Diversity in Medicine

If the nation’s primary care system were a patient, it would be in critical condition, researchers have found.

In delivery of primary care, including access and coordination, the U.S. trails well behind 10 other wealthy countries, according to a new report from the Commonwealth Fund.

The document, released March 15, concludes that the shortcomings in the U.S. system – from a lack of a relationship with a primary care physician to unequal access to after-hours care – “disproportionately affect Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COVID-19 pandemic.”

“This report really shows that the U.S. is falling behind. We know that a strong primary care system yields better health outcomes. We have a lot to learn from other high-income countries,” coauthor Munira Z. Gunja, MPH, a senior researcher for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations, told this news organization. “At baseline, we really need to make sure that everyone has health insurance in this country so they can actually use primary care services, and we need to increase the supply of those services.”

The report draws from the Commonwealth Fund’s 2019 and 2020 International Health Policy Surveys and the 2020 International Profiles of Health Care Systems. Among the main points:

• U.S. adults are the least likely to have a regular physician or place of care or a long-standing relationship with a primary care provider: 43% of American adults have a long-term relationship with a primary care doctor, compared with highs of 71% in Germany and the Netherlands.
• Access to home visits or after-hours care – excluding emergency department visits – is lowest in the United States (45%). In the Netherlands, Norway, New Zealand, and Germany, the rate is 90% to 96%.
• Half of primary care providers in the United States report adequate coordination with specialists and hospitals – around the average for the 11 countries studied.

‘Dismal mess’

Experts reacted to the report with a mix of concern and frustration – but not surprise.

“The results in this report are not surprising, and we have known them all for a number of years now,” Timothy Hoff, PhD, a health policy expert at Northeastern University, Boston, said. “Primary care doctors remain the backbone of our primary care system. But there are too few of them in the United States, and there likely will remain too few of them in the future. This opens the door to other and more diverse forms of innovation that will be required to help complement the work they do.”

Dr. Hoff, author of Searching for the Family Doctor: Primary Care on the Brink, added that comparing the United States to smaller countries like Norway or the United Kingdom is “somewhat problematic.”

“Our system has to take care of several hundred million people, trapped in a fragmented and market-based delivery system focused on specialty care, each of whom may have a different insurance plan,” he said. “Doing some of the things very small countries with government-funded insurance and a history of strong primary care delivery do in taking care of far fewer citizens is not realistic.”

Jeffrey Borkan, MD, PhD, chair and professor in the department of family medicine at the Alpert Medical School of Brown University, Providence, R.I., said the most shocking finding in the report is that despite spending far more on health care than any other country, “we cannot manage to provide one of the least expensive and most efficacious services: a relationship with a primary care doctor.”

Arthur Caplan, PhD, director of the Division of Medical Ethics at New York University Langone Medical Center, called primary care in this country “a dismal mess. It has been for many years. This is especially so in mental health. Access in many counties is nonexistent, and many primary care physicians are opting into boutique care.”

R. Shawn Martin, CEO of the 133,000-member American Academy of Family Physicians, said, “None of this surprises me. I think these are trendlines; we have been following this for many, many years here at the Academy.”

Mr. Martin added that he was disappointed that the recent, large investments in sharing and digitizing information have not closed the gaps that hinder the efficient and widespread delivery of primary care.

The findings in the report weren’t all bad. More primary care providers in the United States (30%) screen their patients for social needs such as housing, food security, and transportation – the highest among all 11 nations studied.

Also, Commonwealth Fund said the proportion of patients who said they received information on meeting their social needs and screening for domestic violence or social isolation was low everywhere. However, the percentage in the United States, Canada, and Norway was the highest, at 9%. Sweden had the lowest rate for such screenings, at 1%.

The researchers noted that social determinants of health account for as much as 55% of health outcomes. “In some countries, like the United States, the higher rates of receiving such information may be a response to the higher rates of material hardship, along with a weaker safety net,” the report states.

Ms. Gunja and her colleagues suggested several options for changes in policies, including narrowing the wage gap between primary care providers and higher-paid specialists; subsidizing medical school tuition to give students incentives to enter primary care; investing in telehealth to make primary care more accessible; and rewarding and holding providers accountable for continuity of care.

“The U.S. had the largest wage gap and highest tuition fees among the countries we studied,” Ms. Gunja told this news organization..

Researchers noted that U.S. patients could benefit from the introduction of incentives such as those paid in New Zealand to primary health organizations, which receive additional funding per capita to promote health and coordinate care.

But Dr. Caplan was skeptical that those measures would do much to correct the problems.

“We have no will to fix this ongoing, scandalous situation,” he said. “Specialist care still pays inordinately large salaries. Nurses and physician extenders are underused. Academic prestige does little to reward primary care. Plus, patients are not pressing for better access. Sorry, but I see no solutions pending in the current climate. Obamacare barely survived.”

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

If the nation’s primary care system were a patient, it would be in critical condition, researchers have found.

In delivery of primary care, including access and coordination, the U.S. trails well behind 10 other wealthy countries, according to a new report from the Commonwealth Fund.

The document, released March 15, concludes that the shortcomings in the U.S. system – from a lack of a relationship with a primary care physician to unequal access to after-hours care – “disproportionately affect Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COVID-19 pandemic.”

“This report really shows that the U.S. is falling behind. We know that a strong primary care system yields better health outcomes. We have a lot to learn from other high-income countries,” coauthor Munira Z. Gunja, MPH, a senior researcher for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations, told this news organization. “At baseline, we really need to make sure that everyone has health insurance in this country so they can actually use primary care services, and we need to increase the supply of those services.”

The report draws from the Commonwealth Fund’s 2019 and 2020 International Health Policy Surveys and the 2020 International Profiles of Health Care Systems. Among the main points:

• U.S. adults are the least likely to have a regular physician or place of care or a long-standing relationship with a primary care provider: 43% of American adults have a long-term relationship with a primary care doctor, compared with highs of 71% in Germany and the Netherlands.
• Access to home visits or after-hours care – excluding emergency department visits – is lowest in the United States (45%). In the Netherlands, Norway, New Zealand, and Germany, the rate is 90% to 96%.
• Half of primary care providers in the United States report adequate coordination with specialists and hospitals – around the average for the 11 countries studied.

‘Dismal mess’

Experts reacted to the report with a mix of concern and frustration – but not surprise.

“The results in this report are not surprising, and we have known them all for a number of years now,” Timothy Hoff, PhD, a health policy expert at Northeastern University, Boston, said. “Primary care doctors remain the backbone of our primary care system. But there are too few of them in the United States, and there likely will remain too few of them in the future. This opens the door to other and more diverse forms of innovation that will be required to help complement the work they do.”

Dr. Hoff, author of Searching for the Family Doctor: Primary Care on the Brink, added that comparing the United States to smaller countries like Norway or the United Kingdom is “somewhat problematic.”

“Our system has to take care of several hundred million people, trapped in a fragmented and market-based delivery system focused on specialty care, each of whom may have a different insurance plan,” he said. “Doing some of the things very small countries with government-funded insurance and a history of strong primary care delivery do in taking care of far fewer citizens is not realistic.”

Jeffrey Borkan, MD, PhD, chair and professor in the department of family medicine at the Alpert Medical School of Brown University, Providence, R.I., said the most shocking finding in the report is that despite spending far more on health care than any other country, “we cannot manage to provide one of the least expensive and most efficacious services: a relationship with a primary care doctor.”

Arthur Caplan, PhD, director of the Division of Medical Ethics at New York University Langone Medical Center, called primary care in this country “a dismal mess. It has been for many years. This is especially so in mental health. Access in many counties is nonexistent, and many primary care physicians are opting into boutique care.”

R. Shawn Martin, CEO of the 133,000-member American Academy of Family Physicians, said, “None of this surprises me. I think these are trendlines; we have been following this for many, many years here at the Academy.”

Mr. Martin added that he was disappointed that the recent, large investments in sharing and digitizing information have not closed the gaps that hinder the efficient and widespread delivery of primary care.

The findings in the report weren’t all bad. More primary care providers in the United States (30%) screen their patients for social needs such as housing, food security, and transportation – the highest among all 11 nations studied.

Also, Commonwealth Fund said the proportion of patients who said they received information on meeting their social needs and screening for domestic violence or social isolation was low everywhere. However, the percentage in the United States, Canada, and Norway was the highest, at 9%. Sweden had the lowest rate for such screenings, at 1%.

The researchers noted that social determinants of health account for as much as 55% of health outcomes. “In some countries, like the United States, the higher rates of receiving such information may be a response to the higher rates of material hardship, along with a weaker safety net,” the report states.

Ms. Gunja and her colleagues suggested several options for changes in policies, including narrowing the wage gap between primary care providers and higher-paid specialists; subsidizing medical school tuition to give students incentives to enter primary care; investing in telehealth to make primary care more accessible; and rewarding and holding providers accountable for continuity of care.

“The U.S. had the largest wage gap and highest tuition fees among the countries we studied,” Ms. Gunja told this news organization..

Researchers noted that U.S. patients could benefit from the introduction of incentives such as those paid in New Zealand to primary health organizations, which receive additional funding per capita to promote health and coordinate care.

But Dr. Caplan was skeptical that those measures would do much to correct the problems.

“We have no will to fix this ongoing, scandalous situation,” he said. “Specialist care still pays inordinately large salaries. Nurses and physician extenders are underused. Academic prestige does little to reward primary care. Plus, patients are not pressing for better access. Sorry, but I see no solutions pending in the current climate. Obamacare barely survived.”

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

If the nation’s primary care system were a patient, it would be in critical condition, researchers have found.

In delivery of primary care, including access and coordination, the U.S. trails well behind 10 other wealthy countries, according to a new report from the Commonwealth Fund.

The document, released March 15, concludes that the shortcomings in the U.S. system – from a lack of a relationship with a primary care physician to unequal access to after-hours care – “disproportionately affect Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COVID-19 pandemic.”

“This report really shows that the U.S. is falling behind. We know that a strong primary care system yields better health outcomes. We have a lot to learn from other high-income countries,” coauthor Munira Z. Gunja, MPH, a senior researcher for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations, told this news organization. “At baseline, we really need to make sure that everyone has health insurance in this country so they can actually use primary care services, and we need to increase the supply of those services.”

The report draws from the Commonwealth Fund’s 2019 and 2020 International Health Policy Surveys and the 2020 International Profiles of Health Care Systems. Among the main points:

• U.S. adults are the least likely to have a regular physician or place of care or a long-standing relationship with a primary care provider: 43% of American adults have a long-term relationship with a primary care doctor, compared with highs of 71% in Germany and the Netherlands.
• Access to home visits or after-hours care – excluding emergency department visits – is lowest in the United States (45%). In the Netherlands, Norway, New Zealand, and Germany, the rate is 90% to 96%.
• Half of primary care providers in the United States report adequate coordination with specialists and hospitals – around the average for the 11 countries studied.

‘Dismal mess’

Experts reacted to the report with a mix of concern and frustration – but not surprise.

“The results in this report are not surprising, and we have known them all for a number of years now,” Timothy Hoff, PhD, a health policy expert at Northeastern University, Boston, said. “Primary care doctors remain the backbone of our primary care system. But there are too few of them in the United States, and there likely will remain too few of them in the future. This opens the door to other and more diverse forms of innovation that will be required to help complement the work they do.”

Dr. Hoff, author of Searching for the Family Doctor: Primary Care on the Brink, added that comparing the United States to smaller countries like Norway or the United Kingdom is “somewhat problematic.”

“Our system has to take care of several hundred million people, trapped in a fragmented and market-based delivery system focused on specialty care, each of whom may have a different insurance plan,” he said. “Doing some of the things very small countries with government-funded insurance and a history of strong primary care delivery do in taking care of far fewer citizens is not realistic.”

Jeffrey Borkan, MD, PhD, chair and professor in the department of family medicine at the Alpert Medical School of Brown University, Providence, R.I., said the most shocking finding in the report is that despite spending far more on health care than any other country, “we cannot manage to provide one of the least expensive and most efficacious services: a relationship with a primary care doctor.”

Arthur Caplan, PhD, director of the Division of Medical Ethics at New York University Langone Medical Center, called primary care in this country “a dismal mess. It has been for many years. This is especially so in mental health. Access in many counties is nonexistent, and many primary care physicians are opting into boutique care.”

R. Shawn Martin, CEO of the 133,000-member American Academy of Family Physicians, said, “None of this surprises me. I think these are trendlines; we have been following this for many, many years here at the Academy.”

Mr. Martin added that he was disappointed that the recent, large investments in sharing and digitizing information have not closed the gaps that hinder the efficient and widespread delivery of primary care.

The findings in the report weren’t all bad. More primary care providers in the United States (30%) screen their patients for social needs such as housing, food security, and transportation – the highest among all 11 nations studied.

Also, Commonwealth Fund said the proportion of patients who said they received information on meeting their social needs and screening for domestic violence or social isolation was low everywhere. However, the percentage in the United States, Canada, and Norway was the highest, at 9%. Sweden had the lowest rate for such screenings, at 1%.

The researchers noted that social determinants of health account for as much as 55% of health outcomes. “In some countries, like the United States, the higher rates of receiving such information may be a response to the higher rates of material hardship, along with a weaker safety net,” the report states.

Ms. Gunja and her colleagues suggested several options for changes in policies, including narrowing the wage gap between primary care providers and higher-paid specialists; subsidizing medical school tuition to give students incentives to enter primary care; investing in telehealth to make primary care more accessible; and rewarding and holding providers accountable for continuity of care.

“The U.S. had the largest wage gap and highest tuition fees among the countries we studied,” Ms. Gunja told this news organization..

Researchers noted that U.S. patients could benefit from the introduction of incentives such as those paid in New Zealand to primary health organizations, which receive additional funding per capita to promote health and coordinate care.

But Dr. Caplan was skeptical that those measures would do much to correct the problems.

“We have no will to fix this ongoing, scandalous situation,” he said. “Specialist care still pays inordinately large salaries. Nurses and physician extenders are underused. Academic prestige does little to reward primary care. Plus, patients are not pressing for better access. Sorry, but I see no solutions pending in the current climate. Obamacare barely survived.”

The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A survey of 323 women cardiologists who were working while they were pregnant showed that nearly 75% experienced discriminatory maternity-leave practices, some of which were likely violations of the Family and Medical Leave Act (FMLA).

More than 40% saw their salaries decreased during their year of pregnancy, 38% were required to perform extra service or call before taking maternity leave, exposing them to occupational hazards such as radiation, and 40% experienced a pregnancy complication, significantly higher than the general population and other medical specialties.

Additionally, of those who performed extra service or call, 18% were placed on bedrest before delivery, compared with 7.4% who did not perform extra service or call.

More than half of respondents reported that pregnancy negatively impacted their careers, and 42.4% said they experienced pressure to return to work and a delay in promotions, both illegal practices under the FMLA.

The survey is published in the Journal of the American College of Cardiology.

“Childbearing is difficult for women in cardiology with more than double the rate of gestational complications of the U.S. population, frequent income loss out of proportion to reduced productivity, and for nearly half, has an adverse impact on their career,” lead author Martha Gulati, MD, University of Arizona, Phoenix, said in a statement.

“While many professions struggle to create environments supportive of pregnancy and child-rearing, the prevalence of illegal behavior in cardiology is quite high and presents substantial legal risk for employers,” Dr. Gulati added.

C. Noel Bairey Merz, MD, professor of cardiology at Cedars-Sinai Smidt Heart Institute, Los Angeles, and a coauthor of the survey, told this news organization that it’s not surprising that such a situation exists, even “in this day and age.”

“I’m not surprised as a woman in cardiology myself. I was told by my training director that if I took off more than my allowed sick leave when I had my first and second children, I would have to repeat the year of training, so not surprised at all. I hear this from colleagues all the time,” Dr. Bairey Merz said.

The exchange left her feeling fearful for her career.

“Who wants to repeat a year? It pushes you back from a career standpoint, financially, everything. It also made me angry. I had a colleague who busted his leg in a motorcycle accident. He was unable to do any procedures for 16 weeks, and he didn’t have to repeat the year,” she pointed out.

The challenge that pregnancy represents is frequently cited by women as a deterrent for applying for a cardiology fellowship, Laxmi S. Mehta, MD, Ohio State University, Columbus, and colleagues wrote in an accompanying editorial.

The findings from the survey “reveal restrictive maternity leave data in a profession that has historically and currently continues to have a diversity problem,” they wrote.

“Maternity and pregnancy issues are a thing in cardiology,” Dr. Mehta said in an interview. “It’s one of the reasons why women get deterred from going into the field. It makes it challenging to choose cardiology if you perceive that the culture is negative, that it’s hard to be pregnant, or to bear children, or to take care of them post partum. It is problematic and it should not be occurring now.”

Leadership that condones such restrictive policies or even promotes them through ignorance and inaction needs to be held accountable, she added.

“We need to move forward from this negativity and make it more warm and welcoming to have families, whether you are a trainee or a practicing cardiologist, male or female. We need transparent and consistent parental leave policies and things like lactation support when a woman returns to work. That is a big issue,” Dr. Mehta said.

Having cardiovascular leaders champion the cause of adequate maternity and paternity leave are crucial to creating a newer, inclusive environment in cardiology.

As an example, Dr. Mehta recounted her own experience when she was in training 17 years ago.

“When I interviewed for a cardiology fellowship, one of the female program directors asked me if I was planning to have children, because if I did, the other fellows wouldn’t like it if they had to cover for me,” she said. “I ended up doing my fellowship where the chief of cardiology encouraged me to have children. He said: ‘Have your children during training, we will support you.’ And he did. I still had to do all of the call make-up and that stuff, but I worked in a supportive environment, and it made all the difference.”

“It’s about allyship,” she added. “You will have some people who are supportive and some who are not, but when you have the chief supporting you, you have a strong ally.”

The researchers suggest that one strategy is to temporarily replace cardiologists on maternity leave with locums, or “deepen the bench of coverage for clinical work, as is done for other absences. Given the expanding coverage of parental and family medical leaves, and awareness of these issues nationally, the need for this is likely to become less of an exception and more the rule.”

For example, nine states and Washington, D.C. now provide paid parental leave, they wrote, “and there is pending legislation in others.”

Dr. Bairey Merz and Dr. Mehta reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A survey of 323 women cardiologists who were working while they were pregnant showed that nearly 75% experienced discriminatory maternity-leave practices, some of which were likely violations of the Family and Medical Leave Act (FMLA).

More than 40% saw their salaries decreased during their year of pregnancy, 38% were required to perform extra service or call before taking maternity leave, exposing them to occupational hazards such as radiation, and 40% experienced a pregnancy complication, significantly higher than the general population and other medical specialties.

Additionally, of those who performed extra service or call, 18% were placed on bedrest before delivery, compared with 7.4% who did not perform extra service or call.

More than half of respondents reported that pregnancy negatively impacted their careers, and 42.4% said they experienced pressure to return to work and a delay in promotions, both illegal practices under the FMLA.

The survey is published in the Journal of the American College of Cardiology.

“Childbearing is difficult for women in cardiology with more than double the rate of gestational complications of the U.S. population, frequent income loss out of proportion to reduced productivity, and for nearly half, has an adverse impact on their career,” lead author Martha Gulati, MD, University of Arizona, Phoenix, said in a statement.

“While many professions struggle to create environments supportive of pregnancy and child-rearing, the prevalence of illegal behavior in cardiology is quite high and presents substantial legal risk for employers,” Dr. Gulati added.

C. Noel Bairey Merz, MD, professor of cardiology at Cedars-Sinai Smidt Heart Institute, Los Angeles, and a coauthor of the survey, told this news organization that it’s not surprising that such a situation exists, even “in this day and age.”

“I’m not surprised as a woman in cardiology myself. I was told by my training director that if I took off more than my allowed sick leave when I had my first and second children, I would have to repeat the year of training, so not surprised at all. I hear this from colleagues all the time,” Dr. Bairey Merz said.

The exchange left her feeling fearful for her career.

“Who wants to repeat a year? It pushes you back from a career standpoint, financially, everything. It also made me angry. I had a colleague who busted his leg in a motorcycle accident. He was unable to do any procedures for 16 weeks, and he didn’t have to repeat the year,” she pointed out.

The challenge that pregnancy represents is frequently cited by women as a deterrent for applying for a cardiology fellowship, Laxmi S. Mehta, MD, Ohio State University, Columbus, and colleagues wrote in an accompanying editorial.

The findings from the survey “reveal restrictive maternity leave data in a profession that has historically and currently continues to have a diversity problem,” they wrote.

“Maternity and pregnancy issues are a thing in cardiology,” Dr. Mehta said in an interview. “It’s one of the reasons why women get deterred from going into the field. It makes it challenging to choose cardiology if you perceive that the culture is negative, that it’s hard to be pregnant, or to bear children, or to take care of them post partum. It is problematic and it should not be occurring now.”

Leadership that condones such restrictive policies or even promotes them through ignorance and inaction needs to be held accountable, she added.

“We need to move forward from this negativity and make it more warm and welcoming to have families, whether you are a trainee or a practicing cardiologist, male or female. We need transparent and consistent parental leave policies and things like lactation support when a woman returns to work. That is a big issue,” Dr. Mehta said.

Having cardiovascular leaders champion the cause of adequate maternity and paternity leave are crucial to creating a newer, inclusive environment in cardiology.

As an example, Dr. Mehta recounted her own experience when she was in training 17 years ago.

“When I interviewed for a cardiology fellowship, one of the female program directors asked me if I was planning to have children, because if I did, the other fellows wouldn’t like it if they had to cover for me,” she said. “I ended up doing my fellowship where the chief of cardiology encouraged me to have children. He said: ‘Have your children during training, we will support you.’ And he did. I still had to do all of the call make-up and that stuff, but I worked in a supportive environment, and it made all the difference.”

“It’s about allyship,” she added. “You will have some people who are supportive and some who are not, but when you have the chief supporting you, you have a strong ally.”

The researchers suggest that one strategy is to temporarily replace cardiologists on maternity leave with locums, or “deepen the bench of coverage for clinical work, as is done for other absences. Given the expanding coverage of parental and family medical leaves, and awareness of these issues nationally, the need for this is likely to become less of an exception and more the rule.”

For example, nine states and Washington, D.C. now provide paid parental leave, they wrote, “and there is pending legislation in others.”

Dr. Bairey Merz and Dr. Mehta reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

A survey of 323 women cardiologists who were working while they were pregnant showed that nearly 75% experienced discriminatory maternity-leave practices, some of which were likely violations of the Family and Medical Leave Act (FMLA).

More than 40% saw their salaries decreased during their year of pregnancy, 38% were required to perform extra service or call before taking maternity leave, exposing them to occupational hazards such as radiation, and 40% experienced a pregnancy complication, significantly higher than the general population and other medical specialties.

Additionally, of those who performed extra service or call, 18% were placed on bedrest before delivery, compared with 7.4% who did not perform extra service or call.

More than half of respondents reported that pregnancy negatively impacted their careers, and 42.4% said they experienced pressure to return to work and a delay in promotions, both illegal practices under the FMLA.

The survey is published in the Journal of the American College of Cardiology.

“Childbearing is difficult for women in cardiology with more than double the rate of gestational complications of the U.S. population, frequent income loss out of proportion to reduced productivity, and for nearly half, has an adverse impact on their career,” lead author Martha Gulati, MD, University of Arizona, Phoenix, said in a statement.

“While many professions struggle to create environments supportive of pregnancy and child-rearing, the prevalence of illegal behavior in cardiology is quite high and presents substantial legal risk for employers,” Dr. Gulati added.

C. Noel Bairey Merz, MD, professor of cardiology at Cedars-Sinai Smidt Heart Institute, Los Angeles, and a coauthor of the survey, told this news organization that it’s not surprising that such a situation exists, even “in this day and age.”

“I’m not surprised as a woman in cardiology myself. I was told by my training director that if I took off more than my allowed sick leave when I had my first and second children, I would have to repeat the year of training, so not surprised at all. I hear this from colleagues all the time,” Dr. Bairey Merz said.

The exchange left her feeling fearful for her career.

“Who wants to repeat a year? It pushes you back from a career standpoint, financially, everything. It also made me angry. I had a colleague who busted his leg in a motorcycle accident. He was unable to do any procedures for 16 weeks, and he didn’t have to repeat the year,” she pointed out.

The challenge that pregnancy represents is frequently cited by women as a deterrent for applying for a cardiology fellowship, Laxmi S. Mehta, MD, Ohio State University, Columbus, and colleagues wrote in an accompanying editorial.

The findings from the survey “reveal restrictive maternity leave data in a profession that has historically and currently continues to have a diversity problem,” they wrote.

“Maternity and pregnancy issues are a thing in cardiology,” Dr. Mehta said in an interview. “It’s one of the reasons why women get deterred from going into the field. It makes it challenging to choose cardiology if you perceive that the culture is negative, that it’s hard to be pregnant, or to bear children, or to take care of them post partum. It is problematic and it should not be occurring now.”

Leadership that condones such restrictive policies or even promotes them through ignorance and inaction needs to be held accountable, she added.

“We need to move forward from this negativity and make it more warm and welcoming to have families, whether you are a trainee or a practicing cardiologist, male or female. We need transparent and consistent parental leave policies and things like lactation support when a woman returns to work. That is a big issue,” Dr. Mehta said.

Having cardiovascular leaders champion the cause of adequate maternity and paternity leave are crucial to creating a newer, inclusive environment in cardiology.

As an example, Dr. Mehta recounted her own experience when she was in training 17 years ago.

“When I interviewed for a cardiology fellowship, one of the female program directors asked me if I was planning to have children, because if I did, the other fellows wouldn’t like it if they had to cover for me,” she said. “I ended up doing my fellowship where the chief of cardiology encouraged me to have children. He said: ‘Have your children during training, we will support you.’ And he did. I still had to do all of the call make-up and that stuff, but I worked in a supportive environment, and it made all the difference.”

“It’s about allyship,” she added. “You will have some people who are supportive and some who are not, but when you have the chief supporting you, you have a strong ally.”

The researchers suggest that one strategy is to temporarily replace cardiologists on maternity leave with locums, or “deepen the bench of coverage for clinical work, as is done for other absences. Given the expanding coverage of parental and family medical leaves, and awareness of these issues nationally, the need for this is likely to become less of an exception and more the rule.”

For example, nine states and Washington, D.C. now provide paid parental leave, they wrote, “and there is pending legislation in others.”

Dr. Bairey Merz and Dr. Mehta reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Severe food insecurity was associated with metabolic syndrome and unfavorable cardiometabolic markers in Hispanic/Latino youth, researchers report.

The findings, published March 16 in Pediatrics, highlight the need to investigate interventions that address food insecurity among Hispanic/Latino youth, a segment of the U.S. population at high risk of cardiometabolic complications.

“Among Hispanic/Latino youth, no study, to our knowledge has evaluated food insecurity’s role in metabolic syndrome and metabolic syndrome–relevant cardiometabolic markers in this population,” lead author Luis E. Maldonado, PhD, of the University of North Carolina at Chapel Hill, and colleagues explained.

The researchers conducted a cross-sectional study to evaluate the associations between lower household and child food security and metabolic syndrome, as well as clinically measured cardiometabolic markers, including fasting plasma glucose, waist circumference, triglycerides, systolic and diastolic blood pressure, and high-density lipoprotein cholesterol (HDL-C).

Household food security (high, marginal, low, very low) and child food security (high, marginal, low/very low) measures were evaluated separately, and were adjusted for participant age, sex, site, parental education, and poverty-income ratio.

Data were obtained from the Hispanic Community Children’s Health Study/Study of Latino Youth, a study of offspring of adults enrolled in the Hispanic Community Health Survey/Study of Latinos.
 

Results

The study cohort included 1,325 Hispanic/Latino youth aged 8-16 years. For both household food security and child food security, youth in the lowest food security category had significantly lower HDL-C compared with youth with high food security (household food security, –3.17; 95% confidence interval, –5.65 to –0.70; child food security, –1.81; 95% CI, –3.54 to –0.09).

In addition, low/very low compared with high child food security was associated with higher triglycerides (beta, 8.68; 95% CI, 1.75-15.61), higher fasting plasma glucose (beta, 1.37; 95% CI, 0.08-2.65), and metabolic syndrome composite variable expected log counts (beta, 2.12; 95% CI, 0.02-0.45).

Furthermore, the researchers found statistically significant interactions between each of the two food security measures and receipt of any food assistance in the previous year in models of triglycerides (P for interactions: household food security, .03 and child food security, .005) and HDL-C (P for interactions: household food security, .01 and child food security, .04).

After evaluating the effect of parental place of birth, they found a statistically significant association for triglycerides only (P for interactions: household food security, .05 and child food security, .008).

“Our study is among the first to document adverse associations between household and child food security measures with a metabolic syndrome score variable and several metabolic syndrome–relevant cardiometabolic markers among US Hispanic/Latino youth,” the researchers wrote.

The researchers acknowledged that the cross-sectional nature of the study was a key limitation; thus, causality could not be inferred.

“In the future, we plan to conduct more qualitative work to better understand how Hispanic/Latino families respond to food insecurity, which may identify the factors that shape their response,” study author Sandra S. Albrecht, PhD, of Columbia University, New York, NY, said in an interview.
 

Recommendations for pediatricians

Food insecurity researcher Yankun Wang, PhD candidate at Indiana University, Bloomington, commented: “I would recommend pediatricians pay more attention to children from low-income households since they are more likely to have mental and physical health issues due to food insecurity.

“It can be very helpful if pediatricians could help families obtain SNAP benefits, enroll youth in the school breakfast and lunch programs, and promote nutrition education in schools,” Mr. Wang added.

This study was supported by grant funding from the National Heart, Lung, and Blood Institute. The authors reported no relevant disclosures.

Severe food insecurity was associated with metabolic syndrome and unfavorable cardiometabolic markers in Hispanic/Latino youth, researchers report.

The findings, published March 16 in Pediatrics, highlight the need to investigate interventions that address food insecurity among Hispanic/Latino youth, a segment of the U.S. population at high risk of cardiometabolic complications.

“Among Hispanic/Latino youth, no study, to our knowledge has evaluated food insecurity’s role in metabolic syndrome and metabolic syndrome–relevant cardiometabolic markers in this population,” lead author Luis E. Maldonado, PhD, of the University of North Carolina at Chapel Hill, and colleagues explained.

The researchers conducted a cross-sectional study to evaluate the associations between lower household and child food security and metabolic syndrome, as well as clinically measured cardiometabolic markers, including fasting plasma glucose, waist circumference, triglycerides, systolic and diastolic blood pressure, and high-density lipoprotein cholesterol (HDL-C).

Household food security (high, marginal, low, very low) and child food security (high, marginal, low/very low) measures were evaluated separately, and were adjusted for participant age, sex, site, parental education, and poverty-income ratio.

Data were obtained from the Hispanic Community Children’s Health Study/Study of Latino Youth, a study of offspring of adults enrolled in the Hispanic Community Health Survey/Study of Latinos.
 

Results

The study cohort included 1,325 Hispanic/Latino youth aged 8-16 years. For both household food security and child food security, youth in the lowest food security category had significantly lower HDL-C compared with youth with high food security (household food security, –3.17; 95% confidence interval, –5.65 to –0.70; child food security, –1.81; 95% CI, –3.54 to –0.09).

In addition, low/very low compared with high child food security was associated with higher triglycerides (beta, 8.68; 95% CI, 1.75-15.61), higher fasting plasma glucose (beta, 1.37; 95% CI, 0.08-2.65), and metabolic syndrome composite variable expected log counts (beta, 2.12; 95% CI, 0.02-0.45).

Furthermore, the researchers found statistically significant interactions between each of the two food security measures and receipt of any food assistance in the previous year in models of triglycerides (P for interactions: household food security, .03 and child food security, .005) and HDL-C (P for interactions: household food security, .01 and child food security, .04).

After evaluating the effect of parental place of birth, they found a statistically significant association for triglycerides only (P for interactions: household food security, .05 and child food security, .008).

“Our study is among the first to document adverse associations between household and child food security measures with a metabolic syndrome score variable and several metabolic syndrome–relevant cardiometabolic markers among US Hispanic/Latino youth,” the researchers wrote.

The researchers acknowledged that the cross-sectional nature of the study was a key limitation; thus, causality could not be inferred.

“In the future, we plan to conduct more qualitative work to better understand how Hispanic/Latino families respond to food insecurity, which may identify the factors that shape their response,” study author Sandra S. Albrecht, PhD, of Columbia University, New York, NY, said in an interview.
 

Recommendations for pediatricians

Food insecurity researcher Yankun Wang, PhD candidate at Indiana University, Bloomington, commented: “I would recommend pediatricians pay more attention to children from low-income households since they are more likely to have mental and physical health issues due to food insecurity.

“It can be very helpful if pediatricians could help families obtain SNAP benefits, enroll youth in the school breakfast and lunch programs, and promote nutrition education in schools,” Mr. Wang added.

This study was supported by grant funding from the National Heart, Lung, and Blood Institute. The authors reported no relevant disclosures.

Severe food insecurity was associated with metabolic syndrome and unfavorable cardiometabolic markers in Hispanic/Latino youth, researchers report.

The findings, published March 16 in Pediatrics, highlight the need to investigate interventions that address food insecurity among Hispanic/Latino youth, a segment of the U.S. population at high risk of cardiometabolic complications.

“Among Hispanic/Latino youth, no study, to our knowledge has evaluated food insecurity’s role in metabolic syndrome and metabolic syndrome–relevant cardiometabolic markers in this population,” lead author Luis E. Maldonado, PhD, of the University of North Carolina at Chapel Hill, and colleagues explained.

The researchers conducted a cross-sectional study to evaluate the associations between lower household and child food security and metabolic syndrome, as well as clinically measured cardiometabolic markers, including fasting plasma glucose, waist circumference, triglycerides, systolic and diastolic blood pressure, and high-density lipoprotein cholesterol (HDL-C).

Household food security (high, marginal, low, very low) and child food security (high, marginal, low/very low) measures were evaluated separately, and were adjusted for participant age, sex, site, parental education, and poverty-income ratio.

Data were obtained from the Hispanic Community Children’s Health Study/Study of Latino Youth, a study of offspring of adults enrolled in the Hispanic Community Health Survey/Study of Latinos.
 

Results

The study cohort included 1,325 Hispanic/Latino youth aged 8-16 years. For both household food security and child food security, youth in the lowest food security category had significantly lower HDL-C compared with youth with high food security (household food security, –3.17; 95% confidence interval, –5.65 to –0.70; child food security, –1.81; 95% CI, –3.54 to –0.09).

In addition, low/very low compared with high child food security was associated with higher triglycerides (beta, 8.68; 95% CI, 1.75-15.61), higher fasting plasma glucose (beta, 1.37; 95% CI, 0.08-2.65), and metabolic syndrome composite variable expected log counts (beta, 2.12; 95% CI, 0.02-0.45).

Furthermore, the researchers found statistically significant interactions between each of the two food security measures and receipt of any food assistance in the previous year in models of triglycerides (P for interactions: household food security, .03 and child food security, .005) and HDL-C (P for interactions: household food security, .01 and child food security, .04).

After evaluating the effect of parental place of birth, they found a statistically significant association for triglycerides only (P for interactions: household food security, .05 and child food security, .008).

“Our study is among the first to document adverse associations between household and child food security measures with a metabolic syndrome score variable and several metabolic syndrome–relevant cardiometabolic markers among US Hispanic/Latino youth,” the researchers wrote.

The researchers acknowledged that the cross-sectional nature of the study was a key limitation; thus, causality could not be inferred.

“In the future, we plan to conduct more qualitative work to better understand how Hispanic/Latino families respond to food insecurity, which may identify the factors that shape their response,” study author Sandra S. Albrecht, PhD, of Columbia University, New York, NY, said in an interview.
 

Recommendations for pediatricians

Food insecurity researcher Yankun Wang, PhD candidate at Indiana University, Bloomington, commented: “I would recommend pediatricians pay more attention to children from low-income households since they are more likely to have mental and physical health issues due to food insecurity.

“It can be very helpful if pediatricians could help families obtain SNAP benefits, enroll youth in the school breakfast and lunch programs, and promote nutrition education in schools,” Mr. Wang added.

This study was supported by grant funding from the National Heart, Lung, and Blood Institute. The authors reported no relevant disclosures.

Mycosis fungoides (MF) and Sézary syndrome (SS) are non-Hodgkin T-cell lymphomas that make up the majority of cutaneous T-cell lymphomas. These conditions commonly affect Black patients, with an incidence rate of 12.6 cases of cutaneous T-cell lymphomas per million individuals vs 9.8 per million individuals in non–skin of color (SoC) patients.¹ However, educational resources tend to focus on the clinical manifestations of MF/SS in lighter skin types, describing MF as erythematous patches, plaques, or tumors presenting in non–sun-exposed areas of the skin and SS as generalized erythroderma.² Skin of color, comprised of Fitzpatrick skin types (FSTs) IV to VI,³ is poorly represented across dermatology textbooks,^4,5 medical student resources,⁶ and peer-reviewed publications,⁷ raising awareness for the need to address this disparity.

Skin of color patients with MF/SS display variable morphologies, including features such as hyperpigmentation and hypopigmentation,⁸ the latter being exceedingly rare in non-SoC patients.⁹ Familiarity with these differences among providers is essential to allow for equitable diagnosis and treatment across all skin types, especially in light of data predicting that by 2044 more than 50% of the US population will be people of color.¹⁰ Patients with SoC are of many ethnic and racial backgrounds, including Black, Hispanic, American Indian, Pacific Islander, and Asian.¹¹

Along with morphologic differences, there also are several racial disparities in the prognosis and survival of patients with MF/SS. Black patients diagnosed with MF present with greater body surface area affected, and Black women with MF have reduced survival rates compared to their White counterparts.¹² Given these racial disparities in survival and representation in educational resources, we aimed to quantify the frequency of various morphologic characteristics of MF/SS in patients with SoC vs non-SoC patients to facilitate better recognition of early MF/SS in SoC patients by medical providers.

Methods

We performed a retrospective chart review following approval from the institutional review board at Northwestern University (Chicago, Illinois). We identified all patients with FSTs IV to VI and biopsy-proven MF/SS who had been clinically photographed in our clinic from January 1998 to December 2019. Only photographs that were high quality enough to review morphologic features were included in our review. Fitzpatrick skin type was determined based on electronic medical record documentation. If photographs were available from multiple visits for the same patient, only those showing posttreatment nonactive lesions were included. Additionally, 36 patients with FSTs I to III (non-SoC) and biopsy-proven MF/SS were included in our review as a comparison with the SoC cohort. The primary outcomes for this study included the presence of scale, erythema, hyperpigmentation, hypopigmentation, violaceous color, lichenification, silver hue, dyschromia, alopecia, poikiloderma, atrophy, and ulceration in active lesions. Dyschromia was defined by the presence of both hypopigmentation and hyperpigmentation. Poikiloderma was defined by hypopigmentation and hyperpigmentation, telangiectasia, and atrophy. Secondary outcomes included evaluation of those same characteristics in posttreatment nonactive lesions. All photographs were independently assessed by 3 authors (M.L.E., C.J.W., J.M.M.), and discrepancies were resolved by further review of the photograph in question and discussion.

Statistical Analysis—Summary statistics were applied to describe demographic and clinical characteristics. The χ² test was used for categorical variables. Results achieving P<.05 were considered statistically significant.

Results

We reviewed photographs of 111 patients across all skin types (8, FST I; 12, FST II; 16, FST III; 17, FST IV; 44, FST V; 14, FST VI). The cohort was 47% female, and the mean age was 49.7 years (range, 15–86 years). The majority of the cohort had early-stage MF (stage IA or IB). There were more cases of SS in the SoC cohort than the non-SoC cohort (Table). Only 5 photographs had discrepancies and required discussion among the reviewers to achieve consensus.

Regarding morphologic characteristics in active lesions (Figure 1), scale was present in almost all patients (99% in SoC, 94% in non-SoC). Erythema was present in nearly all non-SoC patients (94%) but only in 69% of SoC patients (P=.003). Poikiloderma also was found to be present at higher frequencies in non-SoC patients compared with SoC patients (19% and 4%, respectively [P=.008]). However, hyperpigmentation (80% vs 39%), lichenification (43% vs 17%), and silver hue (25% vs 3%) were more common in SoC patients than non-SoC patients (P<.05). There were no significant differences in the remaining features, including hypopigmentation (39% vs 25%), dyschromia (24% vs 19%), violaceous color (44% vs 25%), atrophy (11% vs 22%), alopecia (23% vs 31%), and ulceration (16% vs 8%) between SoC and non-SoC patients (P>.05). Photographs of MF in patients with SoC can be seen in Figure 2.

Posttreatment (nonactive) photographs were available for 26 patients (6 non-SoC, 20 SoC). We found that across all FST groups, hyperpigmentation was more common than hypopigmentation in areas of previously active disease. Statistical analysis was not completed given that few non-SoC photographs were available for comparison.

Comment

This qualitative review demonstrates the heterogeneity of MF/SS in SoC patients and that these conditions do not present in this population with the classic erythematous patches and plaques found in non-SoC patients. We found that hyperpigmentation, lichenification, and silver hue were present at higher rates in patients with FSTs IV to VI compared to those with FSTs I to III, which had higher rates of erythema and poikiloderma. Familiarity with these morphologic features along with increased exposure to clinical photographs of MF/SS in SoC patients will aid in the visual recognition required for this diagnosis, since erythema is harder to identify in darker skin types. Recognizing the unique findings of MF in patients with SoC as well as in patients with lighter skin types will enable earlier diagnosis and treatment of MF/SS across all skin types. If MF is diagnosed and treated early, life expectancy is similar to that of patients without MF.¹³ However, the 5-year survival rate for advanced-stage MF/SS is 52% across all skin types, and studies have found that Black patients with advanced-stage disease have worse outcomes despite accounting for demographic factors and tumor stage.^14,15 Given the worse outcomes in SoC patients with advanced-stage MF/SS, earlier diagnosis could help address this disparity.^8,13,14 Similar morphologic features could be used in diagnosing other inflammatory conditions; studies have shown that the lack of recognition of erythema in Black children has led to delayed diagnosis of atopic dermatitis and subsequent inadequate treatment.^16,17

The morphologic presentation of MF/SS in SoC patients also can influence an optimal treatment plan for this population. Hypopigmented MF responds better to phototherapy than hyperpigmented MF, as phototherapy has been shown to have decreased efficacy with increasing FST.¹⁸ Therefore, for patients with FSTs IV to VI, topical agents such as nitrogen mustard or bexarotene may be more suitable treatment options, as the efficacy of these treatments is independent of skin color.⁸ However, nitrogen mustard commonly leads to postinflammatory hyperpigmentation, and topical bexarotene may lead to erythema or irritation; therefore, providers must counsel patients on these possible side effects. For refractory disease, adjunct systemic treatments such as oral bexarotene, subcutaneous interferon, methotrexate, or radiation therapy may be considered.⁸

In addition to aiding in the prompt diagnosis and treatment of MF/SS in SoC patients, our findings may be used to better assess the extent of disease and distinguish between active MF/SS lesions vs xerosis cutis or residual dyschromia from previously treated lesions. It is important to note that these morphologic features must be taken into account with a complete history and work-up. The differential diagnosis of MF/SS includes conditions such as atopic dermatitis, psoriasis, tinea corporis, and drug reactions, which may have similar morphology in SoC.¹⁹

Limitations of our study include the single-center design and the use of photographs instead of in-person examination; however, our cutaneous lymphoma clinic serves a diverse patient population, and our 3 reviewers rated the photographs independently. Discussion amongst the reviewers to address discrepancies was only required for 5 photographs, indicating the high inter-reviewer reliability. Additionally, the original purpose of FST was to assess for the propensity of the skin to burn when undergoing phototherapy, not to serve as a marker for skin color. We recommend trainees and clinicians be mindful about the purpose of FST and to use inclusive language (eg, using the terms skin irritation, skin tenderness, or skin becoming darker from the sun instead of tanning) when determining FST in darker-skinned individuals.²⁰ Future directions include examining if certain treatments are associated with prolonged dyschromia.

Conclusion

In our single-institution retrospective study, we found differences in the morphologic presentation of MF/SS in SoC patients vs non-SoC patients. While erythema is a common feature in non-SoC patients, clinical features of hyperpigmentation, lichenification, and silver hue should be carefully evaluated in the diagnosis of MF/SS in SoC patients. Knowledge of the heterogenous presentation of MF/SS in patients with SoC allows for expedited diagnosis and treatment, leading to better clinical outcomes. Valuable resources, including Taylor and Kelly’s Dermatology for Skin of Color, the Skin of Color Society, and VisualDx educate providers on how dermatologic conditions present in darker skin types. However, there is still work to be done to enhance diversity in educational resources in order to provide equitable care to patients of all skin types.

Mycosis fungoides (MF) and Sézary syndrome (SS) are non-Hodgkin T-cell lymphomas that make up the majority of cutaneous T-cell lymphomas. These conditions commonly affect Black patients, with an incidence rate of 12.6 cases of cutaneous T-cell lymphomas per million individuals vs 9.8 per million individuals in non–skin of color (SoC) patients.¹ However, educational resources tend to focus on the clinical manifestations of MF/SS in lighter skin types, describing MF as erythematous patches, plaques, or tumors presenting in non–sun-exposed areas of the skin and SS as generalized erythroderma.² Skin of color, comprised of Fitzpatrick skin types (FSTs) IV to VI,³ is poorly represented across dermatology textbooks,^4,5 medical student resources,⁶ and peer-reviewed publications,⁷ raising awareness for the need to address this disparity.

Skin of color patients with MF/SS display variable morphologies, including features such as hyperpigmentation and hypopigmentation,⁸ the latter being exceedingly rare in non-SoC patients.⁹ Familiarity with these differences among providers is essential to allow for equitable diagnosis and treatment across all skin types, especially in light of data predicting that by 2044 more than 50% of the US population will be people of color.¹⁰ Patients with SoC are of many ethnic and racial backgrounds, including Black, Hispanic, American Indian, Pacific Islander, and Asian.¹¹

Along with morphologic differences, there also are several racial disparities in the prognosis and survival of patients with MF/SS. Black patients diagnosed with MF present with greater body surface area affected, and Black women with MF have reduced survival rates compared to their White counterparts.¹² Given these racial disparities in survival and representation in educational resources, we aimed to quantify the frequency of various morphologic characteristics of MF/SS in patients with SoC vs non-SoC patients to facilitate better recognition of early MF/SS in SoC patients by medical providers.

Methods

We performed a retrospective chart review following approval from the institutional review board at Northwestern University (Chicago, Illinois). We identified all patients with FSTs IV to VI and biopsy-proven MF/SS who had been clinically photographed in our clinic from January 1998 to December 2019. Only photographs that were high quality enough to review morphologic features were included in our review. Fitzpatrick skin type was determined based on electronic medical record documentation. If photographs were available from multiple visits for the same patient, only those showing posttreatment nonactive lesions were included. Additionally, 36 patients with FSTs I to III (non-SoC) and biopsy-proven MF/SS were included in our review as a comparison with the SoC cohort. The primary outcomes for this study included the presence of scale, erythema, hyperpigmentation, hypopigmentation, violaceous color, lichenification, silver hue, dyschromia, alopecia, poikiloderma, atrophy, and ulceration in active lesions. Dyschromia was defined by the presence of both hypopigmentation and hyperpigmentation. Poikiloderma was defined by hypopigmentation and hyperpigmentation, telangiectasia, and atrophy. Secondary outcomes included evaluation of those same characteristics in posttreatment nonactive lesions. All photographs were independently assessed by 3 authors (M.L.E., C.J.W., J.M.M.), and discrepancies were resolved by further review of the photograph in question and discussion.

Statistical Analysis—Summary statistics were applied to describe demographic and clinical characteristics. The χ² test was used for categorical variables. Results achieving P<.05 were considered statistically significant.

Results

We reviewed photographs of 111 patients across all skin types (8, FST I; 12, FST II; 16, FST III; 17, FST IV; 44, FST V; 14, FST VI). The cohort was 47% female, and the mean age was 49.7 years (range, 15–86 years). The majority of the cohort had early-stage MF (stage IA or IB). There were more cases of SS in the SoC cohort than the non-SoC cohort (Table). Only 5 photographs had discrepancies and required discussion among the reviewers to achieve consensus.

Regarding morphologic characteristics in active lesions (Figure 1), scale was present in almost all patients (99% in SoC, 94% in non-SoC). Erythema was present in nearly all non-SoC patients (94%) but only in 69% of SoC patients (P=.003). Poikiloderma also was found to be present at higher frequencies in non-SoC patients compared with SoC patients (19% and 4%, respectively [P=.008]). However, hyperpigmentation (80% vs 39%), lichenification (43% vs 17%), and silver hue (25% vs 3%) were more common in SoC patients than non-SoC patients (P<.05). There were no significant differences in the remaining features, including hypopigmentation (39% vs 25%), dyschromia (24% vs 19%), violaceous color (44% vs 25%), atrophy (11% vs 22%), alopecia (23% vs 31%), and ulceration (16% vs 8%) between SoC and non-SoC patients (P>.05). Photographs of MF in patients with SoC can be seen in Figure 2.

Posttreatment (nonactive) photographs were available for 26 patients (6 non-SoC, 20 SoC). We found that across all FST groups, hyperpigmentation was more common than hypopigmentation in areas of previously active disease. Statistical analysis was not completed given that few non-SoC photographs were available for comparison.

Comment

This qualitative review demonstrates the heterogeneity of MF/SS in SoC patients and that these conditions do not present in this population with the classic erythematous patches and plaques found in non-SoC patients. We found that hyperpigmentation, lichenification, and silver hue were present at higher rates in patients with FSTs IV to VI compared to those with FSTs I to III, which had higher rates of erythema and poikiloderma. Familiarity with these morphologic features along with increased exposure to clinical photographs of MF/SS in SoC patients will aid in the visual recognition required for this diagnosis, since erythema is harder to identify in darker skin types. Recognizing the unique findings of MF in patients with SoC as well as in patients with lighter skin types will enable earlier diagnosis and treatment of MF/SS across all skin types. If MF is diagnosed and treated early, life expectancy is similar to that of patients without MF.¹³ However, the 5-year survival rate for advanced-stage MF/SS is 52% across all skin types, and studies have found that Black patients with advanced-stage disease have worse outcomes despite accounting for demographic factors and tumor stage.^14,15 Given the worse outcomes in SoC patients with advanced-stage MF/SS, earlier diagnosis could help address this disparity.^8,13,14 Similar morphologic features could be used in diagnosing other inflammatory conditions; studies have shown that the lack of recognition of erythema in Black children has led to delayed diagnosis of atopic dermatitis and subsequent inadequate treatment.^16,17

The morphologic presentation of MF/SS in SoC patients also can influence an optimal treatment plan for this population. Hypopigmented MF responds better to phototherapy than hyperpigmented MF, as phototherapy has been shown to have decreased efficacy with increasing FST.¹⁸ Therefore, for patients with FSTs IV to VI, topical agents such as nitrogen mustard or bexarotene may be more suitable treatment options, as the efficacy of these treatments is independent of skin color.⁸ However, nitrogen mustard commonly leads to postinflammatory hyperpigmentation, and topical bexarotene may lead to erythema or irritation; therefore, providers must counsel patients on these possible side effects. For refractory disease, adjunct systemic treatments such as oral bexarotene, subcutaneous interferon, methotrexate, or radiation therapy may be considered.⁸

In addition to aiding in the prompt diagnosis and treatment of MF/SS in SoC patients, our findings may be used to better assess the extent of disease and distinguish between active MF/SS lesions vs xerosis cutis or residual dyschromia from previously treated lesions. It is important to note that these morphologic features must be taken into account with a complete history and work-up. The differential diagnosis of MF/SS includes conditions such as atopic dermatitis, psoriasis, tinea corporis, and drug reactions, which may have similar morphology in SoC.¹⁹

Limitations of our study include the single-center design and the use of photographs instead of in-person examination; however, our cutaneous lymphoma clinic serves a diverse patient population, and our 3 reviewers rated the photographs independently. Discussion amongst the reviewers to address discrepancies was only required for 5 photographs, indicating the high inter-reviewer reliability. Additionally, the original purpose of FST was to assess for the propensity of the skin to burn when undergoing phototherapy, not to serve as a marker for skin color. We recommend trainees and clinicians be mindful about the purpose of FST and to use inclusive language (eg, using the terms skin irritation, skin tenderness, or skin becoming darker from the sun instead of tanning) when determining FST in darker-skinned individuals.²⁰ Future directions include examining if certain treatments are associated with prolonged dyschromia.

Conclusion

In our single-institution retrospective study, we found differences in the morphologic presentation of MF/SS in SoC patients vs non-SoC patients. While erythema is a common feature in non-SoC patients, clinical features of hyperpigmentation, lichenification, and silver hue should be carefully evaluated in the diagnosis of MF/SS in SoC patients. Knowledge of the heterogenous presentation of MF/SS in patients with SoC allows for expedited diagnosis and treatment, leading to better clinical outcomes. Valuable resources, including Taylor and Kelly’s Dermatology for Skin of Color, the Skin of Color Society, and VisualDx educate providers on how dermatologic conditions present in darker skin types. However, there is still work to be done to enhance diversity in educational resources in order to provide equitable care to patients of all skin types.

Mycosis fungoides (MF) and Sézary syndrome (SS) are non-Hodgkin T-cell lymphomas that make up the majority of cutaneous T-cell lymphomas. These conditions commonly affect Black patients, with an incidence rate of 12.6 cases of cutaneous T-cell lymphomas per million individuals vs 9.8 per million individuals in non–skin of color (SoC) patients.¹ However, educational resources tend to focus on the clinical manifestations of MF/SS in lighter skin types, describing MF as erythematous patches, plaques, or tumors presenting in non–sun-exposed areas of the skin and SS as generalized erythroderma.² Skin of color, comprised of Fitzpatrick skin types (FSTs) IV to VI,³ is poorly represented across dermatology textbooks,^4,5 medical student resources,⁶ and peer-reviewed publications,⁷ raising awareness for the need to address this disparity.

Skin of color patients with MF/SS display variable morphologies, including features such as hyperpigmentation and hypopigmentation,⁸ the latter being exceedingly rare in non-SoC patients.⁹ Familiarity with these differences among providers is essential to allow for equitable diagnosis and treatment across all skin types, especially in light of data predicting that by 2044 more than 50% of the US population will be people of color.¹⁰ Patients with SoC are of many ethnic and racial backgrounds, including Black, Hispanic, American Indian, Pacific Islander, and Asian.¹¹

Along with morphologic differences, there also are several racial disparities in the prognosis and survival of patients with MF/SS. Black patients diagnosed with MF present with greater body surface area affected, and Black women with MF have reduced survival rates compared to their White counterparts.¹² Given these racial disparities in survival and representation in educational resources, we aimed to quantify the frequency of various morphologic characteristics of MF/SS in patients with SoC vs non-SoC patients to facilitate better recognition of early MF/SS in SoC patients by medical providers.

Methods

We performed a retrospective chart review following approval from the institutional review board at Northwestern University (Chicago, Illinois). We identified all patients with FSTs IV to VI and biopsy-proven MF/SS who had been clinically photographed in our clinic from January 1998 to December 2019. Only photographs that were high quality enough to review morphologic features were included in our review. Fitzpatrick skin type was determined based on electronic medical record documentation. If photographs were available from multiple visits for the same patient, only those showing posttreatment nonactive lesions were included. Additionally, 36 patients with FSTs I to III (non-SoC) and biopsy-proven MF/SS were included in our review as a comparison with the SoC cohort. The primary outcomes for this study included the presence of scale, erythema, hyperpigmentation, hypopigmentation, violaceous color, lichenification, silver hue, dyschromia, alopecia, poikiloderma, atrophy, and ulceration in active lesions. Dyschromia was defined by the presence of both hypopigmentation and hyperpigmentation. Poikiloderma was defined by hypopigmentation and hyperpigmentation, telangiectasia, and atrophy. Secondary outcomes included evaluation of those same characteristics in posttreatment nonactive lesions. All photographs were independently assessed by 3 authors (M.L.E., C.J.W., J.M.M.), and discrepancies were resolved by further review of the photograph in question and discussion.

Statistical Analysis—Summary statistics were applied to describe demographic and clinical characteristics. The χ² test was used for categorical variables. Results achieving P<.05 were considered statistically significant.

Results

We reviewed photographs of 111 patients across all skin types (8, FST I; 12, FST II; 16, FST III; 17, FST IV; 44, FST V; 14, FST VI). The cohort was 47% female, and the mean age was 49.7 years (range, 15–86 years). The majority of the cohort had early-stage MF (stage IA or IB). There were more cases of SS in the SoC cohort than the non-SoC cohort (Table). Only 5 photographs had discrepancies and required discussion among the reviewers to achieve consensus.

Regarding morphologic characteristics in active lesions (Figure 1), scale was present in almost all patients (99% in SoC, 94% in non-SoC). Erythema was present in nearly all non-SoC patients (94%) but only in 69% of SoC patients (P=.003). Poikiloderma also was found to be present at higher frequencies in non-SoC patients compared with SoC patients (19% and 4%, respectively [P=.008]). However, hyperpigmentation (80% vs 39%), lichenification (43% vs 17%), and silver hue (25% vs 3%) were more common in SoC patients than non-SoC patients (P<.05). There were no significant differences in the remaining features, including hypopigmentation (39% vs 25%), dyschromia (24% vs 19%), violaceous color (44% vs 25%), atrophy (11% vs 22%), alopecia (23% vs 31%), and ulceration (16% vs 8%) between SoC and non-SoC patients (P>.05). Photographs of MF in patients with SoC can be seen in Figure 2.

Posttreatment (nonactive) photographs were available for 26 patients (6 non-SoC, 20 SoC). We found that across all FST groups, hyperpigmentation was more common than hypopigmentation in areas of previously active disease. Statistical analysis was not completed given that few non-SoC photographs were available for comparison.

Comment

This qualitative review demonstrates the heterogeneity of MF/SS in SoC patients and that these conditions do not present in this population with the classic erythematous patches and plaques found in non-SoC patients. We found that hyperpigmentation, lichenification, and silver hue were present at higher rates in patients with FSTs IV to VI compared to those with FSTs I to III, which had higher rates of erythema and poikiloderma. Familiarity with these morphologic features along with increased exposure to clinical photographs of MF/SS in SoC patients will aid in the visual recognition required for this diagnosis, since erythema is harder to identify in darker skin types. Recognizing the unique findings of MF in patients with SoC as well as in patients with lighter skin types will enable earlier diagnosis and treatment of MF/SS across all skin types. If MF is diagnosed and treated early, life expectancy is similar to that of patients without MF.¹³ However, the 5-year survival rate for advanced-stage MF/SS is 52% across all skin types, and studies have found that Black patients with advanced-stage disease have worse outcomes despite accounting for demographic factors and tumor stage.^14,15 Given the worse outcomes in SoC patients with advanced-stage MF/SS, earlier diagnosis could help address this disparity.^8,13,14 Similar morphologic features could be used in diagnosing other inflammatory conditions; studies have shown that the lack of recognition of erythema in Black children has led to delayed diagnosis of atopic dermatitis and subsequent inadequate treatment.^16,17

The morphologic presentation of MF/SS in SoC patients also can influence an optimal treatment plan for this population. Hypopigmented MF responds better to phototherapy than hyperpigmented MF, as phototherapy has been shown to have decreased efficacy with increasing FST.¹⁸ Therefore, for patients with FSTs IV to VI, topical agents such as nitrogen mustard or bexarotene may be more suitable treatment options, as the efficacy of these treatments is independent of skin color.⁸ However, nitrogen mustard commonly leads to postinflammatory hyperpigmentation, and topical bexarotene may lead to erythema or irritation; therefore, providers must counsel patients on these possible side effects. For refractory disease, adjunct systemic treatments such as oral bexarotene, subcutaneous interferon, methotrexate, or radiation therapy may be considered.⁸

In addition to aiding in the prompt diagnosis and treatment of MF/SS in SoC patients, our findings may be used to better assess the extent of disease and distinguish between active MF/SS lesions vs xerosis cutis or residual dyschromia from previously treated lesions. It is important to note that these morphologic features must be taken into account with a complete history and work-up. The differential diagnosis of MF/SS includes conditions such as atopic dermatitis, psoriasis, tinea corporis, and drug reactions, which may have similar morphology in SoC.¹⁹

Limitations of our study include the single-center design and the use of photographs instead of in-person examination; however, our cutaneous lymphoma clinic serves a diverse patient population, and our 3 reviewers rated the photographs independently. Discussion amongst the reviewers to address discrepancies was only required for 5 photographs, indicating the high inter-reviewer reliability. Additionally, the original purpose of FST was to assess for the propensity of the skin to burn when undergoing phototherapy, not to serve as a marker for skin color. We recommend trainees and clinicians be mindful about the purpose of FST and to use inclusive language (eg, using the terms skin irritation, skin tenderness, or skin becoming darker from the sun instead of tanning) when determining FST in darker-skinned individuals.²⁰ Future directions include examining if certain treatments are associated with prolonged dyschromia.

Conclusion

In our single-institution retrospective study, we found differences in the morphologic presentation of MF/SS in SoC patients vs non-SoC patients. While erythema is a common feature in non-SoC patients, clinical features of hyperpigmentation, lichenification, and silver hue should be carefully evaluated in the diagnosis of MF/SS in SoC patients. Knowledge of the heterogenous presentation of MF/SS in patients with SoC allows for expedited diagnosis and treatment, leading to better clinical outcomes. Valuable resources, including Taylor and Kelly’s Dermatology for Skin of Color, the Skin of Color Society, and VisualDx educate providers on how dermatologic conditions present in darker skin types. However, there is still work to be done to enhance diversity in educational resources in order to provide equitable care to patients of all skin types.

At the American College of Cardiology’s 70th annual scientific sessions, 93% of the results from the late-breaking clinical trial sessions and featured clinical research sessions were presented by men.

Although women were well represented on panels, and chaired or cochaired sessions, thanks to the ACC’s ongoing efforts to promote gender diversity and inclusion, they rarely got to give the big talks.

“Unfortunately, women continue to be underrepresented among CV clinical trial leadership, leading to a lack of subject diversity,” Mary Norine Walsh, MD, medical director of heart failure and cardiac transplantation at Ascension St. Vincent Heart Center, Indianapolis, Ind., wrote in a review published online Feb. 28 in the Journal of the American College of Cardiology.

An analysis of cardiovascular trials published during the past 4 years showed that women comprised only 10.1% of clinical trial leadership committees, and more than half of the trials had no women at all as part of the trial leadership team. About 10% of the trials had a woman as first or senior author.

In an interview, Dr. Walsh said she was prompted to write her review because she found the absence of women presenters at ACC 21 so striking.

“ACC 21 was held virtually because of COVID. This gave me the opportunity to easily view all of the research sessions. I attended all of the late-breaking clinical trials and featured clinical research sessions live while they were being presented, and it slowly dawned on me as I was watching that the vast majority of the presenters were men,” she said.

“The ACC does what it can to ensure a good gender mix of panelists and session chairs, but what it cannot control is who presents the data. The fact that 93% of these talks were given by men was astonishing to me,” Dr. Walsh said.

Of the three trials presented by women, one was on sex-specific outcomes in high-risk patients receiving ticagrelor with or without aspirin after percutaneous coronary intervention (a subanalysis of the TWILIGHT study); one was on the impact of COVID-19 on the global cardiovascular workforce (the ACC 2020 Well Being Study); and one was on the prevention of cardiac dysfunction during adjuvanttherapy with candesartan and metoprolol (the PRADA study).

Most of the presenters were regulars at the ACC podium. As Dr. Walsh observed: “This was assuredly not the inaugural turn at the international podium for these male trial presenters.”

So why are women so noticeably absent among the leaders of cardiovascular clinical trials research?

The root cause for this underrepresentation begins with the low number of women who lead clinical trials in cardiovascular medicine and surgery, and the fact that there are fewer female cardiologists than male cardiologists to begin with.

Then there is the lack of mentorship, which, Dr. Walsh said, “really does occur along gendered lines, with men mentoring men.”

In addition, industry-funded trials tend to feed a nondiverse investigator pipeline and other research collaborations often encompass established networks, Dr. Walsh noted.

“When industry is embarking on a new trial of a drug or device, it tends to lean back on who they have had led before. It really gets down to who you know, so getting new people in is fairly difficult,” she said.

Several initiatives to increase diversity in CV clinical trial leadership are ongoing by the ACC and other organizations.

For example, Women as One gives “escalator awards” to boost or escalate the training of highly qualified female cardiologists through targeted funding, mentorship, and networking.

The ACC’s “Clinical Trial Research: Upping Your Game” program aims to develop and train the next generation of a diverse and inclusive clinical trials workforce, focusing not only on women but on other traditionally underrepresented groups.

“We’re now in our third cohort of investigators who are early in their careers. We’re arming them with the skills to become successful in becoming investigators and then going up the chain to trial leadership. We are focusing our efforts on those who are underrepresented in cardiology – women, native Americans, Latinx, and Black investigators. We are hoping to increase diversity through that way, but more still needs to be done,” she said.

Trial sponsors, whether federally funded or industry sponsored, need to insist on diversity of the trial steering committee, and principal investigators need to consider diversity.

“A rethinking of who is eligible to present important trial results is needed,” Dr. Walsh said.

“The informal, or formal, pecking order of CV trial leadership needs to be reworked. All members of the steering committee should be possible presenters, and women should not be asked to report late-breaking results of trials that are reporting sex-specific results or data that are pertinent only to a female population.”

A version of this article first appeared on Medscape.com.

At the American College of Cardiology’s 70th annual scientific sessions, 93% of the results from the late-breaking clinical trial sessions and featured clinical research sessions were presented by men.

Although women were well represented on panels, and chaired or cochaired sessions, thanks to the ACC’s ongoing efforts to promote gender diversity and inclusion, they rarely got to give the big talks.

“Unfortunately, women continue to be underrepresented among CV clinical trial leadership, leading to a lack of subject diversity,” Mary Norine Walsh, MD, medical director of heart failure and cardiac transplantation at Ascension St. Vincent Heart Center, Indianapolis, Ind., wrote in a review published online Feb. 28 in the Journal of the American College of Cardiology.

An analysis of cardiovascular trials published during the past 4 years showed that women comprised only 10.1% of clinical trial leadership committees, and more than half of the trials had no women at all as part of the trial leadership team. About 10% of the trials had a woman as first or senior author.

In an interview, Dr. Walsh said she was prompted to write her review because she found the absence of women presenters at ACC 21 so striking.

“ACC 21 was held virtually because of COVID. This gave me the opportunity to easily view all of the research sessions. I attended all of the late-breaking clinical trials and featured clinical research sessions live while they were being presented, and it slowly dawned on me as I was watching that the vast majority of the presenters were men,” she said.

“The ACC does what it can to ensure a good gender mix of panelists and session chairs, but what it cannot control is who presents the data. The fact that 93% of these talks were given by men was astonishing to me,” Dr. Walsh said.

Of the three trials presented by women, one was on sex-specific outcomes in high-risk patients receiving ticagrelor with or without aspirin after percutaneous coronary intervention (a subanalysis of the TWILIGHT study); one was on the impact of COVID-19 on the global cardiovascular workforce (the ACC 2020 Well Being Study); and one was on the prevention of cardiac dysfunction during adjuvanttherapy with candesartan and metoprolol (the PRADA study).

Most of the presenters were regulars at the ACC podium. As Dr. Walsh observed: “This was assuredly not the inaugural turn at the international podium for these male trial presenters.”

So why are women so noticeably absent among the leaders of cardiovascular clinical trials research?

The root cause for this underrepresentation begins with the low number of women who lead clinical trials in cardiovascular medicine and surgery, and the fact that there are fewer female cardiologists than male cardiologists to begin with.

Then there is the lack of mentorship, which, Dr. Walsh said, “really does occur along gendered lines, with men mentoring men.”

In addition, industry-funded trials tend to feed a nondiverse investigator pipeline and other research collaborations often encompass established networks, Dr. Walsh noted.

“When industry is embarking on a new trial of a drug or device, it tends to lean back on who they have had led before. It really gets down to who you know, so getting new people in is fairly difficult,” she said.

Several initiatives to increase diversity in CV clinical trial leadership are ongoing by the ACC and other organizations.

For example, Women as One gives “escalator awards” to boost or escalate the training of highly qualified female cardiologists through targeted funding, mentorship, and networking.

The ACC’s “Clinical Trial Research: Upping Your Game” program aims to develop and train the next generation of a diverse and inclusive clinical trials workforce, focusing not only on women but on other traditionally underrepresented groups.

“We’re now in our third cohort of investigators who are early in their careers. We’re arming them with the skills to become successful in becoming investigators and then going up the chain to trial leadership. We are focusing our efforts on those who are underrepresented in cardiology – women, native Americans, Latinx, and Black investigators. We are hoping to increase diversity through that way, but more still needs to be done,” she said.

Trial sponsors, whether federally funded or industry sponsored, need to insist on diversity of the trial steering committee, and principal investigators need to consider diversity.

“A rethinking of who is eligible to present important trial results is needed,” Dr. Walsh said.

“The informal, or formal, pecking order of CV trial leadership needs to be reworked. All members of the steering committee should be possible presenters, and women should not be asked to report late-breaking results of trials that are reporting sex-specific results or data that are pertinent only to a female population.”

A version of this article first appeared on Medscape.com.

At the American College of Cardiology’s 70th annual scientific sessions, 93% of the results from the late-breaking clinical trial sessions and featured clinical research sessions were presented by men.

Although women were well represented on panels, and chaired or cochaired sessions, thanks to the ACC’s ongoing efforts to promote gender diversity and inclusion, they rarely got to give the big talks.

“Unfortunately, women continue to be underrepresented among CV clinical trial leadership, leading to a lack of subject diversity,” Mary Norine Walsh, MD, medical director of heart failure and cardiac transplantation at Ascension St. Vincent Heart Center, Indianapolis, Ind., wrote in a review published online Feb. 28 in the Journal of the American College of Cardiology.

An analysis of cardiovascular trials published during the past 4 years showed that women comprised only 10.1% of clinical trial leadership committees, and more than half of the trials had no women at all as part of the trial leadership team. About 10% of the trials had a woman as first or senior author.

In an interview, Dr. Walsh said she was prompted to write her review because she found the absence of women presenters at ACC 21 so striking.

“ACC 21 was held virtually because of COVID. This gave me the opportunity to easily view all of the research sessions. I attended all of the late-breaking clinical trials and featured clinical research sessions live while they were being presented, and it slowly dawned on me as I was watching that the vast majority of the presenters were men,” she said.

“The ACC does what it can to ensure a good gender mix of panelists and session chairs, but what it cannot control is who presents the data. The fact that 93% of these talks were given by men was astonishing to me,” Dr. Walsh said.

Of the three trials presented by women, one was on sex-specific outcomes in high-risk patients receiving ticagrelor with or without aspirin after percutaneous coronary intervention (a subanalysis of the TWILIGHT study); one was on the impact of COVID-19 on the global cardiovascular workforce (the ACC 2020 Well Being Study); and one was on the prevention of cardiac dysfunction during adjuvanttherapy with candesartan and metoprolol (the PRADA study).

Most of the presenters were regulars at the ACC podium. As Dr. Walsh observed: “This was assuredly not the inaugural turn at the international podium for these male trial presenters.”

So why are women so noticeably absent among the leaders of cardiovascular clinical trials research?

The root cause for this underrepresentation begins with the low number of women who lead clinical trials in cardiovascular medicine and surgery, and the fact that there are fewer female cardiologists than male cardiologists to begin with.

Then there is the lack of mentorship, which, Dr. Walsh said, “really does occur along gendered lines, with men mentoring men.”

In addition, industry-funded trials tend to feed a nondiverse investigator pipeline and other research collaborations often encompass established networks, Dr. Walsh noted.

“When industry is embarking on a new trial of a drug or device, it tends to lean back on who they have had led before. It really gets down to who you know, so getting new people in is fairly difficult,” she said.

Several initiatives to increase diversity in CV clinical trial leadership are ongoing by the ACC and other organizations.

For example, Women as One gives “escalator awards” to boost or escalate the training of highly qualified female cardiologists through targeted funding, mentorship, and networking.

The ACC’s “Clinical Trial Research: Upping Your Game” program aims to develop and train the next generation of a diverse and inclusive clinical trials workforce, focusing not only on women but on other traditionally underrepresented groups.

“We’re now in our third cohort of investigators who are early in their careers. We’re arming them with the skills to become successful in becoming investigators and then going up the chain to trial leadership. We are focusing our efforts on those who are underrepresented in cardiology – women, native Americans, Latinx, and Black investigators. We are hoping to increase diversity through that way, but more still needs to be done,” she said.

Trial sponsors, whether federally funded or industry sponsored, need to insist on diversity of the trial steering committee, and principal investigators need to consider diversity.

“A rethinking of who is eligible to present important trial results is needed,” Dr. Walsh said.

“The informal, or formal, pecking order of CV trial leadership needs to be reworked. All members of the steering committee should be possible presenters, and women should not be asked to report late-breaking results of trials that are reporting sex-specific results or data that are pertinent only to a female population.”

A version of this article first appeared on Medscape.com.

THE COMPARISON

A Multicolored (pink, brown, and white) indurated plaques in a butterfly distribution on the face of a 30-year-old woman with a darker skin tone.

B Pink, elevated, indurated plaques with hypopigmentation in a butterfly distribution on the face of a 19-year-old woman with a lighter skin tone.

Cutaneous lupus erythematosus may occur with or without systemic lupus erythematosus. Discoid lupus erythematosus (DLE), a form of chronic cutaneous lupus, is most commonly found on the scalp, face, and ears.¹

Epidemiology

DLE is most common in adult women (age range, 20–40 years).² It occurs more frequently in women of African descent.^3,4

Key clinical features in people with darker skin tones

Clinical features of DLE lesions include erythema, induration, follicular plugging, dyspigmentation, and scarring alopecia.¹ In patients of African descent, lesions may be annular and hypopigmented to depigmented centrally with a border of hyperpigmentation. Active lesions may be painful and/or pruritic.²

DLE lesions occur in photodistributed areas, although not exclusively. Photoprotective clothing and sunscreen are an important part of the treatment plan.¹ Although sunscreen is recommended for patients with DLE, those with darker skin tones may find some sunscreens cosmetically unappealing due to a mismatch with their normal skin color.⁵ Tinted sunscreens may be beneficial additions.

Worth noting

Approximately 5% to 25% of patients with cutaneous lupus go on to develop systemic lupus erythematosus.⁶

Health disparity highlight

Discoid lesions may cause cutaneous scars that are quite disfiguring and may negatively impact quality of life. Some patients may have a few scattered lesions, whereas others have extensive disease covering most of the scalp. DLE lesions of the scalp have classic clinical features including hair loss, erythema, hypopigmentation, and hyperpigmentation. The clinician’s comfort with performing a scalp examination with cultural humility is an important acquired skill and is especially important when the examination is performed on patients with more tightly coiled hair.⁷ For example, physicians may adopt the “compliment, discuss, and suggest” method when counseling patients.⁸

THE COMPARISON

A Multicolored (pink, brown, and white) indurated plaques in a butterfly distribution on the face of a 30-year-old woman with a darker skin tone.

B Pink, elevated, indurated plaques with hypopigmentation in a butterfly distribution on the face of a 19-year-old woman with a lighter skin tone.

Cutaneous lupus erythematosus may occur with or without systemic lupus erythematosus. Discoid lupus erythematosus (DLE), a form of chronic cutaneous lupus, is most commonly found on the scalp, face, and ears.¹

Epidemiology

DLE is most common in adult women (age range, 20–40 years).² It occurs more frequently in women of African descent.^3,4

Key clinical features in people with darker skin tones

Clinical features of DLE lesions include erythema, induration, follicular plugging, dyspigmentation, and scarring alopecia.¹ In patients of African descent, lesions may be annular and hypopigmented to depigmented centrally with a border of hyperpigmentation. Active lesions may be painful and/or pruritic.²

DLE lesions occur in photodistributed areas, although not exclusively. Photoprotective clothing and sunscreen are an important part of the treatment plan.¹ Although sunscreen is recommended for patients with DLE, those with darker skin tones may find some sunscreens cosmetically unappealing due to a mismatch with their normal skin color.⁵ Tinted sunscreens may be beneficial additions.

Worth noting

Approximately 5% to 25% of patients with cutaneous lupus go on to develop systemic lupus erythematosus.⁶

Health disparity highlight

Discoid lesions may cause cutaneous scars that are quite disfiguring and may negatively impact quality of life. Some patients may have a few scattered lesions, whereas others have extensive disease covering most of the scalp. DLE lesions of the scalp have classic clinical features including hair loss, erythema, hypopigmentation, and hyperpigmentation. The clinician’s comfort with performing a scalp examination with cultural humility is an important acquired skill and is especially important when the examination is performed on patients with more tightly coiled hair.⁷ For example, physicians may adopt the “compliment, discuss, and suggest” method when counseling patients.⁸

THE COMPARISON

A Multicolored (pink, brown, and white) indurated plaques in a butterfly distribution on the face of a 30-year-old woman with a darker skin tone.

B Pink, elevated, indurated plaques with hypopigmentation in a butterfly distribution on the face of a 19-year-old woman with a lighter skin tone.

Cutaneous lupus erythematosus may occur with or without systemic lupus erythematosus. Discoid lupus erythematosus (DLE), a form of chronic cutaneous lupus, is most commonly found on the scalp, face, and ears.¹

Epidemiology

DLE is most common in adult women (age range, 20–40 years).² It occurs more frequently in women of African descent.^3,4

Key clinical features in people with darker skin tones

Clinical features of DLE lesions include erythema, induration, follicular plugging, dyspigmentation, and scarring alopecia.¹ In patients of African descent, lesions may be annular and hypopigmented to depigmented centrally with a border of hyperpigmentation. Active lesions may be painful and/or pruritic.²

DLE lesions occur in photodistributed areas, although not exclusively. Photoprotective clothing and sunscreen are an important part of the treatment plan.¹ Although sunscreen is recommended for patients with DLE, those with darker skin tones may find some sunscreens cosmetically unappealing due to a mismatch with their normal skin color.⁵ Tinted sunscreens may be beneficial additions.

Worth noting

Approximately 5% to 25% of patients with cutaneous lupus go on to develop systemic lupus erythematosus.⁶

Health disparity highlight

Discoid lesions may cause cutaneous scars that are quite disfiguring and may negatively impact quality of life. Some patients may have a few scattered lesions, whereas others have extensive disease covering most of the scalp. DLE lesions of the scalp have classic clinical features including hair loss, erythema, hypopigmentation, and hyperpigmentation. The clinician’s comfort with performing a scalp examination with cultural humility is an important acquired skill and is especially important when the examination is performed on patients with more tightly coiled hair.⁷ For example, physicians may adopt the “compliment, discuss, and suggest” method when counseling patients.⁸

When Annie Uhing, MD, is stressed about work, she can call her mom. She and her mom are close, yes, but her mom is also a physician and understands the ups and downs of medical education and the unique challenges of being a woman in medicine.

“My mom and I were talking about this the other day – I don’t think we know any other mother-daughter pairs of doctors,” said Dr. Uhing.

Courtesy Dr. Charlene Gaebler-Uhing

In the United States, the number of female physicians has risen steadily since the mid- and late-20th century. As of 2019, women made up more than half of medical school classes across the country and 36.3% of the physician workforce.

Still, most female physicians are concentrated in a handful of specialties (such as pediatrics and obstetrics and gynecology) while the percentages of women in other areas remains extremely low (urology and orthopedic surgery). Many female physicians share anecdotal stories about not being taken seriously, like when a patient mistook them for a nurse, or preferred the advice of a male colleague to their own.

To celebrate International Women’s Day, this news organization talked to two families of female doctors about their experiences in medicine and how they inspire and support one another inside and outside the hospital.
 

Deborah, Charlene, and Annie

When Deborah Gaebler-Spira, MD, started medical school at the University of Illinois in 1975, women made up just 15% of her class. “For me, the idea that as a woman you could have a vocation that could be quite meaningful and self-directed – that was very important,” said Dr. Gaebler-Spira, now a pediatric rehabilitation physician at the Shirley Ryan Ability Lab and professor at Northwestern University in Chicago.

She blocked out a lot of discouragement along the way. In undergrad, the dean of the college warned Dr. Gaebler-Spira she’d never make it as a doctor. In medical school interviews, administrators could be hostile. “There was this feeling that you were taking a place of someone who really deserved it,” she said. When selecting a residency, Dr. Gaebler-Spira decided against a career in obstetrics because of the overt misogyny in the field at the time.

Instead, she went into pediatrics and physical medicine and rehabilitation, eventually working to become an expert in cerebral palsy. Along the way, Dr. Gaebler-Spira made lifelong friends with other female physicians and found strong female mentors, including Billie Adams, MD, and Helen Emery, MD.

When her sister, Charlene Gaebler-Uhing, MD, also decided to go into medicine, Dr. Gaebler-Spira said she “thought it was a sign of sanity as she was always much more competitive than I was! And if I could do it, no question she was able!”

Dr. Gaebler-Uhing, now an adolescent medicine specialist at Children’s Wisconsin in Milwaukee, followed her older sister’s footsteps to medical school in 1983, after first considering a career in social work.

While there were now more women going into medicine – her medical school class was about 25% women – problems persisted. During clinical rotations in residency, Dr. Gaebler-Uhing was often the only woman on a team and made the conscious decision to go professionally by her nickname, Charlie. “If a woman’s name was on the consult, her opinion and insights did not get the same value or respect as a male physician’s,” she said. “The only way they knew I was a woman was if they really knew me.”

The Gaebler sisters leaned on each other professionally and personally throughout their careers. When both sisters practiced in Chicago, they referred patients to one another. And Dr. Gaebler-Uhing said her older sister was a great role model for how to balance the dual roles of physician and parent, as few of the older female doctors who trained her were married or had a child.

Now Dr. Gaebler-Uhing’s daughter, Annie Uhing, MD, is entering medicine herself. She is currently pediatric resident at the University of Wisconsin American Family Hospital. She plans to do a chief year and then a pediatric endocrinology fellowship.

Growing up, Dr. Uhing wasn’t always sure she wanted to work as much as her parents, who are both doctors. But her mom provided a great example few of her friends had at home: “If you want to work, you should work and do what you want to do and it’s not wrong to want to have a really high-powered job as a woman,” said Dr. Uhing.

 

Kathryn, Susan, and Rita

The three sisters Kathryn Hudson, MD, Susan Schmidt, MD, and Rita Butler, MD, were inspired to go into medicine by their mother, Rita Watson, MD, who was one of the first female interventional cardiologists in the United States.

“I think we had a front row seat to what being a doctor was like,” said Dr. Hudson, a hematologist and oncologist and director of survivorship at Texas Oncology in Austin. Both parents were MDs – their dad was a pharmaceutical researcher at Merck – and they would excitedly discuss patient cases and drug development at the dinner table, said Dr. Butler, an interventional cardiology fellow at the Lankenau Heart Institute in Wynnewood, Pa.

All three sisters have vivid memories of ‘Take Your Daughter to Work Day’ at their mom’s hospital. “I remember going to Take Your Daughter to Work Day with her and watching her in action and thinking, oh my gosh, my mom is so cool and I want to be like her,” said Dr. Schmidt, a pediatric critical care specialist at St. Christopher’s Hospital for Children in Philadelphia. “I’ve always felt special that my mom was doing something really cool and really saving lives,” said Dr. Schmidt.

Their fourth sibling, John, isn’t a physician and “I honestly wonder if it’s because he never went to Take Your Daughter to Work Day!” said Dr. Butler.

Having a mother who had both a high-powered medical career and a family helped the three women know they could do the same. “It is a difficult journey, don’t get me wrong, but I never questioned that I could do it because my mom did it first,” said Dr. Hudson.

As adults, the sisters confide in one another as they navigate modern motherhood and careers, switching between discussing medical cases and parenting advice.

As hard as their mom worked while they were growing up, she didn’t have the pressure of living up to the “super mom” ideal we have now, said Dr. Butler. “Everyone wants women to work like they don’t have kids and everyone wants women to parent like they don’t have a job,” she said. Having two sisters who can provide reassurance and advice in that area goes a long way, she said.

“I think sharing that experience of navigating motherhood, a medical career, and marriage, and adult life with sisters who are going through all the same things is really special and I feel really fortunate for that,” said Dr. Schmidt.

*This story was updated on 3/8/2022.

When Annie Uhing, MD, is stressed about work, she can call her mom. She and her mom are close, yes, but her mom is also a physician and understands the ups and downs of medical education and the unique challenges of being a woman in medicine.

“My mom and I were talking about this the other day – I don’t think we know any other mother-daughter pairs of doctors,” said Dr. Uhing.

Courtesy Dr. Charlene Gaebler-Uhing

In the United States, the number of female physicians has risen steadily since the mid- and late-20th century. As of 2019, women made up more than half of medical school classes across the country and 36.3% of the physician workforce.

Still, most female physicians are concentrated in a handful of specialties (such as pediatrics and obstetrics and gynecology) while the percentages of women in other areas remains extremely low (urology and orthopedic surgery). Many female physicians share anecdotal stories about not being taken seriously, like when a patient mistook them for a nurse, or preferred the advice of a male colleague to their own.

To celebrate International Women’s Day, this news organization talked to two families of female doctors about their experiences in medicine and how they inspire and support one another inside and outside the hospital.
 

Deborah, Charlene, and Annie

When Deborah Gaebler-Spira, MD, started medical school at the University of Illinois in 1975, women made up just 15% of her class. “For me, the idea that as a woman you could have a vocation that could be quite meaningful and self-directed – that was very important,” said Dr. Gaebler-Spira, now a pediatric rehabilitation physician at the Shirley Ryan Ability Lab and professor at Northwestern University in Chicago.

She blocked out a lot of discouragement along the way. In undergrad, the dean of the college warned Dr. Gaebler-Spira she’d never make it as a doctor. In medical school interviews, administrators could be hostile. “There was this feeling that you were taking a place of someone who really deserved it,” she said. When selecting a residency, Dr. Gaebler-Spira decided against a career in obstetrics because of the overt misogyny in the field at the time.

Instead, she went into pediatrics and physical medicine and rehabilitation, eventually working to become an expert in cerebral palsy. Along the way, Dr. Gaebler-Spira made lifelong friends with other female physicians and found strong female mentors, including Billie Adams, MD, and Helen Emery, MD.

When her sister, Charlene Gaebler-Uhing, MD, also decided to go into medicine, Dr. Gaebler-Spira said she “thought it was a sign of sanity as she was always much more competitive than I was! And if I could do it, no question she was able!”

Dr. Gaebler-Uhing, now an adolescent medicine specialist at Children’s Wisconsin in Milwaukee, followed her older sister’s footsteps to medical school in 1983, after first considering a career in social work.

While there were now more women going into medicine – her medical school class was about 25% women – problems persisted. During clinical rotations in residency, Dr. Gaebler-Uhing was often the only woman on a team and made the conscious decision to go professionally by her nickname, Charlie. “If a woman’s name was on the consult, her opinion and insights did not get the same value or respect as a male physician’s,” she said. “The only way they knew I was a woman was if they really knew me.”

The Gaebler sisters leaned on each other professionally and personally throughout their careers. When both sisters practiced in Chicago, they referred patients to one another. And Dr. Gaebler-Uhing said her older sister was a great role model for how to balance the dual roles of physician and parent, as few of the older female doctors who trained her were married or had a child.

Now Dr. Gaebler-Uhing’s daughter, Annie Uhing, MD, is entering medicine herself. She is currently pediatric resident at the University of Wisconsin American Family Hospital. She plans to do a chief year and then a pediatric endocrinology fellowship.

Growing up, Dr. Uhing wasn’t always sure she wanted to work as much as her parents, who are both doctors. But her mom provided a great example few of her friends had at home: “If you want to work, you should work and do what you want to do and it’s not wrong to want to have a really high-powered job as a woman,” said Dr. Uhing.

 

Kathryn, Susan, and Rita

The three sisters Kathryn Hudson, MD, Susan Schmidt, MD, and Rita Butler, MD, were inspired to go into medicine by their mother, Rita Watson, MD, who was one of the first female interventional cardiologists in the United States.

“I think we had a front row seat to what being a doctor was like,” said Dr. Hudson, a hematologist and oncologist and director of survivorship at Texas Oncology in Austin. Both parents were MDs – their dad was a pharmaceutical researcher at Merck – and they would excitedly discuss patient cases and drug development at the dinner table, said Dr. Butler, an interventional cardiology fellow at the Lankenau Heart Institute in Wynnewood, Pa.

All three sisters have vivid memories of ‘Take Your Daughter to Work Day’ at their mom’s hospital. “I remember going to Take Your Daughter to Work Day with her and watching her in action and thinking, oh my gosh, my mom is so cool and I want to be like her,” said Dr. Schmidt, a pediatric critical care specialist at St. Christopher’s Hospital for Children in Philadelphia. “I’ve always felt special that my mom was doing something really cool and really saving lives,” said Dr. Schmidt.

Their fourth sibling, John, isn’t a physician and “I honestly wonder if it’s because he never went to Take Your Daughter to Work Day!” said Dr. Butler.

Having a mother who had both a high-powered medical career and a family helped the three women know they could do the same. “It is a difficult journey, don’t get me wrong, but I never questioned that I could do it because my mom did it first,” said Dr. Hudson.

As adults, the sisters confide in one another as they navigate modern motherhood and careers, switching between discussing medical cases and parenting advice.

As hard as their mom worked while they were growing up, she didn’t have the pressure of living up to the “super mom” ideal we have now, said Dr. Butler. “Everyone wants women to work like they don’t have kids and everyone wants women to parent like they don’t have a job,” she said. Having two sisters who can provide reassurance and advice in that area goes a long way, she said.

“I think sharing that experience of navigating motherhood, a medical career, and marriage, and adult life with sisters who are going through all the same things is really special and I feel really fortunate for that,” said Dr. Schmidt.

*This story was updated on 3/8/2022.

When Annie Uhing, MD, is stressed about work, she can call her mom. She and her mom are close, yes, but her mom is also a physician and understands the ups and downs of medical education and the unique challenges of being a woman in medicine.

“My mom and I were talking about this the other day – I don’t think we know any other mother-daughter pairs of doctors,” said Dr. Uhing.

Courtesy Dr. Charlene Gaebler-Uhing

In the United States, the number of female physicians has risen steadily since the mid- and late-20th century. As of 2019, women made up more than half of medical school classes across the country and 36.3% of the physician workforce.

Still, most female physicians are concentrated in a handful of specialties (such as pediatrics and obstetrics and gynecology) while the percentages of women in other areas remains extremely low (urology and orthopedic surgery). Many female physicians share anecdotal stories about not being taken seriously, like when a patient mistook them for a nurse, or preferred the advice of a male colleague to their own.

To celebrate International Women’s Day, this news organization talked to two families of female doctors about their experiences in medicine and how they inspire and support one another inside and outside the hospital.
 

Deborah, Charlene, and Annie

When Deborah Gaebler-Spira, MD, started medical school at the University of Illinois in 1975, women made up just 15% of her class. “For me, the idea that as a woman you could have a vocation that could be quite meaningful and self-directed – that was very important,” said Dr. Gaebler-Spira, now a pediatric rehabilitation physician at the Shirley Ryan Ability Lab and professor at Northwestern University in Chicago.

She blocked out a lot of discouragement along the way. In undergrad, the dean of the college warned Dr. Gaebler-Spira she’d never make it as a doctor. In medical school interviews, administrators could be hostile. “There was this feeling that you were taking a place of someone who really deserved it,” she said. When selecting a residency, Dr. Gaebler-Spira decided against a career in obstetrics because of the overt misogyny in the field at the time.

Instead, she went into pediatrics and physical medicine and rehabilitation, eventually working to become an expert in cerebral palsy. Along the way, Dr. Gaebler-Spira made lifelong friends with other female physicians and found strong female mentors, including Billie Adams, MD, and Helen Emery, MD.

When her sister, Charlene Gaebler-Uhing, MD, also decided to go into medicine, Dr. Gaebler-Spira said she “thought it was a sign of sanity as she was always much more competitive than I was! And if I could do it, no question she was able!”

Dr. Gaebler-Uhing, now an adolescent medicine specialist at Children’s Wisconsin in Milwaukee, followed her older sister’s footsteps to medical school in 1983, after first considering a career in social work.

While there were now more women going into medicine – her medical school class was about 25% women – problems persisted. During clinical rotations in residency, Dr. Gaebler-Uhing was often the only woman on a team and made the conscious decision to go professionally by her nickname, Charlie. “If a woman’s name was on the consult, her opinion and insights did not get the same value or respect as a male physician’s,” she said. “The only way they knew I was a woman was if they really knew me.”

The Gaebler sisters leaned on each other professionally and personally throughout their careers. When both sisters practiced in Chicago, they referred patients to one another. And Dr. Gaebler-Uhing said her older sister was a great role model for how to balance the dual roles of physician and parent, as few of the older female doctors who trained her were married or had a child.

Now Dr. Gaebler-Uhing’s daughter, Annie Uhing, MD, is entering medicine herself. She is currently pediatric resident at the University of Wisconsin American Family Hospital. She plans to do a chief year and then a pediatric endocrinology fellowship.

Growing up, Dr. Uhing wasn’t always sure she wanted to work as much as her parents, who are both doctors. But her mom provided a great example few of her friends had at home: “If you want to work, you should work and do what you want to do and it’s not wrong to want to have a really high-powered job as a woman,” said Dr. Uhing.

 

Kathryn, Susan, and Rita

The three sisters Kathryn Hudson, MD, Susan Schmidt, MD, and Rita Butler, MD, were inspired to go into medicine by their mother, Rita Watson, MD, who was one of the first female interventional cardiologists in the United States.

“I think we had a front row seat to what being a doctor was like,” said Dr. Hudson, a hematologist and oncologist and director of survivorship at Texas Oncology in Austin. Both parents were MDs – their dad was a pharmaceutical researcher at Merck – and they would excitedly discuss patient cases and drug development at the dinner table, said Dr. Butler, an interventional cardiology fellow at the Lankenau Heart Institute in Wynnewood, Pa.

All three sisters have vivid memories of ‘Take Your Daughter to Work Day’ at their mom’s hospital. “I remember going to Take Your Daughter to Work Day with her and watching her in action and thinking, oh my gosh, my mom is so cool and I want to be like her,” said Dr. Schmidt, a pediatric critical care specialist at St. Christopher’s Hospital for Children in Philadelphia. “I’ve always felt special that my mom was doing something really cool and really saving lives,” said Dr. Schmidt.

Their fourth sibling, John, isn’t a physician and “I honestly wonder if it’s because he never went to Take Your Daughter to Work Day!” said Dr. Butler.

Having a mother who had both a high-powered medical career and a family helped the three women know they could do the same. “It is a difficult journey, don’t get me wrong, but I never questioned that I could do it because my mom did it first,” said Dr. Hudson.

As adults, the sisters confide in one another as they navigate modern motherhood and careers, switching between discussing medical cases and parenting advice.

As hard as their mom worked while they were growing up, she didn’t have the pressure of living up to the “super mom” ideal we have now, said Dr. Butler. “Everyone wants women to work like they don’t have kids and everyone wants women to parent like they don’t have a job,” she said. Having two sisters who can provide reassurance and advice in that area goes a long way, she said.

“I think sharing that experience of navigating motherhood, a medical career, and marriage, and adult life with sisters who are going through all the same things is really special and I feel really fortunate for that,” said Dr. Schmidt.

*This story was updated on 3/8/2022.

Photographs courtesy of Richard P. Usatine, MD.

THE COMPARISON

A Multicolored (pink, brown, and white) indurated plaques in a butterfly distribution on the face of a 30-year-old woman with a darker skin tone.

B Pink, elevated, indurated plaques with hypopigmentation in a butterfly distribution on the face of a 19-year-old woman with a lighter skin tone.

Cutaneous lupus erythematosus may occur with or without systemic lupus erythematosus. Discoid lupus erythematosus (DLE), a form of chronic cutaneous lupus, is most commonly found on the scalp, face, and ears.¹

Epidemiology

Discoid lupus erythematosus is most common in adult women (age range, 20–40 years).² It occurs more frequently in women of African descent.^3,4

Key clinical features in people with darker skin tones:

Clinical features of DLE lesions include erythema, induration, follicular plugging, dyspigmentation, and scarring alopecia.¹ In patients of African descent, lesions may be annular and hypopigmented to depigmented centrally with a border of hyperpigmentation. Active lesions may be painful and/or pruritic.²

Discoid lupus erythematosus lesions occur in photodistributed areas, although not exclusively. Photoprotective clothing and sunscreen are an important part of the treatment plan.¹ Although sunscreen is recommended for patients with DLE, those with darker skin tones may find some sunscreens cosmetically unappealing due to a mismatch with their normal skin color.⁵ Tinted sunscreens may be beneficial additions.

Worth noting

Approximately 5% to 25% of patients with cutaneous lupus go on to develop systemic lupus erythematosus.⁶

Health disparity highlight

Discoid lesions may cause cutaneous scars that are quite disfiguring and may negatively impact quality of life. Some patients may have a few scattered lesions, whereas others have extensive disease covering most of the scalp. Discoid lupus erythematosus lesions of the scalp have classic clinical features including hair loss, erythema, hypopigmentation, and hyperpigmentation. The clinician’s comfort with performing a scalp examination with cultural humility is an important acquired skill and is especially important when the examination is performed on patients with more tightly coiled hair.⁷ For example, physicians may adopt the “compliment, discuss, and suggest” method when counseling patients.⁸

Photographs courtesy of Richard P. Usatine, MD.

THE COMPARISON

A Multicolored (pink, brown, and white) indurated plaques in a butterfly distribution on the face of a 30-year-old woman with a darker skin tone.

B Pink, elevated, indurated plaques with hypopigmentation in a butterfly distribution on the face of a 19-year-old woman with a lighter skin tone.

Cutaneous lupus erythematosus may occur with or without systemic lupus erythematosus. Discoid lupus erythematosus (DLE), a form of chronic cutaneous lupus, is most commonly found on the scalp, face, and ears.¹

Epidemiology

Discoid lupus erythematosus is most common in adult women (age range, 20–40 years).² It occurs more frequently in women of African descent.^3,4

Key clinical features in people with darker skin tones:

Clinical features of DLE lesions include erythema, induration, follicular plugging, dyspigmentation, and scarring alopecia.¹ In patients of African descent, lesions may be annular and hypopigmented to depigmented centrally with a border of hyperpigmentation. Active lesions may be painful and/or pruritic.²

Discoid lupus erythematosus lesions occur in photodistributed areas, although not exclusively. Photoprotective clothing and sunscreen are an important part of the treatment plan.¹ Although sunscreen is recommended for patients with DLE, those with darker skin tones may find some sunscreens cosmetically unappealing due to a mismatch with their normal skin color.⁵ Tinted sunscreens may be beneficial additions.

Worth noting

Approximately 5% to 25% of patients with cutaneous lupus go on to develop systemic lupus erythematosus.⁶

Health disparity highlight

Discoid lesions may cause cutaneous scars that are quite disfiguring and may negatively impact quality of life. Some patients may have a few scattered lesions, whereas others have extensive disease covering most of the scalp. Discoid lupus erythematosus lesions of the scalp have classic clinical features including hair loss, erythema, hypopigmentation, and hyperpigmentation. The clinician’s comfort with performing a scalp examination with cultural humility is an important acquired skill and is especially important when the examination is performed on patients with more tightly coiled hair.⁷ For example, physicians may adopt the “compliment, discuss, and suggest” method when counseling patients.⁸

Photographs courtesy of Richard P. Usatine, MD.

THE COMPARISON

A Multicolored (pink, brown, and white) indurated plaques in a butterfly distribution on the face of a 30-year-old woman with a darker skin tone.

B Pink, elevated, indurated plaques with hypopigmentation in a butterfly distribution on the face of a 19-year-old woman with a lighter skin tone.

Cutaneous lupus erythematosus may occur with or without systemic lupus erythematosus. Discoid lupus erythematosus (DLE), a form of chronic cutaneous lupus, is most commonly found on the scalp, face, and ears.¹

Epidemiology

Discoid lupus erythematosus is most common in adult women (age range, 20–40 years).² It occurs more frequently in women of African descent.^3,4

Key clinical features in people with darker skin tones:

Clinical features of DLE lesions include erythema, induration, follicular plugging, dyspigmentation, and scarring alopecia.¹ In patients of African descent, lesions may be annular and hypopigmented to depigmented centrally with a border of hyperpigmentation. Active lesions may be painful and/or pruritic.²

Discoid lupus erythematosus lesions occur in photodistributed areas, although not exclusively. Photoprotective clothing and sunscreen are an important part of the treatment plan.¹ Although sunscreen is recommended for patients with DLE, those with darker skin tones may find some sunscreens cosmetically unappealing due to a mismatch with their normal skin color.⁵ Tinted sunscreens may be beneficial additions.

Worth noting

Approximately 5% to 25% of patients with cutaneous lupus go on to develop systemic lupus erythematosus.⁶

Health disparity highlight

Discoid lesions may cause cutaneous scars that are quite disfiguring and may negatively impact quality of life. Some patients may have a few scattered lesions, whereas others have extensive disease covering most of the scalp. Discoid lupus erythematosus lesions of the scalp have classic clinical features including hair loss, erythema, hypopigmentation, and hyperpigmentation. The clinician’s comfort with performing a scalp examination with cultural humility is an important acquired skill and is especially important when the examination is performed on patients with more tightly coiled hair.⁷ For example, physicians may adopt the “compliment, discuss, and suggest” method when counseling patients.⁸

Columbia University has appointed an interim chair of psychiatry in the wake of a controversial tweet sent out on Feb. 21, according to an email obtained by this news organization that was sent by university leadership to faculty and staff on Feb. 28.

Helen Blair Simpson, MD, PhD, will take over for Jeffrey Lieberman, MD, who was suspended over a tweet he sent that was widely condemned as both racist and sexist.

She will also serve as interim director of the New York State Psychiatric Institute and interim psychiatrist-in-chief at New York–Presbyterian/Columbia University Irving Medical Center, the email stated.

All appointments were effective on Feb. 28.
 

Latest response

Dr. Simpson, who joined the faculty at Columbia in 1999, previously served as a professor and vice chair of research for the psychiatry department, director of Columbia’s Center for Obsessive-Compulsive and Related Disorders, and director of psychiatry research at the New York State Psychiatric Institute. Dr. Simpson is associate editor of JAMA Psychiatry and is president-elect of the Anxiety and Depression Association of America.

Her research has been continuously funded by the National Institute of Mental Health since 1999, and she has advised both the World Health Organization and the American Psychiatric Association on the diagnosis and treatment of OCD.

Dr. Simpson has a bachelor’s degree in biology from Yale University and completed an MD-PhD program at The Rockefeller University and Weill Cornell Medicine, New York. She did her residency in psychiatry at New York–Presbyterian.

The announcement is Columbia’s latest response to the furor that erupted on social media following Dr. Lieberman’s tweet about Sudanese model Nyakim Gatwech, in which he wrote, “Whether a work of art or a freak of nature she’s a beautiful sight to behold.”

Twitter reacted immediately and negatively to the tweet, which even Dr. Lieberman later acknowledged was “racist and sexist” in an email apology he sent Feb. 22 to faculty and staff in the department of psychiatry.

As reported by this news organization, Columbia suspended Dr. Lieberman from his chair position on Feb. 23 and permanently removed him from the post of psychiatrist-in-chief at New York–Presbyterian Hospital/Columbia University Irving Medical Center. Lieberman also resigned as executive director of the New York State Psychiatric Institute.

The email announcing Simpson’s appointment was signed by Katrina Armstrong, MD, incoming CEO, Columbia University Irving Medical Center and dean of the Faculties of Health Sciences and the Vagelos College of Physicians and Surgeons; Anil K. Rustgi, MD, interim executive vice president and dean of the Faculties of Health Sciences and Medicine; Steven J. Corwin, MD; president and CEO, New York–Presbyterian; and Ann Marie Sullivan, MD, commissioner of the New York State Office of Mental Health.

This is a developing story.

A version of this article first appeared on Medscape.com.

Columbia University has appointed an interim chair of psychiatry in the wake of a controversial tweet sent out on Feb. 21, according to an email obtained by this news organization that was sent by university leadership to faculty and staff on Feb. 28.

Helen Blair Simpson, MD, PhD, will take over for Jeffrey Lieberman, MD, who was suspended over a tweet he sent that was widely condemned as both racist and sexist.

She will also serve as interim director of the New York State Psychiatric Institute and interim psychiatrist-in-chief at New York–Presbyterian/Columbia University Irving Medical Center, the email stated.

All appointments were effective on Feb. 28.
 

Latest response

Dr. Simpson, who joined the faculty at Columbia in 1999, previously served as a professor and vice chair of research for the psychiatry department, director of Columbia’s Center for Obsessive-Compulsive and Related Disorders, and director of psychiatry research at the New York State Psychiatric Institute. Dr. Simpson is associate editor of JAMA Psychiatry and is president-elect of the Anxiety and Depression Association of America.

Her research has been continuously funded by the National Institute of Mental Health since 1999, and she has advised both the World Health Organization and the American Psychiatric Association on the diagnosis and treatment of OCD.

Dr. Simpson has a bachelor’s degree in biology from Yale University and completed an MD-PhD program at The Rockefeller University and Weill Cornell Medicine, New York. She did her residency in psychiatry at New York–Presbyterian.

The announcement is Columbia’s latest response to the furor that erupted on social media following Dr. Lieberman’s tweet about Sudanese model Nyakim Gatwech, in which he wrote, “Whether a work of art or a freak of nature she’s a beautiful sight to behold.”

Twitter reacted immediately and negatively to the tweet, which even Dr. Lieberman later acknowledged was “racist and sexist” in an email apology he sent Feb. 22 to faculty and staff in the department of psychiatry.

As reported by this news organization, Columbia suspended Dr. Lieberman from his chair position on Feb. 23 and permanently removed him from the post of psychiatrist-in-chief at New York–Presbyterian Hospital/Columbia University Irving Medical Center. Lieberman also resigned as executive director of the New York State Psychiatric Institute.

The email announcing Simpson’s appointment was signed by Katrina Armstrong, MD, incoming CEO, Columbia University Irving Medical Center and dean of the Faculties of Health Sciences and the Vagelos College of Physicians and Surgeons; Anil K. Rustgi, MD, interim executive vice president and dean of the Faculties of Health Sciences and Medicine; Steven J. Corwin, MD; president and CEO, New York–Presbyterian; and Ann Marie Sullivan, MD, commissioner of the New York State Office of Mental Health.

This is a developing story.

A version of this article first appeared on Medscape.com.

Columbia University has appointed an interim chair of psychiatry in the wake of a controversial tweet sent out on Feb. 21, according to an email obtained by this news organization that was sent by university leadership to faculty and staff on Feb. 28.

Helen Blair Simpson, MD, PhD, will take over for Jeffrey Lieberman, MD, who was suspended over a tweet he sent that was widely condemned as both racist and sexist.

She will also serve as interim director of the New York State Psychiatric Institute and interim psychiatrist-in-chief at New York–Presbyterian/Columbia University Irving Medical Center, the email stated.

All appointments were effective on Feb. 28.
 

Latest response

Dr. Simpson, who joined the faculty at Columbia in 1999, previously served as a professor and vice chair of research for the psychiatry department, director of Columbia’s Center for Obsessive-Compulsive and Related Disorders, and director of psychiatry research at the New York State Psychiatric Institute. Dr. Simpson is associate editor of JAMA Psychiatry and is president-elect of the Anxiety and Depression Association of America.

Her research has been continuously funded by the National Institute of Mental Health since 1999, and she has advised both the World Health Organization and the American Psychiatric Association on the diagnosis and treatment of OCD.

Dr. Simpson has a bachelor’s degree in biology from Yale University and completed an MD-PhD program at The Rockefeller University and Weill Cornell Medicine, New York. She did her residency in psychiatry at New York–Presbyterian.

The announcement is Columbia’s latest response to the furor that erupted on social media following Dr. Lieberman’s tweet about Sudanese model Nyakim Gatwech, in which he wrote, “Whether a work of art or a freak of nature she’s a beautiful sight to behold.”

Twitter reacted immediately and negatively to the tweet, which even Dr. Lieberman later acknowledged was “racist and sexist” in an email apology he sent Feb. 22 to faculty and staff in the department of psychiatry.

As reported by this news organization, Columbia suspended Dr. Lieberman from his chair position on Feb. 23 and permanently removed him from the post of psychiatrist-in-chief at New York–Presbyterian Hospital/Columbia University Irving Medical Center. Lieberman also resigned as executive director of the New York State Psychiatric Institute.

The email announcing Simpson’s appointment was signed by Katrina Armstrong, MD, incoming CEO, Columbia University Irving Medical Center and dean of the Faculties of Health Sciences and the Vagelos College of Physicians and Surgeons; Anil K. Rustgi, MD, interim executive vice president and dean of the Faculties of Health Sciences and Medicine; Steven J. Corwin, MD; president and CEO, New York–Presbyterian; and Ann Marie Sullivan, MD, commissioner of the New York State Office of Mental Health.

This is a developing story.

A version of this article first appeared on Medscape.com.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.

Disparities in health care exist in every specialty. In rheumatology, health disparities look like lack of access to care and lack of education on the part of rheumatologists and their patients, according to a speaker at the 2022 Rheumatology Winter Clinical Symposium.

Health disparities can affect people based on their racial or ethnic group, gender, sexual orientation, a mental or physical disability, socioeconomic status, or religion, Alvin Wells, MD, PhD, director of the department of rheumatology at Advocate Aurora Health in Franklin, Wisc., said in his presentation. But a person’s environment also plays a role – “where you live, work, play, and worship.”

Screenshot RWCS 2022

Social determinants of health can affect short-term and long-term health outcomes, functioning, and quality of life, he noted. “It’s economic stability, it’s access not only to health care, but also to education. And indeed, in my lifetime, as you know, some individuals weren’t allowed to read and write. They weren’t allowed to go to schools. You didn’t get the same type of education, and so that made a dramatic impact in moving forward with future, subsequent generations.”

In a survey of executives, clinical leaders, and clinicians in NEJM Catalyst Innovations in Care Delivery, 48% said widespread disparities in care delivery were present in their organizations. According to the social psychologist James S. House, PhD, some of these disparities like race/ethnicity, socioeconomic status, genetics, and geography are fixed, while others like psychosocial, medical care/insurance, and environmental hazards are modifiable. While factors like education, work, and location might be modifiable for some patients, others don’t have the ability to make these changes, Dr. Wells explained. “It’s not that easy when you think about it.”

Within rheumatology, racial and ethnic disparities exist in rheumatoid arthritis when it comes to disease activity and use of disease-modifying antirheumatic drugs. Disparities in outcomes based on race and geographic location have also been identified for patients with systemic lupus erythematosus, lupus nephritis, and based on race in osteoarthritis and psoriatic arthritis. “Where people live, where they reside, where their zip code is,” makes a difference for patients with rheumatic diseases, Dr. Wells said.

“We’ve heard at this meeting [about] some amazing drugs in treating our patients, both [for] skin and joint disease, but not everybody has the same kind of access,” he said.
 

What actions can medical stakeholders take?

Health equity should be a “desirable goal” for patients who experience health disparities, but it needs to be a “continuous effort,” Dr. Wells said. Focusing on the “how” of eliminating disparities should be a focus rather than checking a box.

Pharmacoequity is also a component of health equity, according to Dr. Wells. Where a person lives can affect their health based on their neighborhood’s level of air pollution, access to green space, and food deserts, but where a person lives also affects what parts of the health system they have access to, according to an editorial published in Circulation: Cardiovascular Quality and Outcomes. When patients aren’t taking their medication, it might be because that person doesn’t have easy access to a pharmacy, noted Dr. Wells. “It really kind of blows you away when you look at the data.”

Different stakeholders in medicine can tackle various aspects of this problem. For example, health care organizations and medical schools can make long-term commitments to prioritizing health equality, Dr. Wells said. “You want to make this a part of your practice, your group, or your university. And then once you get a process in place, don’t just check that box and move on. You want to see it. If you haven’t reached your goal, you need to revamp. If you met your goal, how do [you] improve upon that?”

Medical schools can also do better at improving misconceptions about patients of different races and ethnicities. Dr. Wells cited a striking paper published in Proceedings of the National Academy of Sciences of the U.S.A. that compared false beliefs in biological differences between Black and White people held by White laypeople and medical students. The study found that 58% of laypeople and 40% of first-year medical students believed that Black people have thicker skin than White people. “It’s absolutely amazing when you think about what medical schools can do,” he said.

Increased access to care is another area for improvement, Dr. Wells noted. “If you take people who are uninsured and you look at their health once they get Medicare, the gaps begin to close between the different races.”

In terms of individual actions, Dr. Wells noted that researchers and clinicians can help to make clinical trials better represent the overall population. At your practice, “treat all your patients like a VIP.” Instead of being concerned about the cost of a treatment, ask “is your patient worth it?”

“I have one of my patients on Medicaid. She’s on a biologic drug. And one of the VPs of my hospital is on the same drug. We don’t treat them any differently.”

The private sector is also acting, Dr. Wells said. He cited Novartis’ pledge to partner with 26 historically Black colleges to improve disparities in health and education. “We need to see more of that done from corporate America.”

Are there any short-term solutions?

Eric Ruderman, MD, professor of rheumatology at Northwestern University, Chicago, commented that institutions have been forming committees and focus groups, but “not a lot of action.”

“They’re checking boxes,” he said, “which is very frustrating.” What can rheumatologists do in the short term, he asked?

Dr. Wells noted that there has been some success in using a “carrot” model of using payment models to reduce racial disparities. For example, a recent study analyzing the effects of the Comprehensive Care for Joint Replacement model highlighted the need for payment reform that incentivizes clinicians to spend wisely on patient treatment. Under a payment model that rewards clinicians for treating patients cost effectively, “if I do a great job cost effectively, I could just have more of that money back to my group,” he said.

George Martin, MD, a clinical dermatologist practicing in Maui, recalled the disparity in health care he observed as a child growing up in Philadelphia. “There’s really, within the city, there’s two different levels of health care,” he said. “There’s a tremendous disparity in the quality of the physician in hospital, and way out in the community. Because that’s the point of contact. That’s when either you’re going to prescribe a biologic, or [you’re] going to give them some aspirin and tell them go home. That’s where it starts, point of contact.”

Dr. Wells agreed that it is a big challenge, noting that cities also contribute to pollution, crowding, and other factors that adversely impact health care.

“It’s a shared responsibility. How do we solve that?” Dr. Martin asked. “And if you tell me, I’m going to give you a Nobel Prize.”

Dr. Wells reported he is a reviewer for the Journal of Racial and Ethnic Disparities.