Jenna C. Lester: Why skin disease is often misdiagnosed in darker skin tones | TED

The skin is the human body's largest organ and one of the most powerful predictors of our health. This is erythema migrans, a hallmark feature of Lyme disease, a tick-borne illness present in over 80 countries and estimated to affect 476,000 people in the United States each year. Dermatologists like me are doctors of the skin trained to diagnose and treat skin disease. And this is how we're trained to see erythema migrans, as a bullseye-shaped rash that ranges from red to pink. But this is not at all what it looks like in dark skin. As you can see here, there are hues of violet, of magenta, and even dark brown. If we were to rely only on dermatology textbooks to teach us how to identify skin disease, we would frequently misdiagnose it in patients of color. And this is a huge problem because Lyme disease needs to be treated. Left untreated, Lyme disease has significant health ramifications including arthritis and even nerve damage. And what's more, as we've seen an increase in the incidence of Lyme disease, a phenomenon attributed in part to climate change, as we continue to see and experience the effects of climate change, we may see more people infected with Lyme disease, making it even more important that we're able to accurately diagnose it. Now, this story of erythema migrans is emblematic of a larger issue. In the United States, 47 percent of graduating dermatology residents report feeling uncomfortable diagnosing skin disease in patients with dark skin. 47 percent. I just want that to sink in for a second. This is a staggering statistic, and this means that the people who have just undergone their most intensive training to become doctors of the skin don't feel comfortable diagnosing and treating all patients. And even so, they graduate from residency, and they're eligible to become board-certified dermatologists, qualified to care for all people. Now, I wonder, could this be why we still see and experience health care disparities in all aspects of medicine, including dermatology? I believe there's a connection between the fact that almost half of dermatology residents feel uncomfortable diagnosing and treating certain patients and the poorer health outcomes of those same patients. I speak to patients of color all the time who express an awareness of the fact that their dermatologist is unfamiliar with diagnosing skin disease in their skin tone or uncomfortable teaching them how to care for their hair or scalp. And I wonder, what does this awareness that your doctor is uncomfortable with you due to the physician-patient relationship; to trust in the medical establishment; or to the likelihood that someone returns for additional care? A problem in dermatology is that we're not taught how skin disease appears in all skin tones. As a medical student, my classmates and I quickly realized that we only saw dark skin when we were learning about syphilis. And this observation is supported by research that I published in the British Journal of Dermatology in 2019 that shows an overrepresentation of dark skin in chapters focused on sexually transmitted infections, even while those same skin tones are underrepresented elsewhere in the same textbook. What does this do to impressionable learners? Does it make them think that someone with dark skin is more likely to have a sexually transmitted infection? Now, I know some of you may be thinking, I know an algorithm that can solve this or machine learning to the rescue. And I'm here to gently disagree. And that's because the data from which these algorithms learn are the same photos that overrepresent dark skin in certain skin conditions, even while underrepresenting them in others. In other words, these algorithms will be as biased as we are unless we make significant change. I started the Skin of Color program at the University of California, San Francisco, where I work with medical students and residents in an effort to begin to help them unlearn some of these harmful patterns that make it easier to see some things, like dark skin with syphilis, and harder to see others, like dark skin with erythema migrans. I teach everything from how to identify inflammation in dark skin to how to talk to a Black woman about her hair care practices. And one important fact that I always make sure to mention is that it's neither good nor common for Black women to wash their hair every day. And any treatment regimen focused on taking care of the hair and scalp

should reflect this important understanding. My work at the Skin of Color program, as well as the work of similar programs across the country, demonstrate the importance of creating a dedicated educational environment for residents and medical students to learn the full spectrum of skin disease as they appear in all patients, regardless of skin tone. This is an important first step on a long road towards eliminating health care disparities in dermatology. But let's commit to taking this journey together. Thank you. (Applause)