Medical education is still complicit in poor healthcare outcomes for ethnic minority patientsBMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2760 (Published 23 November 2023) Cite this as: BMJ 2023;383:p2760
- Zeshan Qureshi, paediatrician, UK
Last year I returned to clinical practice in the UK as a paediatric registrar after taking a two year break. I needed a medical refresher, so I attended a compulsory two day course on managing the acutely unwell child. I gained some insights into new approaches, yet it quickly became obvious that the course’s guidance was almost entirely predicated on treating patients with white skin.
The 300 plus page manual we were given in advance included no images of patients with obviously darker skin. Every mannequin that was used on the day was white. And there was no teaching on the day about how to assess acute illness in children with darker skin tones. When I pointed this out, the course providers acknowledged the need for diversity and said that the next course update, which was released last month, worked on this. But why wasn’t the problem tackled earlier?
These omissions are a recurring problem in medicine. In the wake of the course, I’ve been reflecting on two things that I think are inextricably linked: the poor representation of ethnic minority groups in medical education, and the ongoing poorer health outcomes in the same population compared with white people.
Infant mortality rates in England and Wales were 2.2 times higher in Black children compared with white children in 2021. Children from Asian, Mixed, and “other” ethnic groups also had higher mortality rates.1 Ethnic inequalities in child health outcomes are observed globally,23 and part of the problem lies in how healthcare professionals are taught to assess disease. This is particularly evident when it comes to recognising skin pathology.
Medicine is still primarily taught under the assumption that a clinician’s patient will have white skin, with the diagnosis and treatment of illness flowing from this starting point. Ethnic minority groups are under-represented in teaching across presentation slides, lectures, and medical textbooks. An analysis of the New England Journal of Medicine from 1992 to 2017 found that 80% of 1381 images in their “Images in Clinical Medicine” section depicted white skin, despite NEJM being an international journal and white people being a global minority.4 The biases that arise because of such teaching can have tangible negative effects on patient care, contributing to healthcare inequalities.
One global survey found that of 600 healthcare professionals, only 5% felt confident diagnosing skin conditions across a range of skin tones. Unsurprisingly, the people in that 5% were more likely to have had teaching across a range of skin tones, and people from Africa and Latin America were most confident, with their own lived experiences presumably filling in some of the educational gap.5
Inappropriate assessment techniques
In recent years, there has rightly been increased focus on how chronic skin conditions such as eczema present differently in people with darker skin.6 Yet it is also critical to recognise how the presentation of acutely unwell children can differ across skin tones.
In a recent report, the NHS Race and Health Observatory called for NHS England to create a national databank of freely available clinical images of neonates to incorporate into medical training and to aid diagnosis in clinical practice, precisely because of the current lack of diversity in educational materials.7 Signs such as pallor, cyanosis, delayed capillary refill, and jaundice can be harder to detect in patients with darker skin tones using current assessment techniques. Common features that clinicians are told to look out for, like mottling or appearing “pink,” are more specific to white skin. This matters and has serious consequences for how quickly and effectively a child with darker skin is treated.
It is true that image banks and supplies of mannequins were historically limited, but this is no longer the case. Online resources like DFTB Skin deep8 or Black and Brown Skin9 now provide a large archive of available teaching material, much of which is available for free. Mannequins are also increasingly produced in a range of skin tones, without any increase in cost to providers. Students and trainees could easily be taught how slight variations in technique can assess illness in different skin tones—for example, jaundice might be easier to detect on the palms of the hands or soles of the feet in patients with darker skin.
Medical educators need to prepare healthcare professionals to treat an ethnically diverse population. Anti-racist medicine is multifaceted. Medicine and wider society have many areas to tackle to achieve equity in health outcomes and patient experiences. However, when diagnosis or assessment is based on visual signs, using white skin as the sole point of reference is not only inaccurate, it can also contribute to poorer health outcomes in ethnic minority groups. It is particularly important for clinical signs to be accurate when a patient is acutely unwell, as you may have seconds to act and little other information to go on, particularly in the non-verbal child.
All educational material in medicine should recognise diversity of skin tones in its approach to disease, not just because it more accurately describes how illness presents in the global majority, but also because it is essential to help improve the abysmal healthcare outcomes in ethnic minority groups.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
Acknowledgement: Thank you to Andrew Tagg and Hammad Khan for proofreading early drafts of this work.