Skin of Color: A Missing Curriculum
In a recent clinical elective I came across a suspected case of cellulitis. The patient's presentation was textbook: skin warm and painful to the touch, evidence of swelling under the skin, slight fever. Missing, however, was one important clue: the red rash. I reviewed the literature and found dozens of photos showcasing the classic red rash on light-skinned individuals. But my patient had dark skin with a brown-black rash. Once certain, I now doubted my diagnosis.My predicament is not unique. In a recent New York Times article, "Dermatology Has a Problem With Skin Color," the author highlights this problem in medicine[1]. In medical school, we learn to recognize patterns and associations to diagnose patients. The many photos of cellulitis I've seen in my readings and lectures were all of light-skinned individuals. In contrast to examining X-rays, where interpretation relies on recognizing subtle changes between shades of black and white, analyzing a patient's skin encompasses a wider range of color variability and requires greater attention.
A study examining medical textbook images found that although racial distributions were close to that of the U.S. population, pictures of dark skin tone were under-represented[2]. Such limited exposure – as I experienced – can lead to pitfalls and treatment delays.
Throughout my training, I've heard variations of the phrase, "I don't see color" expressed with good intent. In some cases, however, this attitude isn't helpful and may be harmful.
Being "colorblind" is valid when looking at X-rays, but probably not the appropriate approach for diseases of the skin. With the help of VisualDx – an app that houses pictures of many skin diseases with a wider range of skin colors than the average textbook – I was able to confirm my patient's diagnosis and properly treat his cellulitis.
For me, the clinical pearl in this experience is the importance of learning what physical symptoms look like in patients of all colors. As Dr. Lester says in the article, "if you're only trained to look at something in one color, you won't recognize it in another color." Our efforts to be lifelong learners should not be limited to what we see in textbooks, but also include the perspectives of our patients.
References
[1]Rabin RC. Dermatology Has a Problem With Skin Color. The New York Times, The New
York Times, 30 Aug. 2020, www.nytimes.com/2020/08/30/
hispanic.html
[2]Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Social Science & Medicine. 2018;202:38-42
COVID-19 is the biggest health crisis that the U.S. and the world have faced since the 1918 flu pandemic. The immense pain, suffering and stress it has caused the country is immeasurable. At the same time, this crisis has led to some of the greatest acts of courage, compassion, humanitarianism, and leadership we have ever seen among health care professionals.
The overused "heroes work here" does not begin to tell the story of how many DuPage County health professionals – and especially physicians – have heroically helped thousands of patients and their families. As this pandemic has touched every person in the US, from the poor line worker to the President, DuPage County physicians have been leading Illinois and the nation in many ways.
From physicians and nurses walking into the COVID Unit every day, to care for the sick and dying, to the amazing leadership of chief medical officers like Stu Marcus of AMITA and Gary Stuck of Advocate Aurora Healthcare (both based in DuPage) guiding thousands of health care workers to optimize and improve care for so many, area medical professionals have truly redefined leadership during this pandemic. DuPage County’s medical school at Midwestern University, led by fellow physician Dean Thomas Boyle, continues guiding the training of hundreds of future physicians in these most challenging times. And deserving more attention is the incredibly important work that our public officials have been doing. Rashmi Chugh, MD, MPH, chief medical officer at our DuPage County Health Department, works tirelessly to guide our community’s successful medical response during this pandemic and remains an important leader in our DuPage County Medical Society (DCMS).
These and hundreds of physician leaders highlight how central physician leaders have been, and continue to be, during this COVID-19 pandemic here and across the country.
