YESMAR OYARZUN: This is metastasis. I'm your host Yesmar Oyarzun.

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In this episode, we are zooming out to talk about structural issues in medicine. Today, we'll be talking about problems related to race, skin cancer detection and dermatology. For that, we're taking you to New Orleans, Louisiana. Meet Dr. Andrea Murina.

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ANDREA MURINA: I've been a dermatologist for eight years.

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YO: I reached out to Dr. Murina after reading a study that she and others worked on called medical students ability to diagnose common dermatological conditions in skin of color. It turned out that medical students had a hard time diagnosing diseases on darker skinned patients. I want it to know a bit more about how that study was conceived.

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ANDREA MURINA: My first question, which actually didn't answer in this in the actual study was would there be a difference in your visual diagnostic accuracy if you went to school medical school in New Orleans and saw, you know, skin and color patients on a regular basis versus somewhere that would be a little less diverse in terms of the population seen.

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YO: I reached out to Dr. Murina after reading a study that she and others worked on called medical students ability to diagnose common dermatological conditions in skin of color. It turned out that medical students had a hard time diagnosing diseases on darker skinned patients. I want it to know a bit more about how that study was conceived.

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As it turned out, there wasn't much of a difference.

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But Dr. Murina had encroached on a deeper problem in dermatology, that seems to be an open secret, a lack of diversity. In a city like New Orleans with a large black population, there are no black dermatologists, dermatology happens to be the second least diverse medical specialty. And when I looked into this further, there is also a problem with dermatology textbooks. Rarely do you see a dark skinned patient.

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[music]

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YO: When I was around eight, I went to the dermatologist with my dad, I had tiny bumps on my lips and around my mouth. The dermatologist a white man wasn't 100% sure about my condition, but diagnosed me with rosacea. When he walked us back to the lobby, he saw a magazine cover with Bill Clinton's face on it. He picked it up and said, look, the President has rosacea too.

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But seeing Bill Clinton, a light skinned man with flushed cheeks didn't seem like proof to me. In retrospect, I probably had an allergic reaction that wasn't rosacea. But it always struck me that the doctor couldn't find any examples of dark skinned patients with rosacea.

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Now, as I met with Dr. Murina, I wanted to ask, Why are there no dark skinned bodies and dermatology textbooks? How does this impact the field? More importantly, how does it impact patients?

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ANDREA MURINA: When you look at things like melanoma, it turns out that if you are black or Hispanic, if you're not insured, even though the overall proportion of melanoma is lower in those populations, you actually have a higher risk of dying. And so there's this disconnect between our awareness of melanoma and light skin. And the other side of the coin is that blacks and Hispanics have melanoma diagnosed at a more advanced stage. And they have a significant mortality difference from Caucasian patients, because the melanoma is missed. And when I say Miss, the patient may not know about it, a doctor may not see it, it may not be brought up. So there's several factors in how they get to that advanced stage. But the fact is, when they're diagnosed at a higher stage, automatically, they're the mortality difference is significant. So I have the numbers are actually that the five year survival of a black patient with melanoma is 74%. versus a white patient, it's 92.9%.

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YO: So a lot of this has to do with disease detection. And Dr. Murina's study, she put medical students in an unfamiliar situation. She tested students from different parts of the country to see if they could correctly and consistently identify the same set of diseases on dark and on light skin. It turned out that it didn't matter where students were getting trained, they often had the same limitations. They didn't know how to read diseases on darker skin.

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ANDREA MURINA: And I think the study showed a few things that I think are really important. The first is about skin cancer and skin of color will often have have a high melanin content so it will be dark brown in color. And so one of the skin diseases that came up in our study was squamous cell carcinoma and squamous cell carcinoma on the skin, much more Common in light skinned patients. In dark skinned patients, it often looks it can, it can look funny, it can look like a benign growth, it can kind of look like a wart. And so the key is you kind of have to have, you have to have that in the front of your mind that something could be a skin cancer in order to biopsy it and treat it as you would a suspicious lesion and a lighter skinned person. And so, squamous cell carcinoma, I believe there was a 30% difference. So meaning there was, you know, 30% more students were able to recognize squamous cell carcinoma and a light skinned patient versus a dark skinned patient. And so that really highlighted the fact that recognizing that skin cancer in patients of color will have melanin in it is an important teaching point.

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YO: This is shocking. Failing to diagnose for skin cancer can cost someone's life. What were some of the basic tools that students were missing?

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ANDREA MURINA: The second important concept that needs to be taught in medical school is how redness looks in skin of color patients and how does redness or pink we call it erythema medical term for any redness of the skin, and how that appears in the skin of color patients. And that was highlighted with two diseases that came up from our study. And those two diseases with discrepancies were urticaria, which is also known as hives. And then the other was atopic dermatitis.

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YO: This was also astounding to me, since hives and dermatitis are actually two of the most common skin conditions. It admit that dermatologist were missing a lot.

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ANDREA MURINA: It's important to know that medical students don't get a lot of training in dermatology. So they're getting only I think it's 15 or 16 hours of training, which is 1% of their total education. So think about I'm giving them a quiz on something that they really most of them have not spent considerable amount of time studying. So of course, they can get things wrong, right? They can miss eczema, they can miss urticaria. And to me, it's fine. They're still learning. But the point to make is that, is there something that they're not learning that we could teach them and that we have the opportunity to close that gap and make them better physicians to treat the whole population in the United States, not just these lighter skinned patients that are the images that they're seeing when they interact with dermatology. So that 1% is it only being devoted to photos of patients with light skin? Or is there equal time given to also looking at skin of color and diseases that affect, you know, patients with darker skin color.

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YO: Dermatologists have been working to improve these factors for some time. In the early 2000s, Dr. Susan Taylor started the skin of color society, a professional organization for dermatologist who emphasized the importance of including people with dark skin in their research. And in their practice. Dr. Taylor literally wrote the book on skin of color, and has since been working with others to diversify dermatology education.

 

For Dr. Murina, her interest in skin of color developed a little closer to home.

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ANDREA MURINA: It's basically all connected to where I grew up in rural Louisiana, the people that I wanted to serve. And when I came to the city, the big city of New Orleans, I found a patient population that was underserved. That was my place. And I've just gotten so much out of treating patients of all races, all colors, all all comers, all all insurance, or lack thereof. I think that that has brought me the most joy of practice.

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YO: You might realize that patients with skin of color, which generally refers to people with pigmented skin have two problems. One is the recognition of their diseases, and the other is ongoing disparities in health care access. While changing textbooks and diversifying training settings, like having students rotate in more diverse places, might help in this crisis of recognition. dermatologists are also beginning to realize that recognition and diagnosis aren't enough.

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ANDREA MURINA: We need access to care for everybody. You know, patients needed feel that they don't have to undergo this huge expense to get the care that they need that they can see a doctor on a regular basis instead of utilizing emergency care. Those are just big things that when you talk about inequities in health care, I think those are the things that come up to me is the more chronic conditions that really you know, you could have made an impact if it was treated at point A.

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YO: To expand access to health care. Dr. Murina is moving beyond the hospital and working with her team to engage directly with the community, starting with people who many of us see more often and know more intimately than our doctors, hairdressers, and nail technicians.

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ANDREA MURINA: You know, hairdressers are really important because no one else actually looks at our scalp except the hairdressers, you know, nobody else really gets in there. So hairdressers can be a great help when it comes to detecting skin cancer, especially like behind your ears on your scalp. And that's a very common, it's not an uncommon spot for skin cancer. So we use that same model to go out into the community. Think about how many people go and get their nails done right fingernails, toenails. If that could be replicated in other parts of the country. I think that'd be great. And if you think about it, if that could be part of cosmetology school, that would be a great way to educate the public right to have your hairdresser or your nail technician point out something I think would be that would be great.

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YO: All of these efforts will take time. More is being done every day. But when it comes to structural issues that are limiting medical education, disease detection and healthcare access, there are no quick fixes.

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References

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Fenton, Anne, Erika Elliott, Ashkan Shahbandi, Ekene Ezenwa, Chance Morris, Justin McLawhorn, James G. Jackson, Pamela Allen, and Andrea Murina. “Medical Students’ Ability to Diagnose Common Dermatologic Conditions in Skin of Color.” Journal of the American Academy of Dermatology 83, no. 3 (September 2020): 957–58. https://doi.org/10.1016/j.jaad.2019.12.078.

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