Meeting the needs of patients with skin of colour
Patients may prefer dermatologists who look like them, but all dermatologists have a duty to pursue medical and cultural knowledge to effectively care for all patients (1,700 words, 8 minutes)
Skin Spectrum Weekly is published with unrestricted supported from Bausch Health Canada
It may seem that having patients with skin of colour treated by dermatologists who share their skin types and cultural backgrounds is a simple way to ensure the patients receive understanding care. However, that is not a realistic solution and, in some ways, would represent a neglect of the duty of dermatologists to provide the best care possible to all patients.
That was the primary message of a talk by Dr. Renée A. Beach at the 2022 Summer of Dialogue: Focus on the Black Dermatology Patient colloquium on Aug. 17.
Dr. Beach is the founder and medical director of DermAtelier on Avenue, a dermatology practice in Toronto.
“We hear a stated desire from patients who have Black skin or are of Afro-Caribbean descent: ‘I came to see a Black dermatologist because. . .’,” said Dr. Beach. “Or: ‘You will understand my skin. You will know what is going on.”
That may seem to make perfect sense, she said, as someone who is of a particular demographic or background or has a cultural understanding may be better able to relate to a patient. “In theory, there may be nothing wrong with that idea,” Dr. Beach said.
Dr. Beach noted that the ratio of dermatologists in Ontario to the province’s total population is one dermatologist for every 54,237 people. “Just to put this into further context, the average family doctor may have a roster of about 1,000 to 1,500 patients,” she said.
However, Dr. Beach said there are currently only five Black dermatologists in Ontario and approximately 625,000 Black individuals in the province, based on the most recent statistical data from 2016. “So that ratio goes from 54,000 for one dermatologist to 125,000 for one Black dermatologist.”
“Really and truly when we are thinking about what makes a dermatologist effective, it is the willingness to pursue diagnostic clarification, which may mean biopsying more often or it may mean seeing a patient back for an extra follow-up visit,” or moving a patient to a second or third-line therapy, said Dr. Beach.
“What it boils down to is all of us who are practicing dermatologists have to care,” said Dr. Beach. She added that dermatologists have to recognize that some patients will take longer to diagnose, possibly because a dermatologist may not have been exposed to as many clinical presentations during their training or daily practice.
Dr. Beach said there are steps physicians can take to help them provide good care for all patients, regardless of the dermatologist’s background. These include:
Attending skin of colour-specific professional conferences
While attending conferences, seek out presentations on topics that are unfamiliar—work to reduce areas of weak understanding as much as to bolster areas of already deep understanding
Work to support efforts in dermatology education to expose medical students to a range of clinical conditions that appear differently across the skin spectrum
Encourage dermatologists in training to seek elective experiences abroad in different cultures and work environments
“As clinicians, we are not magicians. We are as good as what we are exposed to,” said Dr. Beach.
It is also important to evaluate the language used and how conditions are categorized, she noted.
As an example, she asked why melasma and certain post-inflammatory hyperpigmentation—which disproportionately occur in patients with Brown or Black skin—are considered cosmetic, while conditions such as rosacea are considered medical with various medication options that a drug benefit plan would cover. She said it is worth examining how these conditions are categorized and what that means for the average patient.
Bottom line: Patients may prefer a dermatologist with a similar skin type and cultural background, but that is impractical. To ensure all patients receive the best possible care, dermatologists in practice should be prepared to take extra time to ensure a correct diagnosis for each patient. They should pursue educational opportunities to improve their understanding of disease presentation in skin types they are unfamiliar with and encourage students of dermatology to do the same.
From the literature on dermatology education on skin of colour
Improving the recognition of dermatological conditions in skin of colour amongst undergraduate and postgraduate trainees: A cross-sectional quality improvement project
This paper describes a Quality Improvement Project in the U.K. intended to improve the confidence of medical students and junior doctors in recognizing dermatological conditions in skin of colour (SoC).
The investigators developed two educational interventions to introduce participants to the clinical presentation of dermatological conditions in SoC. A five-point Likert scale to measure the participants' confidence and an eight-question assessment helped quantify knowledge differences.
Results showed that 39% of students and 67% of junior doctors had not received SoC teaching during their undergraduate training. Following the lecture, the mean Likert scores for confidence recognizing conditions in SoC had increased in the medical student and junior doctor cohorts by 2.50 (p<0.0001) and 1.82 (p<0.0001), respectively. The mean assessment scores increased by 3.684 (p<0.0001) and 3.865 (p<0.0001) points, respectively.
The authors write that their results confirm the under-representation of SoC in medical education and highlight the need to diversify undergraduate and postgraduate curricula.
Under-representation of skin of colour in dermatology grand rounds cases: A single-center retrospective study
The study authors evaluated grand rounds presented at a single institution to assess the overall distribution of skin types and variation by diagnosis of the cases.
This study was a retrospective descriptive analysis of photographs of adult and pediatric patients presented at grand round conferences between July 2015 and Dec. 2019. There was no formal criteria or protocol for choosing the weekly cases. Instead, residents choose from cases volunteered from the University of Pennsylvania or private practices by co-residents. They chose cases based on their perception that the cases represented topics that needed further discussion or were of educational value or interest.
Cases without visible background skin were excluded.
Two of the study authors independently coded the photographs by Fitzpatrick skin type, and any discrepancies were evaluated by a third author to achieve consensus. The images were also coded by favoured diagnosis.
A total of 817 cases were evaluated. Fitzpatrick type II was the most represented skin type (43.1%). Combined, skin types V and VI totalled 14.2% of cases.
The authors compared these findings to patient-reported racial demographics for all department outpatient visits at the Perelman School of Medicine from July 1, 2015, to Dec. 31, 2020. In those reports, 41.4% of patients identified as non-white (including American Indian, Asian, East Indian, Hispanic/Black, Pacific Islander, and Black), and 32.3% of patients identified as non-Hispanic Black.
In their conclusion, the authors say their analysis suggests a predominance of light skin types in grand rounds cases, with 76.7% of cases with types Fitzpatrick I to III in a patient population self-identified as 58.6% white.
Dermatology education in skin of colour: Where we are and where do we go?
This paper includes a discussion of studies that have examined the representation of dark-skinned images (DSI) within dermatology resources commonly used to educate medical trainees in Canada and the U.S.
Also discussed are studies exploring the value dermatology residents place on skin of colour (SoC) teaching and exposure to patients with SoC during clinical training.
The authors describe initiatives undertaken by Canadian universities to enhance SoC representation within their dermatology curricula and to improve SoC dermatology education.
They also make recommendations for steps to improve medical education in dermatology for SoC.
Racial and ethnic healthcare disparities in skin cancer in the United States: A review of existing inequities, contributing factors, and potential solutions
The authors of this paper review existing skin cancer literature to quantify racial and ethnic inequities, highlight contributing factors, and propose practical changes.
To conduct the review, investigators searched PubMed to identify articles related to racial and ethnic health care disparities in melanoma, basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and dermatofibrosarcoma protuberans.
The authors identified factors that include not only differences in clinical presentation and genetic risk factors but also cultural beliefs, available educational resources, and access to specialty care and insurance.
The authors conclude that increasing awareness of and familiarization with innate factors and potentially more modifiable contributors can help inform efforts to close the observed gap in racial and ethnic inequities in skin cancer outcomes.
VIDEO: Exploring diversity and facing our biases in healthcare—University of Oklahoma’s skin of colour symposium, 2021
At the intersection of skin and society
On Friday, Aug. 19, Prime Minister Justin Trudeau announced his nomination of Michelle O'Bonsawin to the Supreme Court of Canada.
Justice O’Bonsawin, an Abenaki from the Odanak First Nation, will become the first Indigenous person to serve on the highest court in Canada.
A press release about the nomination notes that O’Bonsawin has served as a judge on the Ontario Superior Court of Justice since 2017. She holds a PhD in law from the University of Ottawa.
O’Bonsawin’s legal expertise includes the areas of mental health, Gladue principles—which apply when an Indigenous person is charged with a crime in a Canadian court—labour and employment law, human rights and privacy law.
Commenting on the nomination in an interview with CBC’s The Current, Indigenous lawyer Bruce McIvor said O'Bonsawin's nomination as the first Indigenous person to Canada's Supreme Court is a historic step, but he thinks the country's highest court needs, at minimum, three Indigenous people.
"In the same way that there's a requirement for three justices from Quebec, [and] there's a tradition of three from Ontario, there should be three Indigenous appointments," said McIvor, a partner at First Peoples Law and a member of the Manitoba Métis Federation.
September is Alopecia Areata Awareness Month in the U.S.
Sept. 1 is National Acne Positivity Day in the U.S.
Something to think about in the week ahead…
As part of the second annual Mercy Alexis keynote lecture at the 2022 Summer of Dialogue Colloquium, Focus on the Black Dermatology Patient, Dr. Pearl Grimes discussed some of the gaps in knowledge related to aesthetic treatment of Black and Brown skin.
Register now for the 2022 Skin Spectrum Summit
Registration is open for the 8th annual Skin Spectrum Summit. This all-day hybrid event will be held on Saturday, Sept. 17, 2022, from 8:00 a.m. to 4:30 p.m. EDT. Delegates can attend the Summit in person at the Chestnut Conference Centre in Toronto, and the presentations will also be viewable virtually through a webinar platform.
The Skin Spectrum Summit is a landmark educational congress of healthcare professionals dedicated to providing better dermatologic care for Canada’s diverse population.
The conference provides education on treating patients across all six Fitzpatrick skin types, emphasizing care for Types IV-VI.
Confirmed faculty for the 8th annual Skin Spectrum Summit include:
Dr. Andrew F. Alexis
Dr. Yvette Miller-Monthrope
Dr. Danielle Marcoux
Dr. Rachel Netahe Asiniwasis
Dr. Raed Alhusayen
Dr. Gary Sibbald
Dr. Geeta Yadav
Dr. Monica Li
Dr. Victoria Smart
Dr. Renée Beach
Dr. Jaggi Rao
Read Skin Spectrum Weekly for updates on Summit faculty and programs.
Register for the 8th annual Skin Spectrum Summit here:
If you like Skin Spectrum Weekly, why not check out our other publications, podcasts and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
A report on the impact of acne scars on patient quality of life, with Dr. Jerry Tan of Windsor, Ont.
How new innovations in cosmetic dermatology can contribute to patient satisfaction, featuring interviews with Dr. Fred Weksberg (Toronto), Dr. Andrei Metelitsa (Calgary) and Dr. Jaggi Rao (Edmonton).
Plus regular features, including the popular column “Vender on Psoriasis” by Hamilton, Ont. dermatologist Dr. Ron Vender.
To apply for a complimentary* subscription or to receive a sample copy, please email email@example.com with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
In the sixth episode of season two of the Vender on Psoriasis Podcast, Canadian dermatologist Dr. Ronald B. Vender talks about paradoxical eczema in psoriasis patients on biologics, real-world blood screening and patient satisfaction with brodalumab
And if you’re looking for a web destination for all things derm, please visit derm.city, “Where Dermatology Lives.”