Achieving Visual Learning Equity: A Course Auditing System of Skin Color of Images in Preclinical Medical Education

Abstract

Background: Supplementary medical school learning resources, including textbooks, United States Medical Licensing Examinations (USMLE) preparatory materials, and internet searches have all been shown to lack equitable representation of brown and black skin images. This creates a knowledge gap for learners and decreases providers’ confidence managing skin disease in all populations. Subsequently, patients with non-white skin experience delayed or missed diagnoses, which contributes to known skin health disparities. Here, we aimed to create a standardized course auditing system to assess the use of brown and black skin images in the preclinical medical education. Methods: We performed a cross-sectional audit of the 2020-2021 preclinical curriculum at the University of Pittsburgh School of Medicine (UPSOM). All human images in the learning material for 34 first- and second-year medical school courses were analyzed. Skin color was categorized as light/white, medium/brown, and dark/black using the Massey-Martin NIS Skin Color Scale. Results: In total, 1,660 unique images were analyzed; 71.3%, (n=1,183) were light/white, 16.1% (n=267) were medium/brown and 12.7% (n=210) were dark/black. Dermatologic images of skin, hair, nail, or mucosal disease made up 62.1% (n=1,031) of the images and 68.1% (n=702) of the dermatologic images were light/white. Images of infectious diseases were more frequently presented in darker skin colors (χ2(2) = 15.46, p<.001). Conclusion: White skin was the standard used for visual learning images. These results further substantiate the lack of representation of brown and black skin in medical education. Using our efforts as a model, we propose guidelines to achieve visual learning equity. First, institutions should create a taskforce to implement a similar course auditing system. Medical school educators should be informed to present skin conditions on a spectrum of skin colors (white, brown, and black skin) to demonstrate differences in disease manifestations based on constitutive skin type. Resources with high quality images of brown and black skin should be made accessible for editing learning material. Course content should be audited regularly with feedback and support given to instructors. It is paramount that we analyze and revise our medical school curricula to ensure the next generation of physicians are educated to care for all patients.