In medical curricula, students are faced with a multitude of cases and ailments as part of teaching and learning materials. Within the field of dermatology, images of atopic eczema, diabetic rashes or chicken pox scars can be witnessed over the course of medical education. A defining similarity has been noted between these images and learning tools. Most of them present with light or white skin, posing a challenge for the future generation of doctors and healthcare workers to identify the presence of diseases on darker skin tones. As medical educators, we need to audit our teaching resources to ensure that they are truly inclusive to enable our doctors to serve the diverse UK and global population and combat health inequalities. This article will discuss ethnic minority representation in medical education, how this impacts clinical practice and what can be done to prepare future practitioners to diagnose and treat patients of all skin types.
The problem we face
The problem of poor representation in medical education has been increasingly coming to light. In 2018, the University of Washington published the first study into racial diversity in textbooks. The results highlighted the distinct lack of representation of Black, Asian and minority ethnic (BAME) groups within the medical education system. The Atlas of Human Anatomy, a popular learning tool used by medical schools globally, holds less than 1 per cent of images featuring dark skin. The highest percentage reached 8 per cent, in Bates’ Guide to Physical Examination and History Taking. Following this, Salma Gilman highlighted this issue in her paper, which uncovered the culture that persists in medicine and the impact this has on clinical practice.
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The most alarming conclusion was that the lack of diversity in medical training and dermatology textbooks had led to misdiagnoses for patients of colour. Medical professionals are often trained to focus on white patients, which can make it difficult for them to recognise symptoms of diseases on various skin tones. One notable story referenced Lyme disease and how early recognition, diagnosis and treatment are essential in improving the prognosis. However, because of the lack of knowledge and awareness surrounding its presentation on skin of colour, these clinical milestones were missed, worsening the patient’s prognosis.
Ongoing interventions
Both the General Medical Council (GMC) and the Medical Schools Council (MSC), organisations leading policy change in clinical and union spaces for doctors, have taken steps to address the issue of a lack of representation. The most recent GMC report emphasised that “system-wide action to prevent or reduce health inequalities” needed to be carried out in order to “prepare doctors to meet the needs of diverse communities”. Organisations such as the GMC are opening modes of communication and reflection with medical schools and their members to implement strategies and interventions that serve the best interest of healthcare and medical education. Similarly, the MSC Equality, Diversity and Inclusion Alliance Report recommended that “Medical schools should audit teaching materials to ensure they cover diversity appropriately. One example of this would be implementing the teaching resources in Mind the Gap which covers clinical presentations in black and brown skin.” However, the conversation must continue, and collaboration is required among all stakeholders in medicine. By supporting lines of communication between bottom-up approaches (student-led initiatives) with top-down influence (GMC and MSC policymakers), change can be made in a sustainable and effective manner.
Continuing the momentum at the grass-roots level, below are suggestions for medical educators to ensure appropriate representation within medical education.
Use of diverse resources within medical education
Mind the Gap, by Malone Mukwende, is one among many educational and representative resources that can be used by medical schools to diversify images used in the curricula. Mind the Gap has aided medical students and the public in recognising diseased conditions on a wider range of skin tones, increasing the likelihood of accurate diagnoses and treatments for patients with darker skin tones. Currently, Mind the Gap is included in eight medical school-recommended reading lists in the UK. Dermatological textbooks that represent black and brown skin are crucial in tackling the internalised racism within the medical education system, and a step towards pushing for a future with adequate knowledge and risk perception of diseases on all skin tones.
De-centring whiteness by changing the language used
While this discussion has been focusing on the limited ethnic minority representation of physical presentations of skin conditions, language is a prevalent driver of this white-centred medical narrative. Looking at the National Health Service (NHS) website, descriptions of symptoms heavily focus on lighter skin tones, with a rash being described as “red” or “pink” and the colouration of jaundice being “orange tinted”. These descriptions, while they are accurate, are relevant only when observing on lighter skin tones. This information is not relevant to the diverse UK population, and this lack of information given to readers means that those with darker skin cannot identify with the written symptoms, Therefore, many fail to recognise certain conditions, leading to future complications owing to late diagnosis and infection. It is vital that medical schools work with national organisations such as the NHS to produce accurate descriptions for various skin tones and widen language used in both professional and educational settings. Medical schools should also audit their own websites, lecture materials and all teaching resources to use language that de-centres whiteness and actively promotes inclusion.
Normalising diversity in medical education
Normalising diversity is arguably one of the major milestones of this movement. Creating a culture within medical education that not only includes diversity in its teaching but accepts it as commonplace means that students from a multitude of backgrounds and ethnicities can be educated in an environment where they feel represented and a sense of belonging. This will enable future doctors to treat all patients equitably. Normalising diversity will be a long process; nevertheless, the movement towards representation cannot diminish. Students can help support this strategy by calling for more cases regarding ethnic minority patients to be integrated within seminars, lectures and problem-based learning groups. Another call for the inclusion of images and recommended reading lists will further enable the normalisation of diversity. While making progress, medical schools should prevent the tokenisation or stereotyping of ethnic minority cases or representation. Learning about disease presentations on darker skin tones should not be a tick-box exercise or deepen harmful stereotypes of diseases associated with darker skin tones. For instance, be mindful not to overuse black and brown images to represent only negative sexual and reproductive health outcomes.
As the sociologist and researcher Rima Wilkes has said: “People need to see themselves across all diseases, and this sentiment must be used by the medical world.” Hopefully, this will inspire medical schools, organisations, manufacturers and other parties to use lessons brought by the movement towards ethnic minority representation in the future of healthcare.
Musarrat Maisha Reza is a senior lecturer in biomedical sciences, and Naabil Khan is a medical student, both at the University of Exeter.
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