In September, Women’s Health published a special report about our country’s shocking dermatologist shortage, especially within “derm deserts,” areas where there is no dermatologist for 50 or even 100 miles. This is particularly concerning for patients with a suspected melanoma—the third-leading cause of cancer death among women ages 25 to 39. Because fast-growing types of the skin cancer can turn deadly in just weeks, getting it diagnosed and removed ASAP can mean the difference between life and death.
For people of color, that pendulum swings closer to death: New research shows that nonwhites have longer delays for melanoma surgery than anyone else. Which is alarming, because they’re more likely to die from melanoma than white patients.
THE DOCTOR WON’T SEE YOU NOW
The specifics: In one new study from the University of North Carolina at Chapel Hill, published in the journal JAMA Dermatology, people of color had a 38 percent higher risk for delays—longer than the recommended six-week max—in getting their skin cancer removed, no matter what type of insurance they had. (After six weeks, there’s a higher chance that melanoma can spread from the skin to other organs or the lymph nodes.)
Compounding this inequity are the findings of a study from Michigan State University, also published in JAMA Dermatology, which shows that black patients in particular had the lowest rates of survival from melanoma. White patients nationwide had the highest rates of survival, followed by Hispanics, then Asian Americans, Native Americans, Pacific Islanders, and finally black patients. One main reason? Patients of color are more likely than whites to be diagnosed with late-stage melanoma—and when it’s progressed beyond the skin, it requires more complicated treatments and has a worse prognosis. To wit, a previous study found that patients of color are four times as likely as white patients to be diagnosed only after melanoma has spread to other parts of their body.
Related: I'm A Swimmer. I'm Black. Surprised? You Should Be.
BIAS AT PLAY
“Systematically, patients of color are getting worse dermatological care,” says dermatologist Adewole Adamson, M.D., an assistant professor of dermatology at the University of North Carolina at Chapel Hill and coauthor of the UNC study. That’s because a “nationwide pattern of patient discrimination is putting lives on the line.” A look at the issues:
Inadequate Training for Doctors
Not okay: Fifty percent of dermatologists report that their medical schools didn’t prepare them to spot the signs of skin cancer on people of color, and only one in 10 dermatology residencies include a rotation specific to treating patients of color. In African Americans and other people of color, more than half of melanomas show up on areas with less pigment, like the palms of the hands and soles of the feet—places where white patients don’t typically get melanoma—so derms may overlook them, says dermatologist Macrene Alexiades, M.D., an associate clinical professor of dermatology at Yale University School of Medicine. “Hands and feet are also at the ends of the blood supply, which have less immunologic surveillance, so melanomas in those areas tend to be more deadly, as they are less likely to be slowed by those natural bodily defenses.”
This lack of understanding plays out in other ways too. “Many dermatologists give the same recommendations about skin-cancer prevention to their patients of color as to white patients, and it should be more nuanced than that,” says Adamson. Rather than just being told to use adequate sunscreen, people of color should be advised to check the palms of their hands and bottoms of their feet to catch melanomas early.
The miseducation of both doctors and patients is widespread. It’s true that people of color, who have more melanin in their skin, have lower rates of skin cancer than those with fair skin, which may make providers less vigilant about doing skin checks on them—and dark-skinned patients think they don’t have to worry about skin cancer. Because of this, people with lighter complexions are generally more aware of skin cancer and told to protect themselves from it. “Dermatologists need to be made more aware that nonwhite patients are still at risk, and convey that to their patients, who may not even understand that people of color can get melanoma,” says Alexiades.
Limited Access to Care
From PCPs to nonphysician practitioners, many health-care pros can biopsy and diagnose a melanoma. But when a dermatologist does it, you’re more likely to get expedient treatment (to be exact: you’ve got a 20 percent lower risk of surgical delay, according to Adamson’s study). “Studies keep finding evidence that when dermatologists are able to perform both the biopsy and excision, the risk of delay is significantly decreased. Unfortunately, we now know just how complicated it can be for some populations to get in to see a dermatologist in a timely fashion,” Adamson says.
This is where “derm deserts” come back into play. “A disproportionate percent of people of color live in poorer areas of the country—which have fewer dermatologists than wealthier enclaves. Many of these poor areas happen to be the ‘derm deserts’ Women’s Health covered in its investigation, and so people are having a difficult time finding a dermatologist near them or getting in for treatment within that safe window of time,” says Adamson. Compounding this, a large percentage of people of color are on Medicaid, a government-subsidized insurance plan—and studies, including Adamson’s, have shown that those who use Medicaid wait longer to see specialists. All of which may explain why nonwhites are more likely to be diagnosed by their family care physicians or nonphysician practitioners.
In a 2012 study of M.D.s of various specialties, every doctor surveyed said that all patients should be treated the same, but when they were shown photographs and asked to match them with words, they were quicker to pair pictures of black people with words like resistant and unpleasant instead of cooperative and willing. While this study didn’t single out dermatologists, what is clear is that dermatology is an overwhelmingly white field. Out of all the residency categories that U.S. medical students applied to in 2015, dermatology ranked 35th out of 46 specialties in terms of attracting minority candidates. The real-world result? This year, only 3 percent of practicing dermatologists identify as African American. Only 4 percent are of Hispanic ancestry. Most are white.
This inequality could lead to situations in which dermatologists don’t spend as much time with patients of color or listen to their concerns as thoroughly. “Bias and racism in health care is something that is pervasive, and that can have devastating, sometimes even deadly, consequences,” says Adamson. “These are not topics that we as physicians have enough frank discussions about, either in medical school or in everyday care. Doctors aren’t taught to consider their internal biases, so they can go unexamined and be perpetuated.”
See why it took this woman 9 months to be diagnosed with melanoma:
HOPE FOR CHANGE
The medical community is beginning to mobilize to bring awareness to—and solve the issues behind—the inadequate care that many people of color receive. In 2016, medical and dental students and faculty at Harvard University formed a coalition to call attention to the lack of diversity at Harvard Medical School (which is actually more diverse than most med schools), inspired by the national organization White Coats 4 Black Lives, formed in 2015. Last year, more than 3,500 physicians and medical students from over 80 medical schools joined the movement and signed a letter publicly stating that health professionals must confront the institutionalized racism that is contributing to the loss of black lives.
“We all have to do our part to stop this pattern,” says Alexiades, who is currently writing a two-volume dermatology textbook—to be published next October and taught in medical schools nationwide—that will include information about skin cancer markers in different skin types, along with diverse photo examples. Beyond the book, Alexiades is calling for other improvements in doctor education: She recently gave a presentation at the American Society for Dermatologic Surgery annual meeting, in which she led six patient-dermatologist consultations—both patients and doctors represented various skin types, and the derms shared their specialized knowledge. She will continue to stage these teaching presentations at future derm conferences. “Patients of every skin type should be used for live demos in medical training for dermatologists, which is currently not usually done. Every time an educational session is presented, whether it’s in medical school or at a conference of dermatologists, it should be required that what’s put forth are data for each skin type, encouraging diversity in the doctors who present and teach, as well as in patients,” says Alexiades. “We’re just now starting to make this happen.”
Adamson, too, has hope that the needle is starting to move in a positive direction. “Addressing these really difficult questions of racial bias in medicine isn’t currently part of medical school curricula. And in a field like dermatology, which is one of the least diverse fields in medicine, it can be even harder to have those conversations and to be heard when we do,” he says. He credits the American Academy of Dermatology with pushing for discussion. The organization has created the Diversity Mentorship Program and has recently published articles in medical journals calling for more awareness of diversity issues in dermatology. “Talking openly about race in the culture at large is causing these conversations to happen more and more in medical circles,” says Adamson. “I’m very heartened by that. Hopefully, this will lead to change.”