PracticalDermatology

“Our ability to reach unity in diversity will be the beauty and the test of our civilization.”

—Mahatma Gandhi

As the United States becomes increasingly diverse, cultural competence is becoming more and more important, not only in our daily lives, but especially in health care delivery. According to the US Census Bureau’s latest batch of race-ethnic population estimates, nearly four in 10 Americans identify with a race or ethnic group other than white; data suggest that the 2010 to 2020 decade will be the first in the nation’s history in which the white population declined in numbers.

Despite a shrinking non-Hispanic white population, there remains a gross health care disparity in black and brown communities in the US, as evidenced most recently by the disproportionate impact of the ongoing COVID-19 pandemic on Black, Indigenous, people of color. A study of selected states and cities with data on COVID-19 deaths by race and ethnicity showed that 34 percent of deaths were among non-Hispanic Black people, though this group accounts for only 12 percent of the total US population.¹ For racial and ethnic minorities in the US, health disparities take on many forms, including higher rates of chronic disease and premature death, compared to the rates among whites.² The majority of these health inequities and disparities revolve around the social determinants of health: where people are born, live, learn, work, play, and worship.

However, culturally incompetent organizations and culturally incompetent practitioners also contribute to negative health outcomes. By cultural incompetency, I mean the difficulty of accommodating diverse situations that determine the health of an individual. This may range from failing to recognize the sociocultural factors that determine presentation and prognosis of conditions to formulating a management plan that has ignored these cultural perspectives. For example, in dermatology, melanoma and non-melanoma skin cancers have poorer prognoses for people from ethnic minorities, of low socioeconomic status, or who are less educated, elderly, and uninsured.³ There’s a lower public awareness overall of the risk of skin cancer in the black community. Black people who do have skin cancer are often diagnosed at later stages than people from other racial groups. Skin cancer awareness campaigns and education materials do not often represent skin cancer in skin of color. From the perspective of health care providers, there’s often a lower index of suspicion for skin cancer in patients of color, because the chances of it actually are lower.⁴ However, doctors trained on the cultural context of skin cancer understand people of color often don’t see themselves as at-risk, and therefore do not get checked (or check themselves) for suspicious moles or growths.

There is also another likely reason people of color often do not go to the dermatologist. Dermatology is currently the second least diverse medical specialty, after orthopedic surgery, with only a minority of physicians identifying as underrepresented in medicine.⁵ According to a 2016 report published in the Journal of the American Academy of Dermatology, only about three percent of US dermatologists identify as black or African American. Research shows patients are more comfortable and less fearful around doctors they can relate to and are more likely to seek out their services.⁶

Skin of color is also underrepresented in dermatology literature and clinical images, which poses a roadblock to proper treatment and medical education.⁷ Due to the nature of our skin, skin conditions often have unique presentations based on the color of our skin despite the same pathophysiology. For example, skin disease that involves redness or pinkness in light skin can be subtler or harder to see in dark skin, and providers who haven’t been adequately trained with such images are prone to misdiagnose people of color. Alternatively, African American, Latino, Asian, Native Indian, and Pacific Islander patients who Google their symptoms looking for answers prior to making a doctor’s appointment often have a hard time pulling up images of dark skin, which can be confusing and frustrating.

The bottom line is representation matters in health care, and cultural competence of the health care provider and staff leads to improved patient adherence and satisfaction. As physicians, we must work harder to better understand and acknowledge the social and cultural norms and differences of certain populations and incorporate that knowledge into practice to provide our patients with proper and quality health care. Although health care disparities are not something we can get rid of completely in the short term, culturally competent organizations and culturally competent practitioners can go a long way to achieve health equity and improve health outcomes.

What is Cultural Competence?

Cultural competence is loosely defined as the ability to understand, appreciate, and interact with people from cultures or belief systems different from one’s own.⁸ In my own practice, cultural competence is an overall approach of having an open mind, feeling empathy, and being accommodating to patients from all walks of life. Most dermatologists in the US are required to complete a standardized and practical training that includes components of cultural competencies, but the reality is cultural competence training cannot be completed in a few hours. These special skills are something health care providers should continue to learn and hone every day.

How to Practice Cultural Competence

The goal of health care in dermatology, like any branch of medicine, is holistic. As physicians we manage patients and their problems, not just diseases. Therefore, we must be competent in clinical medicine—to make sure the patient is not suffering and to help improve their appearance whenever possible—and in tandem be competent at identifying beliefs, the prevalence of diseases, and other factors that may contribute to the individual’s suffering. Unless we understand that context, we’re compromising patient care.

Below are some key ways that dermatologists, nurses, and office staff can display cultural competence in their day-to-day interactions with patients:

Speak Your Patient’s Language. First and foremost, institutions or private practitioners need to have well-qualified interpreters to accommodate any linguistic differences. Language concordance is a particularly important foundation to gain trust, optimize health outcomes, and advance health equity in diverse patient populations. Several studies have shown patients who face language barriers have poorer health outcomes compared with patients who speak the local language.⁹ This is because patients who speak a language different than their practitioner tend to have less committed physician relationships and often do not follow through on taking medications or following other medical instructions. Visual aids, such as simple illustrations, images, informational graphics, and videos, can also help patients better understand health information.¹⁰ This is especially important since health information provided in a stressful or unfamiliar situation is less likely to be retained. Adding “language barrier” as a problem list will only make things worse. In doing so, we are seeking more compensation for being culturally competent and also triggering payers to consider language differences as a “pre-existing” condition.

Exercise Cultural Sensitivity. We must acknowledge and accommodate the beliefs and behaviors of certain cultures to meet compliance regulations and deliver exceptional patient care. As an example, communicating with an opposite-gender-patient from an Islamic or Orthodox Jewish background requires sensitivity to different friendship and family norms. Without respect, empathy, and curiosity from their health care providers, patients may avoid seeing a doctor altogether or may hesitate to share their beliefs and fears when sitting in the exam room.² Physicians should always considerately ask patients questions to show genuine interest and uncover personal orientations to health and illness so they can be integrated into the caretaking of the patient and family and negotiated, if possible, when it comes to making health care decisions.

Physicians should show the same sensitivity when explaining disability and mortality. Cultural views of the boundary between life and death and the rituals that give meaning to this key transition vary widely.¹² There are some cultures that accept aging and death gracefully, whereas others may not. So, when giving a prognosis, it is important to consider culture. If it is a dire situation, doctors should consider that there are certain cultures where we should not necessarily share information about morbidity and mortality in the medical setting, or perhaps at all.

“Natural” treatment of skin conditions and skincare is booming in the US and the rest of the world. As physicians, we may not agree with the use of raw materials on the skin, especially for conditions that have proven pharmaceutical treatments. However, it is important to accommodate patients’ cultural preference and refrain from judgment. It has become more customary for patients to request “natural” treatment for their conditions. From my experience, “natural” products also have diverse meaning based on the cultural context and ranges from products that are labeled and sold as “natural” by retailers to only products that are raw plant, animal, or soil components collected from the field.

Be Mindful of Religion and Spirituality. Religion and spirituality can be uniquely challenging to dermatologists. Persons with visible skin disorders like atopic dermatitis (eczema), psoriasis, or acne have often been stigmatized or even treated as outcasts.¹³ Even in the 21st Century, this remains true in all parts of the world. I have had the privilege of practicing abroad in Ethiopia, and stateside in Atlanta and the Washington DC area, where there’s a large international community. During my career I’ve encountered many instances where religious societies have interpreted common, non-communicable skin conditions as leprosy, often considering this as a curse from God, rather than an infectious treatable condition. The reason for this is that most African and Abrahamic religions pull their understanding of skin diseases as what is contextually defined in the Bible or the Quran. It’s understandably distressing for someone to believe they have an infectious disease like leprosy. Leprosy (now known as Hansen’s disease) is often misunderstood, and it is important to connect with patients who have this type of cultural background and educate them about the scientific origins of various skin disorders, as well as treatment options, recovery, and prevention.

Consider Skin’s Psychological Impact. As with other challenging physical conditions, visible skin disorders can have significant psychological and social effects.¹³ For instance, pigmented disorders like vitiligo or hyperpigmentation on the face are associated with more psychological distress for dark-skinned individuals than for lighter-skinned individuals. Similarly, visible benign tumors, such as syringomas or seborrheic keratoses, can impair appearance and harm a person’s self-esteem. Malignant tumors, such as basal cell or squamous cell carcinoma, can lead to treatments that result in disfigurement from scarring. In a society in which physical attractiveness and wholeness are valued so highly, there are considerable challenges for those with a condition that results in an unusual appearance.¹⁵ These challenges result in negative psychosocial impacts for a significant proportion of people who are affected by skin conditions. On the other hand, certain conditions are acceptable to some cultures—as is some degree of morbidity—occasionally making it difficult for physicians to communicate the importance of early detection and treatment.

Context Matters

Cultural competence alone doesn’t make you a good physician. There are many other factors that make you a good physician. However, learning certain cultural practices and beliefs can give health care providers the context they need to better understand disease processes and diagnosis. The most important step any doctor can take is to acknowledge cultural differences, keep an open mind, and show some empathy. All of these behaviors will improve complacency to treatment, build trust and understanding, and strengthen physician-patient relationships.

1. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/disparities-deaths.html

2. Kodjo C. Cultural competence in clinician communication. Pediatr Rev. 2009;30(2):57-64.

3. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-viii.

4. https://www.skincancer.org/blog/ask-the-expert-is-there-a-skin-cancer-crisis-in-people-of-color/

5. Akhiyat S, Cardwell L, Sokumbi O. Why dermatology is the second least diverse specialty in medicine: How did we get here? Clin Dermatol. 2020 May-Jun;38(3):310-315.

6. https://www.pennmedicine.org/news/news-releases/2020/november/study-finds-patients-prefer-doctors-who-share-their-same-race-ethnicity

7. Adelekun A, Onyekaba G, Lipoff JB. Skin color in dermatology textbooks: An updated evaluation and analysis. J Am Acad Dermatol. 2021 Jan;84(1):194-196.

8. https://www.apa.org/monitor/2015/03/cultural-competence

9. Al Shamsi H, Almutairi AG, Al Mashrafi S, Al Kalbani T. Implications of Language Barriers for Healthcare: A Systematic Review. Oman Med J. 2020;35(2):e122.

10. Andrulis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav. 2007;31 Suppl 1(Suppl 1):S122-S133.

11. https://www.ncbi.nlm.nih.gov/books/NBK220821/

12. https://www.dovepress.com/spiritual-and-religious-aspects-of-skin-and-skin-disorders-peer-reviewed-fulltext-article-PRBM

13. Rumsey N. Psychosocial adjustment to skin conditions resulting in visible difference (disfigurement): What do we know? Why don’t we know more? How shall we move forward?. Int J Womens Dermatol. 2017;4(1):2-7.