
This week
May is Skin Cancer Awareness Month in the U.S.
May 3 to May 9 is National Sun Awareness Week in the U.K.
May 3 is World Press Freedom Day
Something to think about in the week ahead…
Next week
At the first-ever Atopic Dermatitis Summit on April 23, 2022, Dr. Marissa Joseph spoke about key diagnostic features of atopic dermatitis in deeper skin tones. Skin Spectrum Weekly will report on Dr. Joseph’s presentation.