An Australian medical student discusses the dangers of underrepresenting and misrepresenting people of colour in medical education.

Growing up, I was accustomed to watching TV shows with characters that looked nothing like me—blue eyes, white skin and straight hair. On a rare occasion, a black character would make a cameo, but rarely the main character.  I quickly realised this was a microcosm of what it means to live in a world that has been programmed with white as the default setting. Now as a medical student, my experience of underrepresentation is not limited to a TV screen but also the screen in a lecture theatre. 

Colour is an invaluable diagnostic tool in our clinical reasoning. We rely on various colour changes like redness, paleness, yellowing and blueish tinges to tell us a lot about what is going on in someone’s body. Redness or erythema might mark inflammation, pallor might suggest anaemia and blueish tinge might suggest a state of oxygen depletion. All of these are potentially serious medical states that need early recognition and  treatment. 

One does not need to be an artist to know that the background colour will impact the appearance of subsequent colours layered on top. Yet most medical teaching has always been skewed towards portraying these skin changes on a background of white skin only. While this is a problem affecting all of medicine, this is especially problematic in dermatology where there is a greater reliance on visual inspection of skin changes for clinical reasoning. Without adequate exposure to diverse skin tones, it is unlikely that we will firstly be comfortable and secondly be precise with our clinical approach to skin presentations on darker skin. 

To feel comfortable and confident in our clinical approach to a patients’ presentation, one needs experience. As it stands, because medical teaching and resources mostly show conditions on white skin, it is easier for us to develop the pattern-recognition ability to detect and diagnose conditions on white skin. On the other hand, it is less likely that we will feel confident recognising pathognomonic features in skin of colour. This is especially true as many signs can appear very different on skin of colour. For example, the malar rash of lupus is taught to us as being classically an erythematous rash. But this is only true for white skin, as the rash can appear more subtle and sometimes purple on skin of colour. Without the knowledge about these differences, our clinical approach to a patient may lack confidence and experience – something patients can be receptive to. Black patients in an American study  described exactly this – that they could sense their doctor was feeling uneasy around their skin presentation. They also felt that their doctor performed a hasty physical examination, or no examination at all—something that could, in part, be attributed to limited exposure to diverse skin tones during training. 

Black patients with melanoma are diagnosed later and deteriorate more rapidly with poorer survival. These findings are most likely a consequence of teaching which has overrepresented white skin and underrepresented darker skin tones. 

Secondly, inadequate training in the recognition of skin presentations on darker skin can result in imprecise clinical judgment. One study from the UK found that when General Practitioners were shown images of melanoma on white skin and darker skin, they were less likely to detect and diagnose melanoma in black patients compared to white patients. Delayed detection of melanoma in darker skin will undermine the benefits of earlier treatments, which results in poorer prognosis. There are a number of studies that have found this — black patients with melanoma are diagnosed later and deteriorate more rapidly with poorer survival. These findings are most likely a consequence of teaching which has overrepresented white skin and underrepresented darker skin tones. 

The issue of underrepresentation in teaching extends back to the underlying deficit in medical resources. A 2020 study found only half of the textbooks that were studied depicted common conditions like acne on darker skin, and a 2019 study found that only 20-30% of the images in educational material displayed skin conditions on darker skin. 

The flip side of underrepresentation is misrepresentation. The aforementioned  study also  found that, while the textbooks rarely showed common conditions on darker skin, it predominantly showed infectious diseases such as syphilis on darker skin. This is likely due to an underlying racial bias, rooted in a long history of exploitation of Black bodies in coercive and unethical medical research relating to the disease.

If these statistics represent the pool of medical resources available, it makes it inherently difficult for a medical student to find resources that show conditions, apart from syphilis, on darker skin. Even resorting to a google search will also fail to represent darker skin, as the algorithm appears to preferentially favour white skin. You would have to scroll long and far to find a cameo of a patient with darker skin.  

Many medical professionals have recognised this underrepresentation and have put in tremendous efforts to address this issue. Earlier this year, a British medical student Malone Mukwende was motivated by limited resources and inadequate answers to his perennial question, “but what will it look like on darker skin?,” so he created a handbook, Mind the Gap: A handbook of clinical signs in Black and Brown skin. The handbook has, rightfully, received global attention. For me, it symbolises what BIPOC communities have always had to do in exclusionary spaces — create their own spaces.

Dr Michelle Rodrigues is an Australian dermatologist who has also created a space for patients with darker skin by establishing the first specialist clinic in Melbourne for people of colour. She has also been influential in the inclusion of darker skin in dermatology training, which is vital as it has downstream influence on all levels of medical training. 

So as medical students how should we take part in deprogramming these white default settings? Some simple steps we could all take is to first notice when we are shown an image of a skin presentation on white skin alone and then second, to pose the question, ‘how would this condition look like on darker skin?’.