A group of U.S. researchers have discovered a lack of skin of colour articles in published scientific dermatology journals.
One of the lead researchers, Dr. Jenny Murase, at the University of California, San Francisco, said George Floyd’s death accelerated a reckoning in the dermatology profession with its focus on skin conditions.
“The inequities in our education became even more apparent than they’ve been in the past,” she explained.
Britney Wilson, a medical student from the Rutgers New Jersey Medical School, was another author of the study. She says she wanted to look into into the lack of skin of colour in dermatology literature because her own experience with the medical system.
“I know from my personal experiences that I didn’t have a physician of colour and they didn’t quite understand how to deal with my skin, or my hair. So I was just curious about where this gap in the knowledge is coming from,” she explained.
Wilson also noted that there had been prior studies that had been published in dermatology literature that showed physicians and residents weren’t being exposed to skin of colour.
“So it left me wondering, ‘If your school’s not teaching you about this and if there’s no textbooks on it, then where are people gonna learn how to manage certain conditions in patients with darker skin or kinkier hair?’”
Knowing that peer reviewed-literature was one of the only options for doctors to learn more about different skins of colour, Wilson decided to look at the top 52 dermatology publications to see “how well they are doing with documenting information on patients of colour.”
The published American study looked at 52 journals published between January 2018 to October 2020 and found the average percentage of overall publications relevant to people of colour is 16 per cent, ranging from two to 17 per cent. The study also found that higher-ranked journals tend to publish a smaller proportion of articles on skin of colour compared to lower-ranked journals.
Dermatology literature educates doctors in diagnosis and treatment. But if doctors cannot access dermatology literature on people with skin of colour, they cannot provide the highest quality of care to all patients, the study explained.
In Calgary, this type of research is having an impact. Dr. Jori Hardin, dermatologist and clinical assistant professor in the division of dermatology at the Cumming School of Medicine at University of Calgary, said Murase’s study is one of many that highlights that “dermatology is a field with pattern recognition and if the patterns that we’re teaching are mostly white skin, then you’re only getting half of the appropriate training or information.”
The American study found that journals from North America and Europe exhibited the lowest percentage of articles on people of colour (less than five per cent) while nearly two-thirds of all articles on skin of colour originated from a country with a high population of people with skin of colour.
From the results of the study, the researchers put together a list of recommendations to encourage inclusion of diverse patients in future dermatological publications and sent out a letter to the journals they analysed.
These recommendations included for journals to:
- Aim for at least 16 per cent of skin of colour in each issue
- Publish special editions on skin of colour only
- Encourage high-impact journals to publish more skin of colour content
- Use the key word of “skin of colour” to help the reader better identify literature
- Include Fitzpatrick skin type (a numerical classification schema for human skin colour, as defined by Wikipedia) when presenting dermatology patients clinically
However, many of the journals’ responses to the letters were underwhelming.
“It was really shocking to have some of the responses to those letters,” said Murase, co-author and researcher of the study.
“We sent individual letters to each publication to give them advice on how they could improve the content and we got responses like, ‘I don’t know the relevance’ [or] ‘I don’t understand the point of this.’”
Wilson also noted that she was surprised that some journals felt like the letter was out of scope.
“I feel like if anything, it’s something your readers should know, no matter what type of journal. If it’s a dermatology journal, the reader should be aware of the need to publish more papers that cover a wide range of skin complexions and ethnicities,” she said.
Murase argued that the main issue behind the lack of diversity of skin of colour in journals stems from the journal’s inability to identify the problem.
“Because if it doesn’t affect you, then of course you do not see the relevance.”
Wilson also noted that from her research, she was surprised that paediatrics dermatology did really well with including different skin of colour in its literature.
Quincy K. Ruffin, the diversity, equity and inclusion consultant with Unmasking the BiasPhere, also commented that “these issues with skin cancers and that sort of thing, for the minority community or the Black community, it’s not seen as an issue for them, to them. They don’t know how to check for certain melanomas on their skin. So they’re not going out to go to the doctor and ask,” he said.
Ruffin suggests that practitioners should seek out people to let them know of the issues and train general practitioners to look out for them so they can “see that it is a bigger issue than they might think right now.”
He also thinks that training needs to go even further and that it starts with doctor-patient communication.
“If there’s not good communication between the doctor and the patient, then all sorts of things happen. So actually getting doctors to understand that there are things that are affecting them, that put a wall between themselves and the patient, it can make it so that the doctor can actually do something about those things,” he said.
Which is why lead researchers of these studies, Wilson and Ruffin, are collaborating towards taking this type of research to the next level.
Both are currently creating a research study looking at stereotype threat and implicit bias.
“We will be looking at the ways in which these two phenomena can affect the experiences of dermatology patients when they are interacting with dermatologists who are not of their race,” Wilson explained.
Stereotype threat is the risk of confirming negative stereotypes about an individual’s own racial, ethnic, gender or cultural group. Ruffin said that patients experiencing stereotype threat can be more difficult to treat because they’ll be less likely to comply with the advice of the doctor.
This is why it is important to include more representation of skin of colour not only in literature, but as Ruffin states “it’s more important to train these clinicians and doctors on how to avoid triggering those stereotype threats and having these microaggressions, which trigger it as well,” he said.
The researchers also note that the standard used to determine skin colour, the Fitzpatrick scale, is problematic because it ranks the darkness of skin, but not how easily some burn – a key concern for dermatologists.
“There’s a movement to try to change the Fitzpatrick skin types because someone from Korea or Japan, they have incredibly fair skin. They’ll burn in five minutes out in the sun, but they’re still labelled skin type three. So there’s definitely a movement to reflect about the actual amount of pigment present in the skin, as opposed to this very old-fashioned way of doing it,” Murase explained.
Murase hopes that these journals will make it a top priority to include more skin of colour in literature so that they can understand that it is a very relevant issue.
Correction: An earlier version of this story indicated that the Dermatitis Society did not support skin of colour improvement suggestions made by Dr. Murase and her research group. Indeed, the Dermatitis Society did support these. The Calgary Journal regrets the error.