Although the problem is slowly being addressed, McKinley-Grant says it is crucial that health care providers are trained in recognizing diseasesand subtle changesin all skin types.
Almost every mother, regardless of the ethnicity or age of her child, can tell when they are pale and not feeling well, she says. The underlying hues of the skin are not only the result of the presence of melanin, but also reflect red blood cell counts and oxygen levelsmeasures that are vital signs for all humans. We need to train our health care providers to recognize changes in hue in all skin types, including the skin of Black and brown people.
When we invite people for lectures or to contribute to a textbook or health care literature, she adds, we need to start making it almost mandatory that they show a diversity of ethnicity and skin color in the presentation, with images of disease in black and brown skin.
Rashes that may look red on a light-skinned patient tend to appear darker brown or purple on brown or black skin. Anemia appears as gray on dark skin rather than ghostly pale on light skin, while the darkening of skin associated with hyperpigmentation, itself a sign of Addisons disease and other conditions, may go unnoticed on dark skin. For inflammation, says McKinley-Grant, its important to ask the patient where the warmth and pain is and whether the area in question looks like their normal skin color.
Dermatologists also discern problems in people with darker skin tones by looking for patterns. Pattern recognition is a huge part of our training, says Freeman. We get 12,000 to 16,000 hours of supervised patient care. That allows us to learn to recognize patterns. So if you see a pattern but dont know how to interpret it, call a dermatologist.
That may be easier said than done these days. Since 1999, American Academy of Dermatology surveys have steadily shown that skin doctors themselves report there are not enough of them to go around, especially with the increasing demands on the profession as a result of population aging and rising rates of skin cancer and other cutaneous diseases.
Dermatology is one of the highest paying fields of medicine, and it has one of the lowest burnout rates. The ever-increasing market for cosmetic dermatologywhich is paid for out-of-pockethas put an even greater burden on residency programs.
At Harvard, 70 percent of our residents stay in medical or academic dermatology, says Freeman, but were probably the only school in the country with that statistic. Not everyone who wants to is able to match into the field, and these are really good students. Its common to take a year off from medical school and do a year of dermatological research just to get in.
Many schools are combining residencies in internal medicine and dermatology. Dermatologists look at a rash and then develop a differential diagnosis, then ultimately get a history, says Loscalzo. Internists do just the opposite, gathering a lot of history, looking at all aspects of the patients physical exam, and then trying to correlate whats going on with the skin to whats happening internally. Its a totally different heuristic, and a combined residency is a great way to learn both worlds.
To train AI at high levels of accuracy, you need an enormous collection of photos, and even the largest dermatology photo libraries dont have standardized diagnoses where a group of dermatologists agree.
Continuing medical education, workshops, and events like Mass Generals annual Dermatology Bootcamp, hosted by Kourosh, are helping to bridge the gap. Through programs like this, dermatologists at HMS are always more than ready to teach and give lectures to other providers and trainees in our hospital system and the community, Kourosh says.
In addition, the use of telehealth has helped extend expertise. Although its use increased 53 percent between 2016 and 2017, according to a 2019 article from the American Medical Association, its use has expanded again. Earlier this year, the AMA detailed extensive changes to telehealth, all allowed for in the Coronavirus Aid, Relief, and Economic Security Act of 2020. Among those changes: expanding the list of services that can be delivered remotely, ensuring payment of physician fees for those services, and updating the requirements for accessing remote care to permit physicians to conduct telehealth visits from their homesand patients to access them from theirs.
These changes have been especially useful for dermatology and are increasing access to health care in all specialties, particularly for underserved patients in rural areas and elsewhere, for members of the military, and, during this pandemic, for patients sheltering in place, says McKinley-Grant.
Apps and artificial intelligence also hold promise, though, according to Kourosh and others they have a long way to go. To train AI at high levels of accuracy, Kourosh says, you need an enormous collection of photos, and even the largest dermatology photo libraries dont have standardized diagnoses where a group of dermatologists agree. Add to that the dearth of patients of color represented in most collections. Multiple efforts are being made now to do this correctly and safely for patients, but it may take years, she adds.
Until then, internists, primary care doctors, and other specialists remain patients first line of defense. Its true that time is a bigger limitation than in the past, admits Loscalzo, but if youre not carefully considering skin symptoms, youre not being a thorough physician.
Elizabeth Gehrman is a Boston-based writer.
Images: Juti/Essentials Collection/Getty Images (top); John Soares (Freeman); Mark Finkenstein (McKinley-Grant)
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Attuned to the Signs of Trouble | Harvard Medicine magazine - Harvard Medical School