Disparities in Visual Diagnosis in Diverse Skin Following Pre-Clerkship Medical Curriculum

Abstract

Background Disparities in the diagnosis of skin conditions in the United States have long disadvantaged people of color. Addressing healthcare inequities through education is vital to improving quality of care. Pre-clinical medical curriculum introduces students to skin disorders through lectures. Classic clinical presentations are described using key phrases or “buzzwords” in vignettes; however clinical image exposure introduces the visual diagnostic and pattern recognition skills used in real healthcare settings. Past studies have shown that medical graduates do not feel adequately prepared in dermatology overall and struggle to recognize lesions equally in darker skin. Most skin lesions initially present to primary care physicians, emphasizing the need for improved training for non-dermatologic specialties beginning with undergraduate medical education. Methods Participants were recruited from students at the end of pre-clinical skin curriculum. They completed a needs assessment showing eleven different skin disorders that included two clinical images each, one in darker skin and one in lighter (Fitzpatrick IV-VI vs. I-III), with no vignettes. The disorders were chosen based on the American Academy of Dermatology’s recommended medical student curriculum, USMLE Step 1, and prevalence according to a previous study assessing most common skin disorders in African American, Asian or Pacific Islander, Caucasian, and Hispanics of any race. Participants were asked to identify the images from a list of possible answers. The study assessed if students were able to visually recognize skin disorders and if any disparities exist concerning skin of color. Results Students demonstrated overall proficiency in visual diagnosis; however, students did not reliably recognize squamous cell carcinoma, eczema, and Stevens-Johnson Syndrome in darker skin. Conversely, they were less able to recognize basal cell carcinoma and tinea versicolor in lighter skin. Overall, students demonstrated lower scores for recognition of nine of the assessed disorders in darker skin. Conclusion The current pre-clerkship curriculum does not adequately prepare medical students to recognize skin disorders in darker skin. We believe that curriculum change should include more diverse visual representations and specific instruction concerning how the appearances of these disorders may vary depending on skin color, to better prepare medical students to care for the entire patient population.