The Great Divide: Racism in Medicine

As an African-American dermatologist, I must deal with the notion that my privilege does not shield me from bias and discrimination. My mother is a practicing pediatrician. Her father was a dentist during the roaring days of Harlem. One of my lifelong goals is to continue the work of my ancestors and continue to fight against systems that work to prevent other skin of color and marginalized people from getting to where I am and further. Tyler Perry recently said we have to, “meet each person at their humanity and refuse hate.”

My mission in my practice and life is to recognize the humanity of every person who comes through the door regardless of skin color.

Increasingly, dermatologists are taking stock of the unique needs of patients of all skin tones and confronting the lack of diversity—in research, education, pharmaceutical advertising, hiring practices, and more—that has existed in medicine generally, and our specialty specifically for generations. As a result, the care that we provide to patients is improving. But there is much more to be done.

To better serve patients and advance our specialty, dermatologists and aesthetic physicians must be aware of the needs of individuals across all racial, ethnic, and cultural backgrounds. We must think about the whole human in front of us and emphasize the treatment of the patient and not just the wrinkle, rash, or skin cancer. We must also be cognizant of the ways that our behavior can either improve or complicate the experiences of our patients, peers, family, friends, and neighbors.

To that end, ECRI and the Institute for Safe Medication Practices PSO recently analyzed a full year of events related to racial or ethnic minority groups and found that patients and health care providers are frequently on the receiving end of inappropriate comments about race, including:

• Patient/family making inappropriate comments regarding race or ethnicity: 56%
• Patient claiming that others are racist or engaged in racist behavior: 22%
• Patient/family reporting disparate care because of patient/family race or ethnicity: 9%
• Staff making inappropriate comments regarding race or ethnicity: 7%
• Staff reporting management or supervisor discriminating against them: 4%
• Patient requesting for provider or staff member based on race or ethnicity: 1%
• Interpretation or translation services not provided: 1%

As a black woman, I face discrimination and microaggressions continuously. I have been assumed to be “the help,” sexualized and told to “use what I’ve got,” and had people ask to touch my hair.

My status as an accomplished professional doesn’t insulate me. I’ve been told I “look too young” to be a doctor, was told or had it implied that I wasn’t dressed properly when wearing a business suit, and fielded questions about “what’s going on” with my hair. These types of comments are commonly used to indirectly reference my race.

Although I have published more than 100 papers, conduct clinical trials, and lecture around the world, I am sometimes not taken seriously, including among other medical professionals. It took effort to be recognized by other physicians in the area as a leading dermatologist.

I am not alone. Research shows that black Yale graduates die earlier than their white counterparts. Among graduates of the class of 1970, the rate of early death at age 60 or younger was 3-times as high among black alumni compared to whites. Black males overall in the US tend to die younger than any other demographic group. Presumably, upwardly mobile graduates of one of the country’s most prestigious universities would be protected from some of the many factors thought to contribute to premature death in black men. This phenomenon could reflect the long-term impacts of discrimination on these individuals. There is also speculation that the constant challenges and stress of trying to overcome discriminatory obstacles take a health toll on these individuals.

The American Medical Association (AMA) and other governing bodies have recognized racism as a public health threat and are actively working to dismantle racist policies and practices across all of the health care. In policy adopted in 2020, AMA prescribes steps to combat racism, including 1.) acknowledging the harm caused by racism and unconscious bias within medical research and health care; 2.) identifying tactics to counter racism and mitigate its health effects; 3.) encouraging medical education curricula to promote a greater understanding of the topic; 4.) supporting external policy development and funding for researching racism’s health risks and damages, and 5.) working to prevent influences of racism and bias in health technology innovation.

Racism is not just stress-inducing, it is exhausting for those of us who deal with it daily. The exacting stress on the human body produces increased levels of cortisol, which lead to many of the negative outcomes discussed above. Surely discrimination is a threat to public and individual health.

Racial Disparities in Health Care

Research increasingly shows the ways that persistent racism impacts people of color in all aspects of life. Systemic racism describes how racism has influenced various aspects of our society, including our social, educational, employment, and healthcare systems. While we may be making progress (though arguably not quickly enough), the long-term effects of systemic racism persist.

Published nearly 20 years ago, “Unequal Treatment” is a report from the National Academies’ Institute of Medicine that clearly identified systemic racism as a key contributor to health disparities. The report ranked the detrimental health effects of systemic racism above the impacts of poverty, lack of health care access, and other social factors.

Data indicate that one’s ZIP code could be a greater predictor of life expectancy than one’s genetic code. The Robert Wood Johnson Foundation provides an interactive search that helps demonstrate the point. I practice in New Jersey where the wealthiest county, Hunterdon, is 91% white. The poorest county, Cumberland, is 63% white. While the average life expectancy for the state is 79.8 years, it is 83.4 years for Hunterdon County and only 75.36 for Cumberland County. Residents of the less diverse, more affluent county exceed average life expectancy, while residents of the more diverse, poorer county of the same state, are dying younger.

No doubt a variety of factors contribute to this disparity, including income, occupation and related exposures, proximity to advanced healthcare, and more. But even these factors may at least indirectly correlate with race. Access to the best schools and medical care is linked to where you live. Even access to supermarkets and fresh fruits and vegetables can be impacted by your ZIP code.

Importantly, these factors can be modified, if not immediately, then over time. As physicians, we must facilitate true partnerships with patients. We must avoid any assumptions about our patients and take the time to ask the right questions and provide reasonable solutions. Just because the patient is in your office does not mean the patient is a resident of the local community or that he or she experiences the community as you do.

The key is that we need to show empathy to all patients at all times especially when dealing with sensitive racial/ethnic/cultural issues.

Think both about your practice and your behavior, as well as the individuals you treat.

• Do you show—actually demonstrate with your body language—that you listen to patients and are willing to be their partner in care?
• Do you demonstrate cultural sensitivity and provide a space that is inviting to people of diverse backgrounds?
• Do you ask questions of all patients about prescription drug coverage and whether will it cover the drug you are prescribing? If not, is there an alternative?
• Is the patient not using their medication because they don’t like the base or is it possible they did not refill a prescription they cannot afford? Is the OTC or cosmeceutical you are recommending something the patient will be able to find?
• Do your office hours meet the needs of all patients, including those who may work shifts, rely on public transportation, or require childcare?
• Would it be acceptable—and more convenient—for the patient to return every 6 weeks rather than 4?

Moving Forward

There is much work to be done, but we are making some inroads. For starters, CeraVe is establishing a fund at Howard University to help its faculty further their expertise and build the infrastructure needed to conduct clinical trials with a focus on skin of color. Located in Washington DC, Howard University is one of the only historically Black universities with a dermatology department. The first stage of the partnership will help fund faculty education to obtain certification to conduct clinical trials.

Another noteworthy program, the DREAM Initiative, is a partnership between Allergen Aesthetics and Skinbetter Science with The National Racial Equity Medical Residency Curriculum to assist students, faculty, and staff in dermatology and plastic surgery residency programs in identifying and addressing the risk of implicit bias in academic and clinical settings.

As part of the initiative, The Full Spectrum of Dermatology: A Diverse and Inclusive Atlas, is a dermatology atlas that will display images of the most commonly seen dermatology conditions in an array of skin tones. It was developed by co-editors Misty Eleryan, MD, MS, and Adam Friedman, MD.

The American Society for Dermatologic Surgery (ASDS) has an active DEI committee, chaired by Mona Gohara, MD and Omer Ibrahim, MD. I and members of the committee try to discuss every aspect of diversity, equity, inclusion, and accessibility and implement policy as well as give recommendations to the ASDS community about what we feel strongly should be best policies and practices for these areas. We are all currently mentoring younger residents and fellows and trying to teach our mentees about what the field of dermatology is truly like.

Finally, I encourage everyone to take Harvard’s implicit bias test to see where they have blind spots so that they can address them and be better students, residents, physicians, and people.