Two pandemics: Opportunities for diversity, equity and inclusion in dermatology.

In the setting of the tragic dual pandemics in the United States, SARS-Cov-2 superimposed upon ongoing racism, our specialty is being transformed. In 2020, this intersection has awakened many to the importance of diversity, equity, and inclusion in medicine and dermatology and has highlighted the importance of existing efforts to address structural racism and health care disparities. Deep reflection and specific actions confronting the complex causes of racism, inequities, and disparities in dermatology have led dermatology societies and their respective diversity committees, dermatology departments, and dermatology residency programs to take on initiatives that will have a long-term impact on these issues. We would like to take this moment to reflect on change in dermatology and imagine where we should be going.

Structural racism affects patients in dermatology, just as it affects outcomes in SARS-CoV-2 infections. In particular, structural racism limits access to care for communities of color. It has been well established that certain people have better access to dermatologists (Feng et al., 2018). To mitigate this inequity, the American Academy of Dermatology (AAD) started the AccessDerm program in 2018, which provides store-and-forward teledermatology services to those who would otherwise be unable to access dermatologic care. AccessDerm has assisted > 449 participating primary care providers, who in turn serve > 300,000 patients at 27 clinics belonging to the National Association for Community Health Centers, Rural Health Association, and Indian Health Service. Although we have all experienced the challenges of teledermatology, this is an important tool for improving access; however, it is not necessarily an all-encompassing solution.

Additionally, some dermatology departments provide no-cost services to underserved communities. For example, the attending and resident physicians from the University of Pennsylvania’s Department of Dermatology serve Puentes de Salud, which provides high-quality dermatology care to Philadelphia’s rapidly growing Latinx immigrant population. The University of Texas Southwestern’s Agape Clinic is a free dermatology clinic that serves marginalized communities. As a specialty, we should continue to promote legislation and policies that provide sustainable ways for all patients to access dermatologic care. In the meantime, organizations, departments, and individual providers should continue to think of ways to increase access to care.

Improving dermatology workforce diversity improves access to dermatologic care. Physicians from underrepresented groups are more likely to care for underserved patients, practice in low resource areas, care for patients who report poor health status, and have patients with Medicaid or who are uninsured (Xierali and Nivet, 2018). For these reasons, many have worked to improve mentorship in dermatology, an essential component to improving the diversity of our workforce. Many dermatology societies, including the AAD, Women’s Dermatologic Society, Society for Investigative Dermatology, Association of Professors of Dermatology (APD), Skin of Color Society (SOCS), and the Dermatology Section of the National Medical Association, have committed to encouraging and guiding medical student members of the Student National Medical Association and Latino Medical Student Association. Dermatologists from the AAD, Women’s Dermatologic Society, Society for Investigative Dermatology, APD, and SOCS have represented dermatology at the Student National Medical Association and Latino Medical Student Association annual meetings and have connected with medical students interested in dermatology. They have also hosted virtual diversity and inclusion panel discussions for students underrepresented in medicine (UIM) throughout the year. Additionally, these societies, along with the American Hair Research Society and Dermatology Foundation, have created medical student mentorships, observerships, and/or research programs that offer grants specifically for UIM medical students. These opportunities are essential for initial exposure to dermatology but are also important in building a competitive residency application that includes research and academic publications. This early exposure and mentorship, particularly by physicians in academic dermatology, could increase students’ likelihood of pursuing a career in academic dermatology. Racial and ethnic diversity in academic dermatology still needs attention (Xierali et al., 2020), and this is one way to address this deficit.

A more immediate mechanism to increase dermatology workforce diversity is to improve the success of UIM medical students applying to dermatology residency programs. In addition to using early exposure and mentorship to help applicants strengthen their applications, we must design a residency application process that minimizes bias. The APD is leading these efforts by developing recommendations and resources for holistic residency application review. Holistic review is a mission-aligned selection process that encourages committees to consider the whole applicant, including academic performance in the context of life experiences and distance traveled. Deemphasizing the importance of standardized tests is a component of holistic review and may improve the success of UIM students in attempting to match in dermatology. Standardized tests are biased against UIM students (Isaq et al., 2020) and have not been shown to predict clinical competence (Chen et al., 2019). The AAD’s yearly Diversity Champions Workshop is an instructive program that gives residency programs specific strategies to build a pipeline of UIM students and improve diversity.

The paucity of images of dermatologic conditions in skin-of-color educational resources has been documented (Alvarado and Feng, 2020). To close this gap, VisualDx, an online medical diagnosis tool, demonstrates pathology on dark skin in high proportion compared with other resources. The VisualDx website reports that approximately 30% of images in VisualDx are skin types IV to VI. Skin-of-color textbooks, rich in skin-of-color images, have been published since 1998 and include Taylor and Kelly’s Dermatology for Skin of Color (2016), The Dermatology Atlas for Skin of Color by Drs. Diane Jackson-Richards and Amit Pandya (2014), and Skin of Color by Drs. Andrew Alexis and Victoria Barbarosa (2013). Increasingly, textbooks that are not specifically focused on skin of color, such as Andrews’ Diseases of the Skin (2019), have improved their representation of skin-of-color images.

A study examining the experience of resident physicians and program directors revealed that few programs have a specific curriculum focused on skin of color. Additionally, few programs had a skin-of-color expert on faculty (Nijhawan et al., 2008). The gap in skin-of-color education is being addressed by the development of a skin-of-color curriculum sponsored by the AAD. Skin-of-color-themed conferences, such as the SOCS Annual Scientific Symposium and Skin of Color Update Series, are also helpful supplemental educational opportunities. Notably, the inclusion of skin-of-color speakers and diversity-focused sessions at the AAD annual meetings has increased from 2.5% in 2013 to 6.8% in 2019 (personal communication, Henry Lim, MD).

Finally, the SOCS hosted four conversations among clinical experts, thought leaders, and advocates in a collaborative discussion on the issues of health disparities, structural racism, and specific dermatologic diseases that disproportionately affect people of color in a series of four educational webinars cosponsored by the New England Journal of Medicine Group and VisualDx. These conversations serve to promote awareness of skin of color and the values of diversity, equity, and inclusion. They have been archived online and are available to all.

This national moment of illness, tragedy, and despair precipitated by the SARS-CoV-2 and civil unrest caused by insidious racial discrimination have sparked a reexamination of diversity, equity, and inclusion within dermatology. Although positive steps have indeed occurred over the past several years and in the first 10 months of 2020, much work remains to be done. We encourage you to join us in this important effort.

Funding

None.

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N/A.

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Susan Taylor reports the following roles: vice president of the American Academy of Dermatology; vice chair of Diversity, Equity and Inclusion in the Department of Dermatology at the University of Pennsylvania; co-chair of the AAD SOC Curriculum Committee; SOCS founder and former board member; panel member of SOCS’ Systemic Racism in Medicine series; a former WDS board member; and member of the Dermatology section - National Medical Association.