Melanin: Medicine’s Blind Spot

Authored by: Syed Hasan

Medical students learn the ins and outs of diagnosing diseases and prescribing treatment throughout medical school and their residency. One recurring practice in these crucial years is simulating patient care by working with photographs and manikins. These are the formative experiences that future doctors utilize throughout their careers. Unfortunately, these manikins fail to provide an accurate representation of patient populations. 

With large advancements in the fields of sterilization, surgical equipment, and even direct disease treatment, the implementation of a diverse set of manikins has yet to be brought to mass media attention. Dermatology is a field that focuses entirely on diagnosing and treating disorders associated with the skin. This is a specialty heavily reliant on manikins and photographs to teach students how various conditions manifest. In an article published collectively by prominent research hospitals, the Departments of Dermatology emphasized that “dermatological disease presents differently in different skin tones, and current dermatology training may not equip graduates to make diagnoses with ease” [1]. The lack of diversity in physician training has an impact on patient care that is long-lasting and detrimental. Information that is built with a limited reference can never fully be representative of the entire population. Medical professionals entering the workforce with these gaps in knowledge regarding patient prognosis will increase the proportion of future misdiagnoses. As Kaundinya and Kundu explain: “the core of this underrepresentation of brown and black skin is white centering and defining white as normal when characterizing skin conditions” [2]. Educating students solely on disease manifestation in lighter and fairer skin tones not only limits physician understanding but increases the risks of disease going unnoticed or undertreated in patients with darker (underrepresented) skin tones.

Pseudofolliculitis barbae is one of many diseases that do not manifest with universal symptoms. To expand, “the misdiagnosis and inadequate treatment of PFB, a type of folliculitis common in individuals with curly hair, can lead to scarring, permanent hair loss, and bacterial infections” [3]. Not only is the lack of diversity detrimental to diagnoses, they worsen healthcare outcomes for the people in these predominantly underrepresented groups. 

To mitigate disparities within healthcare, change must begin at the root cause. The underrepresentation in medical textbook photographs and manikins in live demonstrations compound itself in the deeper issue of the underrepresentation of darker skin tones in medicine overall. In a study done on pulse oximeters, a staple noninvasive device that measures oxygen levels in a person’s blood, it was found that “SpO2 is frequently overestimated in Black adults and infants, and in subjects with darker skin. As a result, these patients are more likely to experience occult hypoxemia than White subjects, which may lead to delayed medical attention” [4]. If a device found in nearly every clinic has errors in its readings due to light absorption in individuals with more melanin, what population was the device tested on before becoming widely introduced into healthcare? 

The lack of knowledge within the field is clear, a change is not only needed but possibly imminent. In the University of Botswana, year four and year five medical students were introduced to online modules covering multiple diseases and how they present on darker skin tones, an area lacking in medical education as a whole but highlighted in areas that have limited resources and dermatologists. Through this research, authors found that they had “successfully designed population-specific, skin-of-color dermatology PALMs and demonstrated their effectiveness in improving medical student application of basic descriptive terminology and recognition of diagnoses” [5]. Students improved their abilities to diagnose common conditions, such as skin lesions, in a significantly shorter amount of time. This study opens doors to limitless possibilities for healthcare on an international scale. The implementation of a diverse set of photographs for various diseases increases representation and broadens education. At its core, funding for this issue prevents delayed treatments, misdiagnoses, reduces incidence of undiagonosis, and thus saves numerous lives.   

Works Cited

1. Narla, S., Heath, C. R., Alexis, A., & Silverberg, J. I. (2023). Racial disparities in dermatology. Archives of dermatological research, 315(5), 1215–1223. https://doi.org/10.1007/s00403-022-02507-z 

2. Kaundinya, T., & Kundu, R. V. (2021, June 11). Diversity of skin images in medical texts: Recommendations for student advocacy in medical education. Journal of medical education and curricular development. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202324/  

3. Ongoro, G., Avestruz, Z., & Stover, S. (2023, December 4). Skin inclusion: Addressing deficits in medical education to promote diversity in dermatological diagnosis and treatment. Clinical, cosmetic and investigational dermatology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10706051/ 

4. Al-Halawani, R., Charlton, P. H., Qassem, M., & Kyriacou, P. A. (2023). A review of the effect of skin pigmentation on pulse oximeter accuracy. Physiological measurement, 44(5), 05TR01. https://doi.org/10.1088/1361-6579/acd51a 

5. Slaught, C., Madu, P., Chang, A. Y., Williams, V. L., Kebaetse, M. B., Nkomazana, O., Molefe-Baikai, O. J., Bekele, N. A., Omech, B., Kellman, P. J., Krasne, S., & Kovarik, C. L. (2022). Novel Education Modules Addressing the Underrepresentation of Skin of Color in Dermatology Training. Journal of cutaneous medicine and surgery, 26(1), 17–24. https://doi.org/10.1177/12034754211035093