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“Until the color of a man’s skin is of no more significance than the color of his eyes.” — Bob Marley, “War”

Racial inequity in the U.S. health system is, in many ways, far deadlier than police violence.

The failures of the health care industry to appropriately care for Black patients are well-documented, resulting in the lowest life expectancy of any major group in the U.S. In addition to poverty, lack of access to care, and inadequate treatment, people of color are also dying due to bias in medical education, clinicians’ insufficient exam skills, and lack of appropriate information tools. The medical community needs to wake up and start fixing the way we recruit, train, and equip clinicians to reverse the trend of Black Americans dying too early and too often.

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My specialty, dermatology, is a prime example of the kinds of changes we need.

The skin is considered a window into health. But clinicians who haven’t been properly trained often fail to see some conditions in patients with Black skin. Reggae pioneer Bob Marley died of melanoma, a treatable skin cancer that is often missed and misdiagnosed in Black people. It becomes fatal if left untreated.

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I’ve seen patients of color misdiagnosed because clinicians could not recognize their rashes. I’ve seen immunologic diseases such as lupus, life-threatening drug reactions, and other conditions that manifest themselves on the skin get missed for the same reasons. I recall one very ill patient who was transferred to our hospital two weeks after a life-threatening drug reaction began from a sulfa-based antibiotic used to treat a urinary tract infection. She had body-wide blistering and ended up in the burn unit because the nurse and physician who initially evaluated her did not recognize the early skin clues and missed the diagnosis entirely. It was a miracle that she survived.

What went wrong in that case is a sadly common occurrence.

Inflammation caused by increased blood flow appears red or pink on white skin. That’s what clinicians are trained to recognize. In brown or Black skin, though, inflammation often appears brown or violaceous. Most medical and nursing students, and even many experienced clinicians, don’t know that because most medical textbooks severely underrepresent disease manifestations on pigmented skin. This failure to train clinicians to effectively diagnose disease in people with pigmented skin contributes to lopsidedly negative outcomes for Black patients.

But unlike many of the pervasive economic, historic, and cultural factors driving poor health in the Black community, we can fix this problem today by having health systems and medical and nursing schools teach the skin exam in people of color to reduce error and bias; train clinicians about specific treatments for diseases that occur more often in patients of color; and advance tools and education that position clinicians to provide excellent care for every patient.

Racial bias in medicine is also tied to the images clinicians use to communicate with their patients. Showing patients one or more pictures of their condition is highly effective for communicating a diagnosis, educating them, and building trust. This is especially true in the current environment of Covid-19 when telemedicine is increasingly being used. But when people of color have their clinicians explain a disease process with images that do not look like them or their condition, it creates confusion, undermines trust, and ultimately affects patient behavior and outcomes.

Early on in my career, I recognized that showing reference images to patients that represent not only their condition but also their skin type can transform the conversation. It takes less than a minute to show a patient a comparable image to explain his or her diagnosis, but it makes a monumental difference and it shows you took the time to care.

Practices, clinics, and hospitals need to diversify their patient education materials to start dissolving these barriers to better patient-doctor relationships and optimal patient health. Medical image databases, books, and decision support tools must showcase the entire spectrum of skin colors to better represent the diverse patient populations we care for. By teaching clinicians-to-be using a range of skin types, and increasing access to diverse images that build patient knowledge and trust, we can start bringing equity to the practice of medicine, diagnosis, and patient education.

The horrific death of George Floyd has led many white Americans like me to reexamine our personal biases and the structural racism that has plagued our country since its founding. Medical professionals must address racial disparities in care immediately and start taking the life-expectancy gap for Black Americans as seriously as any other factor contributing to the deaths of thousands of people every year. To do this, we all need to acknowledge that racism in medicine is not simply about poor access, inequitable care, or hiring bias — it is also at the core of how we teach and practice medicine with people of color. We can, and must, do better.

Art Papier is a physician and CEO of VisualDx, a medical informatics company affiliated with the University of Rochester.

  • Please, please, please I beg of you repost this article in every physician, NP/PA forum you can. I was truly blessed as a wee resident to have a derm rotation where the preceptor was all about finding me examples of skin diseases on African American & differently pigmented skin. It has served me well. I do my best to pass along the same info furiously trying to search for pictures on line to my junior colleagues & students. I am a Fitzpatrick I with vitiligo (kinda funny I know) but if I treated by what I expected to see on fair skin I’d be lost!
    My friends, & family are also a wonderfully diverse bunch. Unfortunately it seems because this training on the beautifully deeply pigmented skin of nieces is lacking in their doc… I get a LOT of blurry photos of rashes.
    We need to spread the love on the training. We need to learn to embrace the inclusiveness here too.

  • I have experienced this occurrence at least once. Thank you for addressing this life threatening habit within the medical profession.

  • “Medical professionals must address racial disparities in care immediately and start taking the life-expectancy gap for Black Americans as seriously as any other factor contributing to the deaths of thousands of people every year.” I think that the component of racial discrimination in the healthcare system contributes very little to shorter Black life spans. Look to poverty, stress, violence and a lower standard of self-care (for a variety of reasons)

    • Carlos, many years ago, even before medical school, I started questioning how much patient behaviors and circumstances contributed to poor outcomes, vs. the contribution of clinician behaviors. Then as an investigator at the CDC, as I explored health outcomes by SES, I began to see the sort of, I guess the word is terrifying… reality of maternal and child health outcomes in the US. Briefly, much of the disparity is the far higher proportion of the Black population living in severe poverty. No surprise there. The surprising thing is that in Black women who emerge from poverty to highly successful careers and high SES their high SES is not NEARLY as protective as it is white women, so the racial disparities are far more dramatic than in poor populations. Black women are far less likely to smoke (before, during and after pregnancy) than whites. Yet prematurity and low birthweight are actually higher in Blacks than whites and specifically, lower in nonsmoking blacks than in white smokers. In general, black women with white physicians are far less likely to be referred for breast and colon cancer screening than white counterparts despite their much higher risk of death if they actually develop those diseases. When their more fulminant and deadly conditions present during relative youth, with dramatic symptoms, like rapidly growing breast masses in young women in their thirties or abd pain, severe weight loss and anemia, pallor is missed and fainting and anorexia dismissed as malingering or depression. We have met the enemy… and it is we.

    • Sorry… I meant prematurity and low birthweight are more common in nonsmoking blacks than in white smokers. It’s hard to even write that. Conversely, the health impact of smoking in blacks is far more dramatic than in whites. Perhaps because of this Lowe level of smoking I blacks, the advertising pressure to smoke in black communities is relentless. Anyway, wanted to correct that error.

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