Jenna C. Lester Why skin disease is often misdiagnosed in darker skin tones TED
The skin is the human body’s largest organ
and one of the most powerful
predictors of our health.
This is erythema migrans,
a hallmark feature of Lyme disease,
a tick-borne illness
present in over 80 countries
and estimated to affect 476,000 people
in the United States each year.
Dermatologists like me
are doctors of the skin
trained to diagnose
and treat skin disease.
And this is how we’re trained
to see erythema migrans,
as a bullseye-shaped rash
that ranges from red to pink.
But this is not at all
what it looks like in dark skin.
As you can see here,
there are hues of violet, of magenta,
and even dark brown.
If we were to rely
only on dermatology textbooks
to teach us how to identify skin disease,
we would frequently
misdiagnose it in patients of color.
And this is a huge problem
because Lyme disease needs to be treated.
Left untreated, Lyme disease
has significant health ramifications
including arthritis and even nerve damage.
And what’s more,
as we’ve seen an increase
in the incidence of Lyme disease,
a phenomenon attributed
in part to climate change,
as we continue to see and experience
the effects of climate change,
we may see more people
infected with Lyme disease,
making it even more important
that we’re able to accurately diagnose it.
Now, this story of erythema migrans
is emblematic of a larger issue.
In the United States, 47 percent
of graduating dermatology residents
report feeling uncomfortable diagnosing
skin disease in patients with dark skin.
47 percent. I just want that
to sink in for a second.
This is a staggering statistic,
and this means that the people
who have just undergone
their most intensive training
to become doctors of the skin
don’t feel comfortable
diagnosing and treating all patients.
And even so, they graduate from residency,
and they’re eligible to become
board-certified dermatologists,
qualified to care for all people.
Now, I wonder, could this be
why we still see and experience
health care disparities
in all aspects of medicine,
including dermatology?
I believe there’s a connection
between the fact
that almost half of dermatology residents
feel uncomfortable diagnosing
and treating certain patients
and the poorer health outcomes
of those same patients.
I speak to patients of color all the time
who express an awareness of the fact
that their dermatologist is unfamiliar
with diagnosing skin disease
in their skin tone
or uncomfortable teaching them
how to care for their hair or scalp.
And I wonder, what does this awareness
that your doctor is uncomfortable with you
due to the physician-patient relationship;
to trust in the medical establishment;
or to the likelihood that someone
returns for additional care?
A problem in dermatology is
that we’re not taught how skin disease
appears in all skin tones.
As a medical student,
my classmates and I quickly realized
that we only saw dark skin
when we were learning about syphilis.
And this observation
is supported by research that I published
in the British Journal
of Dermatology in 2019
that shows an overrepresentation
of dark skin in chapters
focused on sexually
transmitted infections,
even while those same skin tones
are underrepresented elsewhere
in the same textbook.
What does this do
to impressionable learners?
Does it make them think
that someone with dark skin
is more likely to have
a sexually transmitted infection?
Now, I know some of you may be thinking,
I know an algorithm that can solve this
or machine learning to the rescue.
And I’m here to gently disagree.
And that’s because the data
from which these algorithms learn
are the same photos
that overrepresent dark skin
in certain skin conditions,
even while underrepresenting
them in others.
In other words, these algorithms
will be as biased as we are
unless we make significant change.
I started the Skin of Color program
at the University
of California, San Francisco,
where I work with
medical students and residents
in an effort to begin to help them unlearn
some of these harmful patterns
that make it easier to see some things,
like dark skin with syphilis,
and harder to see others,
like dark skin with erythema migrans.
I teach everything from how to identify
inflammation in dark skin
to how to talk to a Black woman
about her hair care practices.
And one important fact
that I always make sure to mention
is that it’s neither good nor common
for Black women
to wash their hair every day.
And any treatment regimen
focused on taking care
of the hair and scalp
should reflect
this important understanding.
My work at the Skin of Color program,
as well as the work
of similar programs across the country,
demonstrate the importance of creating
a dedicated educational environment
for residents and medical students
to learn the full spectrum of skin disease
as they appear in all patients,
regardless of skin tone.
This is an important first step
on a long road towards eliminating
health care disparities in dermatology.
But let’s commit
to taking this journey together.
Thank you.
(Applause)