PracticalDermatology

In November 2020, Practical Dermatology® hosted a virtual roundtable discussion on Diversity and Inclusion in Dermatology. This discussion was supported by L’Oreal Dermatological Beauty brands CeraVe, La Roche-Posay, and SkinCeuticals. A panel of dermatologists and industry executives discussed the challenges facing the field due to a lack of diversity in physician and industry representation, clinical trials, and more. From the effects on patient care to treatment outcomes, they share personal insights about the issues, what needs to change, and opportunities to makes those changes a reality that will improve access to dermatology for people of all races and ethnicities.

In part 1 of this 2-part series, which you can read here, this panel of dermatologists and industry professionals discussed that lack of diversity in race and ethnicity in dermatology impacts everything from clinical trials to physician and industry representation. Ahead, in part 2, the roundtable participants continue the discussion about diversity and inclusion with a focus on the impact of systemic racism on health care and potential opportunities to affect meaningful change.

Medical practice today, including dermatology, clearly lacks diversity among its workforce, as do demographics of medical school applicants and matriculants; there is a significant underrepresentation of racial minorities.^1-4

According to the Association of American Medical Colleges’ (AAMC) Diversity in Medicine: Facts and Figures 2019 report, 6.2 percent of graduates from US medical schools during academic year 2018-19 were Black, 5.3 percent were of Hispanic, Latino, or Spanish origin, 21.6 percent were Asian, and 54.6 percent were white. And the numbers don’t appear to be improving. Of accepted applicants to medical schools in 2018-19, nearly half (49.8 percent) were white, 22 percent were Asian, 7.1 percent were Black or African American, and 6.2 percent were Hispanic, Latino, or of Spanish Origin. These numbers are likely a consequence of the fact that data points to lower acceptance rates for African American or Black medical school applicants.⁴ The 2015 AAMC data show medical school acceptance rate was 41.1 percent overall: white (44 percent), Asian (42 percent), Hispanic or Latino (42 percent), and African American or Black applicants (34 percent).

In contrast, the US is projected to become a majority-minority nation for the first time in 2043, according to US Census data.⁵ Minorities, which now represent 37 percent of the US population, are projected to comprise 57 percent of the population in 2060. The total minority population would more than double, from 116.2 million to 241.3 million over the period. The US Census Bureau projects that by 2060, the US will be 31 percent Hispanic, 15 percent Black, and 8.2 percent Asian. The non-Hispanic white population is projected to peak in 2024, at 199.6 million, up from 197.8 million in 2012. But unlike other race or ethnic groups, its population is projected to slowly decrease, falling by nearly 20.6 million from 2024 to 2060.

The lack of racial and ethnic diversity in medical school and the medical workforce, a likely result of racial discrimination, systemic racism, and racial bias, is a concern for many reasons, the roundtable participants concur. (See sidebar Representation Matters.) Underrepresentation of racial and ethnic diversity in dermatology means that people of color are not proportionately influencing the practice of medicine and contributing to the innovation and advancement needed to improve patient care. And as the participants noted in part one of this article series, there is evidence that patient care may suffer as a direct consequence of lack of diversity in the medical community. Changing the demographics of the physician workforce will take many years of work in recruiting and retaining unrepresented minorities into the medical field. (See sidebar Tipping the Scales.) But beyond increasing representation, equally important is addressing the current workforce to identify causes of health care disparity and find ways to improve care for all patients. Identifying microaggressions and biases—and working to end them—is an important step in beginning to combat these issues and improve patient care in the long run.

“Since we know that 94 percent of dermatology residents are not black, how do we teach those 94 percent to respond with sensitivity, interest, and cultural understanding to every patient showing up in front of them?” asks Jonah Shacknai, Executive Chairman, Dermaforce Partners, parent company of SkinBetter Science. “Understanding the diagnosis, disease mechanism, and treatment is critical, but if we can’t make a patient feel comfortable and heard and wanting to come to a dermatologist’s office in the first place, we’ve lost the battle because we’ll know how to deal medically with a patient that we are never going to see.”

Identifying Systemic Racism and Bias and the Effects on Patient Care

Jeanine Downie, MD, a dermatologist in New Jersey, agrees that all physicians treating patients must be racially, ethnically, and religiously sensitive, but, unfortunately, this isn’t always the case. It’s important to recognize both overt racism as well as bias that can harm patients. She points to a case in 2017 when a Caucasian dermatologist in Tennessee who was training a Caucasian physician assistant reportedly greeted his African American patient by saying, “Hi, Aunt Jemima…”

“This is a doctor the patient had been seeing for a while who she liked and trusted. And he said it a second time: ‘I said, Aunt Jemima, how are you doing?’ He totally berated her and she had to get psychiatric counseling,” Dr. Downie explains, adding that the patient brought the story to the news media. “And he had the nerve to say that he misspoke. Misspoke is when I say ‘Saul, wait a minute.’ But I mean, ‘Paul, wait a minute.’ That’s misspeaking. But to intentionally do that and then have the audacity to put it on misspeaking, I was livid and I still am to this day. That’s an example of overt and flagrant racism.”

And, Dr. Downie points out, this dermatologist is still practicing and was never sanctioned by the American Society for Dermatologic Surgery or the American Academy of Dermatology. She says that such overt and flagrant racism has a long history in medicine, and hurts all of us.

“And it makes us further distrust and further distrust,” Dr. Downie adds. She recalls a time during her chief resident year at Mount Sinai when she learned about a dermatology lecture she wasn’t invited to. “It was headed by a physician who was at NYU who had been intricately involved with the Tuskegee syphilis experiments. And I stood there shocked and amazed, but they didn’t want me in the room. There were no Black people in the room listening to the lecture. They had me doing something off the floor and didn’t even invite me. And I sat down in the front row because I’m me and I was already a chief resident. So there’s no way I wasn’t finishing the program. And I asked like a thousand questions and I probably made an annoyance of myself, but I couldn’t believe that somebody I had respected all these years was intricately involved with the Tuskegee syphilis experiments. I was shocked. So that’s another example of overt racism as part of the issue for why Black people don’t trust getting in clinical trials to begin with that we have to fight to overcome.”

Corey Hartman, MD, a dermatologist in Birmingham, AL, agrees, and emphasizes the harmful effects of systemic racism and lack of access to health care for many minority patients. “I live in Birmingham, Alabama. I grew up in New Orleans. Birmingham is very segregated and there are areas where if you live in this particular area of town, you’re not going to have access, you’re not going to have proximity to a dermatologist. You’re not going to have proximity to certain other health professionals that you need to get to. And why is that? That’s based on red lining and discrimination in housing and all sorts of deliberate laws and policies. The system really was built on purpose. And if you just follow the ripples, it affects people in many other areas than are intended,” Dr. Hartman explains. “If you’re looking for examples of systemic racism and how they pertain to access to health and disparities, I think that that is one of the most glaring examples that’s out there and not just in this city, but in many cities across the country. I have a practice that is four blocks from my house. It’s convenient to me, but all the practices are right here in the same area. You go to other areas and there are no dermatologists for miles and miles and miles. That’s going to impact their ability to get help for all these issues that we’re talking about, which only feeds the problem because then they don’t have access to clinical trials, preventative care, healthy choices. Doctors don’t get to see them and learn the way that these different disease states present, et cetera.”

Stephanie Manson Brown, MBBS, MRCS, MFPM, Vice President, Head of Clinical at Allergan, says one of the things that really opened her eyes to the systemic issues that create disparities was learning that a lot of medical instrumentation is calibrated for white individuals. “The pulse oximeter is actually calibrated for whites, and they’ve been shown to consistently overestimate oxygen levels in dark skinned people by up to seven percent,” she explains. “And the other thing is the BMI was originally based on white males. And so there’s a lot of history in medicine where it’s been very much focused on white men, in particular, but white individuals, that actually demonstrates that there is a lot of bias within medical education and medical practice.”

“In some ways I feel awkward even speaking to this subject, because I have obviously not been on the receiving end of this type of discrimination, but I feel it incumbent to note a couple of things,” says Mr. Shacknai. “Dr. Downie made reference to overt racism, and Dr. Hartman is talking about systemic racism. One of the subtler features of this relates to medication selection. A lot of physicians, will, unconsciously assess a patient, particularly a patient of color, and make a judgment as to which medications they can afford. And, often, there is an implicit assumption that the patient is on Medicaid or some other form of assistance, and therefore, I’m going to choose from list B rather than list A because they will not be able to get drugs on list A. I have also heard reports of physicians, who are otherwise respectable in their communities, refusing to prescribe complicated drugs like isotretinoin to patients of color because of an assumption they will not be compliant. So, one of the things that iPledge did, despite its unpopularity, is provide assurance to dermatologists that patients will have to follow an established protocol to get the next prescription filled. These quiet microaggressions and biases, although perhaps less overtly offensive to patients, are just as injurious. But in terms of therapeutic outcome, there are a lot of second tier medications and treatments chosen for patients because of a doctor’s perception of what that patient can afford, or what they will take. That’s bad, and no less harmful to the ultimate outcome of patient care.”

Dr. Downie agrees. When patients begin a treatment regimen with something substandard, then it just goes downhill from there. “And they’re like, forget it, dermatologists don’t work for me. And it’s because they started off giving them an inferior medication,” she says.

Patricia Brieva, PhD, Director, Skin Care, L’oréal USA Research & Innovation, says she’s probably experienced this without even knowing; how would she know what a doctor might prescribe it she weren’t Hispanic? And she wonders about the larger ramifications of this. If there are patients of color with skin conditions that typically should be treated with a tier-one medication, but they are only being offered tier two or tier three, what is the difference in efficacy? What is the impact of under-prescribing to certain patient population? As we look at the literature, is there a need for a study that could really show at an early stage how impactful it could be to under-prescribe or prescribe something inadequate, she asks.

Dr. Hartman agrees that it would be groundbreaking to have access to information about the effects of this bias on patient outcomes.

Chudy Nduaka, DVM, PHD, DABT, Therapeutic Area Head, Dermatology, US Medical Affairs, AbbVie, agrees and has been confronted with this kind of experience. “I remember moving to a new area and my wife and I went in to see a new doctor and walking into the office—we’re both Black—and they asked me about a type of Medicaid card which I was not aware of. It was my wife who told me what it was, that is Medicaid. And I was confused because I thought should I have Medicaid? Because obviously I have insurance, but not Medicaid. But an assumption was made of just me walking in as a Black man to receive attention in a doctor’s office, which, is terrible.”

“It is,” Mr. Shacknai says. “And it’s not, it’s not just Black patients. It’s Latinx patients. It’s patients who look different from what the doctor expects. There’s sort of this inference in their mind that this patient can’t afford it or this patient isn’t going to follow instructions. So I’m going to have to dumb down the protocol or what I’m willing to give them, because I don’t trust the patient to follow these instructions.”

Seemal R. Desai, MD, a dermatologist in Dallas, says this is why it’s imperative that when talking about Diversity, Equity, and Inclusion (DEI) initiatives to address skin of color with a very wide umbrella and realize that it’s not just racial phenotypes and genotypes or ethnic phenotypes and genotypes. “We need to be careful because there has been so much excitement about helping DEI initiatives from organizations, from industry, from within physicians themselves, but we also need to be careful that by doing this we then don’t prop up one group within the skin of color umbrella, and then marginalize someone else with skin of color. And that could be an Asian or Hispanic person, that could be someone who identifies as one ethnicity, but racially are a different genome and phenotype,” Dr. Desai explains, noting that the injustices that have occurred throughout the COVID-19 pandemic have shed light on the disparities in health care for people of color. “I think we need to intentionally use the right terminology across all of the different groups we, as the experts, are involved in. Skin of color really means a variety of different things, both racially and ethnically.”

Melissa Kanchanapoomi Levin, MD, a dermatologist in New York city agrees, but says that it’s also important not to skirt around certain issues and to identify racism that affects particular patients of color. “I think I can speak as an Asian American person, an Asian-American dermatologist. And I think a lot of times, Asian Americans are painted as this model minority and who don’t feel like they need to have this conversation, don’t need to examine their own biases and their own racism, which is very apparent in the Asian American community and the Asian immigrant community. So, while I agree that this is a conversation that needs to focus on inclusivity, I do think it is the time also to not tiptoe around speaking about injustices and a very big systemic, implicit, explicit biases against the Black community in our country.”

Dr. Desai says this is why it’s so important that everyone recognizes their own biases and uncover how those implicit biases are much more profound and deeper than most people even realize. “I grew up in Atlanta and did my training there. And then in Birmingham at the University of Alabama. I also went to med school at an HBCU medical school at Morehouse School of Medicine, where we had a class of 53 and the whole mission of the school was supporting the underserved and health disparities, which is what attracted me to that school,” Dr. Desai says. “But I’m sure there have been times where even in these bubbles, there’ve been microaggressions that I’ve not even realized, despite what I believe in deep down. I think you’re completely right that there’s a lot of self-examination that has to go on with this process, even from those of us who are the experts.”

Steps to Improve and Deliver Dermatology Care in a More Equitable Way

Harvard University, which engenders more respect than most other universities in the United States, created an implicit bias test years ago, says Dr. Downie. “I think that we should have medical students take it. I think you should take it again as a resident. I think you should take it every couple of years as an attending. Because things shift and things change and things that you weren’t doing before, you’re doing all of a sudden. And people need to realize what their implicit biases are. So I would challenge everybody to put that in as part of the core curriculum into every dermatology program. But quite frankly, I think it should be in every residency. Period. Because bias is part of the root of bad medicine and not being biased is part of the root of good medicine,” she says. “We’re here to deliver better care to our patients, so I think it would be important for people to take that implicit bias test and see where they are. That’s something that’s relatively easy to do. It’s online. It doesn’t take that long. It doesn’t cost anything and it can really help you open your eyes as long as you’re willing to learn from what it is that the implicit bias test shows you.”

Referring to the DREAM Initiative, which was launched by SkinBetter Science and Allergan Aesethetics to promote diversity and inclusion awareness within the aesthetics industry and within the dermatology world, Mr. Shacknai says its model curriculum for residents in dermatology and plastic surgery, piloted at the George Washington University under the direction of Adam J. Friedman, MD, contains a self-assessment tool that is monadic for implicit bias. But, like Dr. Downie, he agrees that taking the test is just a first step. “I wear this watch and it tells me every morning that I haven’t gotten enough sleep, but what am I really going to do about it. I always mean to go to bed earlier, but something comes up. So these self-assessment tests are the same way,” he adds. These tests can alert us to our biases, but working through those biases is equally important. That’s why changes to curricula are needed to make real, long-term changes. There is a need for training regarding racial and ethnic cultural sensitives.

“I don’t know that there are simple steps which will clean up dermatology, plastic surgery, or any other specialty in two years. And that is a real concern,” says Mr. Shacknai. “I think in many communities this is a topic du jour. I fear that this has a two-year shelf life and then people will think we’ve addressed this and move on. The consultant that we and Dr. Friedman have been working with on the model curriculum development is a national leader in diversity and cultural sensitivity training. She has been very frank with us to say we have to get on this with urgency, and get into as many residency programs as possible before programs move on to other issues.”

Companies are interested in these issues now. The George Floyd tragedy and other similar tragedies have brought a subject matter to light that has been neglected for years. And the most tangible thing that we can do is to make sure that this doesn’t go away, that we pat ourselves on the back because we took a bias test, or we had a round table, or we self-satisfied in one way or another, but we’re just letting the issues drop in a few years, Mr. Shacknai explains. This has to be a commitment that continues on indefinitely.

Agreeing, Dr. Nduaka says that many people are asking how can they help move this conversation forward. “For a physician, a dermatologist who has a busy practice, how could you help to ensure that you are not overlooking patients of color or minorities? Can you do simple things, such as extending your hours on certain days so that minorities who may be working multiple jobs are able to come for an appointment in the evening—at 6 or 7pm. Or, one day of the week, can you start later? Instead of opening at 8am, start at 9 or 10am, so that you can work a little longer and provide more access to your practice to those who can’t come during normal business hours? Because honestly, just to schedule a visit, to see a doctor, if you’re working a full-time job that is 8:00 to 5:00 or whatever, you don’t have that opportunity to do that. Something as simple as that, and I know that some academic centers are beginning to do that, is it doable in community practices?”

Dr. Desai says this is a great idea, emphasizing that improving health care disparities is not dependent on monumental steps out of the gate. Smaller things can be more impactful; he notes that his own adoption of telederm in the early days of the pandemic has led to greater access for some of his patients.

“I had never done a telederm visit in my entire life until March 19. I had no interest in it. I had no plans to do it. And literally overnight, I bought five iPads, and signed up for Doximity. Long story short, we started adopting telederm and realizing that many of my patients who travel a fairly long distance to come see me initially, didn’t even want to do telederm because some of them didn’t have a smartphone to do telederm from. But what’s transpired since then is that for some of my patients who have had access issues in even coming to see me, some of these things that we’ve tried to implement to make their telederm lives easier during the pandemic has actually led to better care for them, because now they feel more comfortable reaching out for an appointment, for a consult. It’s been really interesting to see how even operational changes to practices can affect what we do. Especially if your population is underserved like that,” Dr. Desai explains.

Rhonda Peebles, Head of US Dermatology, UCB, says there are also things that industry can do to help impact change, beginning with representation of people of color in industry. “I think we’re largely underrepresented in dermatology. And what I find unique about dermatology, and I’ve worked in marketing in a lot of different therapeutic areas, dermatology is the most relationship-oriented in terms of how dermatologists work with industry. The two really go hand in hand. And I can tell you as someone who each year was traveling around to all of the congresses from a medical dermatology stand point—so I think I was in 50 different meetings every year—there’s not a lot of people who look like me from industry. And industry does a lot for patients. If we think about how we communicate with your patients on an ongoing basis, there’s a role we can play there. I don’t single-handedly have all the answers, but I think it’s something that we should consider. ”

And, of course, diversity in representation begets more diversity, Dr. Nduaka says. “When you have people of color take up these industry leadership positions, they tend to go back to their network to recruit diverse candidates. So there is a change coming. I’m seeing it now in the last year or so that some of these leadership positions in industry are now being filled by people of color, which is great. And you will see that, whether in the medical side of the business or in the commercial side of the business, there will be a change in the types of colleagues you are seeing. More diversity in the work place.”

This change in leadership will bring so much change to the industry in general. It will help on the marketing side and with ad campaigns. People will think more about what the population looks like and make sure ad campaigns do not target just Caucasian patients. Diversity in industry allows for diversity in what people bring to the table and conversation, Dr. Nduaka adds. “So I think it’s a good thing and it’s coming.”

Dr. Manson Brown says ensuring diversity really goes back to recruitment and connecting with the right groups, such as participating in virtual diversity recruitment fairs, and also connecting with HBCU Connect. “But it doesn’t just start with the grassroots, it’s about supporting and locking talent all the way through. There definitely needs to be more done there because I think there’s certainly a lack of diversity in senior leadership roles, which is really very, very apparent. And it’s something that needs to be supported all the way through with mentorship and different programs, to support people from diverse backgrounds. And ensuring that we’ve got that ability to be able to provide that support network.”

She also advocates measurable long-term goals. It’s not just about saying we want to address this, she explains. “It’s about identifying how it’s done, how it’s done in a sustainable manner, and making sure that people feel that they are in a culture that they can contribute rather than just being added onto the group.”

The importance of recruiting young students—as early as grade school and high school—in order to recruit people of color and put them on path toward the possibility of medical school and a career in medicine was noted by the panelists in part one of this article series. Dr. Brieva agrees with the need for industry to commit to creating career paths for young students. “I’ve been sent to a lot of science fairs and I find them very enjoyable because I get to tell people what chemical engineers do. When I was in high school, I didn’t know what a chemical engineer did. My first year of college, I really realized it. And I think it’s all about educating and telling people very early on what’s out there and what’s in the field,” she says. “Even just having dermatologists visit elementary school level students, to go back, that can make a real big impact in certain communities. And for me, I can volunteer in more science fairs moving forward. I think it’s really impactful to think from that point of view.”

Knowledge is the Path to Improvement

“I think one of the salient things is that when we know better, we do better,” Dr. Downie says. Part of the anti-racist movement is when you see something, say something, like a package in the airport, she explains. If someone says something racist in front of you, say something. “The bottom line is that you have to confront that. When people hear racist things —and it’s going to be more majority people than it is minority people—when you hear something, say something so that you can help. Just the fact that we’re having this discussion with a multi-racial group of people helps us, it makes me sleep better at night.”

Dr. Levin concurs. “I think it’s important for us to call out our field and colleagues and our industry. But I also think to have a comprehensive conversation, it’s also important to highlight the long-term work that the Skin of Color Society has done, and those who have been committed to this for decades,” she says. She notes that that work is only a small percent of the overall field of dermatology from industry to physicians.

Mr. Shacknai stresses the need for holding ourselves accountable as organizations, as an industry, as a specialty to see if anything’s actually moving the needle. “We’ve got a problem in the United States. This isn’t going away because we’re having a moment. This is bad. And to say systemic is almost inadequate in some ways. It’s intrinsic is really what it is,” he adds.

“We’re all making an effort to clean up the house of dermatology, but we are a tiny fragment of all of the house of medicine. And there are specialties out there that have had other issues with a significantly higher minority population health disparity issues. I mean, if you look at cardiology and some of the things that happened in cardiology in the early days of hypertension drug development. I mean, we could spend hours looking at that, some of the travesties that went on there,” Dr. Desai says. He is glad the American Medical Association House of Delegates, of which he is a member, recently adopted a resolution where the AMA has specifically, publicly listed in health policy, that racism is a public health threat. “And it is. But how fantastic that at least now the AMA has gone out on record saying that, and now there’s policy calling it, not just a problem, not just to address issues, but calling it a true public health issue and a public health threat. What I would love to see is while we improve our own internal house, I would love to see us take a broader role in having more dialogue outside of dermatology with other specialties. And I think that would only further show our value as dermatology in the house of medicine.”

“The interesting feature of 2020 has been that many of the police and justice practices have absolutely been unveiled. I think everyone had a sense this stuff was going on, but suddenly the horrors were captured on video. There is no escaping the reality now,” Mr. Shacknai says. “And, to me, as interesting, and maybe as insidious, is what the pandemic has revealed. If you look at mortality rates, morbidity rates across different populations, it couldn’t be clearer that when you have over-representation of morbidity and mortality in a certain group, that it’s not phenotypic. I think everyone in some ways in organized medicine was hoping it was phenotypic at the beginning. But it isn’t, it’s all about lifestyle, quality of healthcare, access to healthcare. So in some ways that’s as revelatory a moment as what we’ve seen in some of the police injustice practices. And it would be a shame to lose that insight, which isn’t a revelation, but it should have great impact on everyone that’s sort of observing health and medicine. The shroud has been lifted—we all knew it, but if you’re looking for data to prove it in just a clearly understandable form, this is the moment.”

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