Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin
August 5, 2020 1:49 PM Subscribe
Malone Mukwende, 20, is a second-year medical student at St George’s, University of London. “On arrival at medical school I noticed the lack of teaching in darker skin. We were often being taught to look for symptoms such as red rashes which I was aware would not appear as described in my own skin,” he told BME Medics. “When flagging this to tutors it was clear that they didn’t know of any other way to describe these conditions on patients of darker skin tones and I knew that I had to make a change to that.” (Atlanta Black Star, July 9, 2020) The result is "Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin."
As Mukwende explains, “The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. This is something which is not commonly practiced in medical textbooks as there is a ‘white skin bias’. It is important that we as future healthcare professionals are aware of these differences so that we don’t compromise our care for certain groups.
“The booklet addresses many issues that have been further exacerbated during the Covid-19 pandemic, such as families being asked if potential Covid patients are ‘pale’ or if their lips ‘turned blue’. These are not useful descriptors for a black patient and, as a result, their care is compromised from the first point of contact. It is essential we begin to educate others so they are aware of such differences and the power of the clinical language we currently use. We will be hosting a training session for clinical skills peer tutors which will take place in July 2020." [...] Mind the Gap is not currently published and so is not available to distribute however discussions with potential publishers are ongoing. (Article on Mukwende's "Mind the Gap: a Handbook of Clinical Signs on Black and Brown Skin", via the St George's University of London website, June 18, 2020)
Medical student creates handbook to show symptoms on darker skin, at UK's The Tab (July 14, 2020): A second-year medical student has written a book to help medics recognise symptoms on Black and Asian skin tones. Photo comparison: This picture demonstrates how differently the same disease can present on dark versus light skin. A user submitted photograph of Kawasaki disease (left) versus the American Heart Association's reference photo.
A U.S.-focused general article: Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color (STAT News, July 21, 2020) The dearth of images in the Covid-19 literature is just the newest example of the glaring lack of representation of Black and brown skin that has persisted in dermatology research journals and textbooks for decades. The issue is coming under closer scrutiny now as dermatologists, like many physicians, grapple more openly with systemic racism and the health disparities it is causing in their field. [...] Many worry the field’s shift toward using artificial intelligence to aid diagnosis of disease will further deepen the divide, because the machine learning algorithms are trained with datasets consisting primarily of fair-skinned images.
Also at issue: While many textbooks depict the vast majority of skin diseases using light skin, there is one notable exception: Black skin is more often used to depict sexually transmitted diseases, a glaring example of stereotyping that is all the more painful given the U.S. government’s complicity in the notorious Tuskegee experiments that left syphilis untreated for decades in a group of poor, Black men. [Yale professor of dermatology, Jean] Bolognia said she is extremely sensitive about not stigmatizing people of color by using only images of darkly pigmented skin to illustrate sexually transmitted diseases or drug users. [Bolognia has spent more than 20 years editing the widely-used textbook, Dermatology]. “I noticed this as a student, the images of STDs were nearly all of patients with darkly pigmented skin, but the people I saw with syphilis were often fair-skinned,” she said. “I wondered about the possibility that pictures were being taken of individuals who were less likely to say no.” [Bolognia, at work on the fifth edition of Dermatology, said providing a wide spectrum of skin tones is critical; "I feel you can always do better and I realize I don’t have enough images of Asian skin, so that is something I’m addressing.”]
Dermatologists say the lack of images is one reason why many conditions, including Lyme disease, spider bites, and cancers can go misdiagnosed or underdiagnosed in darker skinned patients, sometimes with dangerous results. The five-year melanoma survival rate for Black patients is just 70% compared with 94% for white patients.
Linked in the STAT article:
- The textbook Dermatology for Skin of Color
- AI-Driven Dermatology Could Leave Dark-Skinned Patients Behind (The Atlantic, August 16, 2018)
- Fee-for-service and structural forces may drive racial disparities in US dermatology (Letter to the Editor, British Journal of Medicine, 2020, by Jules Lipoff, assistant professor of clinical dermatology at the University of Pennsylvania)
- Skin of Color Society ("The Society is committed to the education of health care providers and the general public on dermatologic health issues related to skin of color.") Mission statement; media coverage archive; the Society's Find a Doctor database)
Review of Nonmelanoma Skin Cancer in African Americans, Hispanics, and Asians (Dermatologic Surgery: July 2018 - Volume 44 - Issue 7 - p 903-910) A complete PubMed search was conducted spanning dates from 1947 to June 2017 yielding a total of 185 manuscripts, from which 45 were included in this review. RESULTS: Relative to Caucasians, NMSC, comprised squamous cell carcinoma and basal cell carcinoma, has unique demographic and clinical features in African Americans, Hispanics, and Asians.
Dermatologic health disparities (PubMed link with abstract /Published in final edited form as: Dermatol Clin. 2012 Jan; 30(1): 53–viii) Skin cancer morbidity and mortality are disproportionally higher in blacks, Hispanics, and people of low SES [socioeconomic status]. Melanoma is more common in non-Hispanic whites and people of high socioeconomic status (SES), yet blacks, Hispanics, people of low SES, and older age persons often present with more advanced disease or have increased mortality.
Pediatric Skin of Color (2015) is "the first textbook devoted to the issues of pediatric skin of color. [...] Written for dermatologists and pediatric dermatologists, this text includes data on African American, Asian (Southeast and East), Hispanic/Latino, and Middle Eastern patients, as well as Indigenous populations (i.e. Native Americans, Aborigines)."
Patient Woke Up From Surgery With Her Hair Braided Thanks to Black Male Surgeon (Black & Magazine, July 24, 2020) India Marshall, a 29-year old African American woman from North Carolina who recently underwent skull surgery, is thankful to her surgeon, Dr. Jewel Greywoode, who is also Black, not only for successfully performing the operation but also for braiding her hair which helped her recover faster. India shared her experience on Twitter [Thread reader link], saying that at first, she thought Black nurses did her braids. But when she came back weeks later for her post-operative appointment, she found out that it was done by the surgeon, a Black man who has 3 young daughters.
It started when Marshall was searching for a surgeon to remove benign bone growths on her skull, called osteomas. It was difficult for her to find the right doctor until she finally bumped into Greywoode. Marshall said Greywoode, an ENT doctor who specializes in cosmetic and functional facial plastic surgery, made her feel comfortable with his approach. She said he was the only doctor who thought of a way to do the surgery with fewer scars, hair loss, and numbness.
Reported elsewhere as Surgeon's kind gesture proves 'why Black doctors are important,' patient says (Today.com, June 26, 2020) India Marshall described the "emotional moment" she realized her doctor had braided her hair before her surgery to make her recovery easier. [...] “I know that I could only have gotten that type of care and experience with a Black doctor because he understood my hair,” [Marshall] said. “He also brought up that he didn't use sutures or stitches because he didn't want to cut my hair when removing it. The staples are easier to take out. So that was just another example of how he was able to understand me as a Black woman and the importance of my hair and preserving it.”
As Mukwende explains, “The aim of this booklet is to educate students and essential allied health care professionals on the importance of recognising that certain clinical signs do not present the same on darker skin. This is something which is not commonly practiced in medical textbooks as there is a ‘white skin bias’. It is important that we as future healthcare professionals are aware of these differences so that we don’t compromise our care for certain groups.
“The booklet addresses many issues that have been further exacerbated during the Covid-19 pandemic, such as families being asked if potential Covid patients are ‘pale’ or if their lips ‘turned blue’. These are not useful descriptors for a black patient and, as a result, their care is compromised from the first point of contact. It is essential we begin to educate others so they are aware of such differences and the power of the clinical language we currently use. We will be hosting a training session for clinical skills peer tutors which will take place in July 2020." [...] Mind the Gap is not currently published and so is not available to distribute however discussions with potential publishers are ongoing. (Article on Mukwende's "Mind the Gap: a Handbook of Clinical Signs on Black and Brown Skin", via the St George's University of London website, June 18, 2020)
Medical student creates handbook to show symptoms on darker skin, at UK's The Tab (July 14, 2020): A second-year medical student has written a book to help medics recognise symptoms on Black and Asian skin tones. Photo comparison: This picture demonstrates how differently the same disease can present on dark versus light skin. A user submitted photograph of Kawasaki disease (left) versus the American Heart Association's reference photo.
A U.S.-focused general article: Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color (STAT News, July 21, 2020) The dearth of images in the Covid-19 literature is just the newest example of the glaring lack of representation of Black and brown skin that has persisted in dermatology research journals and textbooks for decades. The issue is coming under closer scrutiny now as dermatologists, like many physicians, grapple more openly with systemic racism and the health disparities it is causing in their field. [...] Many worry the field’s shift toward using artificial intelligence to aid diagnosis of disease will further deepen the divide, because the machine learning algorithms are trained with datasets consisting primarily of fair-skinned images.
Also at issue: While many textbooks depict the vast majority of skin diseases using light skin, there is one notable exception: Black skin is more often used to depict sexually transmitted diseases, a glaring example of stereotyping that is all the more painful given the U.S. government’s complicity in the notorious Tuskegee experiments that left syphilis untreated for decades in a group of poor, Black men. [Yale professor of dermatology, Jean] Bolognia said she is extremely sensitive about not stigmatizing people of color by using only images of darkly pigmented skin to illustrate sexually transmitted diseases or drug users. [Bolognia has spent more than 20 years editing the widely-used textbook, Dermatology]. “I noticed this as a student, the images of STDs were nearly all of patients with darkly pigmented skin, but the people I saw with syphilis were often fair-skinned,” she said. “I wondered about the possibility that pictures were being taken of individuals who were less likely to say no.” [Bolognia, at work on the fifth edition of Dermatology, said providing a wide spectrum of skin tones is critical; "I feel you can always do better and I realize I don’t have enough images of Asian skin, so that is something I’m addressing.”]
Dermatologists say the lack of images is one reason why many conditions, including Lyme disease, spider bites, and cancers can go misdiagnosed or underdiagnosed in darker skinned patients, sometimes with dangerous results. The five-year melanoma survival rate for Black patients is just 70% compared with 94% for white patients.
Linked in the STAT article:
- The textbook Dermatology for Skin of Color
- AI-Driven Dermatology Could Leave Dark-Skinned Patients Behind (The Atlantic, August 16, 2018)
- Fee-for-service and structural forces may drive racial disparities in US dermatology (Letter to the Editor, British Journal of Medicine, 2020, by Jules Lipoff, assistant professor of clinical dermatology at the University of Pennsylvania)
- Skin of Color Society ("The Society is committed to the education of health care providers and the general public on dermatologic health issues related to skin of color.") Mission statement; media coverage archive; the Society's Find a Doctor database)
Review of Nonmelanoma Skin Cancer in African Americans, Hispanics, and Asians (Dermatologic Surgery: July 2018 - Volume 44 - Issue 7 - p 903-910) A complete PubMed search was conducted spanning dates from 1947 to June 2017 yielding a total of 185 manuscripts, from which 45 were included in this review. RESULTS: Relative to Caucasians, NMSC, comprised squamous cell carcinoma and basal cell carcinoma, has unique demographic and clinical features in African Americans, Hispanics, and Asians.
Dermatologic health disparities (PubMed link with abstract /Published in final edited form as: Dermatol Clin. 2012 Jan; 30(1): 53–viii) Skin cancer morbidity and mortality are disproportionally higher in blacks, Hispanics, and people of low SES [socioeconomic status]. Melanoma is more common in non-Hispanic whites and people of high socioeconomic status (SES), yet blacks, Hispanics, people of low SES, and older age persons often present with more advanced disease or have increased mortality.
Pediatric Skin of Color (2015) is "the first textbook devoted to the issues of pediatric skin of color. [...] Written for dermatologists and pediatric dermatologists, this text includes data on African American, Asian (Southeast and East), Hispanic/Latino, and Middle Eastern patients, as well as Indigenous populations (i.e. Native Americans, Aborigines)."
Patient Woke Up From Surgery With Her Hair Braided Thanks to Black Male Surgeon (Black & Magazine, July 24, 2020) India Marshall, a 29-year old African American woman from North Carolina who recently underwent skull surgery, is thankful to her surgeon, Dr. Jewel Greywoode, who is also Black, not only for successfully performing the operation but also for braiding her hair which helped her recover faster. India shared her experience on Twitter [Thread reader link], saying that at first, she thought Black nurses did her braids. But when she came back weeks later for her post-operative appointment, she found out that it was done by the surgeon, a Black man who has 3 young daughters.
It started when Marshall was searching for a surgeon to remove benign bone growths on her skull, called osteomas. It was difficult for her to find the right doctor until she finally bumped into Greywoode. Marshall said Greywoode, an ENT doctor who specializes in cosmetic and functional facial plastic surgery, made her feel comfortable with his approach. She said he was the only doctor who thought of a way to do the surgery with fewer scars, hair loss, and numbness.
Reported elsewhere as Surgeon's kind gesture proves 'why Black doctors are important,' patient says (Today.com, June 26, 2020) India Marshall described the "emotional moment" she realized her doctor had braided her hair before her surgery to make her recovery easier. [...] “I know that I could only have gotten that type of care and experience with a Black doctor because he understood my hair,” [Marshall] said. “He also brought up that he didn't use sutures or stitches because he didn't want to cut my hair when removing it. The staples are easier to take out. So that was just another example of how he was able to understand me as a Black woman and the importance of my hair and preserving it.”
Thank you for this post. I have family members who are directly affected by this 'white skin bias’. I will be so happy to share this information with them.
Thank you. And thank you, Malone Mukwende!
posted by shoesfullofdust at 4:15 PM on August 5, 2020 [2 favorites]
Thank you. And thank you, Malone Mukwende!
posted by shoesfullofdust at 4:15 PM on August 5, 2020 [2 favorites]
Wow - this is an amazing project, and fills such a huge need. Huge applause to Malone for putting in the time and effort to create it. I hope it sells a massive number of copies - clearly there are thousands of med schools and medical practices who could use a copy.
Thank you for putting together such a thorough and informative post, Iris Gambol - I'm really glad to know this exists!
posted by kristi at 4:18 PM on August 5, 2020 [1 favorite]
Thank you for putting together such a thorough and informative post, Iris Gambol - I'm really glad to know this exists!
posted by kristi at 4:18 PM on August 5, 2020 [1 favorite]
This is amazing. I wonder what else that's "obvious" we are missing due to the lack of diversity in the medical field?
posted by Foci for Analysis at 4:24 PM on August 5, 2020
posted by Foci for Analysis at 4:24 PM on August 5, 2020
This is great. I train first aid, as part of my State's volunteer emergency service. This question is (very cursorily!) covered in our course, is approached either well or poorly by individual trainers, and it's really something that is embedded right into medical language. For example: 'cyanosis', as a symptom, could be hypothermia, could be blood loss, could be shock, or it could be the sign of heart attack, or all of the above (all effects of not enough blood circulation). But to have people remember that term, and associate it with skin colour change—from the 'cyan' term for the colour blue—is yeah, white-skin specific: pale skin goes quite literally blue in a way that dark skin doesn't. I'd love for resources on symptoms like this to be part of our training kits.
posted by Fiasco da Gama at 6:33 PM on August 5, 2020 [4 favorites]
posted by Fiasco da Gama at 6:33 PM on August 5, 2020 [4 favorites]
"Jaundice may be missed or not recognized in a baby with darker skin color." (CDC.gov fact sheet)
posted by Iris Gambol at 6:51 PM on August 5, 2020 [3 favorites]
posted by Iris Gambol at 6:51 PM on August 5, 2020 [3 favorites]
This came up in an advanced first aid class I took last year. We were taught to assess patients on several axes, and the best evaluation read out as 'pink, warm and dry' (pink = oxygenation, circulation and perfusion, warm = alive and not hypothermic, dry = not clammy to touch or shocky.)
We had an interesting conversation about what exactly 'pink' meant, and then were taught how to assess oxygenation in darker-skinned people who may not look pale or dusky to an untrained eye.
This was a first aid class. Medical schools jave no excuse for not teaching this kind of thing.
posted by workerant at 7:41 PM on August 5, 2020 [7 favorites]
We had an interesting conversation about what exactly 'pink' meant, and then were taught how to assess oxygenation in darker-skinned people who may not look pale or dusky to an untrained eye.
This was a first aid class. Medical schools jave no excuse for not teaching this kind of thing.
posted by workerant at 7:41 PM on August 5, 2020 [7 favorites]
Mind the Gap is not currently published and so is not available to distribute dammit IP law
posted by away for regrooving at 12:49 AM on August 6, 2020
posted by away for regrooving at 12:49 AM on August 6, 2020
Yesterday I read this article about how pulse oximeters are less accurate (tend to give higher readings) for patients with darker skin than lighter skin. This has all sorts of consequences, from getting treated for COVID, to getting home oxygen systems approved by Medicare. It's amazing how many ways our medical system reifies racism.
posted by ChuraChura at 5:41 AM on August 6, 2020 [10 favorites]
posted by ChuraChura at 5:41 AM on August 6, 2020 [10 favorites]
An excellent collection of images from the excellent STAT article linked in this excellent post.
posted by clawsoon at 6:34 AM on August 6, 2020 [1 favorite]
posted by clawsoon at 6:34 AM on August 6, 2020 [1 favorite]
> Mind the Gap is not currently published and so is not available to distribute
dammit IP law
I suspect it's more "dammit no-one has offered to pay the author."
posted by desuetude at 8:55 AM on August 6, 2020 [2 favorites]
dammit IP law
I suspect it's more "dammit no-one has offered to pay the author."
posted by desuetude at 8:55 AM on August 6, 2020 [2 favorites]
And the related issue, "publishers don't think that med schools will buy it."
posted by desuetude at 8:57 AM on August 6, 2020
posted by desuetude at 8:57 AM on August 6, 2020
So, I'm okay with St. George's protecting their IP in that circumstance.
posted by desuetude at 8:59 AM on August 6, 2020
posted by desuetude at 8:59 AM on August 6, 2020
Came here to boost the instagram @brownskinmatters that clawsoon also linked above!
posted by lucy.jakobs at 9:35 AM on August 6, 2020 [1 favorite]
posted by lucy.jakobs at 9:35 AM on August 6, 2020 [1 favorite]
Genius is the ability to see the obvious.
posted by dances_with_sneetches at 5:58 PM on August 6, 2020
posted by dances_with_sneetches at 5:58 PM on August 6, 2020
Iris Gambol, it can go the other way, too. A friend's biracial baby was misdiagnosed as having jaundice when the kid had naturally yellowish skin.
posted by Nancy Lebovitz at 7:53 AM on August 9, 2020
posted by Nancy Lebovitz at 7:53 AM on August 9, 2020
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I read India Marshall's account about her post-op experience a few weeks ago and cried immediately. Have cried again in rereading it today.
posted by Kitchen Witch at 1:58 PM on August 5, 2020 [5 favorites]