Intended for healthcare professionals


Presenting clinical features on darker skin: five minutes with . . . Malone Mukwende

BMJ 2020; 369 doi: (Published 25 June 2020) Cite this as: BMJ 2020;369:m2578
  1. Abi Rimmer
  1. The BMJ

The medical student who created a handbook presenting clinical features on darker skin describes the ambition behind it

Mind the Gap is a handbook of clinical signs in black and brown skin. Its aim is to teach medical students and other health professionals about the importance of recognising how some conditions can present differently in darker skins.

“On arrival at medical school I noticed a lack of teaching about darker skin. We were often taught to look for symptoms, such as rashes, in a way that I knew wouldn’t appear on my own skin.

“When I raised this with my tutors they often didn’t know how else to describe the condition or they weren’t aware of how they looked in darker skins. I was often told to find out for myself after the sessions—which I didn’t think was the correct way to teach.

“Because the reference points that we use in medicine are so often on white skin you can find yourself subconsciously imagining what a symptom looks like on white skin. We never really accommodate for the fact that there are different skin tones.

“During my second year of medical school I took part in a staff-student partnership with two members of staff and they helped me to create the handbook.

“Gathering the information that we needed was probably one of the hardest things I’ve ever done. It’s almost as if the information didn’t exist, it was so hard to find. But that reiterated to me how important this work is—if I was struggling to find this information then imagine what it would be like for people who don’t have the time or patience to search for it.

“I often found that if I spoke to someone, the information trail would end with them—no one had a single good source of information, they just knew fragments of things. So I had to bring all those fragments together.

“This work is so important because the lack of diversity in medical teaching has the potential to have fatal consequences. It’s already widely known that there are disparities in healthcare. The current covid-19 pandemic has further highlighted why this work is needed.

“We also need to make sure that it’s not the responsibility of patients to educate healthcare professionals about their condition. Having more diversity in medical images could increase patient satisfaction because it will increase their confidence in healthcare professionals. This could lead to secondary improvements, such as patients adhering to their treatment because they’ve had a good experience with healthcare professionals.

“The reaction to the handbook has been overwhelming. I’ve had messages from places like Germany, Brazil, and the Philippines. I’d like to see it becoming a staple resource for medical institutions, such as medical school libraries and GP practices, across the UK and eventually across the world.

“I’d also like to see the medical school curriculum become more representative of the patients that we serve. This needs to be reflected across the entire course, from clinical skills teaching to diversifying the exam content.

“Finally, I’d like to see diversity in healthcare increase—representation matters.”


  • Malone Mukwende is a second year medical student at St George’s, University of London. Follow him on Twitter @malone_mk