DOCTORS' LOUNGE
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“light skinned” Brown immigrant to the US, I now benefit from the
sacrifices that Black people made and continue to make.
Like many future health care practitioners, I feel we all must
learn about prominent instances of medical racism: in reality, they
are all too common. The few examples we are taught in medical
school include the Tuskegee Study of Untreated Syphilis, and the
performance of numerous surgeries without anesthesia on then
enslaved women by the “father of modern Gynecology,” James Sims,
MD. Institutional racism within medicine is as old as medicine itself.
In 2020, inequities and gaps in our medical education persists in
other forms. White normativity in medical education ranges from
incorrect Glomerular Filtration Rate (GFR) estimates factoring race
on no biological basis, 1 to dermatological manifestations of critical
cases of Lyme disease that went unrecognized in darker-skinned
people, delaying diagnosis until later in the course of the disease.
Black children are more likely to be hospitalized for Kawasaki
Disease than their white counterparts due to late recognition of
the life-threatening condition and rash required for its diagnosis. 2
New mothers of dark-skinned neonates are told that life-threatening
conditions such as meningitis presents with an “erythematous rash.”
Dermatologic conditions that are generally described as “erythematous”
such as erythema multiforme typically present differently
in dark skin, and many clinicians might not be familiar with how
common conditions, such as eczema or those more serious, look in
patients with more melanin. With our ever-diversifying population,
medical education reform is paramount.
Despite that history, maternal mortality rate continues to be three
times higher in Black mothers. 3 Depression is underdiagnosed and
is more devastating with a poor prognosis in Black patients, 4 and
Schizophrenia continues to be over diagnosed in Black patients.
People of color have a higher burden of cardiovascular disease,
diabetes, hypertension and mental health concerns, and are half
as likely to receive pain medication than their white counterparts.
Perhaps the most current driver of health care disparities is the
COVID-19 pandemic where racial and ethnic minority patients are
the most likely to be infected and to die. 5 The Indian Health Service
is notoriously underfunded, and Native Americans have suffered
devastating consequences from the pandemic. Other contributors
to this impact are Black and Brown men’s fear of police profiling for
wearing a mask, the compounding factors of socioeconomic class
and living in smaller spaces, the loss of medical care due to lack
of transportation, finances or familial responsibilities and distrust
of the medical system: these all amplify the inequities in health.
One tangible way to address these disparities is by incorporating
more images of disease presentation in dark skin so our eyes
become better trained to recognize them as clinicians. As more
clinicians realized the dire need for this educational reform, a few
steps in the right direction have begun. A few dermatologists are
doing prominent work regarding the representation of dark skin
in medical education. Dr. Nkanyezi Ferguson started Iowa’s first
Ethnic Skin Care Clinic, and Drs. A. Paul Kelly and Susan Taylor
authored a book titled Dermatology for Skin of Color.”
Efforts to address these disparities require the participation of
many institutions to improve patient-provider interactions and
health care outcomes. The Centers for Disease Control and Prevention
recommends implementing standardized protocols in quality
improvement initiatives, as well as identifying and addressing implicit
bias in medicine. Although some institutions recently transitioned
to the calculation of estimated GFR that is not adjusted by race, such
change should be used as a driving point for programs nationally.
Changes of this caliber cannot be merely isolated instances in a
vacuum, but need to be part of broader implementation of racially
competent education at all medical institutions. As medical providers
interested in providing the best care for our patients, this approach
ensures that these changes are ingrained in our practice of medicine.
Diversifying student trainees and faculty within medicine is
critical to ensure the representation of our often-overlooked communities.
Minority patients need providers who look like them,
and whom they perceive as culturally competent and compassionate.
Curricula reform, plus adding health equity and social justice
questions to standardized medical exams, are essential steps to
emphasize the negative consequences of implicit bias and racism on
patients. We should be aware of our biases, examine them and check
ourselves for that awareness always, in the care of each patient.
References
1
Lesley A Inker, Tariq Shafi, Aghogho Okparavero , et al. Effects of Race and
Sex on Measured GFR: The Multi-Ethnic Study of Atherosclerosis. American
journal of Kidney Diseases 2016 Aug;68(5):743-751.
2
Walid M Abuhammour , Rashed A Hasan, Ahmed Eljamal, Basim Asmar.
Kawasaki Disease Hospitalizations in a Predominantly African-American
Population. Clinical Pediatrics 2005 Oct;44(8):721-5.
3
Emily E. Petersen; Nicole L. Davis; David Goodman, et al. Racial/Ethnic Disparities
in Pregnancy-Related Deaths — United States, 2007–2016. Center for Disease
Control and Prevention Morbidity Mortality Weekly Report 2019;68:762–765.
4
Zohaib Sohail, Rahn Kennedy Bailey, William D. Richie. Misconceptions of
Depression in African Americans. Front Psychiatry 2014 Jun; 65 (5).
5
COVID-19 in Racial and Ethnic Minority Groups. June 25, 2020 (https://www.
cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html)
Yomna Amer is a fourth-year medical student at the University of Louisville School
of Medicine.
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