A 'Unicorn' Pushes for Diversity in Dermatology

Teresa Carr

September 12, 2019

Adewole Adamson, MD, is used to being an outlier. He's an assistant professor of internal medicine at Dell Medical School in Austin, Texas, and a black dermatologist. "My residents call me a unicorn," he said.

"You would think that dermatology would be on the front lines of discussing race and healthcare disparities," Adamson told Medscape Medical News, because skin "is the very thing that defines our racial identity."

Adewole Adamson, MD, assistant professor of internal medicine at Dell Medical School in Austin, Texas. Kelly Davidson

Yet of the top 10 medical specialties, only orthopedic surgery is less diverse, according to a call to action published in the Journal of the American Academy of Dermatology in 2016, which made the case that dermatologists should be more representative of the patients they serve. About 13% of Americans — but only 3% of dermatologists — are black. Similarly, Hispanics compose 4% of dermatologists, compared to 16% of the general population.

Dermatology's lack of representation of people of color is associated with documented disparities in their care and health outcomes, as well as difficulty funding relevant research. Since the call to action, efforts to diversify dermatology are gaining momentum. In the latest example, members from 60 medical schools, representing about half of all the medical programs in the country, have signed up to attend the Diversity Champions Workshop today and tomorrow in advance of the Association of Professors of Dermatology Meeting in Chicago, Illinois.

The workshop is the culmination of the Diversity Championship Initiative, developed in part by Amit Pandya, MD, who recently left his position as a clinical professor of dermatology at the University of Texas Southwestern in Dallas after 28 years and currently volunteers as a professor at the school.

The initiative details 25 actions to get underrepresented minorities interested in dermatology as early as middle school and help guide them through the journey to becoming a physician.

In 2017, attendees at a diversity summit hosted by the American Academy of Dermatology (AAD) rated the initiative as one of the top programs to bring more underrepresented minority students into the field. At the end of the conference this week, the leaders will meet with attendees one-on-one to ask which of the 25 steps they plan to implement in their programs and report on next year.

"All of a sudden, it went from my initiative to the AAD's initiative, with funding and the backing of five dermatological societies," Pandya told Medscape Medical News. "It started with a just a few of us advocating for this and now others have joined the bandwagon."

The Making of a "Unicorn"

Adamson, who took time between medical school at Harvard University and starting his residency to earn a master's degree in public policy at Harvard's Kennedy School, said that his mission in medicine has always been to combine patient care with research into health disparities. Initially, he wasn't interested in dermatology.

"It was too niche and hard to get into," Adamson said. "And I just didn't see people working in the field who looked like me."

Two things changed his mind. First, his then girlfriend (now wife) introduced him to her sister and brother in law, both black dermatologists practicing in Atlanta. Shadowing them, he realized the profound need for clinicians who understood issues specifically related to skin of color.

The other deciding factor was his exposure to the science of dermatology during a fellowship year he spent at the National Institutes of Health. "I love immunology, and you can think of the skin as essentially one big immune organ," Adamson said. "I was hooked."

Still, he entered his residency at UT Southwestern with some trepidation about being stranded in a white suburban sea. Those fears were unfounded. "It's actually one of the most diverse dermatology departments in the country," he said, and he gives Pandya, whom he considers an important mentor, significant credit.

Still, Adamson said, when he graduated in 2015, he was one of only a handful of black students to have gone through the program. That same year, Pandya helped develop the Diversity Champions Initiative to encourage more students like Adamson to become dermatologists.

Pandya stressed that when physicians better mirror the populations they serve, everyone — not just minority patients — benefits. He pointed to research published in JAMA Internal Medicine that shows that black and Hispanic physicians are more likely than physicians of other ethnicities to practice in underserved areas where there is a higher percentage of minority patients and more people insured by Medicare and Medicaid.

Amit Pandya, MD, of the University of Texas Southwestern in Dallas, fourth from left, with volunteers at a free clinic that serves predominantly Latino patients.

"What we're trying to do is convince others that diversity actually improves the healthcare of all Americans," he said.

Lack of Diversity Affects Patient Care

Research by the Kaiser Family Foundation shows that health disparities in dermatology are more limited than in other areas of healthcare, but suggests similar trends. Other studies show, for instance, that black children are more likely to suffer from severe atopic dermatitis than white children. One study showed that compared to whites, people of color were hospitalized for psoriasis more often and reported a poorer quality of life because of their skin disease.

A big part of the problem is access to care. Black and Hispanic patients are half as likely as white patients with the same skin condition to have an outpatient visit with a dermatologist, according to a study published in JAMA Dermatology last year.

On the basis of an analysis of 9 years of data collected on 183,054 patients, researchers at Case Western University, in Cleveland, Ohio, linked several other factors to less likelihood of seeing a dermatologist, including being male, being uninsured or insured by Medicare or Medicaid, having lower income, being less educated, or being from the Midwest. The racial differences remained after controlling for factors such as income and insurance status.

Research also suggests that patients of color report better care when they have access to physicians who look like them. In a recent study published in JAMA Dermatology, researchers used a survey and focus groups to explore the perceptions of 19 black patients regarding the care they received at a dermatology clinic that specialized in skin of color. One major theme that emerged was patients' preference for a black dermatologist, who they felt better understood their personal experience with skin and hair.

That's not just a matter of perception, said Adamson. Dermatology is a visual discipline, and because redness, hives, and the scaliness of psoriasis all look different in darker skin, he thinks physicians often aren't exposed to enough images or cases of diseases manifesting in different skin types.

In one recent incident, Adamson said a resident misdiagnosed a black patient as having acne ― the pimple-like lesions were a form of cutaneous lupus. The resident didn't recognize the disease in darker skin. Adamson has warned, in research published in JAMA Dermatology last year, that machine learning could exacerbate disparities, because programs are trained predominantly through use of images of lighter skin. "You're at risk of actually automating bias," he said.

A lack of cultural awareness also hinders care. For example, almost half of black women experience hair thinning and bald patches, according to an AAD survey, most commonly due to central centrifugal cicatricial alopecia (CCCA), which causes destruction of the hair follicles and scarring, or traction alopecia, caused by tension from braids, extensions, and wigs.

Diagnosis and treatment require both a thorough examination and an understanding of how women of color care for their hair. Yet it's not uncommon for patients of color to complain that their physicians know little or nothing about black hair or won't even touch their scalp, said Valerie Callender, MD, professor of dermatology at Howard University College of Medicine in Washington, DC.

"I think there's a bit of concern with examining a woman's hair, especially a woman of color who has locks and braids," she told Medscape Medical News.

Adamson said that he's commonly encountered dermatologists who prescribe medicated shampoo to black women for use every other day. However, having grown up in a household with black women, he said he understands that they wash their hair at most once a week, making the recommendation for how to use the medicine "completely off base."

Disparities in diagnosis and treatment can have much more serious consequences, said Susan Taylor, MD, associate professor of dermatology at the University of Pennsylvania, in Philadelphia. Although melanoma is rarer in skin of color, it's also deadlier. The 5-year melanoma survival rate, according to the Centers for Disease Control and Prevention, is only 66% in black patients compared to 90% in white patients. One reason is that tumors in skin of color tend to be diagnosed at a more advanced stage.

Susan Taylor, MD, associate professor of dermatology at the University of Pennsylvania.

Melanoma occurs in people of color on palms, soles of the feet, fingernails, toenails, and mucous membranes in the mouth and genital area, Taylor told Medscape Medical News, but physicians who link skin cancer risk to light skin rarely perform skin examinations in those populations or don't focus on the right areas.

"Education on the importance of examining the skin of darker people and where to look will ultimately lower mortality by finding it [the cancer] early," she explains.

Unanswered Questions

In people with lighter skin, melanoma is strongly linked to sun exposure. But Adamson's review of the available research, which he detailed in an op-ed in the Washington Post and in social media posts that were widely covered in the popular press, turned up no evidence that the sun causes the disease in people with darker skin. What does cause it and how incidence can be reduced remain unanswered questions.

https://twitter.com/adeadamson/status/1128291197355724800?lang=en

So, too, does the role of sunscreen in skin protection for people of color. Sunscreen does have benefits for people with dark skin: It helps prevent hyperpigmentation, such as freckling, as well as signs of photoaging, including wrinkles and a leathery texture. But a recent FDA study that showed that ingredients commonly used in chemical sunscreens are absorbed into the bloodstream raised concerns about possible health effects.

It angers Adamson that the AAD and other public health groups have long advised everyone to use sunscreen without demanding hard evidence on safety or questioning whether the risk-benefit analysis should be different for people of color. Neither industry nor the medical establishment has had the respect to do the research it takes to answer those questions, he said: "Instead, you just take the easy way out and fearmonger, telling all people that you need to photoprotect or you are going to die from melanoma."

The AAD responded to the issues Adamson raised by creating a Sunscreen for Skin of Color Patients Task Force and inviting him to be a member.

Disparities in dermatologic research are unquestionably the result of a lack of diversity in the profession, said Taylor. A major factor is that dermatologists who conduct trials don't always have access to a diverse population.

A researcher's own ethnicity or race also comes into play, inasmuch as "investigators tend to research things that interest them," said Pandya. "Diversity in the workforce helps expand the types of diseases that are studied."

Taylor said that she's encouraged to see more research than ever before into disorders that disproportionately affect people of color — for instance, hidradenitis suppurativa and atopic dermatitis — or that are more prominent on darker skin, such as vitiligo.

On the other hand, she said, she's still "found it next to impossible" to study CCCA hair loss, which occurs almost exclusively in African American women. "And it's not for lack of trying," she said.

Diversifying Dermatology

In an editorial accompanying the small, qualitative study in JAMA Dermatology of black patients' experience at the dermatologist, Taylor underscored a crucial — and hopeful — finding: Seeing a black physician wasn't essential to a good visit. A successful encounter hinged primarily on whether the dermatologist was culturally sensitive and knowledgeable about the patient's disorder and treatment.

"Those are qualities that can be learned," she said.

Perhaps the biggest impact of having more dermatologists of color, said Taylor, is that it increases representation in education, training, and research, so that all practitioners, regardless of ethnicity, are better prepared to deliver culturally competent care.

Taylor, who founded the nonprofit organization, Skin of Color Society, as well as the country's first skin-of-color clinic at St. Luke's–Roosevelt Hospital Center in New York City, has worked for more than 2 decades to increase the diversity of her profession. Happily, she said, in the past few years, "there's been a sea change where many people have become involved in strategies to increase the number of underrepresented kids in dermatology programs."

Diversifying dermatology and addressing disparities will require prioritizing those issues for the majority of the profession and funders for research, not just for a minority of physicians of color, said Adamson.

"If you only have a few people like me," he said, "who are out here thinking a little bit differently, with a different lens on research in disparities, then you're not going to be able to move the needle."

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