Diversity in Medicine

The historical mistreatment of Black bodies in gynecologic care has bled into present day inequities—from surgeries performed on enslaved Black women and sterilization of low-income Black women under federally funded programs, to higher rates of adverse health-related outcomes among Black women compared with their non-Black counterparts.^1-3 Not only is the foundation of gynecology imperfect, so too is its current-day structure.

It is not enough to identify and describe racial inequities in health care; action plans to provide equitable care are called for. In this report, we aim to 1) contextualize the data on disparities in minimally invasive gynecologic surgery, specifically hysterectomy and myomectomy candidates and postsurgical outcomes, and 2) provide recommendations to close racial gaps in gynecologic treatment for more equitable experiences for minority women.

Black women and uterine fibroids

Uterine leiomyomas, or fibroids, are not only the most common benign pelvic tumor but they also cause a significant medical and financial burden in the United States, with estimated direct costs of $4.1 ̶ 9.4 billion.⁴ Fibroids can affect fertility and cause pain, bulk symptoms, heavy bleeding, anemia requiring blood transfusion, and poor pregnancy outcomes. The burden of disease for uterine fibroids is greatest for Black women. While race is a social construct, women with African ancestry (who we tend to identify as having darker skin) have disproportionately higher rates of uterine fibroids. Black women experience symptoms at a younger age, spanning more of their reproductive years compared with their non-Black counterparts and their disease is often more severe compared with White women.⁵

The incidence of fibroids is 2 to 3 times higher in Black women compared with White women.⁵ According to ultrasound-based studies, the prevalence of fibroids among women aged 18 to 30 years was 26% among Black and 7% among White asymptomatic women.⁶ Earlier onset and more severe symptoms mean that there is a larger potential for impact on fertility for Black women. This coupled with the historical context of mistreatment of Black bodies makes the need for personalized medicine and culturally sensitive care critical. The disproportionately higher rates of uterine fibroids in Black women has been attributed to many factors, including socioeconomic status, health-care access, genetics, and lifestyle and environmental exposures, but the underlying causes of racial/ethnic differences remain unclear.⁷ Amazingly little data exist not only on patient preferences for management approach but also on the influence of genetic and epigenetic mediators and environmental factors that may play a role in fibroid development to guide optimal management and treatment outcomes for Black women with uterine fibroids.⁸

Inequitable management of uterine fibroids

Although tumor size, location, and patient risk factors are used to determine the best treatment approach, the American College of Obstetricians and Gynecologists (ACOG) guidelines suggest that the use of alternative treatments to surgery should be first-line management instead of hysterectomy for most benign conditions.⁹ Conservative management will often help alleviate symptoms, slow the growth of fibroid(s), or bridge women to menopause, and treatment options include hormonal contraception, gonadotropin-releasing hormone agonists, hysteroscopic resection, uterine artery embolization, magnetic resonance-guided focused ultrasound, and myomectomy.

The rate of conservative management prior to hysterectomy varies by setting, reflecting potential bias in treatment decisions. Some medical settings have reported a 29% alternative management rate prior to hysterectomy, while others report much higher rates.¹⁰ A study using patient data from Kaiser Permanente Northern California (KPNC) showed that, within a large, diverse, and integrated health care system, more than 80% of patients received alternative treatments before undergoing hysterectomy; for those with symptomatic leiomyomas, 74.1% used alternative treatments prior to hysterectomy, and in logistic regression there was not a difference by race.¹¹ Nationally, Black women are more likely to have hysterectomy or myomectomy compared with a nonsurgical uterine-sparing therapy.^12,13

With about 600,000 cases per year within the United States, the hysterectomy is the most frequently performed benign gynecologic surgery.¹⁴ The most common indication is for “symptomatic fibroid uterus.” The approach to decision making for route of hysterectomy involves multiple patient and surgeon factors, including history of vaginal delivery, body mass index, history of previous surgery, uterine size, informed patient preference, and surgeon volume.^15-17 ACOG recommends a minimally invasive hysterectomy (MIH) whenever feasible given its benefits in postoperative pain, recovery time, and blood loss. Myomectomy, particularly among women in their reproductive years desiring management of leiomyomas, is a uterine-sparing procedure versus hysterectomy. Minimally invasive myomectomy (MIM), compared with an open abdominal route, provides for lower drop in hemoglobin levels, shorter hospital stay, less adhesion formation, and decreased postoperative pain.¹⁸

Racial variations in hysterectomy rates persist overall and according to hysterectomy type. Black women are 2 to 3 times more likely to undergo hysterectomy for leiomyomas than other racial groups.¹⁹ These differences in rates have been shown to persist even when burden of disease is the same. One study found that Black women had increased odds of hysterectomy compared with their White counterparts even when there was no difference in mean fibroid volume by race,²⁰ calling into question provider bias. Even in a universal insurance setting, Black patients have been found to have higher rates of open hysterectomies.²¹ Previous studies found that, despite growing frequency of laparoscopic and robotic-assisted hysterectomies, patients of a minority race had decreased odds of undergoing a MIH compared with their White counterparts.²²

While little data exist on route of myomectomy by race, a recent study found minority women were more likely to undergo abdominal myomectomy compared with White women; Black women were twice as likely to undergo abdominal myomectomy (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.7–2.0), Asian American women were more than twice as likely (aOR, 2.3; 95% CI, 1.8–2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (aOR, 1.5; 95% CI, 1.2–1.9) when compared with White women.²³ These differences remained after controlling for potential confounders, and there appeared to be an interaction between race and fibroid weight such that racial bias alone may not explain the differences.

Finally, Black women have higher perioperative complication rates compared with non-Black women. Postoperative complications including blood transfusion after myomectomy have been shown to be twice as high among Black women compared with White women. However, once uterine size, comorbidities, and fibroid number were controlled, race was not associated with higher complications. Black women, compared with White women, have been found to have 50% increased odds of morbidity after an abdominal myomectomy.²⁴

Continue to: How to ensure that BIPOC women get the best management...

Eliminating disparities and providing equitable and patient-centered care for Black, Indigenous, and people of color (BIPOC) women will require research, education, training, and targeted quality improvement initiatives.

Research into fibroids and comparative treatment outcomes

Uterine fibroids, despite their major public health impact, remain understudied. With Black women carrying the highest fibroid prevalence and severity burden, especially in their childbearing years, it is imperative that research efforts be focused on outcomes by race and ethnicity. Given the significant economic impact of fibroids, more efforts should be directed toward primary prevention of fibroid formation as well as secondary prevention and limitation of fibroid growth by affordable, effective, and safe means. For example, Bratka and colleagues researched the role of vitamin D in inhibiting growth of leiomyoma cells in animal models.²⁵ Other innovative forms of management under investigation include aromatase inhibitors, green tea, cabergoline, elagolix, paricalcitol, and epigallocatechin gallate.²⁶ Considerations such as stress, diet, and environmental risk factors have yet to be investigated in large studies.

Research contributing to evidence-based guidelines that address the needs of different patient populations affected by uterine fibroids is critical.⁸ Additionally, research conducted by Black women about Black women should be prioritized. In March 2021, the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021 was introduced to fund $150 million in research supported by the National Institutes of Health (NIH). This is an opportunity to develop a research database to inform evidence-based culturally informed care regarding fertility counseling, medical management, and optimal surgical approach, as well as to award funding to minority researchers. There are disparities in distribution of funds from the NIH to minority researchers. Under-represented minorities are awarded fewer NIH grants compared with their counterparts despite initiatives to increase funding. Furthermore, in 2011, Black applicants for NIH funding were two-thirds as likely as White applicants to receive grants from 2000 ̶ 2006, even when accounting for publication record and training.²⁷ Funding BIPOC researchers fuels diversity-driven investigation and can be useful in the charge to increase fibroid research.

Education and training: Changing the work force

Achieving equity requires change in provider work force. In a study of trends across multiple specialties including obstetrics and gynecology, Blacks and Latinx are more under-represented in 2016 than in 1990 across all specialties except for Black women in obstetrics and gynecology.²⁸ It is well documented that under-represented minorities are more likely to engage in practice, research, service, and mentorship activities aligned with their identity.²⁹ As a higher proportion of under-represented minority obstetricians and gynecologists practice in medically underserved areas,³⁰ this presents a unique opportunity for gynecologists to improve care for and increase research involvement among BIPOC women.

Increasing BIPOC representation in medical and health care institutions and practices is not enough, however, to achieve health equity. Data from the Association of American Medical Colleges demonstrate that between 1978 and 2017 the total number of full-time obstetrics and gynecology faculty rose nearly fourfold from 1,688 to 6,347; however, the greatest rise in proportion of faculty who were nontenured was among women who were under-represented minorities.³¹ Additionally, there are disparities in wage by race even after controlling for hours worked and state of residence.³² Medical and academic centers and health care institutions and practices should proactively and systematically engage in the recruitment and retention of under-represented minority physicians and people in leadership roles. This will involve creating safe and inclusive work environments, with equal pay and promotion structures.

Quality initiatives to address provider bias

Provider bias should be addressed in clinical decision making and counseling of patients. Studies focused on ultrasonography have shown an estimated cumulative incidence of fibroids by age 50 of greater than 80% for Black women and nearly 70% for White women.⁵ Due to the prevalence and burden of fibroids among Black women there may be a provider bias in approach to management. Addressing this bias requires quality improvement efforts and investigation into patient and provider factors in management of fibroids. Black women have been a vulnerable population in medicine due to instances of mistreatment, and often times mistrust can play a role in how a patient views his or her care decisions. A patient-centered strategy allows patient factors such as age, uterine size, and cultural background to be considered such that a provider can tailor an approach that is best for the patient. Previous minority women focus groups have demonstrated that women have a strong desire for elective treatment;³³ therefore, providers should listen openly to patients about their values and their perspectives on how fibroids affect their lives. Provider bias toward surgical volume, incentive for surgery, and implicit bias need to be addressed at every institution to work toward equitable and cost-effective care.

Integrated health care systems like Southern and Northern California Permanente Medical Group, using quality initiatives, have increased their minimally invasive surgery rates. Southern California Permanente Medical Group reached a 78% rate of MIH in a system of more than 350 surgeons performing benign indication hysterectomies as reported in 2011.³⁴ Similarly, a study within KPNC, an institution with an MIH rate greater than 95%,³⁵ found that racial disparities in route of MIH were eliminated through a quality improvement initiative described in detail in 2018 (FIGURE and TABLE).³⁶

Conclusions

There are recognized successes in the gynecology field’s efforts to address racial disparities. Prior studies provide insight into opportunities to improve care in medical management of leiomyomas, minimally invasive route of hysterectomy and myomectomy, postsurgical outcomes, and institutional leadership. Particularly, when systemwide approaches are taken in the delivery of health care it is possible to significantly diminish racial disparities in gynecology.³⁵ Much work remains to be done for our health care systems to provide equitable care.

The historical mistreatment of Black bodies in gynecologic care has bled into present day inequities—from surgeries performed on enslaved Black women and sterilization of low-income Black women under federally funded programs, to higher rates of adverse health-related outcomes among Black women compared with their non-Black counterparts.^1-3 Not only is the foundation of gynecology imperfect, so too is its current-day structure.

It is not enough to identify and describe racial inequities in health care; action plans to provide equitable care are called for. In this report, we aim to 1) contextualize the data on disparities in minimally invasive gynecologic surgery, specifically hysterectomy and myomectomy candidates and postsurgical outcomes, and 2) provide recommendations to close racial gaps in gynecologic treatment for more equitable experiences for minority women.

Black women and uterine fibroids

Uterine leiomyomas, or fibroids, are not only the most common benign pelvic tumor but they also cause a significant medical and financial burden in the United States, with estimated direct costs of $4.1 ̶ 9.4 billion.⁴ Fibroids can affect fertility and cause pain, bulk symptoms, heavy bleeding, anemia requiring blood transfusion, and poor pregnancy outcomes. The burden of disease for uterine fibroids is greatest for Black women. While race is a social construct, women with African ancestry (who we tend to identify as having darker skin) have disproportionately higher rates of uterine fibroids. Black women experience symptoms at a younger age, spanning more of their reproductive years compared with their non-Black counterparts and their disease is often more severe compared with White women.⁵

The incidence of fibroids is 2 to 3 times higher in Black women compared with White women.⁵ According to ultrasound-based studies, the prevalence of fibroids among women aged 18 to 30 years was 26% among Black and 7% among White asymptomatic women.⁶ Earlier onset and more severe symptoms mean that there is a larger potential for impact on fertility for Black women. This coupled with the historical context of mistreatment of Black bodies makes the need for personalized medicine and culturally sensitive care critical. The disproportionately higher rates of uterine fibroids in Black women has been attributed to many factors, including socioeconomic status, health-care access, genetics, and lifestyle and environmental exposures, but the underlying causes of racial/ethnic differences remain unclear.⁷ Amazingly little data exist not only on patient preferences for management approach but also on the influence of genetic and epigenetic mediators and environmental factors that may play a role in fibroid development to guide optimal management and treatment outcomes for Black women with uterine fibroids.⁸

Inequitable management of uterine fibroids

Although tumor size, location, and patient risk factors are used to determine the best treatment approach, the American College of Obstetricians and Gynecologists (ACOG) guidelines suggest that the use of alternative treatments to surgery should be first-line management instead of hysterectomy for most benign conditions.⁹ Conservative management will often help alleviate symptoms, slow the growth of fibroid(s), or bridge women to menopause, and treatment options include hormonal contraception, gonadotropin-releasing hormone agonists, hysteroscopic resection, uterine artery embolization, magnetic resonance-guided focused ultrasound, and myomectomy.

The rate of conservative management prior to hysterectomy varies by setting, reflecting potential bias in treatment decisions. Some medical settings have reported a 29% alternative management rate prior to hysterectomy, while others report much higher rates.¹⁰ A study using patient data from Kaiser Permanente Northern California (KPNC) showed that, within a large, diverse, and integrated health care system, more than 80% of patients received alternative treatments before undergoing hysterectomy; for those with symptomatic leiomyomas, 74.1% used alternative treatments prior to hysterectomy, and in logistic regression there was not a difference by race.¹¹ Nationally, Black women are more likely to have hysterectomy or myomectomy compared with a nonsurgical uterine-sparing therapy.^12,13

With about 600,000 cases per year within the United States, the hysterectomy is the most frequently performed benign gynecologic surgery.¹⁴ The most common indication is for “symptomatic fibroid uterus.” The approach to decision making for route of hysterectomy involves multiple patient and surgeon factors, including history of vaginal delivery, body mass index, history of previous surgery, uterine size, informed patient preference, and surgeon volume.^15-17 ACOG recommends a minimally invasive hysterectomy (MIH) whenever feasible given its benefits in postoperative pain, recovery time, and blood loss. Myomectomy, particularly among women in their reproductive years desiring management of leiomyomas, is a uterine-sparing procedure versus hysterectomy. Minimally invasive myomectomy (MIM), compared with an open abdominal route, provides for lower drop in hemoglobin levels, shorter hospital stay, less adhesion formation, and decreased postoperative pain.¹⁸

Racial variations in hysterectomy rates persist overall and according to hysterectomy type. Black women are 2 to 3 times more likely to undergo hysterectomy for leiomyomas than other racial groups.¹⁹ These differences in rates have been shown to persist even when burden of disease is the same. One study found that Black women had increased odds of hysterectomy compared with their White counterparts even when there was no difference in mean fibroid volume by race,²⁰ calling into question provider bias. Even in a universal insurance setting, Black patients have been found to have higher rates of open hysterectomies.²¹ Previous studies found that, despite growing frequency of laparoscopic and robotic-assisted hysterectomies, patients of a minority race had decreased odds of undergoing a MIH compared with their White counterparts.²²

While little data exist on route of myomectomy by race, a recent study found minority women were more likely to undergo abdominal myomectomy compared with White women; Black women were twice as likely to undergo abdominal myomectomy (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.7–2.0), Asian American women were more than twice as likely (aOR, 2.3; 95% CI, 1.8–2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (aOR, 1.5; 95% CI, 1.2–1.9) when compared with White women.²³ These differences remained after controlling for potential confounders, and there appeared to be an interaction between race and fibroid weight such that racial bias alone may not explain the differences.

Finally, Black women have higher perioperative complication rates compared with non-Black women. Postoperative complications including blood transfusion after myomectomy have been shown to be twice as high among Black women compared with White women. However, once uterine size, comorbidities, and fibroid number were controlled, race was not associated with higher complications. Black women, compared with White women, have been found to have 50% increased odds of morbidity after an abdominal myomectomy.²⁴

Continue to: How to ensure that BIPOC women get the best management...

Eliminating disparities and providing equitable and patient-centered care for Black, Indigenous, and people of color (BIPOC) women will require research, education, training, and targeted quality improvement initiatives.

Research into fibroids and comparative treatment outcomes

Uterine fibroids, despite their major public health impact, remain understudied. With Black women carrying the highest fibroid prevalence and severity burden, especially in their childbearing years, it is imperative that research efforts be focused on outcomes by race and ethnicity. Given the significant economic impact of fibroids, more efforts should be directed toward primary prevention of fibroid formation as well as secondary prevention and limitation of fibroid growth by affordable, effective, and safe means. For example, Bratka and colleagues researched the role of vitamin D in inhibiting growth of leiomyoma cells in animal models.²⁵ Other innovative forms of management under investigation include aromatase inhibitors, green tea, cabergoline, elagolix, paricalcitol, and epigallocatechin gallate.²⁶ Considerations such as stress, diet, and environmental risk factors have yet to be investigated in large studies.

Research contributing to evidence-based guidelines that address the needs of different patient populations affected by uterine fibroids is critical.⁸ Additionally, research conducted by Black women about Black women should be prioritized. In March 2021, the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021 was introduced to fund $150 million in research supported by the National Institutes of Health (NIH). This is an opportunity to develop a research database to inform evidence-based culturally informed care regarding fertility counseling, medical management, and optimal surgical approach, as well as to award funding to minority researchers. There are disparities in distribution of funds from the NIH to minority researchers. Under-represented minorities are awarded fewer NIH grants compared with their counterparts despite initiatives to increase funding. Furthermore, in 2011, Black applicants for NIH funding were two-thirds as likely as White applicants to receive grants from 2000 ̶ 2006, even when accounting for publication record and training.²⁷ Funding BIPOC researchers fuels diversity-driven investigation and can be useful in the charge to increase fibroid research.

Education and training: Changing the work force

Achieving equity requires change in provider work force. In a study of trends across multiple specialties including obstetrics and gynecology, Blacks and Latinx are more under-represented in 2016 than in 1990 across all specialties except for Black women in obstetrics and gynecology.²⁸ It is well documented that under-represented minorities are more likely to engage in practice, research, service, and mentorship activities aligned with their identity.²⁹ As a higher proportion of under-represented minority obstetricians and gynecologists practice in medically underserved areas,³⁰ this presents a unique opportunity for gynecologists to improve care for and increase research involvement among BIPOC women.

Increasing BIPOC representation in medical and health care institutions and practices is not enough, however, to achieve health equity. Data from the Association of American Medical Colleges demonstrate that between 1978 and 2017 the total number of full-time obstetrics and gynecology faculty rose nearly fourfold from 1,688 to 6,347; however, the greatest rise in proportion of faculty who were nontenured was among women who were under-represented minorities.³¹ Additionally, there are disparities in wage by race even after controlling for hours worked and state of residence.³² Medical and academic centers and health care institutions and practices should proactively and systematically engage in the recruitment and retention of under-represented minority physicians and people in leadership roles. This will involve creating safe and inclusive work environments, with equal pay and promotion structures.

Quality initiatives to address provider bias

Provider bias should be addressed in clinical decision making and counseling of patients. Studies focused on ultrasonography have shown an estimated cumulative incidence of fibroids by age 50 of greater than 80% for Black women and nearly 70% for White women.⁵ Due to the prevalence and burden of fibroids among Black women there may be a provider bias in approach to management. Addressing this bias requires quality improvement efforts and investigation into patient and provider factors in management of fibroids. Black women have been a vulnerable population in medicine due to instances of mistreatment, and often times mistrust can play a role in how a patient views his or her care decisions. A patient-centered strategy allows patient factors such as age, uterine size, and cultural background to be considered such that a provider can tailor an approach that is best for the patient. Previous minority women focus groups have demonstrated that women have a strong desire for elective treatment;³³ therefore, providers should listen openly to patients about their values and their perspectives on how fibroids affect their lives. Provider bias toward surgical volume, incentive for surgery, and implicit bias need to be addressed at every institution to work toward equitable and cost-effective care.

Integrated health care systems like Southern and Northern California Permanente Medical Group, using quality initiatives, have increased their minimally invasive surgery rates. Southern California Permanente Medical Group reached a 78% rate of MIH in a system of more than 350 surgeons performing benign indication hysterectomies as reported in 2011.³⁴ Similarly, a study within KPNC, an institution with an MIH rate greater than 95%,³⁵ found that racial disparities in route of MIH were eliminated through a quality improvement initiative described in detail in 2018 (FIGURE and TABLE).³⁶

Conclusions

There are recognized successes in the gynecology field’s efforts to address racial disparities. Prior studies provide insight into opportunities to improve care in medical management of leiomyomas, minimally invasive route of hysterectomy and myomectomy, postsurgical outcomes, and institutional leadership. Particularly, when systemwide approaches are taken in the delivery of health care it is possible to significantly diminish racial disparities in gynecology.³⁵ Much work remains to be done for our health care systems to provide equitable care.

The historical mistreatment of Black bodies in gynecologic care has bled into present day inequities—from surgeries performed on enslaved Black women and sterilization of low-income Black women under federally funded programs, to higher rates of adverse health-related outcomes among Black women compared with their non-Black counterparts.^1-3 Not only is the foundation of gynecology imperfect, so too is its current-day structure.

It is not enough to identify and describe racial inequities in health care; action plans to provide equitable care are called for. In this report, we aim to 1) contextualize the data on disparities in minimally invasive gynecologic surgery, specifically hysterectomy and myomectomy candidates and postsurgical outcomes, and 2) provide recommendations to close racial gaps in gynecologic treatment for more equitable experiences for minority women.

Black women and uterine fibroids

Uterine leiomyomas, or fibroids, are not only the most common benign pelvic tumor but they also cause a significant medical and financial burden in the United States, with estimated direct costs of $4.1 ̶ 9.4 billion.⁴ Fibroids can affect fertility and cause pain, bulk symptoms, heavy bleeding, anemia requiring blood transfusion, and poor pregnancy outcomes. The burden of disease for uterine fibroids is greatest for Black women. While race is a social construct, women with African ancestry (who we tend to identify as having darker skin) have disproportionately higher rates of uterine fibroids. Black women experience symptoms at a younger age, spanning more of their reproductive years compared with their non-Black counterparts and their disease is often more severe compared with White women.⁵

The incidence of fibroids is 2 to 3 times higher in Black women compared with White women.⁵ According to ultrasound-based studies, the prevalence of fibroids among women aged 18 to 30 years was 26% among Black and 7% among White asymptomatic women.⁶ Earlier onset and more severe symptoms mean that there is a larger potential for impact on fertility for Black women. This coupled with the historical context of mistreatment of Black bodies makes the need for personalized medicine and culturally sensitive care critical. The disproportionately higher rates of uterine fibroids in Black women has been attributed to many factors, including socioeconomic status, health-care access, genetics, and lifestyle and environmental exposures, but the underlying causes of racial/ethnic differences remain unclear.⁷ Amazingly little data exist not only on patient preferences for management approach but also on the influence of genetic and epigenetic mediators and environmental factors that may play a role in fibroid development to guide optimal management and treatment outcomes for Black women with uterine fibroids.⁸

Inequitable management of uterine fibroids

Although tumor size, location, and patient risk factors are used to determine the best treatment approach, the American College of Obstetricians and Gynecologists (ACOG) guidelines suggest that the use of alternative treatments to surgery should be first-line management instead of hysterectomy for most benign conditions.⁹ Conservative management will often help alleviate symptoms, slow the growth of fibroid(s), or bridge women to menopause, and treatment options include hormonal contraception, gonadotropin-releasing hormone agonists, hysteroscopic resection, uterine artery embolization, magnetic resonance-guided focused ultrasound, and myomectomy.

The rate of conservative management prior to hysterectomy varies by setting, reflecting potential bias in treatment decisions. Some medical settings have reported a 29% alternative management rate prior to hysterectomy, while others report much higher rates.¹⁰ A study using patient data from Kaiser Permanente Northern California (KPNC) showed that, within a large, diverse, and integrated health care system, more than 80% of patients received alternative treatments before undergoing hysterectomy; for those with symptomatic leiomyomas, 74.1% used alternative treatments prior to hysterectomy, and in logistic regression there was not a difference by race.¹¹ Nationally, Black women are more likely to have hysterectomy or myomectomy compared with a nonsurgical uterine-sparing therapy.^12,13

With about 600,000 cases per year within the United States, the hysterectomy is the most frequently performed benign gynecologic surgery.¹⁴ The most common indication is for “symptomatic fibroid uterus.” The approach to decision making for route of hysterectomy involves multiple patient and surgeon factors, including history of vaginal delivery, body mass index, history of previous surgery, uterine size, informed patient preference, and surgeon volume.^15-17 ACOG recommends a minimally invasive hysterectomy (MIH) whenever feasible given its benefits in postoperative pain, recovery time, and blood loss. Myomectomy, particularly among women in their reproductive years desiring management of leiomyomas, is a uterine-sparing procedure versus hysterectomy. Minimally invasive myomectomy (MIM), compared with an open abdominal route, provides for lower drop in hemoglobin levels, shorter hospital stay, less adhesion formation, and decreased postoperative pain.¹⁸

Racial variations in hysterectomy rates persist overall and according to hysterectomy type. Black women are 2 to 3 times more likely to undergo hysterectomy for leiomyomas than other racial groups.¹⁹ These differences in rates have been shown to persist even when burden of disease is the same. One study found that Black women had increased odds of hysterectomy compared with their White counterparts even when there was no difference in mean fibroid volume by race,²⁰ calling into question provider bias. Even in a universal insurance setting, Black patients have been found to have higher rates of open hysterectomies.²¹ Previous studies found that, despite growing frequency of laparoscopic and robotic-assisted hysterectomies, patients of a minority race had decreased odds of undergoing a MIH compared with their White counterparts.²²

While little data exist on route of myomectomy by race, a recent study found minority women were more likely to undergo abdominal myomectomy compared with White women; Black women were twice as likely to undergo abdominal myomectomy (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.7–2.0), Asian American women were more than twice as likely (aOR, 2.3; 95% CI, 1.8–2.8), and Hispanic American women were 50% more likely to undergo abdominal myomectomy (aOR, 1.5; 95% CI, 1.2–1.9) when compared with White women.²³ These differences remained after controlling for potential confounders, and there appeared to be an interaction between race and fibroid weight such that racial bias alone may not explain the differences.

Finally, Black women have higher perioperative complication rates compared with non-Black women. Postoperative complications including blood transfusion after myomectomy have been shown to be twice as high among Black women compared with White women. However, once uterine size, comorbidities, and fibroid number were controlled, race was not associated with higher complications. Black women, compared with White women, have been found to have 50% increased odds of morbidity after an abdominal myomectomy.²⁴

Continue to: How to ensure that BIPOC women get the best management...

Eliminating disparities and providing equitable and patient-centered care for Black, Indigenous, and people of color (BIPOC) women will require research, education, training, and targeted quality improvement initiatives.

Research into fibroids and comparative treatment outcomes

Uterine fibroids, despite their major public health impact, remain understudied. With Black women carrying the highest fibroid prevalence and severity burden, especially in their childbearing years, it is imperative that research efforts be focused on outcomes by race and ethnicity. Given the significant economic impact of fibroids, more efforts should be directed toward primary prevention of fibroid formation as well as secondary prevention and limitation of fibroid growth by affordable, effective, and safe means. For example, Bratka and colleagues researched the role of vitamin D in inhibiting growth of leiomyoma cells in animal models.²⁵ Other innovative forms of management under investigation include aromatase inhibitors, green tea, cabergoline, elagolix, paricalcitol, and epigallocatechin gallate.²⁶ Considerations such as stress, diet, and environmental risk factors have yet to be investigated in large studies.

Research contributing to evidence-based guidelines that address the needs of different patient populations affected by uterine fibroids is critical.⁸ Additionally, research conducted by Black women about Black women should be prioritized. In March 2021, the Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021 was introduced to fund $150 million in research supported by the National Institutes of Health (NIH). This is an opportunity to develop a research database to inform evidence-based culturally informed care regarding fertility counseling, medical management, and optimal surgical approach, as well as to award funding to minority researchers. There are disparities in distribution of funds from the NIH to minority researchers. Under-represented minorities are awarded fewer NIH grants compared with their counterparts despite initiatives to increase funding. Furthermore, in 2011, Black applicants for NIH funding were two-thirds as likely as White applicants to receive grants from 2000 ̶ 2006, even when accounting for publication record and training.²⁷ Funding BIPOC researchers fuels diversity-driven investigation and can be useful in the charge to increase fibroid research.

Education and training: Changing the work force

Achieving equity requires change in provider work force. In a study of trends across multiple specialties including obstetrics and gynecology, Blacks and Latinx are more under-represented in 2016 than in 1990 across all specialties except for Black women in obstetrics and gynecology.²⁸ It is well documented that under-represented minorities are more likely to engage in practice, research, service, and mentorship activities aligned with their identity.²⁹ As a higher proportion of under-represented minority obstetricians and gynecologists practice in medically underserved areas,³⁰ this presents a unique opportunity for gynecologists to improve care for and increase research involvement among BIPOC women.

Increasing BIPOC representation in medical and health care institutions and practices is not enough, however, to achieve health equity. Data from the Association of American Medical Colleges demonstrate that between 1978 and 2017 the total number of full-time obstetrics and gynecology faculty rose nearly fourfold from 1,688 to 6,347; however, the greatest rise in proportion of faculty who were nontenured was among women who were under-represented minorities.³¹ Additionally, there are disparities in wage by race even after controlling for hours worked and state of residence.³² Medical and academic centers and health care institutions and practices should proactively and systematically engage in the recruitment and retention of under-represented minority physicians and people in leadership roles. This will involve creating safe and inclusive work environments, with equal pay and promotion structures.

Quality initiatives to address provider bias

Provider bias should be addressed in clinical decision making and counseling of patients. Studies focused on ultrasonography have shown an estimated cumulative incidence of fibroids by age 50 of greater than 80% for Black women and nearly 70% for White women.⁵ Due to the prevalence and burden of fibroids among Black women there may be a provider bias in approach to management. Addressing this bias requires quality improvement efforts and investigation into patient and provider factors in management of fibroids. Black women have been a vulnerable population in medicine due to instances of mistreatment, and often times mistrust can play a role in how a patient views his or her care decisions. A patient-centered strategy allows patient factors such as age, uterine size, and cultural background to be considered such that a provider can tailor an approach that is best for the patient. Previous minority women focus groups have demonstrated that women have a strong desire for elective treatment;³³ therefore, providers should listen openly to patients about their values and their perspectives on how fibroids affect their lives. Provider bias toward surgical volume, incentive for surgery, and implicit bias need to be addressed at every institution to work toward equitable and cost-effective care.

Integrated health care systems like Southern and Northern California Permanente Medical Group, using quality initiatives, have increased their minimally invasive surgery rates. Southern California Permanente Medical Group reached a 78% rate of MIH in a system of more than 350 surgeons performing benign indication hysterectomies as reported in 2011.³⁴ Similarly, a study within KPNC, an institution with an MIH rate greater than 95%,³⁵ found that racial disparities in route of MIH were eliminated through a quality improvement initiative described in detail in 2018 (FIGURE and TABLE).³⁶

Conclusions

There are recognized successes in the gynecology field’s efforts to address racial disparities. Prior studies provide insight into opportunities to improve care in medical management of leiomyomas, minimally invasive route of hysterectomy and myomectomy, postsurgical outcomes, and institutional leadership. Particularly, when systemwide approaches are taken in the delivery of health care it is possible to significantly diminish racial disparities in gynecology.³⁵ Much work remains to be done for our health care systems to provide equitable care.

Bullying in academic medicine, especially among women, is rife, underreported, and remains largely unaddressed, new research suggests.

Investigators reviewed close to 70 studies, encompassing over 82,000 medical consultants or trainees in academic medical settings, and found that men were identified as the most common perpetrators – close to 70% of respondents – whereas women were the most common victims (56%).

Collectively, respondents in all of the studies identified the most common bullies to be consultants (54%), followed by residents (22%), and nurses (15%).

Disturbingly, less than one-third of victims overall reported that they were bullied, and close to 60% who formally reported the abuse said they did not have a positive outcome.

“We found that bullies are commonly men and senior consultants, while more than half of their victims are women,” senior author Harriette G.C. Van Spall, MD, MPH, associate professor of medicine and director of e-health and virtual care, Division of Cardiology, McMaster University, Hamilton, Ont., said in an interview.

“The greatest barriers to addressing academic bullying are the fear of reprisal, lack of impact of reporting, and non-enforcement of anti-bullying policies,” she added.

The study was published online July 12 in BMJ Open.
 

Personal experience

The study was “inspired by experiences that I endured over a period of time and am grateful to have survived,” said Dr. Van Spall.

“Some behaviors were excruciating to deal with, protesting against them would bring more on, and every day was filled with dread. It took sheer will to show up at work to care for patients, to complete research I was leading, and to have hope, and my academic output, income, and personal well-being dropped during those years,” she added.

Dr. Van Spall thought the subject “merited research because our performance as clinicians, researchers, and educators relies on our work environment.”

To investigate, the researchers reviewed 68 studies (n = 82,349 respondents) conducted between 1999 and 2021 in academic medical settings, in which victims were either consultants or trainees. Many of the studies (31) were conducted in the U.S.

Other countries included the United Kingdom, Canada, Australia, Pakistan, Egypt, Iran, Turkey, New Zealand, Lithuania, Greece, India, Germany, Nigeria, Oman, and Finland.

Studies were required to describe the method and impact of bullying; characteristics of the perpetrators and victims; or interventions that were used to address the bullying.

“Bullying” was defined as “the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviors that include overwork, destabilization, and isolation in order to impede the education or career of the target.”
 

Systemic sexism

Bullying behaviors, reported in 28 studies (n = 35,779 respondents), were grouped into destabilization, threats to professional status, overwork, and isolation, with overwork found to be the most common form of bullying.

The most common impact of being bullied was psychological distress, reported by 39.1% of respondents in 14 studies, followed by considerations of quitting (35.9%; 7 studies), and worsening of clinical performance (34.6%, 8 studies).

“Among demographic groups, men were identified as the most common perpetrators (67.2% of 4,722 respondents in 5 studies) and women the most common victims (56.2% of 15,246 respondents in 27 studies),” the authors report.

“Academic medicine in many institutions is encumbered by systemic sexism that is evident in processes around remuneration, recognition, opportunities for advancement, and leadership positions,” said Dr. Van Spall.

“There are fewer women at decision-making tables in academic medicine, the climb is uphill at the best of times, and women are likely easier targets for bullies, as their voices are easier to drown out,” she added.

She noted that many men do “exhibit wonderful attributes of professionalism and decency,” but “some in positions of power are given impunity by virtue of other accomplishments.”
 

Multiple deterrents

Thirty-one studies (n = 15,868) described characteristics of the bullies and showed the most common to be consultants (53.6% [30 studies]), residents (22% [22 studies]), and nurses (14.9% [21 studies]).

Only a minority of victims (28.9% of 9,410 victims [10 studies]) formally reported the bullying. The researchers identified multiple deterrents to reporting.

When a formal complaint was submitted (n = 1,139 respondents), it most frequently had no perceived effect (35.6%); more than one-fifth (21.9%) experienced worsening of the bullying, and only 13.7% reported improvement.

The common institutional facilitators of bullying, described in 25 studies, included lack of enforcement of anti-bullying policies (13 studies), the hierarchical structure of medicine (7 studies), and normalization of bullying (10 studies).

Forty-nine studies looked at strategies to address academic bullying, including anti-bullying policies, mandatory workshops on mistreatment, establishing an anti-bullying oversight committee, and institutional support for victims. However, the studies testing the effectiveness of these interventions “had a high risk of bias.”
 

Support available

Commenting on the research for this news organization, Roberta Gebhard, DO, past president of the American Medical Women’s Association (AMWA) and a member of the advisory board for Physician Just Equity, called it a “good study, large, international, and well-written.”

Dr. Gebhard, a member of the Governing Council for the American Medical Association Women Physician Section, was not associated with this study but said she is currently researching women who left medical school and residency.

“A common reason for leaving is being bullied. Bullying is often not reported and if reported, often not addressed. Or, if addressed, the person who reports it is often retaliated against, which is a common experience, especially in women.”

She advised female physicians who are bullied to get support from other female physicians – for example, by joining the AMWA, which has an online women’s leadership group.

“Having other women physicians throughout the country you can call for advice and support can be helpful,” said Dr. Gebhard, a family practice physician based in Grand Island, New York.

Dr. Van Spall receives support from the Canadian Institutes of Health Research, the Heart and Stroke Foundation, the Women As One Escalator Award, and McMaster Department of Medicine. The study authors and Dr. Gebhard have disclosed no relevant financial relationships.

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

Bullying in academic medicine, especially among women, is rife, underreported, and remains largely unaddressed, new research suggests.

Investigators reviewed close to 70 studies, encompassing over 82,000 medical consultants or trainees in academic medical settings, and found that men were identified as the most common perpetrators – close to 70% of respondents – whereas women were the most common victims (56%).

Collectively, respondents in all of the studies identified the most common bullies to be consultants (54%), followed by residents (22%), and nurses (15%).

Disturbingly, less than one-third of victims overall reported that they were bullied, and close to 60% who formally reported the abuse said they did not have a positive outcome.

“We found that bullies are commonly men and senior consultants, while more than half of their victims are women,” senior author Harriette G.C. Van Spall, MD, MPH, associate professor of medicine and director of e-health and virtual care, Division of Cardiology, McMaster University, Hamilton, Ont., said in an interview.

“The greatest barriers to addressing academic bullying are the fear of reprisal, lack of impact of reporting, and non-enforcement of anti-bullying policies,” she added.

The study was published online July 12 in BMJ Open.
 

Personal experience

The study was “inspired by experiences that I endured over a period of time and am grateful to have survived,” said Dr. Van Spall.

“Some behaviors were excruciating to deal with, protesting against them would bring more on, and every day was filled with dread. It took sheer will to show up at work to care for patients, to complete research I was leading, and to have hope, and my academic output, income, and personal well-being dropped during those years,” she added.

Dr. Van Spall thought the subject “merited research because our performance as clinicians, researchers, and educators relies on our work environment.”

To investigate, the researchers reviewed 68 studies (n = 82,349 respondents) conducted between 1999 and 2021 in academic medical settings, in which victims were either consultants or trainees. Many of the studies (31) were conducted in the U.S.

Other countries included the United Kingdom, Canada, Australia, Pakistan, Egypt, Iran, Turkey, New Zealand, Lithuania, Greece, India, Germany, Nigeria, Oman, and Finland.

Studies were required to describe the method and impact of bullying; characteristics of the perpetrators and victims; or interventions that were used to address the bullying.

“Bullying” was defined as “the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviors that include overwork, destabilization, and isolation in order to impede the education or career of the target.”
 

Systemic sexism

Bullying behaviors, reported in 28 studies (n = 35,779 respondents), were grouped into destabilization, threats to professional status, overwork, and isolation, with overwork found to be the most common form of bullying.

The most common impact of being bullied was psychological distress, reported by 39.1% of respondents in 14 studies, followed by considerations of quitting (35.9%; 7 studies), and worsening of clinical performance (34.6%, 8 studies).

“Among demographic groups, men were identified as the most common perpetrators (67.2% of 4,722 respondents in 5 studies) and women the most common victims (56.2% of 15,246 respondents in 27 studies),” the authors report.

“Academic medicine in many institutions is encumbered by systemic sexism that is evident in processes around remuneration, recognition, opportunities for advancement, and leadership positions,” said Dr. Van Spall.

“There are fewer women at decision-making tables in academic medicine, the climb is uphill at the best of times, and women are likely easier targets for bullies, as their voices are easier to drown out,” she added.

She noted that many men do “exhibit wonderful attributes of professionalism and decency,” but “some in positions of power are given impunity by virtue of other accomplishments.”
 

Multiple deterrents

Thirty-one studies (n = 15,868) described characteristics of the bullies and showed the most common to be consultants (53.6% [30 studies]), residents (22% [22 studies]), and nurses (14.9% [21 studies]).

Only a minority of victims (28.9% of 9,410 victims [10 studies]) formally reported the bullying. The researchers identified multiple deterrents to reporting.

When a formal complaint was submitted (n = 1,139 respondents), it most frequently had no perceived effect (35.6%); more than one-fifth (21.9%) experienced worsening of the bullying, and only 13.7% reported improvement.

The common institutional facilitators of bullying, described in 25 studies, included lack of enforcement of anti-bullying policies (13 studies), the hierarchical structure of medicine (7 studies), and normalization of bullying (10 studies).

Forty-nine studies looked at strategies to address academic bullying, including anti-bullying policies, mandatory workshops on mistreatment, establishing an anti-bullying oversight committee, and institutional support for victims. However, the studies testing the effectiveness of these interventions “had a high risk of bias.”
 

Support available

Commenting on the research for this news organization, Roberta Gebhard, DO, past president of the American Medical Women’s Association (AMWA) and a member of the advisory board for Physician Just Equity, called it a “good study, large, international, and well-written.”

Dr. Gebhard, a member of the Governing Council for the American Medical Association Women Physician Section, was not associated with this study but said she is currently researching women who left medical school and residency.

“A common reason for leaving is being bullied. Bullying is often not reported and if reported, often not addressed. Or, if addressed, the person who reports it is often retaliated against, which is a common experience, especially in women.”

She advised female physicians who are bullied to get support from other female physicians – for example, by joining the AMWA, which has an online women’s leadership group.

“Having other women physicians throughout the country you can call for advice and support can be helpful,” said Dr. Gebhard, a family practice physician based in Grand Island, New York.

Dr. Van Spall receives support from the Canadian Institutes of Health Research, the Heart and Stroke Foundation, the Women As One Escalator Award, and McMaster Department of Medicine. The study authors and Dr. Gebhard have disclosed no relevant financial relationships.

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

Bullying in academic medicine, especially among women, is rife, underreported, and remains largely unaddressed, new research suggests.

Investigators reviewed close to 70 studies, encompassing over 82,000 medical consultants or trainees in academic medical settings, and found that men were identified as the most common perpetrators – close to 70% of respondents – whereas women were the most common victims (56%).

Collectively, respondents in all of the studies identified the most common bullies to be consultants (54%), followed by residents (22%), and nurses (15%).

Disturbingly, less than one-third of victims overall reported that they were bullied, and close to 60% who formally reported the abuse said they did not have a positive outcome.

“We found that bullies are commonly men and senior consultants, while more than half of their victims are women,” senior author Harriette G.C. Van Spall, MD, MPH, associate professor of medicine and director of e-health and virtual care, Division of Cardiology, McMaster University, Hamilton, Ont., said in an interview.

“The greatest barriers to addressing academic bullying are the fear of reprisal, lack of impact of reporting, and non-enforcement of anti-bullying policies,” she added.

The study was published online July 12 in BMJ Open.
 

Personal experience

The study was “inspired by experiences that I endured over a period of time and am grateful to have survived,” said Dr. Van Spall.

“Some behaviors were excruciating to deal with, protesting against them would bring more on, and every day was filled with dread. It took sheer will to show up at work to care for patients, to complete research I was leading, and to have hope, and my academic output, income, and personal well-being dropped during those years,” she added.

Dr. Van Spall thought the subject “merited research because our performance as clinicians, researchers, and educators relies on our work environment.”

To investigate, the researchers reviewed 68 studies (n = 82,349 respondents) conducted between 1999 and 2021 in academic medical settings, in which victims were either consultants or trainees. Many of the studies (31) were conducted in the U.S.

Other countries included the United Kingdom, Canada, Australia, Pakistan, Egypt, Iran, Turkey, New Zealand, Lithuania, Greece, India, Germany, Nigeria, Oman, and Finland.

Studies were required to describe the method and impact of bullying; characteristics of the perpetrators and victims; or interventions that were used to address the bullying.

“Bullying” was defined as “the abuse of authority by a perpetrator who targets the victim in an academic setting through punishing behaviors that include overwork, destabilization, and isolation in order to impede the education or career of the target.”
 

Systemic sexism

Bullying behaviors, reported in 28 studies (n = 35,779 respondents), were grouped into destabilization, threats to professional status, overwork, and isolation, with overwork found to be the most common form of bullying.

The most common impact of being bullied was psychological distress, reported by 39.1% of respondents in 14 studies, followed by considerations of quitting (35.9%; 7 studies), and worsening of clinical performance (34.6%, 8 studies).

“Among demographic groups, men were identified as the most common perpetrators (67.2% of 4,722 respondents in 5 studies) and women the most common victims (56.2% of 15,246 respondents in 27 studies),” the authors report.

“Academic medicine in many institutions is encumbered by systemic sexism that is evident in processes around remuneration, recognition, opportunities for advancement, and leadership positions,” said Dr. Van Spall.

“There are fewer women at decision-making tables in academic medicine, the climb is uphill at the best of times, and women are likely easier targets for bullies, as their voices are easier to drown out,” she added.

She noted that many men do “exhibit wonderful attributes of professionalism and decency,” but “some in positions of power are given impunity by virtue of other accomplishments.”
 

Multiple deterrents

Thirty-one studies (n = 15,868) described characteristics of the bullies and showed the most common to be consultants (53.6% [30 studies]), residents (22% [22 studies]), and nurses (14.9% [21 studies]).

Only a minority of victims (28.9% of 9,410 victims [10 studies]) formally reported the bullying. The researchers identified multiple deterrents to reporting.

When a formal complaint was submitted (n = 1,139 respondents), it most frequently had no perceived effect (35.6%); more than one-fifth (21.9%) experienced worsening of the bullying, and only 13.7% reported improvement.

The common institutional facilitators of bullying, described in 25 studies, included lack of enforcement of anti-bullying policies (13 studies), the hierarchical structure of medicine (7 studies), and normalization of bullying (10 studies).

Forty-nine studies looked at strategies to address academic bullying, including anti-bullying policies, mandatory workshops on mistreatment, establishing an anti-bullying oversight committee, and institutional support for victims. However, the studies testing the effectiveness of these interventions “had a high risk of bias.”
 

Support available

Commenting on the research for this news organization, Roberta Gebhard, DO, past president of the American Medical Women’s Association (AMWA) and a member of the advisory board for Physician Just Equity, called it a “good study, large, international, and well-written.”

Dr. Gebhard, a member of the Governing Council for the American Medical Association Women Physician Section, was not associated with this study but said she is currently researching women who left medical school and residency.

“A common reason for leaving is being bullied. Bullying is often not reported and if reported, often not addressed. Or, if addressed, the person who reports it is often retaliated against, which is a common experience, especially in women.”

She advised female physicians who are bullied to get support from other female physicians – for example, by joining the AMWA, which has an online women’s leadership group.

“Having other women physicians throughout the country you can call for advice and support can be helpful,” said Dr. Gebhard, a family practice physician based in Grand Island, New York.

Dr. Van Spall receives support from the Canadian Institutes of Health Research, the Heart and Stroke Foundation, the Women As One Escalator Award, and McMaster Department of Medicine. The study authors and Dr. Gebhard have disclosed no relevant financial relationships.

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

To the Editor:

We read with great interest the article by Chu et al¹ (Cutis. 2021;107:157-159) and commend them for noting the underrepresentation of skin of color (SOC) in the American Academy of Dermatology (AAD) Basic Dermatology Curriculum. The AAD Basic Dermatology Curriculum represents one introductory resource that is ubiquitously utilized by medical students. Herein, we add an analysis of the representation of SOC in the following resources that also comprise the first exposure medical students have to dermatology: Dermatology Clinics Clinical Advisor articles (https://www.clinicaladvisor.com/home/dermatology/dermatology-clinics/), Learn Derm Module (LDM) by VisualDx (https://www.visualdx.com/learnderm/), Lookingbill and Marks’ Principles of Dermatology (6th ed)(LB&M),2 and DermNet NZ (https://dermnetnz.org/). We performed a focused search of the DermNet NZ database for images of the following common dermatologic conditions: acne, rosacea, alopecia, urticaria, arthropod bites, blistering diseases (bullous pemphigoid and pemphigus vulgaris), connective tissue diseases (dermatomyositis and lupus), inflammatory conditions (atopic dermatitis, contact dermatitis, and psoriasis), keloids, benign and malignant neoplasms (nevi, seborrheic keratosis, actinic keratosis, basal and squamous cell carcinomas, and melanoma including acral melanoma), bacterial skin infections (impetigo, erysipelas, cellulitis, staphylococcal scalded skin syndrome, and syphilis), fungal infections (dermatophyte infections), and viral skin infections (herpes, molluscum contagiosum, varicella-zoster virus, and warts). We classified images as light (Fitzpatrick phototypes I–IV) or dark (Fitzpatrick phototypes V or VI). We excluded images without visible background skin (eg, images of oral mucosa, genitalia, nails, palms and soles, dermoscopic images, histopathologic images).

We found the representation of SOC in the resources we selected to be as follows: Dermatology Clinics Clinical Advisor articles (70/367 or 19%); LDM (26/150 or 17%); LB&M (52/374 or 14%); DermNet NZ (11/310 or 4%). Representation of SOC in common dermatologic conditions such as actinic keratosis, alopecia, rosacea, urticaria, and warts was entirely absent across all resources. Other common skin diseases were represented in only one of the resources we analyzed: acne (represented only in LB&M, where only 3/11 images of acne were depicted in SOC); contact dermatitis (represented only in LB&M, where only 1/6 images of contact dermatitis were depicted in SOC); psoriasis (represented only on DermNet NZ, where only 2/25 images of psoriasis were depicted in SOC); seborrheic keratosis (represented only in LB&M, where 1/2 images of seborrheic keratosis were depicted in SOC). Furthermore, none of the resources we analyzed depicted malignancy (basal cell carcinoma, squamous cell carcinoma, and melanoma) in SOC. Although the poor representation of SOC in malignancies can be explained by the predilection of skin cancer for light skin, other dermatologic conditions that are more common in SOC also were poorly represented in these resources in SOC: acral melanoma, not represented in any of the resources we analyzed; subacute cutaneous lupus erythematosus and systemic lupus erythematosus, also not represented in any of the resources we analyzed; keloids, represented only in LB&M.

Although no study has investigated the true prevalence of Fitzpatrick phototypes in the United States, He et al³ demonstrated the prevalence of Fitzpatrick phototypes V and VI to be 25.0% and 18.8%, respectively, in an ethnically diverse study of 3386 participants. Indeed, the representation of SOC in the resources we analyzed falls short of this plausible estimate of SOC in an increasingly diverse US population.

Our work adds to the growing body of literature exposing the deficiencies in SOC representation in dermatology. As Lester et al⁴ noted, such poor representation of SOC is deleterious not just to patients, who may be misdiagnosed, but also more generally to the integrity of the field of dermatology. Moreover, our study, which analyzes introductory resources referenced by the junior medical student, highlights a potential danger of poor SOC representation for trainees—limited exposure to SOC may leave medical students unprepared to recognize lesions in SOC during clerkships and residency. Furthermore, we note an additional concern with minimal SOC representation in online modules such as the AAD and LDM module as well as online databases such as DermNet NZ; images from these resources may be used as training sets for machine learning (ML) software (indeed, DermNet NZ has been used as a training set for ML programs⁵). However, if data sets with poor representation of SOC are used to train ML algorithms, then ML software may be unable to recognize lesions in SOC.⁶ Thus, inadequate representation of SOC in online modules and databases may exacerbate existing inequities in dermatology.

To address the paucity of SOC representation, students can be directed to resources devoted to depicting SOC; however, as discussed eloquently by Chu et al,¹ an attempt to update existing resources also must be made. The senior author in our study (S.J.K.) embraced such an approach, updating the dermatology lectures given to medical students to include more images of SOC. Such a top-down approach may represent a major step in dismantling the systemic biases that pervade dermatology.

A limitation of our analysis was use of the Fitzpatrick scale, which was conceived as a phenotypic scale to assess cutaneous responses to UV irradiation.⁷ Although it is the most commonly used scale to describe race/ethnicity and/or constitute skin color, it is not possible to include all non-White skin types and classify strictly under this umbrella term.

References

1. Chu B, Fathy R, Onyekaba G, et al. Distribution of skin-type diversity in photographs in AAD online educational modules. Cutis. 2021;107:157-159. doi:10.12788/cutis.0196

2. Marks JG Jr, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. 6th ed. Saunders Elsevier; 2018.

3. He SY, McCulloch CE, Boscardin WJ, et al. Self-reported pigmentary phenotypes and race are significant but incomplete predictors of Fitzpatrick skin phototype in an ethnically diverse population. J Am Acad Dermatol. 2014;71:731-737. doi:10.1016/j.jaad.2014.05.023

4. Lester JC, Taylor SC, Chren M-M. Under‐representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol. 2019;180:1521-1522. doi:10.1111/bjd.17608

5. Aggarwal P. Data augmentation in dermatology image recognition using machine learning. Skin Res Technol. 2019;25:815-820. doi:10.1111/srt.12726

6. Adamson AS, Smith A. Machine learning and health care disparities in dermatology. JAMA Dermatol. 2018;154:1247-1248. doi:10.1001/jamadermatol.2018.2348

7. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

Authors’ Response

We thank Mr. Joshi and Dr. Kim for their reply to our article and their added contribution to the literature on inadequate representation of skin of color (SOC) in dermatology educational materials. In recent years, multiple analyses have reviewed textbooks and popular online resources for SOC representation.¹ These resources encompass all levels of education—from the laypatient to the medical student, and to residency and beyond—demonstrating the significant challenges to overcome.

In addition, as Mr. Joshi and Dr. Kim state, the potential for these inadequately representative resources to serve as training data for prediction and classification tools adds further urgency to the broader task at hand, as we do not wish to perpetuate disparities. Several tools already exist, including Derm Assist, a recent Google-produced tool that suggests a list of diagnoses from patient-provided images.² Although Derm Assist has been marked as a CE Class I (low risk) medical device in the European Union, the original research it is built on relied on training data with low representation of darker skin types (2.7% Fitzpatrick V and 0% Fitzpatrick VI),³ drawing concern for its generalizability.

These concerns about SOC representation are not new; dermatology advocates, scholars, and organizations such as the Skin of Color Society have been working to address these deficiencies for many years, contributing to education (including writing of resources and textbooks) and academic research. This work continues today. For instance, Lester et al⁴ described best practices for clinical photography in SOC; this guidance was not yet published at the time of our original submission. Not only should dermatology strive for increased quantity of representation but also quality. This metric is particularly important if the images are intended not just for education but also for use as training data for prediction and classification tools.

Examples of more recent actions at the organizational level include the American Academy of Dermatology (AAD) announcing a 3-year plan to promote diversity, equity, and inclusion⁵ and VisualDx establishing #ProjectIMPACT, a collaboration to reduce health care biases in SOC.⁶ In the AAD 3-year plan, one goal is to “[i]ncrease use of images reflecting full spectrum of skin types and highlight topics on skin of color, health disparities, and cultural competency across all AAD education.”⁵ Although not specifically mentioned, we hope that the AAD has included updating the Basic Dermatology Curriculum, given its inadequate SOC representation, as part of its short-term goals. The greater recognition of these issues through more prevalent analyses published in leading dermatology journals is encouraging, and we hope both that improvements can be successfully implemented and that future studies will reveal improvements in representation.

Brian Chu, BS; Ramie Fathy, AB; Ginikanwa Onyekaba, BS; Jules B. Lipoff, MD

From the Perelman School of Medicine, University of Pennsylvania, Philadelphia. Dr. Lipoff is from the Department of Dermatology and the Leonard Davis Institute of Health Economics.

The authors report no conflict of interest.

Correspondence: Jules B. Lipoff, MD, Department of Dermatology, University of Pennsylvania, Penn Medicine University City, 3737 Market St, Ste 1100, Philadelphia, PA 19104 ([email protected]).

References

1. Perlman KL, Williams NM, Egbeto IA, et al. Skin of color lacks representation in medical student resources: a cross-sectional study. Int J Womens Dermatol. 2021;7:195-196. doi:10.1016/j.ijwd.2020.12.018

2. Bui P, Liu Y. Using AI to help find answers to common skin conditions. Published May 18, 2021. Accessed June 12, 2021. https://blog.google/technology/health/ai-dermatology-preview-io-2021

3. Liu Y, Jain A, Eng C, et al. A deep learning system for differential diagnosis of skin diseases. Nature Medicine. 2020;26:900-908. doi:10.1038/s41591-020-0842-3

4. Lester JC, Clark L, Linos E, et al. Clinical photography in skin of colour: tips and best practices. Br J Dermatol. 2021;184:1177-1179. doi:10.1111/bjd.19811

5. American Academy of Dermatology Association. Diversity in dermatology: diversity committee approved plan 2021-2023. Published January 26, 2021. Accessed June 24, 2021. https://assets.ctfassets.net/1ny4yoiyrqia/xQgnCE6ji5skUlcZQHS2b/65f0a9072811e11afcc33d043e02cd4d/DEI_Plan.pdf

6. VisualDx. #ProjectIMPACT. Accessed June 24, 2021. https://www.visualdx.com/projectimpact/

To the Editor:

We read with great interest the article by Chu et al¹ (Cutis. 2021;107:157-159) and commend them for noting the underrepresentation of skin of color (SOC) in the American Academy of Dermatology (AAD) Basic Dermatology Curriculum. The AAD Basic Dermatology Curriculum represents one introductory resource that is ubiquitously utilized by medical students. Herein, we add an analysis of the representation of SOC in the following resources that also comprise the first exposure medical students have to dermatology: Dermatology Clinics Clinical Advisor articles (https://www.clinicaladvisor.com/home/dermatology/dermatology-clinics/), Learn Derm Module (LDM) by VisualDx (https://www.visualdx.com/learnderm/), Lookingbill and Marks’ Principles of Dermatology (6th ed)(LB&M),2 and DermNet NZ (https://dermnetnz.org/). We performed a focused search of the DermNet NZ database for images of the following common dermatologic conditions: acne, rosacea, alopecia, urticaria, arthropod bites, blistering diseases (bullous pemphigoid and pemphigus vulgaris), connective tissue diseases (dermatomyositis and lupus), inflammatory conditions (atopic dermatitis, contact dermatitis, and psoriasis), keloids, benign and malignant neoplasms (nevi, seborrheic keratosis, actinic keratosis, basal and squamous cell carcinomas, and melanoma including acral melanoma), bacterial skin infections (impetigo, erysipelas, cellulitis, staphylococcal scalded skin syndrome, and syphilis), fungal infections (dermatophyte infections), and viral skin infections (herpes, molluscum contagiosum, varicella-zoster virus, and warts). We classified images as light (Fitzpatrick phototypes I–IV) or dark (Fitzpatrick phototypes V or VI). We excluded images without visible background skin (eg, images of oral mucosa, genitalia, nails, palms and soles, dermoscopic images, histopathologic images).

We found the representation of SOC in the resources we selected to be as follows: Dermatology Clinics Clinical Advisor articles (70/367 or 19%); LDM (26/150 or 17%); LB&M (52/374 or 14%); DermNet NZ (11/310 or 4%). Representation of SOC in common dermatologic conditions such as actinic keratosis, alopecia, rosacea, urticaria, and warts was entirely absent across all resources. Other common skin diseases were represented in only one of the resources we analyzed: acne (represented only in LB&M, where only 3/11 images of acne were depicted in SOC); contact dermatitis (represented only in LB&M, where only 1/6 images of contact dermatitis were depicted in SOC); psoriasis (represented only on DermNet NZ, where only 2/25 images of psoriasis were depicted in SOC); seborrheic keratosis (represented only in LB&M, where 1/2 images of seborrheic keratosis were depicted in SOC). Furthermore, none of the resources we analyzed depicted malignancy (basal cell carcinoma, squamous cell carcinoma, and melanoma) in SOC. Although the poor representation of SOC in malignancies can be explained by the predilection of skin cancer for light skin, other dermatologic conditions that are more common in SOC also were poorly represented in these resources in SOC: acral melanoma, not represented in any of the resources we analyzed; subacute cutaneous lupus erythematosus and systemic lupus erythematosus, also not represented in any of the resources we analyzed; keloids, represented only in LB&M.

Although no study has investigated the true prevalence of Fitzpatrick phototypes in the United States, He et al³ demonstrated the prevalence of Fitzpatrick phototypes V and VI to be 25.0% and 18.8%, respectively, in an ethnically diverse study of 3386 participants. Indeed, the representation of SOC in the resources we analyzed falls short of this plausible estimate of SOC in an increasingly diverse US population.

Our work adds to the growing body of literature exposing the deficiencies in SOC representation in dermatology. As Lester et al⁴ noted, such poor representation of SOC is deleterious not just to patients, who may be misdiagnosed, but also more generally to the integrity of the field of dermatology. Moreover, our study, which analyzes introductory resources referenced by the junior medical student, highlights a potential danger of poor SOC representation for trainees—limited exposure to SOC may leave medical students unprepared to recognize lesions in SOC during clerkships and residency. Furthermore, we note an additional concern with minimal SOC representation in online modules such as the AAD and LDM module as well as online databases such as DermNet NZ; images from these resources may be used as training sets for machine learning (ML) software (indeed, DermNet NZ has been used as a training set for ML programs⁵). However, if data sets with poor representation of SOC are used to train ML algorithms, then ML software may be unable to recognize lesions in SOC.⁶ Thus, inadequate representation of SOC in online modules and databases may exacerbate existing inequities in dermatology.

To address the paucity of SOC representation, students can be directed to resources devoted to depicting SOC; however, as discussed eloquently by Chu et al,¹ an attempt to update existing resources also must be made. The senior author in our study (S.J.K.) embraced such an approach, updating the dermatology lectures given to medical students to include more images of SOC. Such a top-down approach may represent a major step in dismantling the systemic biases that pervade dermatology.

A limitation of our analysis was use of the Fitzpatrick scale, which was conceived as a phenotypic scale to assess cutaneous responses to UV irradiation.⁷ Although it is the most commonly used scale to describe race/ethnicity and/or constitute skin color, it is not possible to include all non-White skin types and classify strictly under this umbrella term.

References

1. Chu B, Fathy R, Onyekaba G, et al. Distribution of skin-type diversity in photographs in AAD online educational modules. Cutis. 2021;107:157-159. doi:10.12788/cutis.0196

2. Marks JG Jr, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. 6th ed. Saunders Elsevier; 2018.

3. He SY, McCulloch CE, Boscardin WJ, et al. Self-reported pigmentary phenotypes and race are significant but incomplete predictors of Fitzpatrick skin phototype in an ethnically diverse population. J Am Acad Dermatol. 2014;71:731-737. doi:10.1016/j.jaad.2014.05.023

4. Lester JC, Taylor SC, Chren M-M. Under‐representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol. 2019;180:1521-1522. doi:10.1111/bjd.17608

5. Aggarwal P. Data augmentation in dermatology image recognition using machine learning. Skin Res Technol. 2019;25:815-820. doi:10.1111/srt.12726

6. Adamson AS, Smith A. Machine learning and health care disparities in dermatology. JAMA Dermatol. 2018;154:1247-1248. doi:10.1001/jamadermatol.2018.2348

7. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

Authors’ Response

We thank Mr. Joshi and Dr. Kim for their reply to our article and their added contribution to the literature on inadequate representation of skin of color (SOC) in dermatology educational materials. In recent years, multiple analyses have reviewed textbooks and popular online resources for SOC representation.¹ These resources encompass all levels of education—from the laypatient to the medical student, and to residency and beyond—demonstrating the significant challenges to overcome.

In addition, as Mr. Joshi and Dr. Kim state, the potential for these inadequately representative resources to serve as training data for prediction and classification tools adds further urgency to the broader task at hand, as we do not wish to perpetuate disparities. Several tools already exist, including Derm Assist, a recent Google-produced tool that suggests a list of diagnoses from patient-provided images.² Although Derm Assist has been marked as a CE Class I (low risk) medical device in the European Union, the original research it is built on relied on training data with low representation of darker skin types (2.7% Fitzpatrick V and 0% Fitzpatrick VI),³ drawing concern for its generalizability.

These concerns about SOC representation are not new; dermatology advocates, scholars, and organizations such as the Skin of Color Society have been working to address these deficiencies for many years, contributing to education (including writing of resources and textbooks) and academic research. This work continues today. For instance, Lester et al⁴ described best practices for clinical photography in SOC; this guidance was not yet published at the time of our original submission. Not only should dermatology strive for increased quantity of representation but also quality. This metric is particularly important if the images are intended not just for education but also for use as training data for prediction and classification tools.

Examples of more recent actions at the organizational level include the American Academy of Dermatology (AAD) announcing a 3-year plan to promote diversity, equity, and inclusion⁵ and VisualDx establishing #ProjectIMPACT, a collaboration to reduce health care biases in SOC.⁶ In the AAD 3-year plan, one goal is to “[i]ncrease use of images reflecting full spectrum of skin types and highlight topics on skin of color, health disparities, and cultural competency across all AAD education.”⁵ Although not specifically mentioned, we hope that the AAD has included updating the Basic Dermatology Curriculum, given its inadequate SOC representation, as part of its short-term goals. The greater recognition of these issues through more prevalent analyses published in leading dermatology journals is encouraging, and we hope both that improvements can be successfully implemented and that future studies will reveal improvements in representation.

Brian Chu, BS; Ramie Fathy, AB; Ginikanwa Onyekaba, BS; Jules B. Lipoff, MD

From the Perelman School of Medicine, University of Pennsylvania, Philadelphia. Dr. Lipoff is from the Department of Dermatology and the Leonard Davis Institute of Health Economics.

The authors report no conflict of interest.

Correspondence: Jules B. Lipoff, MD, Department of Dermatology, University of Pennsylvania, Penn Medicine University City, 3737 Market St, Ste 1100, Philadelphia, PA 19104 ([email protected]).

References

1. Perlman KL, Williams NM, Egbeto IA, et al. Skin of color lacks representation in medical student resources: a cross-sectional study. Int J Womens Dermatol. 2021;7:195-196. doi:10.1016/j.ijwd.2020.12.018

2. Bui P, Liu Y. Using AI to help find answers to common skin conditions. Published May 18, 2021. Accessed June 12, 2021. https://blog.google/technology/health/ai-dermatology-preview-io-2021

3. Liu Y, Jain A, Eng C, et al. A deep learning system for differential diagnosis of skin diseases. Nature Medicine. 2020;26:900-908. doi:10.1038/s41591-020-0842-3

4. Lester JC, Clark L, Linos E, et al. Clinical photography in skin of colour: tips and best practices. Br J Dermatol. 2021;184:1177-1179. doi:10.1111/bjd.19811

5. American Academy of Dermatology Association. Diversity in dermatology: diversity committee approved plan 2021-2023. Published January 26, 2021. Accessed June 24, 2021. https://assets.ctfassets.net/1ny4yoiyrqia/xQgnCE6ji5skUlcZQHS2b/65f0a9072811e11afcc33d043e02cd4d/DEI_Plan.pdf

6. VisualDx. #ProjectIMPACT. Accessed June 24, 2021. https://www.visualdx.com/projectimpact/

To the Editor:

We read with great interest the article by Chu et al¹ (Cutis. 2021;107:157-159) and commend them for noting the underrepresentation of skin of color (SOC) in the American Academy of Dermatology (AAD) Basic Dermatology Curriculum. The AAD Basic Dermatology Curriculum represents one introductory resource that is ubiquitously utilized by medical students. Herein, we add an analysis of the representation of SOC in the following resources that also comprise the first exposure medical students have to dermatology: Dermatology Clinics Clinical Advisor articles (https://www.clinicaladvisor.com/home/dermatology/dermatology-clinics/), Learn Derm Module (LDM) by VisualDx (https://www.visualdx.com/learnderm/), Lookingbill and Marks’ Principles of Dermatology (6th ed)(LB&M),2 and DermNet NZ (https://dermnetnz.org/). We performed a focused search of the DermNet NZ database for images of the following common dermatologic conditions: acne, rosacea, alopecia, urticaria, arthropod bites, blistering diseases (bullous pemphigoid and pemphigus vulgaris), connective tissue diseases (dermatomyositis and lupus), inflammatory conditions (atopic dermatitis, contact dermatitis, and psoriasis), keloids, benign and malignant neoplasms (nevi, seborrheic keratosis, actinic keratosis, basal and squamous cell carcinomas, and melanoma including acral melanoma), bacterial skin infections (impetigo, erysipelas, cellulitis, staphylococcal scalded skin syndrome, and syphilis), fungal infections (dermatophyte infections), and viral skin infections (herpes, molluscum contagiosum, varicella-zoster virus, and warts). We classified images as light (Fitzpatrick phototypes I–IV) or dark (Fitzpatrick phototypes V or VI). We excluded images without visible background skin (eg, images of oral mucosa, genitalia, nails, palms and soles, dermoscopic images, histopathologic images).

We found the representation of SOC in the resources we selected to be as follows: Dermatology Clinics Clinical Advisor articles (70/367 or 19%); LDM (26/150 or 17%); LB&M (52/374 or 14%); DermNet NZ (11/310 or 4%). Representation of SOC in common dermatologic conditions such as actinic keratosis, alopecia, rosacea, urticaria, and warts was entirely absent across all resources. Other common skin diseases were represented in only one of the resources we analyzed: acne (represented only in LB&M, where only 3/11 images of acne were depicted in SOC); contact dermatitis (represented only in LB&M, where only 1/6 images of contact dermatitis were depicted in SOC); psoriasis (represented only on DermNet NZ, where only 2/25 images of psoriasis were depicted in SOC); seborrheic keratosis (represented only in LB&M, where 1/2 images of seborrheic keratosis were depicted in SOC). Furthermore, none of the resources we analyzed depicted malignancy (basal cell carcinoma, squamous cell carcinoma, and melanoma) in SOC. Although the poor representation of SOC in malignancies can be explained by the predilection of skin cancer for light skin, other dermatologic conditions that are more common in SOC also were poorly represented in these resources in SOC: acral melanoma, not represented in any of the resources we analyzed; subacute cutaneous lupus erythematosus and systemic lupus erythematosus, also not represented in any of the resources we analyzed; keloids, represented only in LB&M.

Although no study has investigated the true prevalence of Fitzpatrick phototypes in the United States, He et al³ demonstrated the prevalence of Fitzpatrick phototypes V and VI to be 25.0% and 18.8%, respectively, in an ethnically diverse study of 3386 participants. Indeed, the representation of SOC in the resources we analyzed falls short of this plausible estimate of SOC in an increasingly diverse US population.

Our work adds to the growing body of literature exposing the deficiencies in SOC representation in dermatology. As Lester et al⁴ noted, such poor representation of SOC is deleterious not just to patients, who may be misdiagnosed, but also more generally to the integrity of the field of dermatology. Moreover, our study, which analyzes introductory resources referenced by the junior medical student, highlights a potential danger of poor SOC representation for trainees—limited exposure to SOC may leave medical students unprepared to recognize lesions in SOC during clerkships and residency. Furthermore, we note an additional concern with minimal SOC representation in online modules such as the AAD and LDM module as well as online databases such as DermNet NZ; images from these resources may be used as training sets for machine learning (ML) software (indeed, DermNet NZ has been used as a training set for ML programs⁵). However, if data sets with poor representation of SOC are used to train ML algorithms, then ML software may be unable to recognize lesions in SOC.⁶ Thus, inadequate representation of SOC in online modules and databases may exacerbate existing inequities in dermatology.

To address the paucity of SOC representation, students can be directed to resources devoted to depicting SOC; however, as discussed eloquently by Chu et al,¹ an attempt to update existing resources also must be made. The senior author in our study (S.J.K.) embraced such an approach, updating the dermatology lectures given to medical students to include more images of SOC. Such a top-down approach may represent a major step in dismantling the systemic biases that pervade dermatology.

A limitation of our analysis was use of the Fitzpatrick scale, which was conceived as a phenotypic scale to assess cutaneous responses to UV irradiation.⁷ Although it is the most commonly used scale to describe race/ethnicity and/or constitute skin color, it is not possible to include all non-White skin types and classify strictly under this umbrella term.

References

1. Chu B, Fathy R, Onyekaba G, et al. Distribution of skin-type diversity in photographs in AAD online educational modules. Cutis. 2021;107:157-159. doi:10.12788/cutis.0196

2. Marks JG Jr, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. 6th ed. Saunders Elsevier; 2018.

3. He SY, McCulloch CE, Boscardin WJ, et al. Self-reported pigmentary phenotypes and race are significant but incomplete predictors of Fitzpatrick skin phototype in an ethnically diverse population. J Am Acad Dermatol. 2014;71:731-737. doi:10.1016/j.jaad.2014.05.023

4. Lester JC, Taylor SC, Chren M-M. Under‐representation of skin of colour in dermatology images: not just an educational issue. Br J Dermatol. 2019;180:1521-1522. doi:10.1111/bjd.17608

5. Aggarwal P. Data augmentation in dermatology image recognition using machine learning. Skin Res Technol. 2019;25:815-820. doi:10.1111/srt.12726

6. Adamson AS, Smith A. Machine learning and health care disparities in dermatology. JAMA Dermatol. 2018;154:1247-1248. doi:10.1001/jamadermatol.2018.2348

7. Ware OR, Dawson JE, Shinohara MM, et al. Racial limitations of Fitzpatrick skin type. Cutis. 2020;105:77-80.

Authors’ Response

We thank Mr. Joshi and Dr. Kim for their reply to our article and their added contribution to the literature on inadequate representation of skin of color (SOC) in dermatology educational materials. In recent years, multiple analyses have reviewed textbooks and popular online resources for SOC representation.¹ These resources encompass all levels of education—from the laypatient to the medical student, and to residency and beyond—demonstrating the significant challenges to overcome.

In addition, as Mr. Joshi and Dr. Kim state, the potential for these inadequately representative resources to serve as training data for prediction and classification tools adds further urgency to the broader task at hand, as we do not wish to perpetuate disparities. Several tools already exist, including Derm Assist, a recent Google-produced tool that suggests a list of diagnoses from patient-provided images.² Although Derm Assist has been marked as a CE Class I (low risk) medical device in the European Union, the original research it is built on relied on training data with low representation of darker skin types (2.7% Fitzpatrick V and 0% Fitzpatrick VI),³ drawing concern for its generalizability.

These concerns about SOC representation are not new; dermatology advocates, scholars, and organizations such as the Skin of Color Society have been working to address these deficiencies for many years, contributing to education (including writing of resources and textbooks) and academic research. This work continues today. For instance, Lester et al⁴ described best practices for clinical photography in SOC; this guidance was not yet published at the time of our original submission. Not only should dermatology strive for increased quantity of representation but also quality. This metric is particularly important if the images are intended not just for education but also for use as training data for prediction and classification tools.

Examples of more recent actions at the organizational level include the American Academy of Dermatology (AAD) announcing a 3-year plan to promote diversity, equity, and inclusion⁵ and VisualDx establishing #ProjectIMPACT, a collaboration to reduce health care biases in SOC.⁶ In the AAD 3-year plan, one goal is to “[i]ncrease use of images reflecting full spectrum of skin types and highlight topics on skin of color, health disparities, and cultural competency across all AAD education.”⁵ Although not specifically mentioned, we hope that the AAD has included updating the Basic Dermatology Curriculum, given its inadequate SOC representation, as part of its short-term goals. The greater recognition of these issues through more prevalent analyses published in leading dermatology journals is encouraging, and we hope both that improvements can be successfully implemented and that future studies will reveal improvements in representation.

Brian Chu, BS; Ramie Fathy, AB; Ginikanwa Onyekaba, BS; Jules B. Lipoff, MD

From the Perelman School of Medicine, University of Pennsylvania, Philadelphia. Dr. Lipoff is from the Department of Dermatology and the Leonard Davis Institute of Health Economics.

The authors report no conflict of interest.

Correspondence: Jules B. Lipoff, MD, Department of Dermatology, University of Pennsylvania, Penn Medicine University City, 3737 Market St, Ste 1100, Philadelphia, PA 19104 ([email protected]).

References

1. Perlman KL, Williams NM, Egbeto IA, et al. Skin of color lacks representation in medical student resources: a cross-sectional study. Int J Womens Dermatol. 2021;7:195-196. doi:10.1016/j.ijwd.2020.12.018

2. Bui P, Liu Y. Using AI to help find answers to common skin conditions. Published May 18, 2021. Accessed June 12, 2021. https://blog.google/technology/health/ai-dermatology-preview-io-2021

3. Liu Y, Jain A, Eng C, et al. A deep learning system for differential diagnosis of skin diseases. Nature Medicine. 2020;26:900-908. doi:10.1038/s41591-020-0842-3

4. Lester JC, Clark L, Linos E, et al. Clinical photography in skin of colour: tips and best practices. Br J Dermatol. 2021;184:1177-1179. doi:10.1111/bjd.19811

5. American Academy of Dermatology Association. Diversity in dermatology: diversity committee approved plan 2021-2023. Published January 26, 2021. Accessed June 24, 2021. https://assets.ctfassets.net/1ny4yoiyrqia/xQgnCE6ji5skUlcZQHS2b/65f0a9072811e11afcc33d043e02cd4d/DEI_Plan.pdf

6. VisualDx. #ProjectIMPACT. Accessed June 24, 2021. https://www.visualdx.com/projectimpact/

A hectic Friday morning at the hospital seemed less stressful amid morning greetings and humor from colleagues. In a team room full of hospitalists, life and death are often discussed in detail, ranging from medical discussions to joys and frustrations of the day to philosophy, politics, and more. It is almost impossible to miss something interesting.

People breaking into their native languages over the phone call from home always make me smile. The mention of a “complicated Indian patient unable to use interpreter” caught my attention.

My friend and colleague asked if I would be willing to take over the patient since I could speak Hindi. I was doubtful if I would add anything to make a meaningful difference, given the patient wasn’t even participating in a conversation. However, my colleague’s concern for the patient and faith in me was enough to say, “Sure, let me add her to my list.”

At the bedside, it felt like a classic “acute on chronic” hot mess situation. The patient presented with a generalized rash, anasarca, renal failure, multifocal pneumonia, and delirium. All I could gather from the patient were some incomprehensible words that sounded like Hindi. I called the family to obtain some history and to provide updates. Her son was excited to hear from me, and it didn’t take him long to guess that I was from India. But that could still mean that I might speak any of the twenty-two or more Indian languages.

Answering my questions one by one in perfectly understandable English, he was short and sweet. Suspicious of missing out on details, I offered hesitantly, “You could speak in Hindi with me.” Then came a flood of information with the details, concerns, questions, and what was lost in the translation.

We all attend to patients and families with limited English proficiency (LEP), immigrants, and nonimmigrants. LEP is a term used to describe individuals who do not speak English as their primary language and have a limited ability to read, speak, write, or understand English.¹ Recent data from the American Community Survey (2005-2009) reports that 8.6% of the population (24 million Americans) have LEP.² It’s a large and growing population that needs help overcoming language barriers and the appropriate use of professional medical interpreter services – a backbone to safe, quality, and cost-effective patient care.

The following day at bedside rounds, the nurse reported that the patient was looking and responding better. She could cooperate with interpreter services and could speak “some English.” Over the years, one thing that sounds more alarming than “no English” is “some English” or “enough English.” Around noon I received a page that the patient was refusing intravenous Lasix. At the bedside, however, the patient seemed unaware of the perceived refusal. Further discussions with the nurse lead to a familiar culprit, a relatively common gesture in South Asian cultures, a head bobble or shake.

The nurse reported that the patient shook her head side to side, seemed upset, and said “NO” when trying to administer the medication. On the other hand, the patient reported that she was upset to be at the hospital but had “NO” problem with the medicine.

My patient’s “some English” was indeed “enough English” to put her at risk due to medical error, which is highly likely when patients or providers can speak or understand a language to “get by” or to “make do.” Like my patient, the LEP patient population is more likely to experience medical errors, longer hospital stays, hospital-acquired complications, surgical delays, and readmissions. They are also less likely to receive preventive care, have access to regular care, or be satisfied with their care. They are much more likely to have adverse effects from drug complications, poor understanding of diagnoses, a greater risk of being misunderstood by their physicians or ancillary staff, and less likely to follow physician instructions.^3-5 One study analyzed over 1,000 adverse-incident reports from six Joint Commission-accredited hospitals for LEP and English-speaking patients and found that 49% of LEP patients experienced physical harm versus 29.5% of English-speaking patients.⁶

I updated the patient’s LEP status that was missing in the chart, likely due to altered mental status at the time of admission. Reliable language and English proficiency data are usually entered at the patient’s point of entry with documentation of the language services required during the patient-provider encounter. The U.S. Census Bureau’s operational definition for LEP is a patient’s self-assessed ability to speak English less than “very well,” but how well it correlates with a patient’s actual English ability needs more study. Also, one’s self-assessed perception of ability might vary day to day, and language ability, by itself, is not static; it can differ from moment to moment and situation to situation. It may be easier to understand words in English when the situation is simple and less stressful than when things are complicated and stressful.

With a definition of LEP rather vague and the term somewhat derogatory, its meaning is open to interpretation. One study found that though speaking English less than “very well” was the most sensitive measure for identifying all of the patients who reported that they were unable to communicate effectively with their physicians, it was also the least specific.⁷ This lower specificity could lead to misclassification of some patients as LEP who are, in fact, able to effectively communicate in English with their physicians. This type of misclassification might lead to costly language assistance and carry the potential to cause conflicts between patient and provider. Telling a patient or family that they may have a “limited English proficiency” when they have believed otherwise and feel confident about their skills may come as a challenge. Some patients may also pretend to understand English to avoid being embarrassed about their linguistic abilities or perceive that they might be judged on their abilities in general.

Exiting the room, I gently reminded the RN to use the interpreter services. “Who has never been guilty of using an ad hoc interpreter or rushing through a long interpreter phone call due to time constraints?” I thought. A study from 2011 found that 43% of hospitalized patients with LEP had communicated without an interpreter present during admission, and 40% had communicated without an interpreter present after admission.⁸ In other words, a system in place does not mean service in use. But, the use of a trained interpreter is not only an obligation for care providers but a right for patients as per legal requirements of Title VI of the Civil Rights Act and the Standards for Culturally and Linguistically Appropriate Services (CLAS) by the Department of Health and Human Services’ (HSS) Office of Minority Health.⁹ In January 2010, The Joint Commission released a set of new and revised standards for patient-centered communication as part of an initiative to advance effective communication, cultural competence, and patient- and family-centered care.

Despite the requirements and availability of qualified medical interpreter services, there are multiple perceived and experienced barriers to the use of interpreter services. The most common one is that what comes as a free service for patients is a time commitment for providers. A long list of patients, acuity of the situation, and ease of use/availability of translation aids can change the calculus. One may be able to bill a prolonged service code (99354-99357) in addition to the appropriate E/M code, although a patient cannot be billed for the actual service provided by the interpreter. Longstanding CMS policy also permits reimbursement for translation/interpretation activities, so long as they are not included and paid for as part of the rate for direct service.¹⁰

The patient, however, insisted that she would rather have her son as the interpreter on the 3-way over the phone (OPI) conference call for interpretation. “He speaks good English and knows my medical history well,” she said. I counseled the patient on the benefits of using interpreter services and explained how to use the call button light and the visual aids.

Placing emphasis on educating patients about the benefits of using, and risks of not using, interpreter services is as essential as emphasizing that care providers use the services. Some patients may voluntarily choose to provide their own interpreter. Use of family members, friends, or unqualified staff as interpreters is one of the most commonly reported causes of errors by frontline staff. Using in-language collateral may help these patients understand how medical interpretation may create a better patient experience and outcome. A short factsheet, in different languages, on qualified interpreters’ expected benefits: meaning-for-meaning communication, impartiality, medical privacy, and improved patient safety and satisfaction, can also come in handy.

However, if the patient still refuses, providers should document the refusal of the offer of free language services, the name of the interpreter designated by the patient, the interpreter’s relationship to the LEP person, and the time or portions of the patient encounter that the interpreter’s services were used. Yet, language interpretation alone can be inadequate without document translation. According to one study, despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have signed consent forms in their medical records.¹¹ Health care professionals, therefore, need well-translated documents to treat LEP patients. Translated documents of consent forms for medical procedures, post-discharge instructions, prescription and medical device labels, and drug usage information may enhance informed decision making, safety and reduce stress and medical errors.

An unpopular and underused service needs it all: availability, convenience, monitoring, reporting, and team effort. Due to the sheer unpopularity and underuse of interpreter services, institutions should enhance ease of availability, monitor the use and quality of interpreter services, and optimize reporting of language-related errors. Ease of availability goes hand in hand with tapping local resources. Over the years, and even more so during the pandemic, in-person interpretation has transitioned to telephonic or video interpretation due to availability, safety, and cost issues. There are challenges in translating a language, and the absence of a visual channel adds another layer of complexity.

The current body of evidence does not indicate a superior interpreting method. Still, in one study providers and interpreters exposed to all three methods were more critical of remote methods and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raised questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel.¹²

One way to bypass language barriers is to recognize the value added by hiring and training bilingual health care providers and fostering cultural competence. International medical graduates in many parts of the country aid in closing language barriers. Language-concordant care enhances trust between patients and physicians, optimizes health outcomes, and advances health equity for diverse populations.^13-15 The presence of bilingual providers means more effective and timelier communication and improved patient satisfaction. But, according to a Doximity study, there is a significant “language gap” between those languages spoken by physicians and their patients.¹⁶ Hospitals, therefore, should assess, qualify, and incentivize staff who can serve as on-site medical interpreters for patients as a means to facilitate language concordant care for LEP patients.

The Agency of Healthcare Research and Quality (AHRQ) also has a guide on how hospitals can better identify, report, monitor, and prevent medical errors in patients with LEP. Included is the TeamSTEPPS LEP module to help develop and deploy a customized plan to train staff in teamwork skills and lead a medical teamwork improvement initiative.¹⁷

“Without my family, I was scared that nobody would understand me”

Back to the case. My patient was recovering well, and I was tying up loose ends on the switch day for the hospitalist teams.

“You will likely be discharged in a couple of days,” I said. She and the family were grateful and satisfied with the care. She had used the interpreter services and also received ethnocultural and language concordant and culturally competent care. Reducing language barriers is one of the crucial ways to reduce racial and ethnic disparities in quality of care and health outcomes, and it starts – in many cases – with identifying LEP patients. Proper use and monitoring of interpreter services, reporting language-related errors, hiring and testing bilingual staff’s language proficiency, and educating staff on cultural awareness are essential strategies for caring for LEP patients.

At my weeks’ end, in my handoff note to the incoming providers, I highlighted: “Patient will benefit from a Hindi speaking provider, Limited English Proficiency.”
 

Dr. Saigal is a hospitalist and clinical assistant professor of medicine in the division of hospital medicine at the Ohio State University Wexner Medical Center, Columbus.

References

1. Questions and Answers. Limited English Proficiency: A federal interagency website. www.lep.gov/commonly-asked-questions.

2. United States Census Bureau. Percent of people 5 years and over who speak English less than ‘very well’. www.census.gov/library/visualizations/interactive/people-that-speak-english-less-than-very-well.html.

3. Jacobs EA, et al. Overcoming language barriers in health care: Costs and benefits of interpreter services. Am J Public Health. 2004;94(5):866–869. doi: 10.2105/ajph.94.5.866.

4. Gandhi TK, et al. Drug complications in outpatients. J Gen Intern Med. 2000;15(3):149–154. doi: 10.1046/j.1525-1497.2000.04199.x.

5. Karliner LS, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–754. doi: 10.1111/j.1475-6773.2006.00629.x.

6. Divi C, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007 Apr;19(2):60-7. doi: 10.1093/intqhc/mzl069.

7. Karliner LS, et al. Identification of limited English proficient patients in clinical care. J Gen Intern Med. 2008;23(10):1555-1560. doi:10.1007/s11606-008-0693-y.

8. Schenker Y, et al. Patterns of interpreter use for hospitalized patients with limited English proficiency. J Gen Intern Med. 2011 Jul;26(7):712-7. doi: 10.1007/s11606-010-1619-z.

9. Office of Minority Health, US Department of Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: US Department of Health and Human Services; 2001. https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf.

10. www.medicaid.gov/medicaid/financial-management/medicaid-administrative-claiming/translation-and-interpretation-services/index.html

11. Schenker Y, et al. The Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-Site Interpreter Services. J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl 2):294-9. doi: 10.1007/s11606-007-0359-1.

12. Locatis C, et al. Comparing in-person, video, and telephonic medical interpretation. J Gen Intern Med. 2010;25(4):345-350. doi:10.1007/s11606-009-1236-x.

13. Dunlap JL, et al. The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015 Sep;50(9):1586-9. doi: 10.1016/j.jpedsurg.2014.12.020.

14. Diamond L, et al. A Systematic Review of the Impact of Patient–Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med. 2019 Aug;34(8):1591-1606. doi: 10.1007/s11606-019-04847-5.

15. Ngo-Metzger Q, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl 2):324-30. doi: 10.1007/s11606-007-0340-z.

16. https://press.doximity.com/articles/first-ever-national-study-to-examine-different-languages-spoken-by-us-doctors.

17. Agency for Healthcare Research and Quality. Patients with Limited English Proficiency. www.ahrq.gov/teamstepps/lep/index.html.

A hectic Friday morning at the hospital seemed less stressful amid morning greetings and humor from colleagues. In a team room full of hospitalists, life and death are often discussed in detail, ranging from medical discussions to joys and frustrations of the day to philosophy, politics, and more. It is almost impossible to miss something interesting.

People breaking into their native languages over the phone call from home always make me smile. The mention of a “complicated Indian patient unable to use interpreter” caught my attention.

My friend and colleague asked if I would be willing to take over the patient since I could speak Hindi. I was doubtful if I would add anything to make a meaningful difference, given the patient wasn’t even participating in a conversation. However, my colleague’s concern for the patient and faith in me was enough to say, “Sure, let me add her to my list.”

At the bedside, it felt like a classic “acute on chronic” hot mess situation. The patient presented with a generalized rash, anasarca, renal failure, multifocal pneumonia, and delirium. All I could gather from the patient were some incomprehensible words that sounded like Hindi. I called the family to obtain some history and to provide updates. Her son was excited to hear from me, and it didn’t take him long to guess that I was from India. But that could still mean that I might speak any of the twenty-two or more Indian languages.

Answering my questions one by one in perfectly understandable English, he was short and sweet. Suspicious of missing out on details, I offered hesitantly, “You could speak in Hindi with me.” Then came a flood of information with the details, concerns, questions, and what was lost in the translation.

We all attend to patients and families with limited English proficiency (LEP), immigrants, and nonimmigrants. LEP is a term used to describe individuals who do not speak English as their primary language and have a limited ability to read, speak, write, or understand English.¹ Recent data from the American Community Survey (2005-2009) reports that 8.6% of the population (24 million Americans) have LEP.² It’s a large and growing population that needs help overcoming language barriers and the appropriate use of professional medical interpreter services – a backbone to safe, quality, and cost-effective patient care.

The following day at bedside rounds, the nurse reported that the patient was looking and responding better. She could cooperate with interpreter services and could speak “some English.” Over the years, one thing that sounds more alarming than “no English” is “some English” or “enough English.” Around noon I received a page that the patient was refusing intravenous Lasix. At the bedside, however, the patient seemed unaware of the perceived refusal. Further discussions with the nurse lead to a familiar culprit, a relatively common gesture in South Asian cultures, a head bobble or shake.

The nurse reported that the patient shook her head side to side, seemed upset, and said “NO” when trying to administer the medication. On the other hand, the patient reported that she was upset to be at the hospital but had “NO” problem with the medicine.

My patient’s “some English” was indeed “enough English” to put her at risk due to medical error, which is highly likely when patients or providers can speak or understand a language to “get by” or to “make do.” Like my patient, the LEP patient population is more likely to experience medical errors, longer hospital stays, hospital-acquired complications, surgical delays, and readmissions. They are also less likely to receive preventive care, have access to regular care, or be satisfied with their care. They are much more likely to have adverse effects from drug complications, poor understanding of diagnoses, a greater risk of being misunderstood by their physicians or ancillary staff, and less likely to follow physician instructions.^3-5 One study analyzed over 1,000 adverse-incident reports from six Joint Commission-accredited hospitals for LEP and English-speaking patients and found that 49% of LEP patients experienced physical harm versus 29.5% of English-speaking patients.⁶

I updated the patient’s LEP status that was missing in the chart, likely due to altered mental status at the time of admission. Reliable language and English proficiency data are usually entered at the patient’s point of entry with documentation of the language services required during the patient-provider encounter. The U.S. Census Bureau’s operational definition for LEP is a patient’s self-assessed ability to speak English less than “very well,” but how well it correlates with a patient’s actual English ability needs more study. Also, one’s self-assessed perception of ability might vary day to day, and language ability, by itself, is not static; it can differ from moment to moment and situation to situation. It may be easier to understand words in English when the situation is simple and less stressful than when things are complicated and stressful.

With a definition of LEP rather vague and the term somewhat derogatory, its meaning is open to interpretation. One study found that though speaking English less than “very well” was the most sensitive measure for identifying all of the patients who reported that they were unable to communicate effectively with their physicians, it was also the least specific.⁷ This lower specificity could lead to misclassification of some patients as LEP who are, in fact, able to effectively communicate in English with their physicians. This type of misclassification might lead to costly language assistance and carry the potential to cause conflicts between patient and provider. Telling a patient or family that they may have a “limited English proficiency” when they have believed otherwise and feel confident about their skills may come as a challenge. Some patients may also pretend to understand English to avoid being embarrassed about their linguistic abilities or perceive that they might be judged on their abilities in general.

Exiting the room, I gently reminded the RN to use the interpreter services. “Who has never been guilty of using an ad hoc interpreter or rushing through a long interpreter phone call due to time constraints?” I thought. A study from 2011 found that 43% of hospitalized patients with LEP had communicated without an interpreter present during admission, and 40% had communicated without an interpreter present after admission.⁸ In other words, a system in place does not mean service in use. But, the use of a trained interpreter is not only an obligation for care providers but a right for patients as per legal requirements of Title VI of the Civil Rights Act and the Standards for Culturally and Linguistically Appropriate Services (CLAS) by the Department of Health and Human Services’ (HSS) Office of Minority Health.⁹ In January 2010, The Joint Commission released a set of new and revised standards for patient-centered communication as part of an initiative to advance effective communication, cultural competence, and patient- and family-centered care.

Despite the requirements and availability of qualified medical interpreter services, there are multiple perceived and experienced barriers to the use of interpreter services. The most common one is that what comes as a free service for patients is a time commitment for providers. A long list of patients, acuity of the situation, and ease of use/availability of translation aids can change the calculus. One may be able to bill a prolonged service code (99354-99357) in addition to the appropriate E/M code, although a patient cannot be billed for the actual service provided by the interpreter. Longstanding CMS policy also permits reimbursement for translation/interpretation activities, so long as they are not included and paid for as part of the rate for direct service.¹⁰

The patient, however, insisted that she would rather have her son as the interpreter on the 3-way over the phone (OPI) conference call for interpretation. “He speaks good English and knows my medical history well,” she said. I counseled the patient on the benefits of using interpreter services and explained how to use the call button light and the visual aids.

Placing emphasis on educating patients about the benefits of using, and risks of not using, interpreter services is as essential as emphasizing that care providers use the services. Some patients may voluntarily choose to provide their own interpreter. Use of family members, friends, or unqualified staff as interpreters is one of the most commonly reported causes of errors by frontline staff. Using in-language collateral may help these patients understand how medical interpretation may create a better patient experience and outcome. A short factsheet, in different languages, on qualified interpreters’ expected benefits: meaning-for-meaning communication, impartiality, medical privacy, and improved patient safety and satisfaction, can also come in handy.

However, if the patient still refuses, providers should document the refusal of the offer of free language services, the name of the interpreter designated by the patient, the interpreter’s relationship to the LEP person, and the time or portions of the patient encounter that the interpreter’s services were used. Yet, language interpretation alone can be inadequate without document translation. According to one study, despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have signed consent forms in their medical records.¹¹ Health care professionals, therefore, need well-translated documents to treat LEP patients. Translated documents of consent forms for medical procedures, post-discharge instructions, prescription and medical device labels, and drug usage information may enhance informed decision making, safety and reduce stress and medical errors.

An unpopular and underused service needs it all: availability, convenience, monitoring, reporting, and team effort. Due to the sheer unpopularity and underuse of interpreter services, institutions should enhance ease of availability, monitor the use and quality of interpreter services, and optimize reporting of language-related errors. Ease of availability goes hand in hand with tapping local resources. Over the years, and even more so during the pandemic, in-person interpretation has transitioned to telephonic or video interpretation due to availability, safety, and cost issues. There are challenges in translating a language, and the absence of a visual channel adds another layer of complexity.

The current body of evidence does not indicate a superior interpreting method. Still, in one study providers and interpreters exposed to all three methods were more critical of remote methods and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raised questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel.¹²

One way to bypass language barriers is to recognize the value added by hiring and training bilingual health care providers and fostering cultural competence. International medical graduates in many parts of the country aid in closing language barriers. Language-concordant care enhances trust between patients and physicians, optimizes health outcomes, and advances health equity for diverse populations.^13-15 The presence of bilingual providers means more effective and timelier communication and improved patient satisfaction. But, according to a Doximity study, there is a significant “language gap” between those languages spoken by physicians and their patients.¹⁶ Hospitals, therefore, should assess, qualify, and incentivize staff who can serve as on-site medical interpreters for patients as a means to facilitate language concordant care for LEP patients.

The Agency of Healthcare Research and Quality (AHRQ) also has a guide on how hospitals can better identify, report, monitor, and prevent medical errors in patients with LEP. Included is the TeamSTEPPS LEP module to help develop and deploy a customized plan to train staff in teamwork skills and lead a medical teamwork improvement initiative.¹⁷

“Without my family, I was scared that nobody would understand me”

Back to the case. My patient was recovering well, and I was tying up loose ends on the switch day for the hospitalist teams.

“You will likely be discharged in a couple of days,” I said. She and the family were grateful and satisfied with the care. She had used the interpreter services and also received ethnocultural and language concordant and culturally competent care. Reducing language barriers is one of the crucial ways to reduce racial and ethnic disparities in quality of care and health outcomes, and it starts – in many cases – with identifying LEP patients. Proper use and monitoring of interpreter services, reporting language-related errors, hiring and testing bilingual staff’s language proficiency, and educating staff on cultural awareness are essential strategies for caring for LEP patients.

At my weeks’ end, in my handoff note to the incoming providers, I highlighted: “Patient will benefit from a Hindi speaking provider, Limited English Proficiency.”
 

Dr. Saigal is a hospitalist and clinical assistant professor of medicine in the division of hospital medicine at the Ohio State University Wexner Medical Center, Columbus.

References

1. Questions and Answers. Limited English Proficiency: A federal interagency website. www.lep.gov/commonly-asked-questions.

2. United States Census Bureau. Percent of people 5 years and over who speak English less than ‘very well’. www.census.gov/library/visualizations/interactive/people-that-speak-english-less-than-very-well.html.

3. Jacobs EA, et al. Overcoming language barriers in health care: Costs and benefits of interpreter services. Am J Public Health. 2004;94(5):866–869. doi: 10.2105/ajph.94.5.866.

4. Gandhi TK, et al. Drug complications in outpatients. J Gen Intern Med. 2000;15(3):149–154. doi: 10.1046/j.1525-1497.2000.04199.x.

5. Karliner LS, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–754. doi: 10.1111/j.1475-6773.2006.00629.x.

6. Divi C, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007 Apr;19(2):60-7. doi: 10.1093/intqhc/mzl069.

7. Karliner LS, et al. Identification of limited English proficient patients in clinical care. J Gen Intern Med. 2008;23(10):1555-1560. doi:10.1007/s11606-008-0693-y.

8. Schenker Y, et al. Patterns of interpreter use for hospitalized patients with limited English proficiency. J Gen Intern Med. 2011 Jul;26(7):712-7. doi: 10.1007/s11606-010-1619-z.

9. Office of Minority Health, US Department of Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: US Department of Health and Human Services; 2001. https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf.

10. www.medicaid.gov/medicaid/financial-management/medicaid-administrative-claiming/translation-and-interpretation-services/index.html

11. Schenker Y, et al. The Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-Site Interpreter Services. J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl 2):294-9. doi: 10.1007/s11606-007-0359-1.

12. Locatis C, et al. Comparing in-person, video, and telephonic medical interpretation. J Gen Intern Med. 2010;25(4):345-350. doi:10.1007/s11606-009-1236-x.

13. Dunlap JL, et al. The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015 Sep;50(9):1586-9. doi: 10.1016/j.jpedsurg.2014.12.020.

14. Diamond L, et al. A Systematic Review of the Impact of Patient–Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med. 2019 Aug;34(8):1591-1606. doi: 10.1007/s11606-019-04847-5.

15. Ngo-Metzger Q, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl 2):324-30. doi: 10.1007/s11606-007-0340-z.

16. https://press.doximity.com/articles/first-ever-national-study-to-examine-different-languages-spoken-by-us-doctors.

17. Agency for Healthcare Research and Quality. Patients with Limited English Proficiency. www.ahrq.gov/teamstepps/lep/index.html.

A hectic Friday morning at the hospital seemed less stressful amid morning greetings and humor from colleagues. In a team room full of hospitalists, life and death are often discussed in detail, ranging from medical discussions to joys and frustrations of the day to philosophy, politics, and more. It is almost impossible to miss something interesting.

People breaking into their native languages over the phone call from home always make me smile. The mention of a “complicated Indian patient unable to use interpreter” caught my attention.

My friend and colleague asked if I would be willing to take over the patient since I could speak Hindi. I was doubtful if I would add anything to make a meaningful difference, given the patient wasn’t even participating in a conversation. However, my colleague’s concern for the patient and faith in me was enough to say, “Sure, let me add her to my list.”

At the bedside, it felt like a classic “acute on chronic” hot mess situation. The patient presented with a generalized rash, anasarca, renal failure, multifocal pneumonia, and delirium. All I could gather from the patient were some incomprehensible words that sounded like Hindi. I called the family to obtain some history and to provide updates. Her son was excited to hear from me, and it didn’t take him long to guess that I was from India. But that could still mean that I might speak any of the twenty-two or more Indian languages.

Answering my questions one by one in perfectly understandable English, he was short and sweet. Suspicious of missing out on details, I offered hesitantly, “You could speak in Hindi with me.” Then came a flood of information with the details, concerns, questions, and what was lost in the translation.

We all attend to patients and families with limited English proficiency (LEP), immigrants, and nonimmigrants. LEP is a term used to describe individuals who do not speak English as their primary language and have a limited ability to read, speak, write, or understand English.¹ Recent data from the American Community Survey (2005-2009) reports that 8.6% of the population (24 million Americans) have LEP.² It’s a large and growing population that needs help overcoming language barriers and the appropriate use of professional medical interpreter services – a backbone to safe, quality, and cost-effective patient care.

The following day at bedside rounds, the nurse reported that the patient was looking and responding better. She could cooperate with interpreter services and could speak “some English.” Over the years, one thing that sounds more alarming than “no English” is “some English” or “enough English.” Around noon I received a page that the patient was refusing intravenous Lasix. At the bedside, however, the patient seemed unaware of the perceived refusal. Further discussions with the nurse lead to a familiar culprit, a relatively common gesture in South Asian cultures, a head bobble or shake.

The nurse reported that the patient shook her head side to side, seemed upset, and said “NO” when trying to administer the medication. On the other hand, the patient reported that she was upset to be at the hospital but had “NO” problem with the medicine.

My patient’s “some English” was indeed “enough English” to put her at risk due to medical error, which is highly likely when patients or providers can speak or understand a language to “get by” or to “make do.” Like my patient, the LEP patient population is more likely to experience medical errors, longer hospital stays, hospital-acquired complications, surgical delays, and readmissions. They are also less likely to receive preventive care, have access to regular care, or be satisfied with their care. They are much more likely to have adverse effects from drug complications, poor understanding of diagnoses, a greater risk of being misunderstood by their physicians or ancillary staff, and less likely to follow physician instructions.^3-5 One study analyzed over 1,000 adverse-incident reports from six Joint Commission-accredited hospitals for LEP and English-speaking patients and found that 49% of LEP patients experienced physical harm versus 29.5% of English-speaking patients.⁶

I updated the patient’s LEP status that was missing in the chart, likely due to altered mental status at the time of admission. Reliable language and English proficiency data are usually entered at the patient’s point of entry with documentation of the language services required during the patient-provider encounter. The U.S. Census Bureau’s operational definition for LEP is a patient’s self-assessed ability to speak English less than “very well,” but how well it correlates with a patient’s actual English ability needs more study. Also, one’s self-assessed perception of ability might vary day to day, and language ability, by itself, is not static; it can differ from moment to moment and situation to situation. It may be easier to understand words in English when the situation is simple and less stressful than when things are complicated and stressful.

With a definition of LEP rather vague and the term somewhat derogatory, its meaning is open to interpretation. One study found that though speaking English less than “very well” was the most sensitive measure for identifying all of the patients who reported that they were unable to communicate effectively with their physicians, it was also the least specific.⁷ This lower specificity could lead to misclassification of some patients as LEP who are, in fact, able to effectively communicate in English with their physicians. This type of misclassification might lead to costly language assistance and carry the potential to cause conflicts between patient and provider. Telling a patient or family that they may have a “limited English proficiency” when they have believed otherwise and feel confident about their skills may come as a challenge. Some patients may also pretend to understand English to avoid being embarrassed about their linguistic abilities or perceive that they might be judged on their abilities in general.

Exiting the room, I gently reminded the RN to use the interpreter services. “Who has never been guilty of using an ad hoc interpreter or rushing through a long interpreter phone call due to time constraints?” I thought. A study from 2011 found that 43% of hospitalized patients with LEP had communicated without an interpreter present during admission, and 40% had communicated without an interpreter present after admission.⁸ In other words, a system in place does not mean service in use. But, the use of a trained interpreter is not only an obligation for care providers but a right for patients as per legal requirements of Title VI of the Civil Rights Act and the Standards for Culturally and Linguistically Appropriate Services (CLAS) by the Department of Health and Human Services’ (HSS) Office of Minority Health.⁹ In January 2010, The Joint Commission released a set of new and revised standards for patient-centered communication as part of an initiative to advance effective communication, cultural competence, and patient- and family-centered care.

Despite the requirements and availability of qualified medical interpreter services, there are multiple perceived and experienced barriers to the use of interpreter services. The most common one is that what comes as a free service for patients is a time commitment for providers. A long list of patients, acuity of the situation, and ease of use/availability of translation aids can change the calculus. One may be able to bill a prolonged service code (99354-99357) in addition to the appropriate E/M code, although a patient cannot be billed for the actual service provided by the interpreter. Longstanding CMS policy also permits reimbursement for translation/interpretation activities, so long as they are not included and paid for as part of the rate for direct service.¹⁰

The patient, however, insisted that she would rather have her son as the interpreter on the 3-way over the phone (OPI) conference call for interpretation. “He speaks good English and knows my medical history well,” she said. I counseled the patient on the benefits of using interpreter services and explained how to use the call button light and the visual aids.

Placing emphasis on educating patients about the benefits of using, and risks of not using, interpreter services is as essential as emphasizing that care providers use the services. Some patients may voluntarily choose to provide their own interpreter. Use of family members, friends, or unqualified staff as interpreters is one of the most commonly reported causes of errors by frontline staff. Using in-language collateral may help these patients understand how medical interpretation may create a better patient experience and outcome. A short factsheet, in different languages, on qualified interpreters’ expected benefits: meaning-for-meaning communication, impartiality, medical privacy, and improved patient safety and satisfaction, can also come in handy.

However, if the patient still refuses, providers should document the refusal of the offer of free language services, the name of the interpreter designated by the patient, the interpreter’s relationship to the LEP person, and the time or portions of the patient encounter that the interpreter’s services were used. Yet, language interpretation alone can be inadequate without document translation. According to one study, despite the availability of on-site professional interpreter services, hospitalized patients who do not speak English are less likely to have signed consent forms in their medical records.¹¹ Health care professionals, therefore, need well-translated documents to treat LEP patients. Translated documents of consent forms for medical procedures, post-discharge instructions, prescription and medical device labels, and drug usage information may enhance informed decision making, safety and reduce stress and medical errors.

An unpopular and underused service needs it all: availability, convenience, monitoring, reporting, and team effort. Due to the sheer unpopularity and underuse of interpreter services, institutions should enhance ease of availability, monitor the use and quality of interpreter services, and optimize reporting of language-related errors. Ease of availability goes hand in hand with tapping local resources. Over the years, and even more so during the pandemic, in-person interpretation has transitioned to telephonic or video interpretation due to availability, safety, and cost issues. There are challenges in translating a language, and the absence of a visual channel adds another layer of complexity.

The current body of evidence does not indicate a superior interpreting method. Still, in one study providers and interpreters exposed to all three methods were more critical of remote methods and preferred videoconferencing to the telephone as a remote method. The significantly shorter phone interviews raised questions about the prospects of miscommunication in telephonic interpretation, given the absence of a visual channel.¹²

One way to bypass language barriers is to recognize the value added by hiring and training bilingual health care providers and fostering cultural competence. International medical graduates in many parts of the country aid in closing language barriers. Language-concordant care enhances trust between patients and physicians, optimizes health outcomes, and advances health equity for diverse populations.^13-15 The presence of bilingual providers means more effective and timelier communication and improved patient satisfaction. But, according to a Doximity study, there is a significant “language gap” between those languages spoken by physicians and their patients.¹⁶ Hospitals, therefore, should assess, qualify, and incentivize staff who can serve as on-site medical interpreters for patients as a means to facilitate language concordant care for LEP patients.

The Agency of Healthcare Research and Quality (AHRQ) also has a guide on how hospitals can better identify, report, monitor, and prevent medical errors in patients with LEP. Included is the TeamSTEPPS LEP module to help develop and deploy a customized plan to train staff in teamwork skills and lead a medical teamwork improvement initiative.¹⁷

“Without my family, I was scared that nobody would understand me”

Back to the case. My patient was recovering well, and I was tying up loose ends on the switch day for the hospitalist teams.

“You will likely be discharged in a couple of days,” I said. She and the family were grateful and satisfied with the care. She had used the interpreter services and also received ethnocultural and language concordant and culturally competent care. Reducing language barriers is one of the crucial ways to reduce racial and ethnic disparities in quality of care and health outcomes, and it starts – in many cases – with identifying LEP patients. Proper use and monitoring of interpreter services, reporting language-related errors, hiring and testing bilingual staff’s language proficiency, and educating staff on cultural awareness are essential strategies for caring for LEP patients.

At my weeks’ end, in my handoff note to the incoming providers, I highlighted: “Patient will benefit from a Hindi speaking provider, Limited English Proficiency.”
 

Dr. Saigal is a hospitalist and clinical assistant professor of medicine in the division of hospital medicine at the Ohio State University Wexner Medical Center, Columbus.

References

1. Questions and Answers. Limited English Proficiency: A federal interagency website. www.lep.gov/commonly-asked-questions.

2. United States Census Bureau. Percent of people 5 years and over who speak English less than ‘very well’. www.census.gov/library/visualizations/interactive/people-that-speak-english-less-than-very-well.html.

3. Jacobs EA, et al. Overcoming language barriers in health care: Costs and benefits of interpreter services. Am J Public Health. 2004;94(5):866–869. doi: 10.2105/ajph.94.5.866.

4. Gandhi TK, et al. Drug complications in outpatients. J Gen Intern Med. 2000;15(3):149–154. doi: 10.1046/j.1525-1497.2000.04199.x.

5. Karliner LS, et al. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–754. doi: 10.1111/j.1475-6773.2006.00629.x.

6. Divi C, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007 Apr;19(2):60-7. doi: 10.1093/intqhc/mzl069.

7. Karliner LS, et al. Identification of limited English proficient patients in clinical care. J Gen Intern Med. 2008;23(10):1555-1560. doi:10.1007/s11606-008-0693-y.

8. Schenker Y, et al. Patterns of interpreter use for hospitalized patients with limited English proficiency. J Gen Intern Med. 2011 Jul;26(7):712-7. doi: 10.1007/s11606-010-1619-z.

9. Office of Minority Health, US Department of Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: US Department of Health and Human Services; 2001. https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf.

10. www.medicaid.gov/medicaid/financial-management/medicaid-administrative-claiming/translation-and-interpretation-services/index.html

11. Schenker Y, et al. The Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-Site Interpreter Services. J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl 2):294-9. doi: 10.1007/s11606-007-0359-1.

12. Locatis C, et al. Comparing in-person, video, and telephonic medical interpretation. J Gen Intern Med. 2010;25(4):345-350. doi:10.1007/s11606-009-1236-x.

13. Dunlap JL, et al. The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients. J Pediatr Surg. 2015 Sep;50(9):1586-9. doi: 10.1016/j.jpedsurg.2014.12.020.

14. Diamond L, et al. A Systematic Review of the Impact of Patient–Physician Non-English Language Concordance on Quality of Care and Outcomes. J Gen Intern Med. 2019 Aug;34(8):1591-1606. doi: 10.1007/s11606-019-04847-5.

15. Ngo-Metzger Q, et al. Providing high-quality care for limited English proficient patients: the importance of language concordance and interpreter use. J Gen Intern Med. 2007 Nov;22 Suppl 2(Suppl 2):324-30. doi: 10.1007/s11606-007-0340-z.

16. https://press.doximity.com/articles/first-ever-national-study-to-examine-different-languages-spoken-by-us-doctors.

17. Agency for Healthcare Research and Quality. Patients with Limited English Proficiency. www.ahrq.gov/teamstepps/lep/index.html.

Individuals of South Asian ancestry face twice the risk of heart disease, compared with individuals of European descent, yet existing risk calculators fail to account for this disparity, according to the results of a new study.

These findings confirm previous reports and practice guidelines that identify South Asian ancestry as a risk enhancer for atherosclerotic cardiovascular disease (ASCVD), suggesting that earlier heart disease screening and prevention is warranted in this patient population, lead author Aniruddh P. Patel, MD, research fellow at the Center for Genomic Medicine, Massachusetts General Hospital, Boston, and colleagues said.

“Previous studies in multiple countries have estimated a 1.7- to 4-fold higher risk of ASCVD among South Asian individuals, compared with other ancestries, but have important potential limitations,” Dr. Patel and colleagues wrote in the paper on their prospective cohort study, published in Circulation.

The INTERHEART case-control study, for example, which assessed risk factors for acute myocardial infarction among more than 15,000 cases from 52 countries, is now 2 decades old, and “may not reflect recent advances in cardiovascular disease prevention,” the investigators wrote.

Most studies in the area have been small and retrospective, they added, and have not adequately assessed emerging risk factors, such as prediabetes, which appear to play a relatively greater role in the development of heart disease among South Asians.
 

Methods and results

To address this knowledge gap, Dr. Patel and colleagues analyzed data from the UK Biobank prospective cohort study, including 449,349 middle-aged participants of European ancestry and 8,124 similarly aged participants of South Asian descent who did not have heart disease upon enrollment. Respective rates of incident ASCVD (i.e., MI, ischemic stroke, or coronary revascularization) were analyzed in the context of a variety of lifestyle, anthropometric, and clinical factors.

After a median follow-up of 11.1 years, individuals of South Asian descent had an incident ASCVD rate of 6.8%, compared with 4.4% for individuals of European descent, representing twice the relative risk (adjusted hazard ratio, 2.03; 95% CI, 1.86-2.22; P < .001). Even after accounting for all covariates, risk of ASCVD remained 45% higher for South Asian individuals (aHR, 1.45; 95% CI, 1.28-1.65; P < .001). This elevation in risk was not captured by existing risk calculators, including the American College of Cardiology/American Heart Association Pooled Cohort Equations, or the QRISK3 equations.

The findings were “largely consistent across a range of age, sex, and clinical subgroups,” and “confirm and extend previous reports that hypertension, diabetes, and central adiposity are the leading associations in this observed disparity,” the investigators wrote.
 

Two diabetes subtypes are more prevalent in South Asians

Hypertension, diabetes, and central adiposity do not fully explain South Asians’ higher risk for ASCVD, wrote Namratha R. Kandula, MD, of Northwestern University Medical Center, Chicago, and Alka M. Kanaya, MD, of the University of California, San Francisco, in an accompanying editorial published in Circulation.

Some of the undetected risk may stem from unique diabetes disease factors, Dr. Kandula and Dr. Kanaya added.

“Newer data have demonstrated distinct subtypes of type 2 diabetes, with South Asians having a higher prevalence of both a severe insulin resistant with obesity subtype and a less recognized severe insulin deficient subtype,” they wrote. “Importantly, both of these more prevalent diabetes subtypes in South Asians were associated with a higher incidence of coronary artery calcium, a marker of subclinical atherosclerosis and strong predictor of future ASCVD, compared to other diabetes subtypes.”
 

Diabetes rate is higher for South Asians in the U.S.

Although the present study was conducted in the United Kingdom, the findings likely apply to individuals of South Asian ancestry living in the United States, according to principal author Amit V. Khera, MD, associate director of the precision medicine unit at the Center for Genomic Medicine, Massachusetts General Hospital.

“There are already more than 5 million individuals of South Asian ancestry in the U.S. and this represents one of the fastest-growing ethnic subgroups,” Dr. Khera said in an interview. “As in our study of individuals in the U.K., South Asians in the U.S. suffer from diabetes at much higher rates – 23% versus 12% – and this often occurs even in the absence of obesity.”

Dr. Khera noted that the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease identify South Asian ancestry as a risk-enhancing factor, calling this a “stopgap measure.” More work is needed, he said, in the research arena and in the clinic.
 

Zero South Asians included in studies used to develop risk estimator

“I think the first step is to simply acknowledge that the risk estimators we use in clinical practice have important limitations when it comes to diverse patient populations,” Dr. Khera said in an interview. “We saw this in our study, where – despite a more than doubling of risk – the predicted risk based on the equations used in primary care showed no difference. This risk estimator was developed based on legacy cohort studies, in [which] zero South Asians were included. Despite important differences across race/ethnicity, the current state-of-the-art in the U.S. is to use one equation for Black individuals and another for all other ethnicities.”

Experts suggest steps for reducing heart disease risk

While risk modeling remains suboptimal, Dr. Khera suggested that clinicians can take immediate steps to reduce the risk of heart disease among individuals with South Asian ancestry.

“Despite all of the uncertainty – we still don’t have a complete understanding of why the risk is so high – there are still several things primary care doctors can do for their patients,” Dr. Khera said.

Foremost, he recommended lifestyle and dietary counseling.

“Dietary counseling is particularly effective if put in the context of cultural norms,” Dr. Khera said. “Many South Asians consider fruit juices or white rice to be healthy, when they lead to rapid spikes in blood sugar.”

Dr. Khera also advised earlier heart disease screening, such as coronary calcium scanning “sometime between age 40-50 years,” noting that positive test results may motivate patients to start or adhere to medications, such as cholesterol-lowering therapies. If necessary, clinicians can also refer to heart centers for South Asian patients, which are becoming increasingly common.

According to Cheryl A.M. Anderson, PhD, chair of the AHA’s Council on Epidemiology and Prevention, and professor and dean of the Herbert Wertheim School of Public Health and Human Longevity Science at the University of California, San Diego, the current study suggests that heart disease management strategies for South Asian patients may be lacking.

“We have had a tradition of preventing or trying to treat heart disease in a fashion that doesn’t yet account for the increased risk that might be prevalent in those of South Asian ancestry,” Dr. Anderson said in an interview.

She suggested that improving associated risk-analysis tools could be beneficial, although the tools themselves, in the context of race or ethnicity, may present their own risks.

“We want to be mindful of potential adverse implications from having everything linked to one’s ancestry, which I think this tool doesn’t do,” Dr. Anderson said, referring to the AHA/ACC Pooled Cohort Equations. “But in sort of the bigger picture of things, we always want to expand and refine our toolkit.”

According to Rajesh Dash, MD, PhD, associate professor, cardiologist, and director of the South Asian Translational Heart Initiative (SSATHI) Prevention Clinic and CardioClick Telemedicine Clinic at Stanford (Calif.) HealthCare, the science supports more active risk mitigation strategies for South Asian patients, and the AHA and the ACC “are the two entities that need to lead the way.”

“Certainly the American Heart Association and the American College of Cardiology should be taking a more active leadership role in this,” Dr. Dash said in an interview.

In 2018, the AHA issued a scientific statement about the elevated risk of ASCVD among South Asian individuals, “but it did not rise to the level of specific recommendations, and did not necessarily go as far as to incorporate new screening parameters for that population,” Dr. Dash said. He also noted that the most recent AHA/ACC guideline identifies South Asian ancestry as a risk-enhancing feature, a statement similarly lacking in actionable value.

“That does not definitively lead someone like a primary care physician to a decision to start a statin, or to be more aggressive with a diagnostic workup, like a stress test, for instance, for a patient who they otherwise would not have done one in had they not been South Asian,” Dr. Dash said.

The steps taken by the AHA and the ACC are “a healthy step forward,” he noted, “but not nearly the degree of attention or vigilance that is required, as well as the level of action that is required to change the narrative for the population.”

At the SSATHI Prevention Clinic, Dr. Dash and colleagues aren’t waiting for the narrative to change, and are already taking a more aggressive approach.

The clinic has an average patient age of 41 years, “easily 15 years younger than the average age in most cardiology clinics,” Dr. Dash said, based on the fact that approximately two-thirds of heart attacks in South Asian individuals occur under the age of 55. “We have to look earlier.”

The SSATHI Prevention Clinic screens for both traditional and emerging risk factors, and Dr. Dash suggested that primary care doctors should do the same.

“If you have a South Asian patient as a primary care physician, you should be aggressively looking for risk factors, traditional ones to start, like elevated cholesterol, hypertension, diabetes, or – and I would argue strongly – prediabetes or insulin resistance.”

Dr. Dash also recommended looking into family history, and considering screening for inflammatory biomarkers, the latter of which are commonly elevated at an earlier age among South Asian individuals, and may have a relatively greater prognostic impact.

To encourage broader implementation of this kind of approach, Dr. Dash called for more large-scale studies. Ideally, these would be randomized clinical trials, but, realistically, real-world datasets may be the answer.

The study was supported by the National Heart, Lung, and Blood Institute; the Broad Institute at MIT and Harvard; the National Human Genome Research Institute; and others. The investigators disclosed relationships with IBM Research, Sanofi, Amgen, and others. Dr. Dash disclosed relationships with HealthPals and AstraZeneca. Dr. Anderson reported no relevant conflicts of interest.

Individuals of South Asian ancestry face twice the risk of heart disease, compared with individuals of European descent, yet existing risk calculators fail to account for this disparity, according to the results of a new study.

These findings confirm previous reports and practice guidelines that identify South Asian ancestry as a risk enhancer for atherosclerotic cardiovascular disease (ASCVD), suggesting that earlier heart disease screening and prevention is warranted in this patient population, lead author Aniruddh P. Patel, MD, research fellow at the Center for Genomic Medicine, Massachusetts General Hospital, Boston, and colleagues said.

“Previous studies in multiple countries have estimated a 1.7- to 4-fold higher risk of ASCVD among South Asian individuals, compared with other ancestries, but have important potential limitations,” Dr. Patel and colleagues wrote in the paper on their prospective cohort study, published in Circulation.

The INTERHEART case-control study, for example, which assessed risk factors for acute myocardial infarction among more than 15,000 cases from 52 countries, is now 2 decades old, and “may not reflect recent advances in cardiovascular disease prevention,” the investigators wrote.

Most studies in the area have been small and retrospective, they added, and have not adequately assessed emerging risk factors, such as prediabetes, which appear to play a relatively greater role in the development of heart disease among South Asians.
 

Methods and results

To address this knowledge gap, Dr. Patel and colleagues analyzed data from the UK Biobank prospective cohort study, including 449,349 middle-aged participants of European ancestry and 8,124 similarly aged participants of South Asian descent who did not have heart disease upon enrollment. Respective rates of incident ASCVD (i.e., MI, ischemic stroke, or coronary revascularization) were analyzed in the context of a variety of lifestyle, anthropometric, and clinical factors.

After a median follow-up of 11.1 years, individuals of South Asian descent had an incident ASCVD rate of 6.8%, compared with 4.4% for individuals of European descent, representing twice the relative risk (adjusted hazard ratio, 2.03; 95% CI, 1.86-2.22; P < .001). Even after accounting for all covariates, risk of ASCVD remained 45% higher for South Asian individuals (aHR, 1.45; 95% CI, 1.28-1.65; P < .001). This elevation in risk was not captured by existing risk calculators, including the American College of Cardiology/American Heart Association Pooled Cohort Equations, or the QRISK3 equations.

The findings were “largely consistent across a range of age, sex, and clinical subgroups,” and “confirm and extend previous reports that hypertension, diabetes, and central adiposity are the leading associations in this observed disparity,” the investigators wrote.
 

Two diabetes subtypes are more prevalent in South Asians

Hypertension, diabetes, and central adiposity do not fully explain South Asians’ higher risk for ASCVD, wrote Namratha R. Kandula, MD, of Northwestern University Medical Center, Chicago, and Alka M. Kanaya, MD, of the University of California, San Francisco, in an accompanying editorial published in Circulation.

Some of the undetected risk may stem from unique diabetes disease factors, Dr. Kandula and Dr. Kanaya added.

“Newer data have demonstrated distinct subtypes of type 2 diabetes, with South Asians having a higher prevalence of both a severe insulin resistant with obesity subtype and a less recognized severe insulin deficient subtype,” they wrote. “Importantly, both of these more prevalent diabetes subtypes in South Asians were associated with a higher incidence of coronary artery calcium, a marker of subclinical atherosclerosis and strong predictor of future ASCVD, compared to other diabetes subtypes.”
 

Diabetes rate is higher for South Asians in the U.S.

Although the present study was conducted in the United Kingdom, the findings likely apply to individuals of South Asian ancestry living in the United States, according to principal author Amit V. Khera, MD, associate director of the precision medicine unit at the Center for Genomic Medicine, Massachusetts General Hospital.

“There are already more than 5 million individuals of South Asian ancestry in the U.S. and this represents one of the fastest-growing ethnic subgroups,” Dr. Khera said in an interview. “As in our study of individuals in the U.K., South Asians in the U.S. suffer from diabetes at much higher rates – 23% versus 12% – and this often occurs even in the absence of obesity.”

Dr. Khera noted that the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease identify South Asian ancestry as a risk-enhancing factor, calling this a “stopgap measure.” More work is needed, he said, in the research arena and in the clinic.
 

Zero South Asians included in studies used to develop risk estimator

“I think the first step is to simply acknowledge that the risk estimators we use in clinical practice have important limitations when it comes to diverse patient populations,” Dr. Khera said in an interview. “We saw this in our study, where – despite a more than doubling of risk – the predicted risk based on the equations used in primary care showed no difference. This risk estimator was developed based on legacy cohort studies, in [which] zero South Asians were included. Despite important differences across race/ethnicity, the current state-of-the-art in the U.S. is to use one equation for Black individuals and another for all other ethnicities.”

Experts suggest steps for reducing heart disease risk

While risk modeling remains suboptimal, Dr. Khera suggested that clinicians can take immediate steps to reduce the risk of heart disease among individuals with South Asian ancestry.

“Despite all of the uncertainty – we still don’t have a complete understanding of why the risk is so high – there are still several things primary care doctors can do for their patients,” Dr. Khera said.

Foremost, he recommended lifestyle and dietary counseling.

“Dietary counseling is particularly effective if put in the context of cultural norms,” Dr. Khera said. “Many South Asians consider fruit juices or white rice to be healthy, when they lead to rapid spikes in blood sugar.”

Dr. Khera also advised earlier heart disease screening, such as coronary calcium scanning “sometime between age 40-50 years,” noting that positive test results may motivate patients to start or adhere to medications, such as cholesterol-lowering therapies. If necessary, clinicians can also refer to heart centers for South Asian patients, which are becoming increasingly common.

According to Cheryl A.M. Anderson, PhD, chair of the AHA’s Council on Epidemiology and Prevention, and professor and dean of the Herbert Wertheim School of Public Health and Human Longevity Science at the University of California, San Diego, the current study suggests that heart disease management strategies for South Asian patients may be lacking.

“We have had a tradition of preventing or trying to treat heart disease in a fashion that doesn’t yet account for the increased risk that might be prevalent in those of South Asian ancestry,” Dr. Anderson said in an interview.

She suggested that improving associated risk-analysis tools could be beneficial, although the tools themselves, in the context of race or ethnicity, may present their own risks.

“We want to be mindful of potential adverse implications from having everything linked to one’s ancestry, which I think this tool doesn’t do,” Dr. Anderson said, referring to the AHA/ACC Pooled Cohort Equations. “But in sort of the bigger picture of things, we always want to expand and refine our toolkit.”

According to Rajesh Dash, MD, PhD, associate professor, cardiologist, and director of the South Asian Translational Heart Initiative (SSATHI) Prevention Clinic and CardioClick Telemedicine Clinic at Stanford (Calif.) HealthCare, the science supports more active risk mitigation strategies for South Asian patients, and the AHA and the ACC “are the two entities that need to lead the way.”

“Certainly the American Heart Association and the American College of Cardiology should be taking a more active leadership role in this,” Dr. Dash said in an interview.

In 2018, the AHA issued a scientific statement about the elevated risk of ASCVD among South Asian individuals, “but it did not rise to the level of specific recommendations, and did not necessarily go as far as to incorporate new screening parameters for that population,” Dr. Dash said. He also noted that the most recent AHA/ACC guideline identifies South Asian ancestry as a risk-enhancing feature, a statement similarly lacking in actionable value.

“That does not definitively lead someone like a primary care physician to a decision to start a statin, or to be more aggressive with a diagnostic workup, like a stress test, for instance, for a patient who they otherwise would not have done one in had they not been South Asian,” Dr. Dash said.

The steps taken by the AHA and the ACC are “a healthy step forward,” he noted, “but not nearly the degree of attention or vigilance that is required, as well as the level of action that is required to change the narrative for the population.”

At the SSATHI Prevention Clinic, Dr. Dash and colleagues aren’t waiting for the narrative to change, and are already taking a more aggressive approach.

The clinic has an average patient age of 41 years, “easily 15 years younger than the average age in most cardiology clinics,” Dr. Dash said, based on the fact that approximately two-thirds of heart attacks in South Asian individuals occur under the age of 55. “We have to look earlier.”

The SSATHI Prevention Clinic screens for both traditional and emerging risk factors, and Dr. Dash suggested that primary care doctors should do the same.

“If you have a South Asian patient as a primary care physician, you should be aggressively looking for risk factors, traditional ones to start, like elevated cholesterol, hypertension, diabetes, or – and I would argue strongly – prediabetes or insulin resistance.”

Dr. Dash also recommended looking into family history, and considering screening for inflammatory biomarkers, the latter of which are commonly elevated at an earlier age among South Asian individuals, and may have a relatively greater prognostic impact.

To encourage broader implementation of this kind of approach, Dr. Dash called for more large-scale studies. Ideally, these would be randomized clinical trials, but, realistically, real-world datasets may be the answer.

The study was supported by the National Heart, Lung, and Blood Institute; the Broad Institute at MIT and Harvard; the National Human Genome Research Institute; and others. The investigators disclosed relationships with IBM Research, Sanofi, Amgen, and others. Dr. Dash disclosed relationships with HealthPals and AstraZeneca. Dr. Anderson reported no relevant conflicts of interest.

Individuals of South Asian ancestry face twice the risk of heart disease, compared with individuals of European descent, yet existing risk calculators fail to account for this disparity, according to the results of a new study.

These findings confirm previous reports and practice guidelines that identify South Asian ancestry as a risk enhancer for atherosclerotic cardiovascular disease (ASCVD), suggesting that earlier heart disease screening and prevention is warranted in this patient population, lead author Aniruddh P. Patel, MD, research fellow at the Center for Genomic Medicine, Massachusetts General Hospital, Boston, and colleagues said.

“Previous studies in multiple countries have estimated a 1.7- to 4-fold higher risk of ASCVD among South Asian individuals, compared with other ancestries, but have important potential limitations,” Dr. Patel and colleagues wrote in the paper on their prospective cohort study, published in Circulation.

The INTERHEART case-control study, for example, which assessed risk factors for acute myocardial infarction among more than 15,000 cases from 52 countries, is now 2 decades old, and “may not reflect recent advances in cardiovascular disease prevention,” the investigators wrote.

Most studies in the area have been small and retrospective, they added, and have not adequately assessed emerging risk factors, such as prediabetes, which appear to play a relatively greater role in the development of heart disease among South Asians.
 

Methods and results

To address this knowledge gap, Dr. Patel and colleagues analyzed data from the UK Biobank prospective cohort study, including 449,349 middle-aged participants of European ancestry and 8,124 similarly aged participants of South Asian descent who did not have heart disease upon enrollment. Respective rates of incident ASCVD (i.e., MI, ischemic stroke, or coronary revascularization) were analyzed in the context of a variety of lifestyle, anthropometric, and clinical factors.

After a median follow-up of 11.1 years, individuals of South Asian descent had an incident ASCVD rate of 6.8%, compared with 4.4% for individuals of European descent, representing twice the relative risk (adjusted hazard ratio, 2.03; 95% CI, 1.86-2.22; P < .001). Even after accounting for all covariates, risk of ASCVD remained 45% higher for South Asian individuals (aHR, 1.45; 95% CI, 1.28-1.65; P < .001). This elevation in risk was not captured by existing risk calculators, including the American College of Cardiology/American Heart Association Pooled Cohort Equations, or the QRISK3 equations.

The findings were “largely consistent across a range of age, sex, and clinical subgroups,” and “confirm and extend previous reports that hypertension, diabetes, and central adiposity are the leading associations in this observed disparity,” the investigators wrote.
 

Two diabetes subtypes are more prevalent in South Asians

Hypertension, diabetes, and central adiposity do not fully explain South Asians’ higher risk for ASCVD, wrote Namratha R. Kandula, MD, of Northwestern University Medical Center, Chicago, and Alka M. Kanaya, MD, of the University of California, San Francisco, in an accompanying editorial published in Circulation.

Some of the undetected risk may stem from unique diabetes disease factors, Dr. Kandula and Dr. Kanaya added.

“Newer data have demonstrated distinct subtypes of type 2 diabetes, with South Asians having a higher prevalence of both a severe insulin resistant with obesity subtype and a less recognized severe insulin deficient subtype,” they wrote. “Importantly, both of these more prevalent diabetes subtypes in South Asians were associated with a higher incidence of coronary artery calcium, a marker of subclinical atherosclerosis and strong predictor of future ASCVD, compared to other diabetes subtypes.”
 

Diabetes rate is higher for South Asians in the U.S.

Although the present study was conducted in the United Kingdom, the findings likely apply to individuals of South Asian ancestry living in the United States, according to principal author Amit V. Khera, MD, associate director of the precision medicine unit at the Center for Genomic Medicine, Massachusetts General Hospital.

“There are already more than 5 million individuals of South Asian ancestry in the U.S. and this represents one of the fastest-growing ethnic subgroups,” Dr. Khera said in an interview. “As in our study of individuals in the U.K., South Asians in the U.S. suffer from diabetes at much higher rates – 23% versus 12% – and this often occurs even in the absence of obesity.”

Dr. Khera noted that the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease identify South Asian ancestry as a risk-enhancing factor, calling this a “stopgap measure.” More work is needed, he said, in the research arena and in the clinic.
 

Zero South Asians included in studies used to develop risk estimator

“I think the first step is to simply acknowledge that the risk estimators we use in clinical practice have important limitations when it comes to diverse patient populations,” Dr. Khera said in an interview. “We saw this in our study, where – despite a more than doubling of risk – the predicted risk based on the equations used in primary care showed no difference. This risk estimator was developed based on legacy cohort studies, in [which] zero South Asians were included. Despite important differences across race/ethnicity, the current state-of-the-art in the U.S. is to use one equation for Black individuals and another for all other ethnicities.”

Experts suggest steps for reducing heart disease risk

While risk modeling remains suboptimal, Dr. Khera suggested that clinicians can take immediate steps to reduce the risk of heart disease among individuals with South Asian ancestry.

“Despite all of the uncertainty – we still don’t have a complete understanding of why the risk is so high – there are still several things primary care doctors can do for their patients,” Dr. Khera said.

Foremost, he recommended lifestyle and dietary counseling.

“Dietary counseling is particularly effective if put in the context of cultural norms,” Dr. Khera said. “Many South Asians consider fruit juices or white rice to be healthy, when they lead to rapid spikes in blood sugar.”

Dr. Khera also advised earlier heart disease screening, such as coronary calcium scanning “sometime between age 40-50 years,” noting that positive test results may motivate patients to start or adhere to medications, such as cholesterol-lowering therapies. If necessary, clinicians can also refer to heart centers for South Asian patients, which are becoming increasingly common.

According to Cheryl A.M. Anderson, PhD, chair of the AHA’s Council on Epidemiology and Prevention, and professor and dean of the Herbert Wertheim School of Public Health and Human Longevity Science at the University of California, San Diego, the current study suggests that heart disease management strategies for South Asian patients may be lacking.

“We have had a tradition of preventing or trying to treat heart disease in a fashion that doesn’t yet account for the increased risk that might be prevalent in those of South Asian ancestry,” Dr. Anderson said in an interview.

She suggested that improving associated risk-analysis tools could be beneficial, although the tools themselves, in the context of race or ethnicity, may present their own risks.

“We want to be mindful of potential adverse implications from having everything linked to one’s ancestry, which I think this tool doesn’t do,” Dr. Anderson said, referring to the AHA/ACC Pooled Cohort Equations. “But in sort of the bigger picture of things, we always want to expand and refine our toolkit.”

According to Rajesh Dash, MD, PhD, associate professor, cardiologist, and director of the South Asian Translational Heart Initiative (SSATHI) Prevention Clinic and CardioClick Telemedicine Clinic at Stanford (Calif.) HealthCare, the science supports more active risk mitigation strategies for South Asian patients, and the AHA and the ACC “are the two entities that need to lead the way.”

“Certainly the American Heart Association and the American College of Cardiology should be taking a more active leadership role in this,” Dr. Dash said in an interview.

In 2018, the AHA issued a scientific statement about the elevated risk of ASCVD among South Asian individuals, “but it did not rise to the level of specific recommendations, and did not necessarily go as far as to incorporate new screening parameters for that population,” Dr. Dash said. He also noted that the most recent AHA/ACC guideline identifies South Asian ancestry as a risk-enhancing feature, a statement similarly lacking in actionable value.

“That does not definitively lead someone like a primary care physician to a decision to start a statin, or to be more aggressive with a diagnostic workup, like a stress test, for instance, for a patient who they otherwise would not have done one in had they not been South Asian,” Dr. Dash said.

The steps taken by the AHA and the ACC are “a healthy step forward,” he noted, “but not nearly the degree of attention or vigilance that is required, as well as the level of action that is required to change the narrative for the population.”

At the SSATHI Prevention Clinic, Dr. Dash and colleagues aren’t waiting for the narrative to change, and are already taking a more aggressive approach.

The clinic has an average patient age of 41 years, “easily 15 years younger than the average age in most cardiology clinics,” Dr. Dash said, based on the fact that approximately two-thirds of heart attacks in South Asian individuals occur under the age of 55. “We have to look earlier.”

The SSATHI Prevention Clinic screens for both traditional and emerging risk factors, and Dr. Dash suggested that primary care doctors should do the same.

“If you have a South Asian patient as a primary care physician, you should be aggressively looking for risk factors, traditional ones to start, like elevated cholesterol, hypertension, diabetes, or – and I would argue strongly – prediabetes or insulin resistance.”

Dr. Dash also recommended looking into family history, and considering screening for inflammatory biomarkers, the latter of which are commonly elevated at an earlier age among South Asian individuals, and may have a relatively greater prognostic impact.

To encourage broader implementation of this kind of approach, Dr. Dash called for more large-scale studies. Ideally, these would be randomized clinical trials, but, realistically, real-world datasets may be the answer.

The study was supported by the National Heart, Lung, and Blood Institute; the Broad Institute at MIT and Harvard; the National Human Genome Research Institute; and others. The investigators disclosed relationships with IBM Research, Sanofi, Amgen, and others. Dr. Dash disclosed relationships with HealthPals and AstraZeneca. Dr. Anderson reported no relevant conflicts of interest.

Professional appearance of servicemembers has been a long-standing custom in the US Military. Specific standards are determined by each branch. Initially, men dominated the military.^1,2 As the number of women as well as racial diversity increased in the military, modifications to grooming standards were slow to change and resulted in female hair standards requiring a uniform tight and sleek style or short haircut. Clinicians can be attuned to these occupational standards and their implications on the diagnosis and management of common diseases of the hair and scalp.

History of Hairstyle Standards for Female Servicemembers

For half a century, female servicemembers had limited hairstyle choices. They were not authorized to have hair shorter than one-quarter inch in length. They could choose either short hair worn down or long hair with neatly secured loose ends in the form of a bun or a tucked braid—both of which could not extend past the bottom edge of the uniform collar.^3-5 Female navy sailors and air force airmen with long hair were only allowed to wear ponytails during physical training; however, army soldiers previously were limited to wearing a bun.^3,6,7 Cornrows and microbraids were authorized in the mid-1990s for the US Air Force, but policy stated that locs were prohibited due to their “unkempt” and “matted” nature. Furthermore, the size of hair bulk in the air force was restricted to no more than 3 inches and could not obstruct wear of the uniform cap.⁵ Based on these regulations, female servicemembers with longer hair had to utilize tight hairstyles that caused prolonged traction and pressure along the scalp, which contributed to headaches, a sore scalp, and alopecia over time. Normalization of these symptoms led to underreporting, as women lived with the consequences or turned to shorter hairstyles.

In the last decade alone, female servicemembers have witnessed the greatest number of changes in authorized hairstyles despite being part of the military for more than 50 years (Figure 1).^1-11 In 2014, the language used in the air force instructions to describe locs was revised to remove ethnically offensive terms.^4,5 This same year, the army allowed female soldiers to wear ponytails during physical training, a privilege that had been authorized by other services years prior.^3,6,7 By the end of 2018, locs were authorized by all services, and female sailors could wear a ponytail in all navy uniforms as long as it did not extend 3 inches below the collar.^3,4,6-8 In 2018, the air force increased authorized hair bulk up to 3.5 inches from the previous mandate of 3 inches and approved female buzz cuts^6,9; in 2020, it allowed hair bulk up to 4 inches. As of 2021, female airmen can wear a ponytail and/or braid(s) as long as it starts below the crown of the head and the length does not extend below a horizontal line running between the top of each sleeve inseam at the underarm (Figures 2–4).⁶ In an ongoing effort to be more inclusive of hair density differences, female airmen will be authorized to wear a ponytail not exceeding a maximum width bulk of 1 ft starting June 25, 2021, so long as they can comply with the above regulations.¹¹ The army now allows ponytails and braids across all uniforms, as long they do not extend past the bottom of the shoulder blades. This change came just months after authorizing the wearing of ponytails tucked under the uniform blouse with tactical headgear.¹⁰ These changes allow for a variety of hairstyles for members to practice while avoiding the physical consequences that develop from repetitive traction and pressure along the same areas of the hair and scalp.

Common Hair Disorders in Female Servicemembers

Herein, we discuss 3 of the most common hair and scalp disorders linked to grooming practices utilized by women to meet prior military regulations: trichorrhexis nodosa (TN), extracranial headaches, and traction alopecia (TA). It is essential that health care providers are able to promptly recognize these conditions, understand their risk factors, and be familiar with first-line treatment options. With these new standards, the hope is that the incidence of the following conditions decreases, thus improving servicemembers’ medical readiness and overall quality of life.

Trichorrhexis Nodosa
Acquired TN is a defect in the hair shaft that causes the hair to break easily secondary to chemical, thermal, or mechanical trauma. This can include but is not limited to chemical relaxers, blow-dryers, excessive brushing or styling, flat irons, and tightly packed hairstyles. The condition is characterized by a thickened hair diameter and splitting at the tip. Clinically, it may present as brittle, lusterless, broken hair with split ends, as well as a positive tug test.¹⁴ Management includes gentle hair care and avoidance of harsh hair care practices and treatments.

Extracranial Headaches
Headaches are a common concern among military servicemembers¹⁵ and generally are classified as primary or secondary. A less commonly discussed primary headache disorder includes external-pressure headaches, which result from either sustained compression or traction of the soft tissues of the scalp, usually from wearing headbands, helmets, or tight hairstyles.¹⁶ Additional at-risk groups include those who chronically wear surgical scrub caps or flight caps, especially if clipped or pinned to the hair. In our 38 years of combined military clinical experience, we can attest that these types of headaches are common among female servicemembers. The diagnostic criteria for an external-pressure headache, commonly referred to by patients as a “ponytail headache,” includes at least 2 headache episodes triggered within 1 hour of sustained traction on the scalp, maximal at the site of traction and resolving within 1 hour after relieving the traction.¹⁶ Management includes removal of the pressure-causing source, usually a tight ponytail or bun.

Traction Alopecia
Traction alopecia is hair loss caused by repetitive or prolonged tension on the hair secondary to tight hairstyles. It can be clinically classified into 2 types: marginal and nonmarginal patchy alopecia (Figure 5).^13,17,18 Traction alopecia most commonly is found in individuals with ethnic hair, predominantly Black women. Hairstyles with the highest risk for causing TA include tight buns, ponytails, cornrows, weaves, and locs—all of which are utilized by female servicemembers to maintain a professional appearance and adhere to grooming regulations.^13,18 Other groups at risk include athletes (eg, ballerinas, gymnasts) and those with chronic headwear use (eg, turbans, helmets, nurse caps, wigs).¹⁸ Early TA typically presents with perifollicular erythema followed by follicular-based papules or pustules.^13,18 Marginal TA classically includes frontotemporal hair loss or thinning with or without a fringe sign.^17,18 Nonmarginal TA includes patchy alopecia most commonly involving the parietal or occipital scalp, seen with chignons, buns, ponytails, or the use of clips, extensions, or bobby pins.¹⁸ The first line in management is avoidance of traction-causing hairstyles or headgear. Medical therapy may be warranted and consists of a single agent or combination regimen to include oral or topical antibiotics, topical or intralesional steroids, and topical minoxidil.^13,18

Final Thoughts

Military hair-grooming standards have evolved over time. Recent changes show that the US Department of Defense is seriously evaluating policies that may be inherently exclusive. Prior grooming standards resulted in the widespread use of tight hairstyles and harsh hair treatments among female servicemembers with long hair. These practices resulted in TN, extracranial headaches, and TA, among other hair and scalp disorders. These occupational-related hair conditions impact female servicemembers’ mental and physical well-being and thus impact military readiness. Physicians should recognize that these conditions can be related to occupational grooming standards that may impact hair care practices.

The challenge that remains is a lack of standardized documentation for hair and scalp symptoms in the medical record. Due to a paucity in reporting and documentation, limited objective data exist to guide future recommendations for military grooming standards. Another obstacle is the lack of knowledge of hair diseases among primary care providers and patients, especially due to the underrepresentation of ethnic hair in medical textbooks.¹⁹ As a result, women frequently accept their hair symptoms as normal and either suffer through them, cut their hair short, or wear wigs before considering a visit to the doctor. Furthermore, hair-grooming standards can expose racial disparities, which are the driving force behind the current policy changes. Clinicians can strive to ask about hair and scalp symptoms and document the following in relation to hair and scalp disorders: occupational grooming requirements; skin and hair type; location, number, and size of scalp lesion(s); onset; duration; current and prior hair care practices; history of treatment; and clinical course accompanied with photographic documentation. Ultimately, improved awareness in patients, collaboration between physicians, and consistent clinical documentation can help create positive change and continued improvement in hair-grooming standards within the military. Improved reporting and documentation will facilitate further study into the effectiveness of the updated hair-grooming standards in female servicemembers.

Professional appearance of servicemembers has been a long-standing custom in the US Military. Specific standards are determined by each branch. Initially, men dominated the military.^1,2 As the number of women as well as racial diversity increased in the military, modifications to grooming standards were slow to change and resulted in female hair standards requiring a uniform tight and sleek style or short haircut. Clinicians can be attuned to these occupational standards and their implications on the diagnosis and management of common diseases of the hair and scalp.

History of Hairstyle Standards for Female Servicemembers

For half a century, female servicemembers had limited hairstyle choices. They were not authorized to have hair shorter than one-quarter inch in length. They could choose either short hair worn down or long hair with neatly secured loose ends in the form of a bun or a tucked braid—both of which could not extend past the bottom edge of the uniform collar.^3-5 Female navy sailors and air force airmen with long hair were only allowed to wear ponytails during physical training; however, army soldiers previously were limited to wearing a bun.^3,6,7 Cornrows and microbraids were authorized in the mid-1990s for the US Air Force, but policy stated that locs were prohibited due to their “unkempt” and “matted” nature. Furthermore, the size of hair bulk in the air force was restricted to no more than 3 inches and could not obstruct wear of the uniform cap.⁵ Based on these regulations, female servicemembers with longer hair had to utilize tight hairstyles that caused prolonged traction and pressure along the scalp, which contributed to headaches, a sore scalp, and alopecia over time. Normalization of these symptoms led to underreporting, as women lived with the consequences or turned to shorter hairstyles.

In the last decade alone, female servicemembers have witnessed the greatest number of changes in authorized hairstyles despite being part of the military for more than 50 years (Figure 1).^1-11 In 2014, the language used in the air force instructions to describe locs was revised to remove ethnically offensive terms.^4,5 This same year, the army allowed female soldiers to wear ponytails during physical training, a privilege that had been authorized by other services years prior.^3,6,7 By the end of 2018, locs were authorized by all services, and female sailors could wear a ponytail in all navy uniforms as long as it did not extend 3 inches below the collar.^3,4,6-8 In 2018, the air force increased authorized hair bulk up to 3.5 inches from the previous mandate of 3 inches and approved female buzz cuts^6,9; in 2020, it allowed hair bulk up to 4 inches. As of 2021, female airmen can wear a ponytail and/or braid(s) as long as it starts below the crown of the head and the length does not extend below a horizontal line running between the top of each sleeve inseam at the underarm (Figures 2–4).⁶ In an ongoing effort to be more inclusive of hair density differences, female airmen will be authorized to wear a ponytail not exceeding a maximum width bulk of 1 ft starting June 25, 2021, so long as they can comply with the above regulations.¹¹ The army now allows ponytails and braids across all uniforms, as long they do not extend past the bottom of the shoulder blades. This change came just months after authorizing the wearing of ponytails tucked under the uniform blouse with tactical headgear.¹⁰ These changes allow for a variety of hairstyles for members to practice while avoiding the physical consequences that develop from repetitive traction and pressure along the same areas of the hair and scalp.

Common Hair Disorders in Female Servicemembers

Herein, we discuss 3 of the most common hair and scalp disorders linked to grooming practices utilized by women to meet prior military regulations: trichorrhexis nodosa (TN), extracranial headaches, and traction alopecia (TA). It is essential that health care providers are able to promptly recognize these conditions, understand their risk factors, and be familiar with first-line treatment options. With these new standards, the hope is that the incidence of the following conditions decreases, thus improving servicemembers’ medical readiness and overall quality of life.

Trichorrhexis Nodosa
Acquired TN is a defect in the hair shaft that causes the hair to break easily secondary to chemical, thermal, or mechanical trauma. This can include but is not limited to chemical relaxers, blow-dryers, excessive brushing or styling, flat irons, and tightly packed hairstyles. The condition is characterized by a thickened hair diameter and splitting at the tip. Clinically, it may present as brittle, lusterless, broken hair with split ends, as well as a positive tug test.¹⁴ Management includes gentle hair care and avoidance of harsh hair care practices and treatments.

Extracranial Headaches
Headaches are a common concern among military servicemembers¹⁵ and generally are classified as primary or secondary. A less commonly discussed primary headache disorder includes external-pressure headaches, which result from either sustained compression or traction of the soft tissues of the scalp, usually from wearing headbands, helmets, or tight hairstyles.¹⁶ Additional at-risk groups include those who chronically wear surgical scrub caps or flight caps, especially if clipped or pinned to the hair. In our 38 years of combined military clinical experience, we can attest that these types of headaches are common among female servicemembers. The diagnostic criteria for an external-pressure headache, commonly referred to by patients as a “ponytail headache,” includes at least 2 headache episodes triggered within 1 hour of sustained traction on the scalp, maximal at the site of traction and resolving within 1 hour after relieving the traction.¹⁶ Management includes removal of the pressure-causing source, usually a tight ponytail or bun.

Traction Alopecia
Traction alopecia is hair loss caused by repetitive or prolonged tension on the hair secondary to tight hairstyles. It can be clinically classified into 2 types: marginal and nonmarginal patchy alopecia (Figure 5).^13,17,18 Traction alopecia most commonly is found in individuals with ethnic hair, predominantly Black women. Hairstyles with the highest risk for causing TA include tight buns, ponytails, cornrows, weaves, and locs—all of which are utilized by female servicemembers to maintain a professional appearance and adhere to grooming regulations.^13,18 Other groups at risk include athletes (eg, ballerinas, gymnasts) and those with chronic headwear use (eg, turbans, helmets, nurse caps, wigs).¹⁸ Early TA typically presents with perifollicular erythema followed by follicular-based papules or pustules.^13,18 Marginal TA classically includes frontotemporal hair loss or thinning with or without a fringe sign.^17,18 Nonmarginal TA includes patchy alopecia most commonly involving the parietal or occipital scalp, seen with chignons, buns, ponytails, or the use of clips, extensions, or bobby pins.¹⁸ The first line in management is avoidance of traction-causing hairstyles or headgear. Medical therapy may be warranted and consists of a single agent or combination regimen to include oral or topical antibiotics, topical or intralesional steroids, and topical minoxidil.^13,18

Final Thoughts

Military hair-grooming standards have evolved over time. Recent changes show that the US Department of Defense is seriously evaluating policies that may be inherently exclusive. Prior grooming standards resulted in the widespread use of tight hairstyles and harsh hair treatments among female servicemembers with long hair. These practices resulted in TN, extracranial headaches, and TA, among other hair and scalp disorders. These occupational-related hair conditions impact female servicemembers’ mental and physical well-being and thus impact military readiness. Physicians should recognize that these conditions can be related to occupational grooming standards that may impact hair care practices.

The challenge that remains is a lack of standardized documentation for hair and scalp symptoms in the medical record. Due to a paucity in reporting and documentation, limited objective data exist to guide future recommendations for military grooming standards. Another obstacle is the lack of knowledge of hair diseases among primary care providers and patients, especially due to the underrepresentation of ethnic hair in medical textbooks.¹⁹ As a result, women frequently accept their hair symptoms as normal and either suffer through them, cut their hair short, or wear wigs before considering a visit to the doctor. Furthermore, hair-grooming standards can expose racial disparities, which are the driving force behind the current policy changes. Clinicians can strive to ask about hair and scalp symptoms and document the following in relation to hair and scalp disorders: occupational grooming requirements; skin and hair type; location, number, and size of scalp lesion(s); onset; duration; current and prior hair care practices; history of treatment; and clinical course accompanied with photographic documentation. Ultimately, improved awareness in patients, collaboration between physicians, and consistent clinical documentation can help create positive change and continued improvement in hair-grooming standards within the military. Improved reporting and documentation will facilitate further study into the effectiveness of the updated hair-grooming standards in female servicemembers.

Professional appearance of servicemembers has been a long-standing custom in the US Military. Specific standards are determined by each branch. Initially, men dominated the military.^1,2 As the number of women as well as racial diversity increased in the military, modifications to grooming standards were slow to change and resulted in female hair standards requiring a uniform tight and sleek style or short haircut. Clinicians can be attuned to these occupational standards and their implications on the diagnosis and management of common diseases of the hair and scalp.

History of Hairstyle Standards for Female Servicemembers

For half a century, female servicemembers had limited hairstyle choices. They were not authorized to have hair shorter than one-quarter inch in length. They could choose either short hair worn down or long hair with neatly secured loose ends in the form of a bun or a tucked braid—both of which could not extend past the bottom edge of the uniform collar.^3-5 Female navy sailors and air force airmen with long hair were only allowed to wear ponytails during physical training; however, army soldiers previously were limited to wearing a bun.^3,6,7 Cornrows and microbraids were authorized in the mid-1990s for the US Air Force, but policy stated that locs were prohibited due to their “unkempt” and “matted” nature. Furthermore, the size of hair bulk in the air force was restricted to no more than 3 inches and could not obstruct wear of the uniform cap.⁵ Based on these regulations, female servicemembers with longer hair had to utilize tight hairstyles that caused prolonged traction and pressure along the scalp, which contributed to headaches, a sore scalp, and alopecia over time. Normalization of these symptoms led to underreporting, as women lived with the consequences or turned to shorter hairstyles.

In the last decade alone, female servicemembers have witnessed the greatest number of changes in authorized hairstyles despite being part of the military for more than 50 years (Figure 1).^1-11 In 2014, the language used in the air force instructions to describe locs was revised to remove ethnically offensive terms.^4,5 This same year, the army allowed female soldiers to wear ponytails during physical training, a privilege that had been authorized by other services years prior.^3,6,7 By the end of 2018, locs were authorized by all services, and female sailors could wear a ponytail in all navy uniforms as long as it did not extend 3 inches below the collar.^3,4,6-8 In 2018, the air force increased authorized hair bulk up to 3.5 inches from the previous mandate of 3 inches and approved female buzz cuts^6,9; in 2020, it allowed hair bulk up to 4 inches. As of 2021, female airmen can wear a ponytail and/or braid(s) as long as it starts below the crown of the head and the length does not extend below a horizontal line running between the top of each sleeve inseam at the underarm (Figures 2–4).⁶ In an ongoing effort to be more inclusive of hair density differences, female airmen will be authorized to wear a ponytail not exceeding a maximum width bulk of 1 ft starting June 25, 2021, so long as they can comply with the above regulations.¹¹ The army now allows ponytails and braids across all uniforms, as long they do not extend past the bottom of the shoulder blades. This change came just months after authorizing the wearing of ponytails tucked under the uniform blouse with tactical headgear.¹⁰ These changes allow for a variety of hairstyles for members to practice while avoiding the physical consequences that develop from repetitive traction and pressure along the same areas of the hair and scalp.

Common Hair Disorders in Female Servicemembers

Herein, we discuss 3 of the most common hair and scalp disorders linked to grooming practices utilized by women to meet prior military regulations: trichorrhexis nodosa (TN), extracranial headaches, and traction alopecia (TA). It is essential that health care providers are able to promptly recognize these conditions, understand their risk factors, and be familiar with first-line treatment options. With these new standards, the hope is that the incidence of the following conditions decreases, thus improving servicemembers’ medical readiness and overall quality of life.

Trichorrhexis Nodosa
Acquired TN is a defect in the hair shaft that causes the hair to break easily secondary to chemical, thermal, or mechanical trauma. This can include but is not limited to chemical relaxers, blow-dryers, excessive brushing or styling, flat irons, and tightly packed hairstyles. The condition is characterized by a thickened hair diameter and splitting at the tip. Clinically, it may present as brittle, lusterless, broken hair with split ends, as well as a positive tug test.¹⁴ Management includes gentle hair care and avoidance of harsh hair care practices and treatments.

Extracranial Headaches
Headaches are a common concern among military servicemembers¹⁵ and generally are classified as primary or secondary. A less commonly discussed primary headache disorder includes external-pressure headaches, which result from either sustained compression or traction of the soft tissues of the scalp, usually from wearing headbands, helmets, or tight hairstyles.¹⁶ Additional at-risk groups include those who chronically wear surgical scrub caps or flight caps, especially if clipped or pinned to the hair. In our 38 years of combined military clinical experience, we can attest that these types of headaches are common among female servicemembers. The diagnostic criteria for an external-pressure headache, commonly referred to by patients as a “ponytail headache,” includes at least 2 headache episodes triggered within 1 hour of sustained traction on the scalp, maximal at the site of traction and resolving within 1 hour after relieving the traction.¹⁶ Management includes removal of the pressure-causing source, usually a tight ponytail or bun.

Traction Alopecia
Traction alopecia is hair loss caused by repetitive or prolonged tension on the hair secondary to tight hairstyles. It can be clinically classified into 2 types: marginal and nonmarginal patchy alopecia (Figure 5).^13,17,18 Traction alopecia most commonly is found in individuals with ethnic hair, predominantly Black women. Hairstyles with the highest risk for causing TA include tight buns, ponytails, cornrows, weaves, and locs—all of which are utilized by female servicemembers to maintain a professional appearance and adhere to grooming regulations.^13,18 Other groups at risk include athletes (eg, ballerinas, gymnasts) and those with chronic headwear use (eg, turbans, helmets, nurse caps, wigs).¹⁸ Early TA typically presents with perifollicular erythema followed by follicular-based papules or pustules.^13,18 Marginal TA classically includes frontotemporal hair loss or thinning with or without a fringe sign.^17,18 Nonmarginal TA includes patchy alopecia most commonly involving the parietal or occipital scalp, seen with chignons, buns, ponytails, or the use of clips, extensions, or bobby pins.¹⁸ The first line in management is avoidance of traction-causing hairstyles or headgear. Medical therapy may be warranted and consists of a single agent or combination regimen to include oral or topical antibiotics, topical or intralesional steroids, and topical minoxidil.^13,18

Final Thoughts

Military hair-grooming standards have evolved over time. Recent changes show that the US Department of Defense is seriously evaluating policies that may be inherently exclusive. Prior grooming standards resulted in the widespread use of tight hairstyles and harsh hair treatments among female servicemembers with long hair. These practices resulted in TN, extracranial headaches, and TA, among other hair and scalp disorders. These occupational-related hair conditions impact female servicemembers’ mental and physical well-being and thus impact military readiness. Physicians should recognize that these conditions can be related to occupational grooming standards that may impact hair care practices.

The challenge that remains is a lack of standardized documentation for hair and scalp symptoms in the medical record. Due to a paucity in reporting and documentation, limited objective data exist to guide future recommendations for military grooming standards. Another obstacle is the lack of knowledge of hair diseases among primary care providers and patients, especially due to the underrepresentation of ethnic hair in medical textbooks.¹⁹ As a result, women frequently accept their hair symptoms as normal and either suffer through them, cut their hair short, or wear wigs before considering a visit to the doctor. Furthermore, hair-grooming standards can expose racial disparities, which are the driving force behind the current policy changes. Clinicians can strive to ask about hair and scalp symptoms and document the following in relation to hair and scalp disorders: occupational grooming requirements; skin and hair type; location, number, and size of scalp lesion(s); onset; duration; current and prior hair care practices; history of treatment; and clinical course accompanied with photographic documentation. Ultimately, improved awareness in patients, collaboration between physicians, and consistent clinical documentation can help create positive change and continued improvement in hair-grooming standards within the military. Improved reporting and documentation will facilitate further study into the effectiveness of the updated hair-grooming standards in female servicemembers.

The world is an increasingly diverse place, which has particular relevance for the dermatologist. Skin color plays a significant role in diagnostic approach, as there are important differences in how cutaneous disease presents in patients with skin of color (SOC). Therefore, education about these differences is imperative. In this review, we focus on allergic contact dermatitis (ACD) and patch testing in patients with SOC. We discuss allergens common to this demographic and challenges encountered in patch testing patients with SOC. We also identify key health care disparities in the evaluation and management of ACD in this population.

Has contact allergy in SOC populations been studied in North America?

Over the last 2 decades, there have been only a handful of North American studies that address contact allergy in SOC populations. Patch test results from 114 Black patients and 877 White patients at the Cleveland Clinic from 1988 to 1991 showed that overall allergy frequency was relatively similar (43.0% vs 43.6%). There were notable differences in allergen sensitization. Paraphenylenediamine (PPD), which is used in hair dye, had more positive patch test reactions in Black patients (10.6% vs 4.5%), and both PPD (21.2% vs 4.2%) and imidazolidinyl urea, a formaldehyde-releasing preservative (9.1% vs 2.6%), were more frequently allergenic in Black men compared to White men.¹ Patch test results from the North American Contact Dermatitis Group from 1992 to 1998 described similar results, with minimal variation in the prevalence of ACD among 1014 Black and 8610 White patients (47%–49% vs 46%–49%).² Positive patch test reactions to PPD were higher in Black patients for 2 of 3 test cycles (13.5% vs 5.8% [1994-1996] and 10.3% vs 5.3% [1996-1998]). Positive patch test reactions were higher in White patients for dimethylol dimethyl hydantoin, a formaldehyde-releasing preservative, also for 2 of 3 test cycles (1.8% vs 0% [1992-1994] and 2.8% vs 0.3% [1994-1996]). Finally, positive patch test reactions to thioureas (rubber accelerators) had a mixed picture: 2 test cycles were higher in Black patients (1.9% vs 1.0% [1992-1994] and 1.3% vs 0.7% [1994-1996]), but the third cycle (1996-1998) was lower (0.7% vs 1.4%). Positive patch test reactions to the metal cobalt chloride were higher in Black patients in just 1 test cycle (9.2% vs 6.6% [1992-1994]). The authors suggested that the use of darker hair dyes in the Black community may lead to more sensitization to PPD. They also theorized that this population’s more frequent use of ointment-based skin care products may make them less susceptible to sensitization to preservatives such as formaldehyde, which more commonly are found in water-based products such as creams. They concluded that differences in sensitization patterns likely were driven by cultural practices affecting exposures.²

In 2016, the North American Contact Dermatitis Group reported patch test results in 434 Black and 6634 White patients (1998-2006).³ Again, ACD prevalence was about the same in both groups (45.9% vs 43.6%). However, they reported several allergens with different reaction patterns. Black patients had higher risk ratios (RRs) for 3 rubber accelerators: mercaptobenzothiazole (RR, 2.10), mercapto mix (RR, 2.27), and thiuram mix (RR, 1.44). They also reacted to PPD (RR, 1.56) and the antibiotic bacitracin (RR, 1.34) at higher frequencies than White patients, who more frequently reacted to formaldehyde (RR, 0.58); the formaldehyde-releasing preservatives quaternium-15 (RR, 0.63) and diazolidinyl urea (in petrolatum: RR, 0.44; aqueous: RR, 0.47); the clothing finish ethylene urea melamine formalin resin (RR, 0.45); and the fragrances fragrance mix 1 (RR, 0.65) and balsam of Peru (RR, 0.55).³

Patch testing of 139 African American or Black patients at the Cleveland Clinic (2003-2012) revealed that this population most commonly had positive reactions to nickel (27.5%), fragrance mix (18.1%), bacitracin (13.0%), balsam of Peru (12.3%), and PPD (10.9%). The authors highlighted unique features of physical examination in patients with darker skin types, including lichenification and/or hyperpigmentation in those with ACD and the potential for lack of erythema and/or a papular reaction with patch test readings.⁴ Recently, data was presented at the American Contact Dermatitis Society Annual Meeting (March 2021) on patterns of ACD in Black and White patch tested patients in Philadelphia (2009-2019).⁵ Using the North American 80 comprehensive series, the researchers documented statistically significant differences in allergen sensitivity between the 2 groups. Black patients reacted to disperse blue dye (P=.019) and textile dye mix (P=.001) at higher frequencies. There was a nonsignificant trend of more frequent positive reactions to PPD in Black patients (11% vs 6%).⁵

Notably, all of these studies examined only 1 or 2 racial groups with a focus on Black patients. Some authors commented that this was due to low numbers of Hispanic, Asian and Pacific Islander, and Native American patients in tested populations.^2,3,5 With approximately 13% of the US population self-identifying as Black,⁶ these patients and other minority races typically are underrepresented in large patch test studies. More data on patch test results for these groups is necessary for a complete understanding of patch testing in patients with SOC.

What are the challenges in patch testing SOC populations?

Patch testing in patients with SOC requires additional skills and experience. Darker skin does not reveal erythema as strikingly as lighter skin, making it more difficult to appreciate subtle color changes. Moreover, multiple studies have shown that ACD can have different presentations in Black patients.^4,7,8 Lichenification and hyperpigmentation may be early signs of ACD in comparison to bright erythema and vesicles that can be seen in lighter skin types. It also has been reported that scalp ACD can be mistaken for seborrheic dermatitis due to lack of erythema.⁷ Without a high degree of clinical suspicion, a diagnosis of ACD can be missed in this patient population.

Patch test interpretation also can be challenging in patients with SOC. An early papular or follicular eruption with minimal erythema can signal a positive reaction.^4,7 Because of these potentially subtle changes, patch testers should exercise care and attention when reading results for SOC populations. We recommend ample side lighting, palpation for adequate identification of positive reactions, and double-checking for positives that may have been overlooked on the initial review of findings.^4,7

What health care disparities impact the evaluation and management of ACD?

There are many factors at play in this dialogue. The challenges we identified in diagnosing ACD in darker skin types are important to consider. Lack of familiarity with these unique features can lead to a delay in diagnosis and ultimately a delay in referral for patch testing. This is where dermatology training can help fill in the gap, but are the majority of programs equipped to do so? Inadequate education and exposure to patients with SOC is an issue for many dermatology residency programs. Surveys of residents and program directors in geographically less diverse regions may not receive adequate education or exposure to patients with SOC.⁹ Further, there is a lack of representation of SOC images for general dermatologic conditions in textbooks,^10,11 which has a profound impact on the dermatologist’s ability to recognize common diseases in darker skin types. A 2019 survey of more than 5000 images from 2 dermatology textbooks showed SOC images comprised 22% to 32% of the total images.¹¹ However, SOC images are overrepresented in textbooks for sexually transmitted infections, constituting 47% to 58% of the images; they made up 28% of images for nonvenereal infections.¹¹ Why is that? In this article, we have shown the prevalence of ACD to be nearly equivalent in Black and White patients, yet a perusal of ACD images in dermatology textbooks will tell a different story. This trend deserves our attention; perhaps it is highlighting patterns of systemic racism seen in medicine. If our primary teaching materials are perpetuating stereotypes, we must consider the impact this can have on our personal implicit biases and the health care disparities that can ensue.

Additional factors impact time to diagnosis of ACD and referral for patch testing. A retrospective study examining distance to a North Carolina patch test referral clinic showed that patients living further from the clinic experienced a longer duration of dermatitis prior to patch test consultation and tended to live in areas with a higher county poverty rate.¹² Specifically, a 17.9% increase (P<.001) in the median duration of dermatitis was observed for every 50-mile increase in distance to the patch test clinic. County poverty rate was measured by the percentage of residents living below the poverty threshold; for every 5% increase in county poverty rate, a 16.3% increase (P<.032) in duration of dermatitis was found.¹²

These data highlight a relationship with which many dermatologists are familiar and underscore a need for dermatologists to practice in areas that are more geographically accessible. The recently increased utilization of telehealth modalities can potentially help to bridge this gap by decreasing delays in diagnosis and providing more affordable options for evaluation by a dermatologist for patients with socioeconomic obstacles.

Final Interpretation

The prevalence of ACD among Black and White patients is similar; however, there are important differences in patch test reaction frequencies that may be related to the diverse exposure patterns for each group. Additionally, patients with SOC may have unique clinical presentations of ACD, such as lichenification and hyperpigmentation. Darker skin types also may require specialized techniques for accurate patch test readings. It is imperative that dermatologists are trained to recognize all of these features. Health care disparities come in many forms and, in this setting, can result in delayed referral for patch testing. Additional studies are needed to further examine these health care disparities and identify potential solutions.

The world is an increasingly diverse place, which has particular relevance for the dermatologist. Skin color plays a significant role in diagnostic approach, as there are important differences in how cutaneous disease presents in patients with skin of color (SOC). Therefore, education about these differences is imperative. In this review, we focus on allergic contact dermatitis (ACD) and patch testing in patients with SOC. We discuss allergens common to this demographic and challenges encountered in patch testing patients with SOC. We also identify key health care disparities in the evaluation and management of ACD in this population.

Has contact allergy in SOC populations been studied in North America?

Over the last 2 decades, there have been only a handful of North American studies that address contact allergy in SOC populations. Patch test results from 114 Black patients and 877 White patients at the Cleveland Clinic from 1988 to 1991 showed that overall allergy frequency was relatively similar (43.0% vs 43.6%). There were notable differences in allergen sensitization. Paraphenylenediamine (PPD), which is used in hair dye, had more positive patch test reactions in Black patients (10.6% vs 4.5%), and both PPD (21.2% vs 4.2%) and imidazolidinyl urea, a formaldehyde-releasing preservative (9.1% vs 2.6%), were more frequently allergenic in Black men compared to White men.¹ Patch test results from the North American Contact Dermatitis Group from 1992 to 1998 described similar results, with minimal variation in the prevalence of ACD among 1014 Black and 8610 White patients (47%–49% vs 46%–49%).² Positive patch test reactions to PPD were higher in Black patients for 2 of 3 test cycles (13.5% vs 5.8% [1994-1996] and 10.3% vs 5.3% [1996-1998]). Positive patch test reactions were higher in White patients for dimethylol dimethyl hydantoin, a formaldehyde-releasing preservative, also for 2 of 3 test cycles (1.8% vs 0% [1992-1994] and 2.8% vs 0.3% [1994-1996]). Finally, positive patch test reactions to thioureas (rubber accelerators) had a mixed picture: 2 test cycles were higher in Black patients (1.9% vs 1.0% [1992-1994] and 1.3% vs 0.7% [1994-1996]), but the third cycle (1996-1998) was lower (0.7% vs 1.4%). Positive patch test reactions to the metal cobalt chloride were higher in Black patients in just 1 test cycle (9.2% vs 6.6% [1992-1994]). The authors suggested that the use of darker hair dyes in the Black community may lead to more sensitization to PPD. They also theorized that this population’s more frequent use of ointment-based skin care products may make them less susceptible to sensitization to preservatives such as formaldehyde, which more commonly are found in water-based products such as creams. They concluded that differences in sensitization patterns likely were driven by cultural practices affecting exposures.²

In 2016, the North American Contact Dermatitis Group reported patch test results in 434 Black and 6634 White patients (1998-2006).³ Again, ACD prevalence was about the same in both groups (45.9% vs 43.6%). However, they reported several allergens with different reaction patterns. Black patients had higher risk ratios (RRs) for 3 rubber accelerators: mercaptobenzothiazole (RR, 2.10), mercapto mix (RR, 2.27), and thiuram mix (RR, 1.44). They also reacted to PPD (RR, 1.56) and the antibiotic bacitracin (RR, 1.34) at higher frequencies than White patients, who more frequently reacted to formaldehyde (RR, 0.58); the formaldehyde-releasing preservatives quaternium-15 (RR, 0.63) and diazolidinyl urea (in petrolatum: RR, 0.44; aqueous: RR, 0.47); the clothing finish ethylene urea melamine formalin resin (RR, 0.45); and the fragrances fragrance mix 1 (RR, 0.65) and balsam of Peru (RR, 0.55).³

Patch testing of 139 African American or Black patients at the Cleveland Clinic (2003-2012) revealed that this population most commonly had positive reactions to nickel (27.5%), fragrance mix (18.1%), bacitracin (13.0%), balsam of Peru (12.3%), and PPD (10.9%). The authors highlighted unique features of physical examination in patients with darker skin types, including lichenification and/or hyperpigmentation in those with ACD and the potential for lack of erythema and/or a papular reaction with patch test readings.⁴ Recently, data was presented at the American Contact Dermatitis Society Annual Meeting (March 2021) on patterns of ACD in Black and White patch tested patients in Philadelphia (2009-2019).⁵ Using the North American 80 comprehensive series, the researchers documented statistically significant differences in allergen sensitivity between the 2 groups. Black patients reacted to disperse blue dye (P=.019) and textile dye mix (P=.001) at higher frequencies. There was a nonsignificant trend of more frequent positive reactions to PPD in Black patients (11% vs 6%).⁵

Notably, all of these studies examined only 1 or 2 racial groups with a focus on Black patients. Some authors commented that this was due to low numbers of Hispanic, Asian and Pacific Islander, and Native American patients in tested populations.^2,3,5 With approximately 13% of the US population self-identifying as Black,⁶ these patients and other minority races typically are underrepresented in large patch test studies. More data on patch test results for these groups is necessary for a complete understanding of patch testing in patients with SOC.

What are the challenges in patch testing SOC populations?

Patch testing in patients with SOC requires additional skills and experience. Darker skin does not reveal erythema as strikingly as lighter skin, making it more difficult to appreciate subtle color changes. Moreover, multiple studies have shown that ACD can have different presentations in Black patients.^4,7,8 Lichenification and hyperpigmentation may be early signs of ACD in comparison to bright erythema and vesicles that can be seen in lighter skin types. It also has been reported that scalp ACD can be mistaken for seborrheic dermatitis due to lack of erythema.⁷ Without a high degree of clinical suspicion, a diagnosis of ACD can be missed in this patient population.

Patch test interpretation also can be challenging in patients with SOC. An early papular or follicular eruption with minimal erythema can signal a positive reaction.^4,7 Because of these potentially subtle changes, patch testers should exercise care and attention when reading results for SOC populations. We recommend ample side lighting, palpation for adequate identification of positive reactions, and double-checking for positives that may have been overlooked on the initial review of findings.^4,7

What health care disparities impact the evaluation and management of ACD?

There are many factors at play in this dialogue. The challenges we identified in diagnosing ACD in darker skin types are important to consider. Lack of familiarity with these unique features can lead to a delay in diagnosis and ultimately a delay in referral for patch testing. This is where dermatology training can help fill in the gap, but are the majority of programs equipped to do so? Inadequate education and exposure to patients with SOC is an issue for many dermatology residency programs. Surveys of residents and program directors in geographically less diverse regions may not receive adequate education or exposure to patients with SOC.⁹ Further, there is a lack of representation of SOC images for general dermatologic conditions in textbooks,^10,11 which has a profound impact on the dermatologist’s ability to recognize common diseases in darker skin types. A 2019 survey of more than 5000 images from 2 dermatology textbooks showed SOC images comprised 22% to 32% of the total images.¹¹ However, SOC images are overrepresented in textbooks for sexually transmitted infections, constituting 47% to 58% of the images; they made up 28% of images for nonvenereal infections.¹¹ Why is that? In this article, we have shown the prevalence of ACD to be nearly equivalent in Black and White patients, yet a perusal of ACD images in dermatology textbooks will tell a different story. This trend deserves our attention; perhaps it is highlighting patterns of systemic racism seen in medicine. If our primary teaching materials are perpetuating stereotypes, we must consider the impact this can have on our personal implicit biases and the health care disparities that can ensue.

Additional factors impact time to diagnosis of ACD and referral for patch testing. A retrospective study examining distance to a North Carolina patch test referral clinic showed that patients living further from the clinic experienced a longer duration of dermatitis prior to patch test consultation and tended to live in areas with a higher county poverty rate.¹² Specifically, a 17.9% increase (P<.001) in the median duration of dermatitis was observed for every 50-mile increase in distance to the patch test clinic. County poverty rate was measured by the percentage of residents living below the poverty threshold; for every 5% increase in county poverty rate, a 16.3% increase (P<.032) in duration of dermatitis was found.¹²

These data highlight a relationship with which many dermatologists are familiar and underscore a need for dermatologists to practice in areas that are more geographically accessible. The recently increased utilization of telehealth modalities can potentially help to bridge this gap by decreasing delays in diagnosis and providing more affordable options for evaluation by a dermatologist for patients with socioeconomic obstacles.

Final Interpretation

The prevalence of ACD among Black and White patients is similar; however, there are important differences in patch test reaction frequencies that may be related to the diverse exposure patterns for each group. Additionally, patients with SOC may have unique clinical presentations of ACD, such as lichenification and hyperpigmentation. Darker skin types also may require specialized techniques for accurate patch test readings. It is imperative that dermatologists are trained to recognize all of these features. Health care disparities come in many forms and, in this setting, can result in delayed referral for patch testing. Additional studies are needed to further examine these health care disparities and identify potential solutions.

The world is an increasingly diverse place, which has particular relevance for the dermatologist. Skin color plays a significant role in diagnostic approach, as there are important differences in how cutaneous disease presents in patients with skin of color (SOC). Therefore, education about these differences is imperative. In this review, we focus on allergic contact dermatitis (ACD) and patch testing in patients with SOC. We discuss allergens common to this demographic and challenges encountered in patch testing patients with SOC. We also identify key health care disparities in the evaluation and management of ACD in this population.

Has contact allergy in SOC populations been studied in North America?

Over the last 2 decades, there have been only a handful of North American studies that address contact allergy in SOC populations. Patch test results from 114 Black patients and 877 White patients at the Cleveland Clinic from 1988 to 1991 showed that overall allergy frequency was relatively similar (43.0% vs 43.6%). There were notable differences in allergen sensitization. Paraphenylenediamine (PPD), which is used in hair dye, had more positive patch test reactions in Black patients (10.6% vs 4.5%), and both PPD (21.2% vs 4.2%) and imidazolidinyl urea, a formaldehyde-releasing preservative (9.1% vs 2.6%), were more frequently allergenic in Black men compared to White men.¹ Patch test results from the North American Contact Dermatitis Group from 1992 to 1998 described similar results, with minimal variation in the prevalence of ACD among 1014 Black and 8610 White patients (47%–49% vs 46%–49%).² Positive patch test reactions to PPD were higher in Black patients for 2 of 3 test cycles (13.5% vs 5.8% [1994-1996] and 10.3% vs 5.3% [1996-1998]). Positive patch test reactions were higher in White patients for dimethylol dimethyl hydantoin, a formaldehyde-releasing preservative, also for 2 of 3 test cycles (1.8% vs 0% [1992-1994] and 2.8% vs 0.3% [1994-1996]). Finally, positive patch test reactions to thioureas (rubber accelerators) had a mixed picture: 2 test cycles were higher in Black patients (1.9% vs 1.0% [1992-1994] and 1.3% vs 0.7% [1994-1996]), but the third cycle (1996-1998) was lower (0.7% vs 1.4%). Positive patch test reactions to the metal cobalt chloride were higher in Black patients in just 1 test cycle (9.2% vs 6.6% [1992-1994]). The authors suggested that the use of darker hair dyes in the Black community may lead to more sensitization to PPD. They also theorized that this population’s more frequent use of ointment-based skin care products may make them less susceptible to sensitization to preservatives such as formaldehyde, which more commonly are found in water-based products such as creams. They concluded that differences in sensitization patterns likely were driven by cultural practices affecting exposures.²

In 2016, the North American Contact Dermatitis Group reported patch test results in 434 Black and 6634 White patients (1998-2006).³ Again, ACD prevalence was about the same in both groups (45.9% vs 43.6%). However, they reported several allergens with different reaction patterns. Black patients had higher risk ratios (RRs) for 3 rubber accelerators: mercaptobenzothiazole (RR, 2.10), mercapto mix (RR, 2.27), and thiuram mix (RR, 1.44). They also reacted to PPD (RR, 1.56) and the antibiotic bacitracin (RR, 1.34) at higher frequencies than White patients, who more frequently reacted to formaldehyde (RR, 0.58); the formaldehyde-releasing preservatives quaternium-15 (RR, 0.63) and diazolidinyl urea (in petrolatum: RR, 0.44; aqueous: RR, 0.47); the clothing finish ethylene urea melamine formalin resin (RR, 0.45); and the fragrances fragrance mix 1 (RR, 0.65) and balsam of Peru (RR, 0.55).³

Patch testing of 139 African American or Black patients at the Cleveland Clinic (2003-2012) revealed that this population most commonly had positive reactions to nickel (27.5%), fragrance mix (18.1%), bacitracin (13.0%), balsam of Peru (12.3%), and PPD (10.9%). The authors highlighted unique features of physical examination in patients with darker skin types, including lichenification and/or hyperpigmentation in those with ACD and the potential for lack of erythema and/or a papular reaction with patch test readings.⁴ Recently, data was presented at the American Contact Dermatitis Society Annual Meeting (March 2021) on patterns of ACD in Black and White patch tested patients in Philadelphia (2009-2019).⁵ Using the North American 80 comprehensive series, the researchers documented statistically significant differences in allergen sensitivity between the 2 groups. Black patients reacted to disperse blue dye (P=.019) and textile dye mix (P=.001) at higher frequencies. There was a nonsignificant trend of more frequent positive reactions to PPD in Black patients (11% vs 6%).⁵

Notably, all of these studies examined only 1 or 2 racial groups with a focus on Black patients. Some authors commented that this was due to low numbers of Hispanic, Asian and Pacific Islander, and Native American patients in tested populations.^2,3,5 With approximately 13% of the US population self-identifying as Black,⁶ these patients and other minority races typically are underrepresented in large patch test studies. More data on patch test results for these groups is necessary for a complete understanding of patch testing in patients with SOC.

What are the challenges in patch testing SOC populations?

Patch testing in patients with SOC requires additional skills and experience. Darker skin does not reveal erythema as strikingly as lighter skin, making it more difficult to appreciate subtle color changes. Moreover, multiple studies have shown that ACD can have different presentations in Black patients.^4,7,8 Lichenification and hyperpigmentation may be early signs of ACD in comparison to bright erythema and vesicles that can be seen in lighter skin types. It also has been reported that scalp ACD can be mistaken for seborrheic dermatitis due to lack of erythema.⁷ Without a high degree of clinical suspicion, a diagnosis of ACD can be missed in this patient population.

Patch test interpretation also can be challenging in patients with SOC. An early papular or follicular eruption with minimal erythema can signal a positive reaction.^4,7 Because of these potentially subtle changes, patch testers should exercise care and attention when reading results for SOC populations. We recommend ample side lighting, palpation for adequate identification of positive reactions, and double-checking for positives that may have been overlooked on the initial review of findings.^4,7

What health care disparities impact the evaluation and management of ACD?

There are many factors at play in this dialogue. The challenges we identified in diagnosing ACD in darker skin types are important to consider. Lack of familiarity with these unique features can lead to a delay in diagnosis and ultimately a delay in referral for patch testing. This is where dermatology training can help fill in the gap, but are the majority of programs equipped to do so? Inadequate education and exposure to patients with SOC is an issue for many dermatology residency programs. Surveys of residents and program directors in geographically less diverse regions may not receive adequate education or exposure to patients with SOC.⁹ Further, there is a lack of representation of SOC images for general dermatologic conditions in textbooks,^10,11 which has a profound impact on the dermatologist’s ability to recognize common diseases in darker skin types. A 2019 survey of more than 5000 images from 2 dermatology textbooks showed SOC images comprised 22% to 32% of the total images.¹¹ However, SOC images are overrepresented in textbooks for sexually transmitted infections, constituting 47% to 58% of the images; they made up 28% of images for nonvenereal infections.¹¹ Why is that? In this article, we have shown the prevalence of ACD to be nearly equivalent in Black and White patients, yet a perusal of ACD images in dermatology textbooks will tell a different story. This trend deserves our attention; perhaps it is highlighting patterns of systemic racism seen in medicine. If our primary teaching materials are perpetuating stereotypes, we must consider the impact this can have on our personal implicit biases and the health care disparities that can ensue.

Additional factors impact time to diagnosis of ACD and referral for patch testing. A retrospective study examining distance to a North Carolina patch test referral clinic showed that patients living further from the clinic experienced a longer duration of dermatitis prior to patch test consultation and tended to live in areas with a higher county poverty rate.¹² Specifically, a 17.9% increase (P<.001) in the median duration of dermatitis was observed for every 50-mile increase in distance to the patch test clinic. County poverty rate was measured by the percentage of residents living below the poverty threshold; for every 5% increase in county poverty rate, a 16.3% increase (P<.032) in duration of dermatitis was found.¹²

These data highlight a relationship with which many dermatologists are familiar and underscore a need for dermatologists to practice in areas that are more geographically accessible. The recently increased utilization of telehealth modalities can potentially help to bridge this gap by decreasing delays in diagnosis and providing more affordable options for evaluation by a dermatologist for patients with socioeconomic obstacles.

Final Interpretation

The prevalence of ACD among Black and White patients is similar; however, there are important differences in patch test reaction frequencies that may be related to the diverse exposure patterns for each group. Additionally, patients with SOC may have unique clinical presentations of ACD, such as lichenification and hyperpigmentation. Darker skin types also may require specialized techniques for accurate patch test readings. It is imperative that dermatologists are trained to recognize all of these features. Health care disparities come in many forms and, in this setting, can result in delayed referral for patch testing. Additional studies are needed to further examine these health care disparities and identify potential solutions.

Catheter ablation appears better than drug therapy for treating atrial fibrillation (AFib) in racial and ethnic minorities, according to a new look at CABANA trial data.

CABANA, which was undertaken to compare catheter ablation and rate-control or rhythm-control drug therapy for AFib, concluded there was no significant difference between the two strategies in improving the trial’s composite primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest.

But a closer look at a subgroup of participants reveals an important difference in outcome among racial and ethnic minorities.

In that group, which made up about 10% of the CABANA study population, catheter ablation was significantly better at treating AFib than was drug therapy, producing roughly a 70% relative reduction in the primary endpoint and all-cause mortality.

The benefit for catheter ablation, which was not seen in the nonminority participants, appeared to be due to worse outcomes with drug therapy, the investigators report in an article published July 5 in the Journal of the American College of Cardiology.

“The study really highlights the importance of trying to secure an inclusive and diverse population in clinical trials,” lead author Kevin L. Thomas, MD, Duke University, Durham, N.C., said in an interview.

“When we focused on the racial and ethnic minorities who were included in CABANA, the findings were different. This was a surprise,” Dr. Thomas said.

“The findings from the secondary analysis of CABANA suggest that racial and ethnic minorities that are treated with drugs compared with ablation do worse,” he said. “If we can validate this in a larger sample of patients and this does in fact turn out to be true, then we would change how we practice medicine. We would have discussions with these populations about the benefits of ablation over drugs, and this would be important information to help guide our practice.”

The investigators analyzed data from 1,280 participants enrolled in the North American arm of CABANA. Of these, 127 (9.9%) were of racial or ethnic minorities, as defined by the National Institutes of Health, and were randomly assigned to receive ablation (n = 62) or drug therapy (n = 65).

Compared with nonminorities, participants of racial and ethnic minorities were younger (median age, 65.5 years, vs. 68.5 years) and were more likely to have NYHA functional class greater than or equal to II symptoms (37.0% vs. 22.0%), hypertension (92.1% vs. 76.8%), and an ejection fraction less than 40% (20.8% vs. 7.1%).

The overall median follow-up was 54.9 months. Among ethnic and minority participants, the median follow-up was 48 months, compared with 55.5 months for the nonminority participants.

Although there was no significant difference in the primary composite endpoint in the main CABANA trial, among racial and ethnic minorities treated with ablation, there was a 68% relative reduction in the trial’s primary endpoint (adjusted hazard ratio, 0.32; 95% confidence interval, 0.13-0.78) and a 72% relative reduction in all-cause mortality (aHR, 0.28; 95% CI, 0.10-0.79).

The 4-year Kaplan-Meier primary event rates were similar in both racial/ethnic minority and nonminority groups that received catheter ablation (12.3% vs. 9.9%).

However, the 4-year event rate was much higher among nonminority participants than among racial and ethnic minorities who received drug therapy (27.4% vs. 9.4%).

The corresponding all-cause 4-year mortality rates were 8.1% and 6.7%, respectively, in the ablation arm and 20.2% and 4.5%, respectively, in the drug arm.

Dr. Thomas and colleagues point out that heart failure in racial and ethnic minorities, particularly Black patients, is typically due to hypertensive heart disease, whereas in non-Hispanic White patients, it is overwhelmingly associated with coronary artery disease. “Our results in CABANA, therefore, raise the possibility that the variations in the prevalence of the heart diseases associated with AFib might account for differences in the benefits observed with ablation therapy.”

Prior data suggest that AFib in the setting of heart failure with either reduced or preserved ejection fraction has substantially better clinical outcomes with ablation versus drug therapy, but most studies either do not report racial/ethnic demographics or enroll very low numbers of minorities, they note.

Andrea M. Russo, MD, a professor of medicine at Rowan University, Camden, New Jersey, asks why drug therapy might result in worse outcomes in racial and ethnic minorities in an accompanying editorial.

“Those who received ablation did better than those who received drugs, and the main reason for that is not that ablation works better in minorities than nonminorities, it’s because drugs are worse in minority patients than they are in nonminority patients. This means that either the way we are using the drugs or the ones that we are using in minority patients are resulting in worse overall outcomes,” Dr. Russo told this news organization.

“The minority patients were younger and yet had more hypertension at baseline. There could be all kinds of factors contributing to their health,” she said.

Dr. Russo agrees with Dr. Thomas on the need to enroll diverse populations in clinical trials.

“Dr. Thomas should be commended. He did a fabulous job of looking at this issue. It’s only 10% of the group, but it is better than what we have had so far, and this is a start,” Dr. Russo said. “It’s bringing recognition to how important it is to make sure that we include underrepresented populations in these trials and also that we offer all appropriate therapies to everyone.”

Dr. Thomas reports financial relationships with Janssen, Pfizer, Biosense Webster. Dr. Russo reports no relevant financial relationships. The study was funded by the National Institutes of Health, St. Jude Medical Foundation and Corporation, Biosense Webster, Medtronic, and Boston Scientific.

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

Catheter ablation appears better than drug therapy for treating atrial fibrillation (AFib) in racial and ethnic minorities, according to a new look at CABANA trial data.

CABANA, which was undertaken to compare catheter ablation and rate-control or rhythm-control drug therapy for AFib, concluded there was no significant difference between the two strategies in improving the trial’s composite primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest.

But a closer look at a subgroup of participants reveals an important difference in outcome among racial and ethnic minorities.

In that group, which made up about 10% of the CABANA study population, catheter ablation was significantly better at treating AFib than was drug therapy, producing roughly a 70% relative reduction in the primary endpoint and all-cause mortality.

The benefit for catheter ablation, which was not seen in the nonminority participants, appeared to be due to worse outcomes with drug therapy, the investigators report in an article published July 5 in the Journal of the American College of Cardiology.

“The study really highlights the importance of trying to secure an inclusive and diverse population in clinical trials,” lead author Kevin L. Thomas, MD, Duke University, Durham, N.C., said in an interview.

“When we focused on the racial and ethnic minorities who were included in CABANA, the findings were different. This was a surprise,” Dr. Thomas said.

“The findings from the secondary analysis of CABANA suggest that racial and ethnic minorities that are treated with drugs compared with ablation do worse,” he said. “If we can validate this in a larger sample of patients and this does in fact turn out to be true, then we would change how we practice medicine. We would have discussions with these populations about the benefits of ablation over drugs, and this would be important information to help guide our practice.”

The investigators analyzed data from 1,280 participants enrolled in the North American arm of CABANA. Of these, 127 (9.9%) were of racial or ethnic minorities, as defined by the National Institutes of Health, and were randomly assigned to receive ablation (n = 62) or drug therapy (n = 65).

Compared with nonminorities, participants of racial and ethnic minorities were younger (median age, 65.5 years, vs. 68.5 years) and were more likely to have NYHA functional class greater than or equal to II symptoms (37.0% vs. 22.0%), hypertension (92.1% vs. 76.8%), and an ejection fraction less than 40% (20.8% vs. 7.1%).

The overall median follow-up was 54.9 months. Among ethnic and minority participants, the median follow-up was 48 months, compared with 55.5 months for the nonminority participants.

Although there was no significant difference in the primary composite endpoint in the main CABANA trial, among racial and ethnic minorities treated with ablation, there was a 68% relative reduction in the trial’s primary endpoint (adjusted hazard ratio, 0.32; 95% confidence interval, 0.13-0.78) and a 72% relative reduction in all-cause mortality (aHR, 0.28; 95% CI, 0.10-0.79).

The 4-year Kaplan-Meier primary event rates were similar in both racial/ethnic minority and nonminority groups that received catheter ablation (12.3% vs. 9.9%).

However, the 4-year event rate was much higher among nonminority participants than among racial and ethnic minorities who received drug therapy (27.4% vs. 9.4%).

The corresponding all-cause 4-year mortality rates were 8.1% and 6.7%, respectively, in the ablation arm and 20.2% and 4.5%, respectively, in the drug arm.

Dr. Thomas and colleagues point out that heart failure in racial and ethnic minorities, particularly Black patients, is typically due to hypertensive heart disease, whereas in non-Hispanic White patients, it is overwhelmingly associated with coronary artery disease. “Our results in CABANA, therefore, raise the possibility that the variations in the prevalence of the heart diseases associated with AFib might account for differences in the benefits observed with ablation therapy.”

Prior data suggest that AFib in the setting of heart failure with either reduced or preserved ejection fraction has substantially better clinical outcomes with ablation versus drug therapy, but most studies either do not report racial/ethnic demographics or enroll very low numbers of minorities, they note.

Andrea M. Russo, MD, a professor of medicine at Rowan University, Camden, New Jersey, asks why drug therapy might result in worse outcomes in racial and ethnic minorities in an accompanying editorial.

“Those who received ablation did better than those who received drugs, and the main reason for that is not that ablation works better in minorities than nonminorities, it’s because drugs are worse in minority patients than they are in nonminority patients. This means that either the way we are using the drugs or the ones that we are using in minority patients are resulting in worse overall outcomes,” Dr. Russo told this news organization.

“The minority patients were younger and yet had more hypertension at baseline. There could be all kinds of factors contributing to their health,” she said.

Dr. Russo agrees with Dr. Thomas on the need to enroll diverse populations in clinical trials.

“Dr. Thomas should be commended. He did a fabulous job of looking at this issue. It’s only 10% of the group, but it is better than what we have had so far, and this is a start,” Dr. Russo said. “It’s bringing recognition to how important it is to make sure that we include underrepresented populations in these trials and also that we offer all appropriate therapies to everyone.”

Dr. Thomas reports financial relationships with Janssen, Pfizer, Biosense Webster. Dr. Russo reports no relevant financial relationships. The study was funded by the National Institutes of Health, St. Jude Medical Foundation and Corporation, Biosense Webster, Medtronic, and Boston Scientific.

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

Catheter ablation appears better than drug therapy for treating atrial fibrillation (AFib) in racial and ethnic minorities, according to a new look at CABANA trial data.

CABANA, which was undertaken to compare catheter ablation and rate-control or rhythm-control drug therapy for AFib, concluded there was no significant difference between the two strategies in improving the trial’s composite primary outcome of death, disabling stroke, serious bleeding, or cardiac arrest.

But a closer look at a subgroup of participants reveals an important difference in outcome among racial and ethnic minorities.

In that group, which made up about 10% of the CABANA study population, catheter ablation was significantly better at treating AFib than was drug therapy, producing roughly a 70% relative reduction in the primary endpoint and all-cause mortality.

The benefit for catheter ablation, which was not seen in the nonminority participants, appeared to be due to worse outcomes with drug therapy, the investigators report in an article published July 5 in the Journal of the American College of Cardiology.

“The study really highlights the importance of trying to secure an inclusive and diverse population in clinical trials,” lead author Kevin L. Thomas, MD, Duke University, Durham, N.C., said in an interview.

“When we focused on the racial and ethnic minorities who were included in CABANA, the findings were different. This was a surprise,” Dr. Thomas said.

“The findings from the secondary analysis of CABANA suggest that racial and ethnic minorities that are treated with drugs compared with ablation do worse,” he said. “If we can validate this in a larger sample of patients and this does in fact turn out to be true, then we would change how we practice medicine. We would have discussions with these populations about the benefits of ablation over drugs, and this would be important information to help guide our practice.”

The investigators analyzed data from 1,280 participants enrolled in the North American arm of CABANA. Of these, 127 (9.9%) were of racial or ethnic minorities, as defined by the National Institutes of Health, and were randomly assigned to receive ablation (n = 62) or drug therapy (n = 65).

Compared with nonminorities, participants of racial and ethnic minorities were younger (median age, 65.5 years, vs. 68.5 years) and were more likely to have NYHA functional class greater than or equal to II symptoms (37.0% vs. 22.0%), hypertension (92.1% vs. 76.8%), and an ejection fraction less than 40% (20.8% vs. 7.1%).

The overall median follow-up was 54.9 months. Among ethnic and minority participants, the median follow-up was 48 months, compared with 55.5 months for the nonminority participants.

Although there was no significant difference in the primary composite endpoint in the main CABANA trial, among racial and ethnic minorities treated with ablation, there was a 68% relative reduction in the trial’s primary endpoint (adjusted hazard ratio, 0.32; 95% confidence interval, 0.13-0.78) and a 72% relative reduction in all-cause mortality (aHR, 0.28; 95% CI, 0.10-0.79).

The 4-year Kaplan-Meier primary event rates were similar in both racial/ethnic minority and nonminority groups that received catheter ablation (12.3% vs. 9.9%).

However, the 4-year event rate was much higher among nonminority participants than among racial and ethnic minorities who received drug therapy (27.4% vs. 9.4%).

The corresponding all-cause 4-year mortality rates were 8.1% and 6.7%, respectively, in the ablation arm and 20.2% and 4.5%, respectively, in the drug arm.

Dr. Thomas and colleagues point out that heart failure in racial and ethnic minorities, particularly Black patients, is typically due to hypertensive heart disease, whereas in non-Hispanic White patients, it is overwhelmingly associated with coronary artery disease. “Our results in CABANA, therefore, raise the possibility that the variations in the prevalence of the heart diseases associated with AFib might account for differences in the benefits observed with ablation therapy.”

Prior data suggest that AFib in the setting of heart failure with either reduced or preserved ejection fraction has substantially better clinical outcomes with ablation versus drug therapy, but most studies either do not report racial/ethnic demographics or enroll very low numbers of minorities, they note.

Andrea M. Russo, MD, a professor of medicine at Rowan University, Camden, New Jersey, asks why drug therapy might result in worse outcomes in racial and ethnic minorities in an accompanying editorial.

“Those who received ablation did better than those who received drugs, and the main reason for that is not that ablation works better in minorities than nonminorities, it’s because drugs are worse in minority patients than they are in nonminority patients. This means that either the way we are using the drugs or the ones that we are using in minority patients are resulting in worse overall outcomes,” Dr. Russo told this news organization.

“The minority patients were younger and yet had more hypertension at baseline. There could be all kinds of factors contributing to their health,” she said.

Dr. Russo agrees with Dr. Thomas on the need to enroll diverse populations in clinical trials.

“Dr. Thomas should be commended. He did a fabulous job of looking at this issue. It’s only 10% of the group, but it is better than what we have had so far, and this is a start,” Dr. Russo said. “It’s bringing recognition to how important it is to make sure that we include underrepresented populations in these trials and also that we offer all appropriate therapies to everyone.”

Dr. Thomas reports financial relationships with Janssen, Pfizer, Biosense Webster. Dr. Russo reports no relevant financial relationships. The study was funded by the National Institutes of Health, St. Jude Medical Foundation and Corporation, Biosense Webster, Medtronic, and Boston Scientific.

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

Fidaa Wishah, MD, a pediatric radiologist at Phoenix Children’s Hospital in Arizona, has been fired after the hospital reviewed evidence that included her anti-Israel comments on social media, according to the hospital’s statement.

On May 26, Dr. Wishah posted, “We will uncover your thirst to kill our Palestinian children. … We sense your fear. The fear of your collapse. A state based on atrocity, inhumanity, racism and cannibalism never last long! Hey #israel … your end is coming sooner than you think.”

Phoenix Children’s Hospital did not respond to this news organization’s request for comment but said in a statement to the Jewish News Syndicate : “After a thorough review of the facts related to this matter, this individual is no longer providing care at Phoenix Children’s. All children in the care of Phoenix Children’s receive hope, healing and the best possible health care, regardless of race, color, disability, religion, gender, gender identity, sexual orientation or national origin.”

Dr. Wishah’s profile has been removed from the hospital website. Her LinkedIn profile indicates she had been a pediatric radiology fellow at Stanford (Calif.) University, specializing in advanced magnetic resonance imaging and fetal imaging and had been a senior staff pediatric radiologist at Henry Ford Health System in Detroit.

It wasn’t the first time antisemitic comments have led to the firing of a physician. Last year, this news organization wrote about Lara Kollab, DO, a first-year resident fired for her antisemitic tweets. She was subsequently barred from medicine.

In the same post from May 26, Dr. Wishah also wrote: “We will not be #censored anymore! Bomb our media buildings and we have the phones[.] Bribe the mainstream media and we have our small #socialmedia platforms[.] From our windows ... from our streets ... next the rubble we will expose you to the world[.] We will expose the #massacre and #genocide you #zionists are proud of[.]”

Today, CAIR-AZ, a group whose mission is to “enhance understanding of Islam, protect civil rights, promote justice, and empower American Muslims,” according to its website, announced that it, along with three private law firms, will represent Dr. Wishah in what they referred to as “her wrongful termination case against Phoenix Children’s Hospital.”

The announcement, which mentions that Dr. Wishah was born and raised in Gaza, said, “Dr. Wishah has been a medical doctor since 2010 and has spent the vast majority of her career as a pediatric physician. Despite caring for thousands of children, many of whom are Jewish, she has never been accused of discriminating against any of her patients or colleagues.”

The statement added, “PCH’s decision to terminate Dr. Wishah is shameful and an attack on freedom of speech.”

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

Fidaa Wishah, MD, a pediatric radiologist at Phoenix Children’s Hospital in Arizona, has been fired after the hospital reviewed evidence that included her anti-Israel comments on social media, according to the hospital’s statement.

On May 26, Dr. Wishah posted, “We will uncover your thirst to kill our Palestinian children. … We sense your fear. The fear of your collapse. A state based on atrocity, inhumanity, racism and cannibalism never last long! Hey #israel … your end is coming sooner than you think.”

Phoenix Children’s Hospital did not respond to this news organization’s request for comment but said in a statement to the Jewish News Syndicate : “After a thorough review of the facts related to this matter, this individual is no longer providing care at Phoenix Children’s. All children in the care of Phoenix Children’s receive hope, healing and the best possible health care, regardless of race, color, disability, religion, gender, gender identity, sexual orientation or national origin.”

Dr. Wishah’s profile has been removed from the hospital website. Her LinkedIn profile indicates she had been a pediatric radiology fellow at Stanford (Calif.) University, specializing in advanced magnetic resonance imaging and fetal imaging and had been a senior staff pediatric radiologist at Henry Ford Health System in Detroit.

It wasn’t the first time antisemitic comments have led to the firing of a physician. Last year, this news organization wrote about Lara Kollab, DO, a first-year resident fired for her antisemitic tweets. She was subsequently barred from medicine.

In the same post from May 26, Dr. Wishah also wrote: “We will not be #censored anymore! Bomb our media buildings and we have the phones[.] Bribe the mainstream media and we have our small #socialmedia platforms[.] From our windows ... from our streets ... next the rubble we will expose you to the world[.] We will expose the #massacre and #genocide you #zionists are proud of[.]”

Today, CAIR-AZ, a group whose mission is to “enhance understanding of Islam, protect civil rights, promote justice, and empower American Muslims,” according to its website, announced that it, along with three private law firms, will represent Dr. Wishah in what they referred to as “her wrongful termination case against Phoenix Children’s Hospital.”

The announcement, which mentions that Dr. Wishah was born and raised in Gaza, said, “Dr. Wishah has been a medical doctor since 2010 and has spent the vast majority of her career as a pediatric physician. Despite caring for thousands of children, many of whom are Jewish, she has never been accused of discriminating against any of her patients or colleagues.”

The statement added, “PCH’s decision to terminate Dr. Wishah is shameful and an attack on freedom of speech.”

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

Fidaa Wishah, MD, a pediatric radiologist at Phoenix Children’s Hospital in Arizona, has been fired after the hospital reviewed evidence that included her anti-Israel comments on social media, according to the hospital’s statement.

On May 26, Dr. Wishah posted, “We will uncover your thirst to kill our Palestinian children. … We sense your fear. The fear of your collapse. A state based on atrocity, inhumanity, racism and cannibalism never last long! Hey #israel … your end is coming sooner than you think.”

Phoenix Children’s Hospital did not respond to this news organization’s request for comment but said in a statement to the Jewish News Syndicate : “After a thorough review of the facts related to this matter, this individual is no longer providing care at Phoenix Children’s. All children in the care of Phoenix Children’s receive hope, healing and the best possible health care, regardless of race, color, disability, religion, gender, gender identity, sexual orientation or national origin.”

Dr. Wishah’s profile has been removed from the hospital website. Her LinkedIn profile indicates she had been a pediatric radiology fellow at Stanford (Calif.) University, specializing in advanced magnetic resonance imaging and fetal imaging and had been a senior staff pediatric radiologist at Henry Ford Health System in Detroit.

It wasn’t the first time antisemitic comments have led to the firing of a physician. Last year, this news organization wrote about Lara Kollab, DO, a first-year resident fired for her antisemitic tweets. She was subsequently barred from medicine.

In the same post from May 26, Dr. Wishah also wrote: “We will not be #censored anymore! Bomb our media buildings and we have the phones[.] Bribe the mainstream media and we have our small #socialmedia platforms[.] From our windows ... from our streets ... next the rubble we will expose you to the world[.] We will expose the #massacre and #genocide you #zionists are proud of[.]”

Today, CAIR-AZ, a group whose mission is to “enhance understanding of Islam, protect civil rights, promote justice, and empower American Muslims,” according to its website, announced that it, along with three private law firms, will represent Dr. Wishah in what they referred to as “her wrongful termination case against Phoenix Children’s Hospital.”

The announcement, which mentions that Dr. Wishah was born and raised in Gaza, said, “Dr. Wishah has been a medical doctor since 2010 and has spent the vast majority of her career as a pediatric physician. Despite caring for thousands of children, many of whom are Jewish, she has never been accused of discriminating against any of her patients or colleagues.”

The statement added, “PCH’s decision to terminate Dr. Wishah is shameful and an attack on freedom of speech.”

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

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.

The proportion of underrepresented groups in pediatric fellowships decreased between 2007 and 2019, while those in pediatric residencies remained stagnant, new research revealed.

Researchers acknowledged that some of the factors contributing to the low proportion of minorities in the pediatric workforce may include educational disparities starting in primary or secondary school, such as underfunded schools and lack of educational resources.

“Something I really appreciated about the paper is that this goes beyond a student stepping into medical school, finding a mentor in pediatrics, and then eventually matriculating into a pediatric residency,” said Christle Nwora, MD, an internal medicine–pediatrics resident physician at Johns Hopkins Urban Health Residency Program in Baltimore, who was not involved in the study. “I like the idea of knowing that people aren’t going into the field and being very critical as to why.”

Prior studies, including a 2019 study published in JAMA Network Open, has found that minority students remain underrepresented in medical schools. However, this most recent study, published in Pediatrics, is one of the first to report trends in the race or ethnicity of pediatric residents and fellows.

“It’s been pretty well documented throughout the medical literature that the representation of underrepresented [groups] in medicine is low among all specialties,” study author Kimberly Montez, MD, MPH, FAAP, said in an interview. “This is one of the first studies that [show this trend] in pediatrics, [but] we were kind of expecting [these findings] knowing the rest of the literature out there.”

Dr. Montez and colleagues examined self-reported race and ethnicity data from 2007 to 2019 for pediatric residents and fellows from the GME Census reports. The annual number of pediatric trainees increased from 7,964 to 8,950 between 2007 and 2019. For pediatric subspecialty fellows, that number increased from 2,684 to 3,966.

The number of underrepresented pediatric trainees also increased over time, from 1,277 to 1,478 residents and 382 to 532 subspecialty fellows. However, researchers found that the trend in proportion of underrepresented in medicine (URiM) trainees was unchanged in pediatric residencies – 16% in 2007 to 16.5% in 2019 – and, overall, decreased for URiM subspecialty fellows from 14.2% in 2007 to 13.5% in 2019.

“I was shocked at the fact that there has been no significant increase either over the last 12 years,” said Joan Park, MD, a pediatric resident at Johns Hopkins Hospital, Baltimore, who was not involved in the study. “In the news, we’re seeing way more discussions in regards to racism and representation and the fact that that hasn’t really fueled or caught fire yet in medicine at all to really move that arrow is definitely really shocking.”

The recent study also pointed out that the percentage of underrepresented groups in pediatric residencies and fellowships is considerably lower in comparison with those groups’ representations in the U.S. population. For example, Black or African American people make up 13.4% of the U.S. population but just 5.6% of pediatric trainees. Meanwhile, American Indian or Alaskan Native people make up 1.3% of the U.S. population but make up 0.2% of pediatric trainees.

Dr. Montez hypothesized that the lack of underrepresented groups as pediatric trainees – or in the medical field, in general – may have to do with systemic barriers that span the entire educational continuum and affects them even before they reach medical school, including attendance at underfunded primary and secondary schools.

“Just think about all the barriers that exist for underrepresented minorities in medicine,” said Dr. Montez, assistant professor of pediatrics at Wake Forest University, Winston-Salem, N.C. “We know that underrepresented minorities are accepted and matriculate at lower rates than [those of] their nonminority counterparts. All of this occurs even just before getting into the field of pediatrics. So multiple barriers exist.”

Those barriers may also include racism, bias, and discrimination, which may play out unconsciously when members of an underrepresented group are applying for residencies or med school, such as “recognizing a name that may be from a different ethnic or racial background and then unconsciously biasing yourself against that applicant, for example,” Dr. Montez explained.

Dr. Montez said that although there has been progress, there is still a long way to go. She hopes the study will help academic institutions and professional organizations recognize the importance of diversity in pediatrics. She noted that pediatric trainees are more likely to experience microaggressions, which could potentially cause them to leave a program.

“I hope this will galvanize pediatric programs to really think a lot about the environment that they create for underrepresented minority trainees and also about their recruitment process in terms of making sure it’s standardized, using a holistic review,” Dr. Montez explained.

In 2016, the Association of American Medical Colleges published a diversity and inclusion strategic planning guide to improve training programs. Furthermore, in 2019, the Accreditation Council for Graduate Medical Education instituted a new common program requirement on diversity that requires programs to focus on systematic recruitment and retention of a diverse and inclusive workforce of residents and fellows.

“The same way pediatricians are aware of how the environment will shape the way a child grows up, we have to be mindful of the way an environment that surrounds the medical student will shape where they eventually end up as well,” said Dr. Nwora.

The experts disclosed no conflicts of interest.