Diversity in Medicine

Edward H. Livingston, MD, has resigned as deputy editor of JAMA after he and the journal faced significant backlash over a February 2021 podcast that questioned the existence of structural racism.

JAMA editor in chief Howard Bauchner, MD, apologized to JAMA staff and stakeholders and asked for and received Dr. Livingston’s resignation, according to a statement from AMA CEO James Madara.

More than 2,000 people have signed a petition on Change.org calling for an investigation at JAMA over the podcast, called “Structural Racism for Doctors: What Is It?”

It appears they are now getting their wish. Dr. Bauchner announced that the journal’s oversight committee is investigating how the podcast and a tweet promoting the episode were developed, reviewed, and ultimately posted.

“This investigation and report of its findings will be thorough and completed rapidly,” Dr. Bauchner said.

Dr. Livingston, the host of the podcast, has been heavily criticized across social media. During the podcast, Dr. Livingston, who is White, said: “Structural racism is an unfortunate term. Personally, I think taking racism out of the conversation will help. Many of us are offended by the concept that we are racist.”

The audio of the podcast has been deleted from JAMA’s website. In its place is audio of a statement from Dr. Bauchner. In his statement, which he released last week, he said the comments in the podcast, which also featured Mitch Katz, MD, were “inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA.”

Dr. Katz is an editor at JAMA Internal Medicine and CEO of NYC Health + Hospitals in New York.

Also deleted was a JAMA tweet promoting the podcast episode. The tweet said: “No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast.”

The incident was met with anger and confusion in the medical community.

Herbert C. Smitherman, MD, vice dean of diversity and community affairs at Wayne State University, Detroit, noted after hearing the podcast that it was a symptom of a much larger problem.

“At its core, this podcast had racist tendencies. Those attitudes are why you don’t have as many articles by Black and Brown people in JAMA,” he said. “People’s attitudes, whether conscious or unconscious, are what drive the policies and practices which create the structural racism.”

Dr. Katz responded to the backlash last week with the following statement: “Systemic racism exists in our country. The disparate effects of the pandemic have made this painfully clear in New York City and across the country.

“As clinicians, we must understand how these structures and policies have a direct impact on the health outcomes of the patients and communities we serve. It is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it, or that we should avoid the term ‘systematic racism’ because it makes people uncomfortable. We must and can do better.”

JAMA, an independent arm of the AMA, is taking other steps to address concerns. Its executive publisher, Thomas Easley, held an employee town hall this week, and said JAMA acknowledges that “structural racism is real, pernicious, and pervasive in health care.” The journal is also starting an “end-to-end review” of all editorial processes across all JAMA publications. Finally, the journal will also create a new associate editor’s position who will provide “insight and counsel” on racism and structural racism in health care.

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

Edward H. Livingston, MD, has resigned as deputy editor of JAMA after he and the journal faced significant backlash over a February 2021 podcast that questioned the existence of structural racism.

JAMA editor in chief Howard Bauchner, MD, apologized to JAMA staff and stakeholders and asked for and received Dr. Livingston’s resignation, according to a statement from AMA CEO James Madara.

More than 2,000 people have signed a petition on Change.org calling for an investigation at JAMA over the podcast, called “Structural Racism for Doctors: What Is It?”

It appears they are now getting their wish. Dr. Bauchner announced that the journal’s oversight committee is investigating how the podcast and a tweet promoting the episode were developed, reviewed, and ultimately posted.

“This investigation and report of its findings will be thorough and completed rapidly,” Dr. Bauchner said.

Dr. Livingston, the host of the podcast, has been heavily criticized across social media. During the podcast, Dr. Livingston, who is White, said: “Structural racism is an unfortunate term. Personally, I think taking racism out of the conversation will help. Many of us are offended by the concept that we are racist.”

The audio of the podcast has been deleted from JAMA’s website. In its place is audio of a statement from Dr. Bauchner. In his statement, which he released last week, he said the comments in the podcast, which also featured Mitch Katz, MD, were “inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA.”

Dr. Katz is an editor at JAMA Internal Medicine and CEO of NYC Health + Hospitals in New York.

Also deleted was a JAMA tweet promoting the podcast episode. The tweet said: “No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast.”

The incident was met with anger and confusion in the medical community.

Herbert C. Smitherman, MD, vice dean of diversity and community affairs at Wayne State University, Detroit, noted after hearing the podcast that it was a symptom of a much larger problem.

“At its core, this podcast had racist tendencies. Those attitudes are why you don’t have as many articles by Black and Brown people in JAMA,” he said. “People’s attitudes, whether conscious or unconscious, are what drive the policies and practices which create the structural racism.”

Dr. Katz responded to the backlash last week with the following statement: “Systemic racism exists in our country. The disparate effects of the pandemic have made this painfully clear in New York City and across the country.

“As clinicians, we must understand how these structures and policies have a direct impact on the health outcomes of the patients and communities we serve. It is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it, or that we should avoid the term ‘systematic racism’ because it makes people uncomfortable. We must and can do better.”

JAMA, an independent arm of the AMA, is taking other steps to address concerns. Its executive publisher, Thomas Easley, held an employee town hall this week, and said JAMA acknowledges that “structural racism is real, pernicious, and pervasive in health care.” The journal is also starting an “end-to-end review” of all editorial processes across all JAMA publications. Finally, the journal will also create a new associate editor’s position who will provide “insight and counsel” on racism and structural racism in health care.

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

Edward H. Livingston, MD, has resigned as deputy editor of JAMA after he and the journal faced significant backlash over a February 2021 podcast that questioned the existence of structural racism.

JAMA editor in chief Howard Bauchner, MD, apologized to JAMA staff and stakeholders and asked for and received Dr. Livingston’s resignation, according to a statement from AMA CEO James Madara.

More than 2,000 people have signed a petition on Change.org calling for an investigation at JAMA over the podcast, called “Structural Racism for Doctors: What Is It?”

It appears they are now getting their wish. Dr. Bauchner announced that the journal’s oversight committee is investigating how the podcast and a tweet promoting the episode were developed, reviewed, and ultimately posted.

“This investigation and report of its findings will be thorough and completed rapidly,” Dr. Bauchner said.

Dr. Livingston, the host of the podcast, has been heavily criticized across social media. During the podcast, Dr. Livingston, who is White, said: “Structural racism is an unfortunate term. Personally, I think taking racism out of the conversation will help. Many of us are offended by the concept that we are racist.”

The audio of the podcast has been deleted from JAMA’s website. In its place is audio of a statement from Dr. Bauchner. In his statement, which he released last week, he said the comments in the podcast, which also featured Mitch Katz, MD, were “inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA.”

Dr. Katz is an editor at JAMA Internal Medicine and CEO of NYC Health + Hospitals in New York.

Also deleted was a JAMA tweet promoting the podcast episode. The tweet said: “No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast.”

The incident was met with anger and confusion in the medical community.

Herbert C. Smitherman, MD, vice dean of diversity and community affairs at Wayne State University, Detroit, noted after hearing the podcast that it was a symptom of a much larger problem.

“At its core, this podcast had racist tendencies. Those attitudes are why you don’t have as many articles by Black and Brown people in JAMA,” he said. “People’s attitudes, whether conscious or unconscious, are what drive the policies and practices which create the structural racism.”

Dr. Katz responded to the backlash last week with the following statement: “Systemic racism exists in our country. The disparate effects of the pandemic have made this painfully clear in New York City and across the country.

“As clinicians, we must understand how these structures and policies have a direct impact on the health outcomes of the patients and communities we serve. It is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it, or that we should avoid the term ‘systematic racism’ because it makes people uncomfortable. We must and can do better.”

JAMA, an independent arm of the AMA, is taking other steps to address concerns. Its executive publisher, Thomas Easley, held an employee town hall this week, and said JAMA acknowledges that “structural racism is real, pernicious, and pervasive in health care.” The journal is also starting an “end-to-end review” of all editorial processes across all JAMA publications. Finally, the journal will also create a new associate editor’s position who will provide “insight and counsel” on racism and structural racism in health care.

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

A year and a half ago, I found myself seated in a crowded hall at the national Pediatric Hospital Medicine (PHM) conference. Throughout the conference, trainees like me were warmly welcomed into small groups and lunch tables. I tried to keep my cool while PHM “celebrities” chatted with me in the elevator. Most sessions were prepared with plenty of chairs, and those that were not encouraged latecomers to grab a spot on the floor or the back wall – the more the merrier.

The intention of this “advice for applicants” meeting was to inspire and guide our next steps toward fellowship, but a discomforting reality loomed over us. It was the first year graduating pediatricians could not choose PHM board certification via the practice pathway – we needed an invitation in the form of a fellowship match.

The “hidden curriculum” was not subtle: People who scored a seat would keep their options open within the field of PHM, and those who did not had a murkier future. This message stood in stark contrast to the PHM inclusivity I had experienced all conference, and planted seeds of doubt: Was I welcome here? Did I “deserve” a seat?

I found the experience as a PHM fellowship applicant to be uncomfortable, and my all-too familiar friend “imposter syndrome” set up camp in my brain and made herself at home. I had no way of knowing how many programs to apply to, how many to interview at, or the chances of my matching at all. Once on the interview trail, I realized I was not alone in my discomfort – most applicants harbored some trepidation, and no one truly knew how the chips would fall on Match Day.

I am thrilled and relieved to have come out the other end in a great position. The team I work with and learn from is phenomenal. I am grateful that ACGME accreditation ensures structures are in place for fellows to be supported in their academic and educational efforts and have full confidence that the skills I gain in fellowship will help me contribute to progression of the field of PHM and improve my performance as a clinician-educator.

Sadly, each year PHM match day celebrations are dampened by the knowledge that a large portion of our colleagues are being left out in the cold with an “unmatched” notification in their inboxes. Approximately 200 graduating pediatricians become pediatric hospitalists each year,¹ but only 68 fellowship positions were available in the United States for matriculation in 2020.² In 2019, PHM fellowship candidates navigated the 6-month application journey with aspirations to further their training in the profession they love. Of the candidates who submitted a rank list committing to 2 or more years in PHM fellowship, 35% were denied.

Unfortunately, despite expansion of PHM fellowship programs and fifteen seats added from last year, we learned this December that there still are not enough positions to welcome qualified applicants with open arms: Thirty-three percent of candidates ranked PHM programs first in the NRMP but did not match – the highest unmatched percentage out of all pediatric subspecialties.³

The NRMP report shared a glimpse of our colleagues who received interview invitations and submitted a rank list, but this is likely an underestimation of pediatric graduates who wanted to obtain PHM board certification and wound up on a different path. Some residents anticipated the stiff competition and delayed their plans to apply for fellowship, while others matched into another subspecialty that was able to accommodate them. Many pediatric graduates joined the workforce directly as pediatric hospitalists knowing the practice pathway to certification is not available to them. Along with other physicians without board certification in PHM, they shoulder concerns of being withheld from professional advancement opportunities.

For the foreseeable future it is clear that pediatric hospitalists without board certification will be a large part of our community, and are crucial to providing high-quality care to hospitalized children nationally. In 2019, a national survey of pediatric hospital medicine groups revealed that 50% of pediatric hospitalist hires came directly out of residency, and only 8% of hires were fellowship trained.⁴ The same report revealed that 26% of physicians were board-certified.These percentages are likely to change over the next 5 years as the window of practice pathway certification closes and fellowship programs continue to expand. Only time will tell what the national prevalence of board-certified pediatric hospitalists settles out to be.

Historically, PHM fellowship graduates have assumed roles that include teaching and research responsibilities, and ACGME fellowship requirements have ensured that trainees graduate with skills in medical education and scholarship, and need only 4 weeks of training to be done in a community hospital.⁵ Pediatric hospitalists who do not pursue board certification are seeing the growing pool of PHM fellowship graduates prepared for positions in academic institutions. It is reasonable that they harbor concerns about being siloed toward primarily community hospital roles, and for community hospitalists to feel that this structure undervalues their role within the field of PHM.

At a time when inclusivity and community in medicine are receiving much-needed recognition, the current fellowship application climate has potential to create division within the PHM community. Newly graduating pediatric residents are among the populations disproportionately affected by the practice pathway cutoff. Like other subspecialties with ever-climbing steps up the “ivory tower” of academia and specialization within medicine, the inherent structure of the training pathway makes navigating it more difficult for pediatricians with professional, geographic, and economic diversity or constraints.

Med-Peds–trained colleagues have the added challenge of finding a fellowship position that is willing and able to support their concurrent internal medicine goals. International medical graduates make up about 20% of graduating residents each year, and just 11% of matched PHM fellows.^3,6 Similarly, while DO medical graduates make up 20% of pediatric residents in the United States, only 10% of matched PHM fellows were DOs.^3,6 New pediatricians with families or financial insecurity may be unable to invest in an expensive application process, move to a new city, and accept less than half of the average starting salary of a pediatric hospitalist for 2-3 years.⁷

The prevalence of implicit bias in medicine is well documented, and there is growing evidence that it negatively impacts candidate selection in medical education and contributes to minorities being underrepresented in the physician workforce.⁸ We must recognize the ways that adding a competitive costly hurdle may risk conflict with our mission to encourage diversity of representation within PHM leadership positions.

We have not yet successfully bridged the gap between qualified PHM fellowship candidates and available fellowship positions. I worry that this gap and the lack of transparency surrounding it is resulting in one portion of new pediatricians being welcomed by the subspecialty, and others feeling unsupported and alienated by the larger PHM community as early career physicians.

Right now, the only solution available is expansion of fellowship programs. We see progress with the new addition of fellowship positions every year, but finding funding for each position is often a lengthy endeavor, and the COVID-19 pandemic has tightened the purse strings of many children’s hospitals. It may be many years before the number of available fellowship positions more closely approximates the 200 pediatricians that become hospitalists each year.

The most equitable solution would be offering other avenues to board certification while this gap is being bridged, either by extending the practice pathway option, or making a third pathway that requires less institutional funding per fellow, but still incentivizes institutional investment in fellowship positions and resources (e.g., a pathway requiring some number of years in practice, plus 1 year in fellowship centered around a nonclinical academic curriculum).

In the absence of the solutions above, we collectively hold the responsibility of maintaining inclusivity and support of our PHM colleagues with and without board certification. One important strategy provided by Dr. Gregory Welsh⁹ is to incorporate community hospital medicine rotations into residency training. Sharing this side of PHM with residents may help some graduates avoid a training pathway they may not want or need. More importantly, it would raise trainee exposure and interest toward a service that is both expansive – approximately 70% of pediatric hospitalists practice in a community hospital – and crucial to children’s health nationally.

Pediatric hospitalists who are not eligible for board certification are vital and valued members of the PHM community, and as such need to maintain representation within PHM leadership. Professional development opportunities need to remain accessible outside of fellowship. The blossoming of virtual conferences and Zoom meet-ups in the face of the COVID-19 pandemic have shown us that with innovation (and a good Internet connection), networking and mentorship can be accomplished across thousands of miles.

While there’s great diversity within PHM, this subspecialty has a history of attracting pediatricians with some common core qualities: Grit, creativity, and the belief that a strong team is far greater than the sum of its parts. I have confidence that if we approach this PHM transition period with transparency about our goals and challenges, this community can emerge from it strong and united.

Dr. Ezzio is a first-year pediatric hospital medicine fellow at Helen DeVos Children’s Hospital in Grand Rapids, Mich. Her interests include medical education and advocacy. Dr. Ezzio would like to thank Dr. Jeri Kessenich and Dr. Rachel “Danielle” Fisher for their assistance in revising the article. To submit to, or for inquiries about, our PHM Fellows Column, please contact our Pediatrics Editor, Dr. Anika Kumar ([email protected]).

References

1. Leyenaar JK and Fritner MP. Graduating pediatric residents entering the hospital medicine workforce, 2006-2015. Acad Pediatr. 2018 Mar;18(2):200-7.

2. National Resident Matching Program. Results and data: Specialties matching service 2020 appointment year. Washington, DC 2020.

3. National Resident Matching Program. Results and data: Specialties matching service 2021 appointment year. Washington, DC 2021.

4. 2020 State of Hospital Medicine report. Society of Hospital Medicine. 2020.

5. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

6. National Resident Matching Program. Results and data: 2020 main residency match. Washington, DC 2020.

7. American Academy of Pediatrics Annual Survey of graduating residents 2003-2020.

8. Quinn Capers IV. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education. American Thoracic Society Scholar. 2020 Jun;1(3):211-17.

9. Welsh G. The importance of community pediatric hospital medicine. The Hospitalist. 2021 Jan;25(1):27.

A year and a half ago, I found myself seated in a crowded hall at the national Pediatric Hospital Medicine (PHM) conference. Throughout the conference, trainees like me were warmly welcomed into small groups and lunch tables. I tried to keep my cool while PHM “celebrities” chatted with me in the elevator. Most sessions were prepared with plenty of chairs, and those that were not encouraged latecomers to grab a spot on the floor or the back wall – the more the merrier.

The intention of this “advice for applicants” meeting was to inspire and guide our next steps toward fellowship, but a discomforting reality loomed over us. It was the first year graduating pediatricians could not choose PHM board certification via the practice pathway – we needed an invitation in the form of a fellowship match.

The “hidden curriculum” was not subtle: People who scored a seat would keep their options open within the field of PHM, and those who did not had a murkier future. This message stood in stark contrast to the PHM inclusivity I had experienced all conference, and planted seeds of doubt: Was I welcome here? Did I “deserve” a seat?

I found the experience as a PHM fellowship applicant to be uncomfortable, and my all-too familiar friend “imposter syndrome” set up camp in my brain and made herself at home. I had no way of knowing how many programs to apply to, how many to interview at, or the chances of my matching at all. Once on the interview trail, I realized I was not alone in my discomfort – most applicants harbored some trepidation, and no one truly knew how the chips would fall on Match Day.

I am thrilled and relieved to have come out the other end in a great position. The team I work with and learn from is phenomenal. I am grateful that ACGME accreditation ensures structures are in place for fellows to be supported in their academic and educational efforts and have full confidence that the skills I gain in fellowship will help me contribute to progression of the field of PHM and improve my performance as a clinician-educator.

Sadly, each year PHM match day celebrations are dampened by the knowledge that a large portion of our colleagues are being left out in the cold with an “unmatched” notification in their inboxes. Approximately 200 graduating pediatricians become pediatric hospitalists each year,¹ but only 68 fellowship positions were available in the United States for matriculation in 2020.² In 2019, PHM fellowship candidates navigated the 6-month application journey with aspirations to further their training in the profession they love. Of the candidates who submitted a rank list committing to 2 or more years in PHM fellowship, 35% were denied.

Unfortunately, despite expansion of PHM fellowship programs and fifteen seats added from last year, we learned this December that there still are not enough positions to welcome qualified applicants with open arms: Thirty-three percent of candidates ranked PHM programs first in the NRMP but did not match – the highest unmatched percentage out of all pediatric subspecialties.³

The NRMP report shared a glimpse of our colleagues who received interview invitations and submitted a rank list, but this is likely an underestimation of pediatric graduates who wanted to obtain PHM board certification and wound up on a different path. Some residents anticipated the stiff competition and delayed their plans to apply for fellowship, while others matched into another subspecialty that was able to accommodate them. Many pediatric graduates joined the workforce directly as pediatric hospitalists knowing the practice pathway to certification is not available to them. Along with other physicians without board certification in PHM, they shoulder concerns of being withheld from professional advancement opportunities.

For the foreseeable future it is clear that pediatric hospitalists without board certification will be a large part of our community, and are crucial to providing high-quality care to hospitalized children nationally. In 2019, a national survey of pediatric hospital medicine groups revealed that 50% of pediatric hospitalist hires came directly out of residency, and only 8% of hires were fellowship trained.⁴ The same report revealed that 26% of physicians were board-certified.These percentages are likely to change over the next 5 years as the window of practice pathway certification closes and fellowship programs continue to expand. Only time will tell what the national prevalence of board-certified pediatric hospitalists settles out to be.

Historically, PHM fellowship graduates have assumed roles that include teaching and research responsibilities, and ACGME fellowship requirements have ensured that trainees graduate with skills in medical education and scholarship, and need only 4 weeks of training to be done in a community hospital.⁵ Pediatric hospitalists who do not pursue board certification are seeing the growing pool of PHM fellowship graduates prepared for positions in academic institutions. It is reasonable that they harbor concerns about being siloed toward primarily community hospital roles, and for community hospitalists to feel that this structure undervalues their role within the field of PHM.

At a time when inclusivity and community in medicine are receiving much-needed recognition, the current fellowship application climate has potential to create division within the PHM community. Newly graduating pediatric residents are among the populations disproportionately affected by the practice pathway cutoff. Like other subspecialties with ever-climbing steps up the “ivory tower” of academia and specialization within medicine, the inherent structure of the training pathway makes navigating it more difficult for pediatricians with professional, geographic, and economic diversity or constraints.

Med-Peds–trained colleagues have the added challenge of finding a fellowship position that is willing and able to support their concurrent internal medicine goals. International medical graduates make up about 20% of graduating residents each year, and just 11% of matched PHM fellows.^3,6 Similarly, while DO medical graduates make up 20% of pediatric residents in the United States, only 10% of matched PHM fellows were DOs.^3,6 New pediatricians with families or financial insecurity may be unable to invest in an expensive application process, move to a new city, and accept less than half of the average starting salary of a pediatric hospitalist for 2-3 years.⁷

The prevalence of implicit bias in medicine is well documented, and there is growing evidence that it negatively impacts candidate selection in medical education and contributes to minorities being underrepresented in the physician workforce.⁸ We must recognize the ways that adding a competitive costly hurdle may risk conflict with our mission to encourage diversity of representation within PHM leadership positions.

We have not yet successfully bridged the gap between qualified PHM fellowship candidates and available fellowship positions. I worry that this gap and the lack of transparency surrounding it is resulting in one portion of new pediatricians being welcomed by the subspecialty, and others feeling unsupported and alienated by the larger PHM community as early career physicians.

Right now, the only solution available is expansion of fellowship programs. We see progress with the new addition of fellowship positions every year, but finding funding for each position is often a lengthy endeavor, and the COVID-19 pandemic has tightened the purse strings of many children’s hospitals. It may be many years before the number of available fellowship positions more closely approximates the 200 pediatricians that become hospitalists each year.

The most equitable solution would be offering other avenues to board certification while this gap is being bridged, either by extending the practice pathway option, or making a third pathway that requires less institutional funding per fellow, but still incentivizes institutional investment in fellowship positions and resources (e.g., a pathway requiring some number of years in practice, plus 1 year in fellowship centered around a nonclinical academic curriculum).

In the absence of the solutions above, we collectively hold the responsibility of maintaining inclusivity and support of our PHM colleagues with and without board certification. One important strategy provided by Dr. Gregory Welsh⁹ is to incorporate community hospital medicine rotations into residency training. Sharing this side of PHM with residents may help some graduates avoid a training pathway they may not want or need. More importantly, it would raise trainee exposure and interest toward a service that is both expansive – approximately 70% of pediatric hospitalists practice in a community hospital – and crucial to children’s health nationally.

Pediatric hospitalists who are not eligible for board certification are vital and valued members of the PHM community, and as such need to maintain representation within PHM leadership. Professional development opportunities need to remain accessible outside of fellowship. The blossoming of virtual conferences and Zoom meet-ups in the face of the COVID-19 pandemic have shown us that with innovation (and a good Internet connection), networking and mentorship can be accomplished across thousands of miles.

While there’s great diversity within PHM, this subspecialty has a history of attracting pediatricians with some common core qualities: Grit, creativity, and the belief that a strong team is far greater than the sum of its parts. I have confidence that if we approach this PHM transition period with transparency about our goals and challenges, this community can emerge from it strong and united.

Dr. Ezzio is a first-year pediatric hospital medicine fellow at Helen DeVos Children’s Hospital in Grand Rapids, Mich. Her interests include medical education and advocacy. Dr. Ezzio would like to thank Dr. Jeri Kessenich and Dr. Rachel “Danielle” Fisher for their assistance in revising the article. To submit to, or for inquiries about, our PHM Fellows Column, please contact our Pediatrics Editor, Dr. Anika Kumar ([email protected]).

References

1. Leyenaar JK and Fritner MP. Graduating pediatric residents entering the hospital medicine workforce, 2006-2015. Acad Pediatr. 2018 Mar;18(2):200-7.

2. National Resident Matching Program. Results and data: Specialties matching service 2020 appointment year. Washington, DC 2020.

3. National Resident Matching Program. Results and data: Specialties matching service 2021 appointment year. Washington, DC 2021.

4. 2020 State of Hospital Medicine report. Society of Hospital Medicine. 2020.

5. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

6. National Resident Matching Program. Results and data: 2020 main residency match. Washington, DC 2020.

7. American Academy of Pediatrics Annual Survey of graduating residents 2003-2020.

8. Quinn Capers IV. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education. American Thoracic Society Scholar. 2020 Jun;1(3):211-17.

9. Welsh G. The importance of community pediatric hospital medicine. The Hospitalist. 2021 Jan;25(1):27.

A year and a half ago, I found myself seated in a crowded hall at the national Pediatric Hospital Medicine (PHM) conference. Throughout the conference, trainees like me were warmly welcomed into small groups and lunch tables. I tried to keep my cool while PHM “celebrities” chatted with me in the elevator. Most sessions were prepared with plenty of chairs, and those that were not encouraged latecomers to grab a spot on the floor or the back wall – the more the merrier.

The intention of this “advice for applicants” meeting was to inspire and guide our next steps toward fellowship, but a discomforting reality loomed over us. It was the first year graduating pediatricians could not choose PHM board certification via the practice pathway – we needed an invitation in the form of a fellowship match.

The “hidden curriculum” was not subtle: People who scored a seat would keep their options open within the field of PHM, and those who did not had a murkier future. This message stood in stark contrast to the PHM inclusivity I had experienced all conference, and planted seeds of doubt: Was I welcome here? Did I “deserve” a seat?

I found the experience as a PHM fellowship applicant to be uncomfortable, and my all-too familiar friend “imposter syndrome” set up camp in my brain and made herself at home. I had no way of knowing how many programs to apply to, how many to interview at, or the chances of my matching at all. Once on the interview trail, I realized I was not alone in my discomfort – most applicants harbored some trepidation, and no one truly knew how the chips would fall on Match Day.

I am thrilled and relieved to have come out the other end in a great position. The team I work with and learn from is phenomenal. I am grateful that ACGME accreditation ensures structures are in place for fellows to be supported in their academic and educational efforts and have full confidence that the skills I gain in fellowship will help me contribute to progression of the field of PHM and improve my performance as a clinician-educator.

Sadly, each year PHM match day celebrations are dampened by the knowledge that a large portion of our colleagues are being left out in the cold with an “unmatched” notification in their inboxes. Approximately 200 graduating pediatricians become pediatric hospitalists each year,¹ but only 68 fellowship positions were available in the United States for matriculation in 2020.² In 2019, PHM fellowship candidates navigated the 6-month application journey with aspirations to further their training in the profession they love. Of the candidates who submitted a rank list committing to 2 or more years in PHM fellowship, 35% were denied.

Unfortunately, despite expansion of PHM fellowship programs and fifteen seats added from last year, we learned this December that there still are not enough positions to welcome qualified applicants with open arms: Thirty-three percent of candidates ranked PHM programs first in the NRMP but did not match – the highest unmatched percentage out of all pediatric subspecialties.³

The NRMP report shared a glimpse of our colleagues who received interview invitations and submitted a rank list, but this is likely an underestimation of pediatric graduates who wanted to obtain PHM board certification and wound up on a different path. Some residents anticipated the stiff competition and delayed their plans to apply for fellowship, while others matched into another subspecialty that was able to accommodate them. Many pediatric graduates joined the workforce directly as pediatric hospitalists knowing the practice pathway to certification is not available to them. Along with other physicians without board certification in PHM, they shoulder concerns of being withheld from professional advancement opportunities.

For the foreseeable future it is clear that pediatric hospitalists without board certification will be a large part of our community, and are crucial to providing high-quality care to hospitalized children nationally. In 2019, a national survey of pediatric hospital medicine groups revealed that 50% of pediatric hospitalist hires came directly out of residency, and only 8% of hires were fellowship trained.⁴ The same report revealed that 26% of physicians were board-certified.These percentages are likely to change over the next 5 years as the window of practice pathway certification closes and fellowship programs continue to expand. Only time will tell what the national prevalence of board-certified pediatric hospitalists settles out to be.

Historically, PHM fellowship graduates have assumed roles that include teaching and research responsibilities, and ACGME fellowship requirements have ensured that trainees graduate with skills in medical education and scholarship, and need only 4 weeks of training to be done in a community hospital.⁵ Pediatric hospitalists who do not pursue board certification are seeing the growing pool of PHM fellowship graduates prepared for positions in academic institutions. It is reasonable that they harbor concerns about being siloed toward primarily community hospital roles, and for community hospitalists to feel that this structure undervalues their role within the field of PHM.

At a time when inclusivity and community in medicine are receiving much-needed recognition, the current fellowship application climate has potential to create division within the PHM community. Newly graduating pediatric residents are among the populations disproportionately affected by the practice pathway cutoff. Like other subspecialties with ever-climbing steps up the “ivory tower” of academia and specialization within medicine, the inherent structure of the training pathway makes navigating it more difficult for pediatricians with professional, geographic, and economic diversity or constraints.

Med-Peds–trained colleagues have the added challenge of finding a fellowship position that is willing and able to support their concurrent internal medicine goals. International medical graduates make up about 20% of graduating residents each year, and just 11% of matched PHM fellows.^3,6 Similarly, while DO medical graduates make up 20% of pediatric residents in the United States, only 10% of matched PHM fellows were DOs.^3,6 New pediatricians with families or financial insecurity may be unable to invest in an expensive application process, move to a new city, and accept less than half of the average starting salary of a pediatric hospitalist for 2-3 years.⁷

The prevalence of implicit bias in medicine is well documented, and there is growing evidence that it negatively impacts candidate selection in medical education and contributes to minorities being underrepresented in the physician workforce.⁸ We must recognize the ways that adding a competitive costly hurdle may risk conflict with our mission to encourage diversity of representation within PHM leadership positions.

We have not yet successfully bridged the gap between qualified PHM fellowship candidates and available fellowship positions. I worry that this gap and the lack of transparency surrounding it is resulting in one portion of new pediatricians being welcomed by the subspecialty, and others feeling unsupported and alienated by the larger PHM community as early career physicians.

Right now, the only solution available is expansion of fellowship programs. We see progress with the new addition of fellowship positions every year, but finding funding for each position is often a lengthy endeavor, and the COVID-19 pandemic has tightened the purse strings of many children’s hospitals. It may be many years before the number of available fellowship positions more closely approximates the 200 pediatricians that become hospitalists each year.

The most equitable solution would be offering other avenues to board certification while this gap is being bridged, either by extending the practice pathway option, or making a third pathway that requires less institutional funding per fellow, but still incentivizes institutional investment in fellowship positions and resources (e.g., a pathway requiring some number of years in practice, plus 1 year in fellowship centered around a nonclinical academic curriculum).

In the absence of the solutions above, we collectively hold the responsibility of maintaining inclusivity and support of our PHM colleagues with and without board certification. One important strategy provided by Dr. Gregory Welsh⁹ is to incorporate community hospital medicine rotations into residency training. Sharing this side of PHM with residents may help some graduates avoid a training pathway they may not want or need. More importantly, it would raise trainee exposure and interest toward a service that is both expansive – approximately 70% of pediatric hospitalists practice in a community hospital – and crucial to children’s health nationally.

Pediatric hospitalists who are not eligible for board certification are vital and valued members of the PHM community, and as such need to maintain representation within PHM leadership. Professional development opportunities need to remain accessible outside of fellowship. The blossoming of virtual conferences and Zoom meet-ups in the face of the COVID-19 pandemic have shown us that with innovation (and a good Internet connection), networking and mentorship can be accomplished across thousands of miles.

While there’s great diversity within PHM, this subspecialty has a history of attracting pediatricians with some common core qualities: Grit, creativity, and the belief that a strong team is far greater than the sum of its parts. I have confidence that if we approach this PHM transition period with transparency about our goals and challenges, this community can emerge from it strong and united.

Dr. Ezzio is a first-year pediatric hospital medicine fellow at Helen DeVos Children’s Hospital in Grand Rapids, Mich. Her interests include medical education and advocacy. Dr. Ezzio would like to thank Dr. Jeri Kessenich and Dr. Rachel “Danielle” Fisher for their assistance in revising the article. To submit to, or for inquiries about, our PHM Fellows Column, please contact our Pediatrics Editor, Dr. Anika Kumar ([email protected]).

References

1. Leyenaar JK and Fritner MP. Graduating pediatric residents entering the hospital medicine workforce, 2006-2015. Acad Pediatr. 2018 Mar;18(2):200-7.

2. National Resident Matching Program. Results and data: Specialties matching service 2020 appointment year. Washington, DC 2020.

3. National Resident Matching Program. Results and data: Specialties matching service 2021 appointment year. Washington, DC 2021.

4. 2020 State of Hospital Medicine report. Society of Hospital Medicine. 2020.

5. Oshimura JM et al. Current roles and perceived needs of pediatric hospital medicine fellowship graduates. Hosp Pediatr. 2016;6(10):633-7.

6. National Resident Matching Program. Results and data: 2020 main residency match. Washington, DC 2020.

7. American Academy of Pediatrics Annual Survey of graduating residents 2003-2020.

8. Quinn Capers IV. How clinicians and educators can mitigate implicit bias in patient care and candidate selection in medical education. American Thoracic Society Scholar. 2020 Jun;1(3):211-17.

9. Welsh G. The importance of community pediatric hospital medicine. The Hospitalist. 2021 Jan;25(1):27.

PHYSICIAN LEADERSHIP: RACIAL DISPARITIES AND RACISM. WHERE DO WE GO FROM HERE?

BIFTU MENGESHA, MD, MAS; KAVITA SHAH ARORA, MD, MBE, MS; AND BARBARA LEVY, MD

(COMMENTARY; AUGUST 2020)

Political diatribe paints a huge swath

I read the above referenced article with equal measure of angst and offense, amazement and incredulity, irritation and, some would say, typical white male denial. The authors have succumbed to the zeitgeist currently enveloping our country and painted us all with one huge swath of the same proverbial brush—inappropriately.

No doubt certain reforms are needed in our society and perhaps within areas of medicine. I am for anything that improves all peoples’ lives and health. The country is rightfully clamoring for equality. That means equality for all, however. But by way of one small example of systemic overreaction, many articles now are replete with comments about “Black people and Brown people and white people.” Adjectives have been turned into proper nouns, but applied only to some groups, not all. That foments continued inequity, not equality.

The authors implore us to strive for “engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.” In my view, the best way I can do that is not by words but actions, and that is to do what I am trained to do, which is take care of patients the best I can regardless of their color or creed. I have always done that, and everyone I work with does as well. For the authors to imply I (we) don’t is at a minimum offensive and pejorative, and flat wrong.

I agree to a certain extent that our health care contributes to poor, or at least less desirable, outcomes. But so do the actions or inactions of our patients. I do not agree that it is a racial issue. It affects all people. I see it every day. I am probably in the minority of physicians who think we should go to a single-payor system (note I did not say free). But to state that the system creates poor outcomes only for “Blacks, Indigenous, and Latinx,” I disagree. Tennessee has TennCare (Medicaid) and almost anyone can get it, and if they are pregnant they certainly can. Access is not an issue. All people have to do is avail themselves of it. It does not matter the race!

The authors call for the implementation “of system-wide intersectional and antiracist practices” to address “racism, sexism, gender discrimination, economic and social injustice.” They are preaching to the wrong crowd. If I (we) pursued all these lofty goals, I (we) would not have time to care for the very patients they are now lamenting don’t have enough care or proper care.

I facilitate conversations on a regular basis with my black patients as well as my white patients. I recently asked a patient if she distrusted me because I am a white male. It is enlightening to hear patient comments, which are mostly along the lines of “the world has gone crazy.” That is a polite interpretation of their comments. Maybe they say what they think I want to hear, but I don’t think so.

“Repair what we have broken…” by “uplifting their voices and redistributing our power to them.” I don’t see how I (we) have broken anything. If taking care of all comers as best as one can has broken something, then I am guilty. Regarding that I need to examine how “we have eroded the trust of the very communities we care for” and that we are guilty of “medical experimentation on and exploitation of Black and Brown bodies,” what are we to examine? How have I (we) eroded the trust? Present-day physicians had nothing to do with things like the Tuskegee Institute experiment, and I hardly see how blaming us today for that abominable episode in our HISTORY is a valid point. Implying that we add to that distrust by not giving the same pain relief to certain people because of race is just preposterous. Further, asking to let others lead, for example, on the medical executive committee or in positions such as chief of service or chief of staff usually are not something one “gets” to be, but something one usually is “talked into.” There is not a racial barrier to those roles, at least at my institution, and once again the brush has inappropriately painted us all.

I understand the general gestalt of this article and agree with its basic premises. But while well meaning, this political diatribe belongs in the halls of Congress, not in the halls of our hospitals or the pages of a medical journal. I am tired of being told, directly or indirectly, that I am a racist by TV news, newspapers, social media, professional sports teams, and now by my medical journals. I would ask the authors to be careful who they throw under the bus.

Scott Peters, MD

Oak Ridge, Tennessee

Continue to: Drs. Mengesha, Arora, and Levy respond...

We appreciate the opportunity to respond to Dr. Peters. Our article brings long overdue awareness to systemic and structural problems that result in disproportionately inequitable outcomes for people of color. We are not debating the morality of individuals or talking about racism as an inherently “bad” trait that some people have, but rather recognizing the impact of social structures on health and well-being in which we all—Black, Brown, and White—live. We all have inherent biases, recognized or unrecognized, that impact our actions, decisions, and behaviors. We are humans with upbringing, backgrounds, and learned frameworks influenced by our sociocultural context that conditions our responses to a given situation. This is also woven into our hospitals, exam rooms, and even our medical journals. It constantly influences the health, well-being, and livelihood of patients—nothing that we do in medicine is in isolation of this greater context. Our health care system is steeped in this sociocultural context and impacts all patients in intersecting ways, whether that be by race, class, gender, or other social identities. And while we did not create the system in which we operate, we now have abundant evidence that shows it continually delivers inequitable outcomes particularly for people of color.

We are very clear that physicians and health care professionals strive to provide the very best care for each and every patient. We do not discount the hard work and good intentions of our colleagues. And while some individual patient behaviors may somewhat modify outcomes, we also strongly disagree with the premise that patients are to blame for poor or less desirable outcomes they face. Instead, our position is focused on the impact that the systems we work in are creating barriers to equitable care at levels of influence above a single individual, and that it is our collective professional responsibility to acknowledge and take action to lessen those barriers.

System-wide changes would not be at the expense of patient care, and physicians cannot and in fact should not shoulder these changes alone. Our current paradigm of training does not give us the capacity to do so, and a single individual cannot make such a large system change alone. The change we are advocating for requires collaboration within multidisciplinary and interprofessional teams, long-term planning, and incremental but intentional change. This is not dissimilar to the recognition over 20 years ago by the Institute of Medicine (now the National Academy of Medicine) that “to err is human.” Our eyes were opened to the structural issues resulting in medical errors, and very slowly our profession has acknowledged the necessity to recognize, report, and analyze the root causes of those errors. We do so because it is critically important to ensure that the same error never happens again. It is part of the commitment to honor our oath to “do no harm.” Similarly, racial inequities in health outcomes should also be “never events” as there is no biological basis or individual blame for these inequities, but rather systemic and structural processes (which is de facto racism) that contribute to disproportionately worse outcomes.

Disparities in COVID-19 vaccination rates for people of color is a current example that illustrates the deep distrust in our health care system that historical events, like Tuskegee, have created. In Tennessee, for example, 7% of COVID-19 vaccines have been administered to Black people despite the fact that they make up 15% of cases, 18% of deaths, and 16% of the total population.1 There are other ongoing systemic issues, including inequities in distribution, prioritization, and access, that are contributing to the lower vaccination rates among people of color; however, as physicians and advocates for our patients, it is crucial for us to acknowledge the fear of, and resistance to, government-sponsored health programs which has resulted from events like Tuskegee.

We are advocating for building our systems to help support all of the social and societal determinants of health our patients are faced with, including racism, while they are receiving care from us. Patients are faced with undue morbidity and mortality because of our health care system’s ineffectiveness in incorporating this as a part of systemic care delivery to all. We must work together alongside other health care professionals, public health and policy agencies, and community advocates to stop this deadly cycle. There will be no improvement and no end in sight unless we work together toward this common goal.

Reference 

1. Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations: race/ethnicity. Kaiser Family Foundation website. February 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-covid-19-vaccinations-cases-deaths-race-ethnicity/. Accessed February 11, 2021.

PHYSICIAN LEADERSHIP: RACIAL DISPARITIES AND RACISM. WHERE DO WE GO FROM HERE?

BIFTU MENGESHA, MD, MAS; KAVITA SHAH ARORA, MD, MBE, MS; AND BARBARA LEVY, MD

(COMMENTARY; AUGUST 2020)

Political diatribe paints a huge swath

I read the above referenced article with equal measure of angst and offense, amazement and incredulity, irritation and, some would say, typical white male denial. The authors have succumbed to the zeitgeist currently enveloping our country and painted us all with one huge swath of the same proverbial brush—inappropriately.

No doubt certain reforms are needed in our society and perhaps within areas of medicine. I am for anything that improves all peoples’ lives and health. The country is rightfully clamoring for equality. That means equality for all, however. But by way of one small example of systemic overreaction, many articles now are replete with comments about “Black people and Brown people and white people.” Adjectives have been turned into proper nouns, but applied only to some groups, not all. That foments continued inequity, not equality.

The authors implore us to strive for “engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.” In my view, the best way I can do that is not by words but actions, and that is to do what I am trained to do, which is take care of patients the best I can regardless of their color or creed. I have always done that, and everyone I work with does as well. For the authors to imply I (we) don’t is at a minimum offensive and pejorative, and flat wrong.

I agree to a certain extent that our health care contributes to poor, or at least less desirable, outcomes. But so do the actions or inactions of our patients. I do not agree that it is a racial issue. It affects all people. I see it every day. I am probably in the minority of physicians who think we should go to a single-payor system (note I did not say free). But to state that the system creates poor outcomes only for “Blacks, Indigenous, and Latinx,” I disagree. Tennessee has TennCare (Medicaid) and almost anyone can get it, and if they are pregnant they certainly can. Access is not an issue. All people have to do is avail themselves of it. It does not matter the race!

The authors call for the implementation “of system-wide intersectional and antiracist practices” to address “racism, sexism, gender discrimination, economic and social injustice.” They are preaching to the wrong crowd. If I (we) pursued all these lofty goals, I (we) would not have time to care for the very patients they are now lamenting don’t have enough care or proper care.

I facilitate conversations on a regular basis with my black patients as well as my white patients. I recently asked a patient if she distrusted me because I am a white male. It is enlightening to hear patient comments, which are mostly along the lines of “the world has gone crazy.” That is a polite interpretation of their comments. Maybe they say what they think I want to hear, but I don’t think so.

“Repair what we have broken…” by “uplifting their voices and redistributing our power to them.” I don’t see how I (we) have broken anything. If taking care of all comers as best as one can has broken something, then I am guilty. Regarding that I need to examine how “we have eroded the trust of the very communities we care for” and that we are guilty of “medical experimentation on and exploitation of Black and Brown bodies,” what are we to examine? How have I (we) eroded the trust? Present-day physicians had nothing to do with things like the Tuskegee Institute experiment, and I hardly see how blaming us today for that abominable episode in our HISTORY is a valid point. Implying that we add to that distrust by not giving the same pain relief to certain people because of race is just preposterous. Further, asking to let others lead, for example, on the medical executive committee or in positions such as chief of service or chief of staff usually are not something one “gets” to be, but something one usually is “talked into.” There is not a racial barrier to those roles, at least at my institution, and once again the brush has inappropriately painted us all.

I understand the general gestalt of this article and agree with its basic premises. But while well meaning, this political diatribe belongs in the halls of Congress, not in the halls of our hospitals or the pages of a medical journal. I am tired of being told, directly or indirectly, that I am a racist by TV news, newspapers, social media, professional sports teams, and now by my medical journals. I would ask the authors to be careful who they throw under the bus.

Scott Peters, MD

Oak Ridge, Tennessee

Continue to: Drs. Mengesha, Arora, and Levy respond...

We appreciate the opportunity to respond to Dr. Peters. Our article brings long overdue awareness to systemic and structural problems that result in disproportionately inequitable outcomes for people of color. We are not debating the morality of individuals or talking about racism as an inherently “bad” trait that some people have, but rather recognizing the impact of social structures on health and well-being in which we all—Black, Brown, and White—live. We all have inherent biases, recognized or unrecognized, that impact our actions, decisions, and behaviors. We are humans with upbringing, backgrounds, and learned frameworks influenced by our sociocultural context that conditions our responses to a given situation. This is also woven into our hospitals, exam rooms, and even our medical journals. It constantly influences the health, well-being, and livelihood of patients—nothing that we do in medicine is in isolation of this greater context. Our health care system is steeped in this sociocultural context and impacts all patients in intersecting ways, whether that be by race, class, gender, or other social identities. And while we did not create the system in which we operate, we now have abundant evidence that shows it continually delivers inequitable outcomes particularly for people of color.

We are very clear that physicians and health care professionals strive to provide the very best care for each and every patient. We do not discount the hard work and good intentions of our colleagues. And while some individual patient behaviors may somewhat modify outcomes, we also strongly disagree with the premise that patients are to blame for poor or less desirable outcomes they face. Instead, our position is focused on the impact that the systems we work in are creating barriers to equitable care at levels of influence above a single individual, and that it is our collective professional responsibility to acknowledge and take action to lessen those barriers.

System-wide changes would not be at the expense of patient care, and physicians cannot and in fact should not shoulder these changes alone. Our current paradigm of training does not give us the capacity to do so, and a single individual cannot make such a large system change alone. The change we are advocating for requires collaboration within multidisciplinary and interprofessional teams, long-term planning, and incremental but intentional change. This is not dissimilar to the recognition over 20 years ago by the Institute of Medicine (now the National Academy of Medicine) that “to err is human.” Our eyes were opened to the structural issues resulting in medical errors, and very slowly our profession has acknowledged the necessity to recognize, report, and analyze the root causes of those errors. We do so because it is critically important to ensure that the same error never happens again. It is part of the commitment to honor our oath to “do no harm.” Similarly, racial inequities in health outcomes should also be “never events” as there is no biological basis or individual blame for these inequities, but rather systemic and structural processes (which is de facto racism) that contribute to disproportionately worse outcomes.

Disparities in COVID-19 vaccination rates for people of color is a current example that illustrates the deep distrust in our health care system that historical events, like Tuskegee, have created. In Tennessee, for example, 7% of COVID-19 vaccines have been administered to Black people despite the fact that they make up 15% of cases, 18% of deaths, and 16% of the total population.1 There are other ongoing systemic issues, including inequities in distribution, prioritization, and access, that are contributing to the lower vaccination rates among people of color; however, as physicians and advocates for our patients, it is crucial for us to acknowledge the fear of, and resistance to, government-sponsored health programs which has resulted from events like Tuskegee.

We are advocating for building our systems to help support all of the social and societal determinants of health our patients are faced with, including racism, while they are receiving care from us. Patients are faced with undue morbidity and mortality because of our health care system’s ineffectiveness in incorporating this as a part of systemic care delivery to all. We must work together alongside other health care professionals, public health and policy agencies, and community advocates to stop this deadly cycle. There will be no improvement and no end in sight unless we work together toward this common goal.

Reference 

1. Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations: race/ethnicity. Kaiser Family Foundation website. February 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-covid-19-vaccinations-cases-deaths-race-ethnicity/. Accessed February 11, 2021.

PHYSICIAN LEADERSHIP: RACIAL DISPARITIES AND RACISM. WHERE DO WE GO FROM HERE?

BIFTU MENGESHA, MD, MAS; KAVITA SHAH ARORA, MD, MBE, MS; AND BARBARA LEVY, MD

(COMMENTARY; AUGUST 2020)

Political diatribe paints a huge swath

I read the above referenced article with equal measure of angst and offense, amazement and incredulity, irritation and, some would say, typical white male denial. The authors have succumbed to the zeitgeist currently enveloping our country and painted us all with one huge swath of the same proverbial brush—inappropriately.

No doubt certain reforms are needed in our society and perhaps within areas of medicine. I am for anything that improves all peoples’ lives and health. The country is rightfully clamoring for equality. That means equality for all, however. But by way of one small example of systemic overreaction, many articles now are replete with comments about “Black people and Brown people and white people.” Adjectives have been turned into proper nouns, but applied only to some groups, not all. That foments continued inequity, not equality.

The authors implore us to strive for “engaged, passionate, and innovative leadership deliberately aimed toward antiracism and equity.” In my view, the best way I can do that is not by words but actions, and that is to do what I am trained to do, which is take care of patients the best I can regardless of their color or creed. I have always done that, and everyone I work with does as well. For the authors to imply I (we) don’t is at a minimum offensive and pejorative, and flat wrong.

I agree to a certain extent that our health care contributes to poor, or at least less desirable, outcomes. But so do the actions or inactions of our patients. I do not agree that it is a racial issue. It affects all people. I see it every day. I am probably in the minority of physicians who think we should go to a single-payor system (note I did not say free). But to state that the system creates poor outcomes only for “Blacks, Indigenous, and Latinx,” I disagree. Tennessee has TennCare (Medicaid) and almost anyone can get it, and if they are pregnant they certainly can. Access is not an issue. All people have to do is avail themselves of it. It does not matter the race!

The authors call for the implementation “of system-wide intersectional and antiracist practices” to address “racism, sexism, gender discrimination, economic and social injustice.” They are preaching to the wrong crowd. If I (we) pursued all these lofty goals, I (we) would not have time to care for the very patients they are now lamenting don’t have enough care or proper care.

I facilitate conversations on a regular basis with my black patients as well as my white patients. I recently asked a patient if she distrusted me because I am a white male. It is enlightening to hear patient comments, which are mostly along the lines of “the world has gone crazy.” That is a polite interpretation of their comments. Maybe they say what they think I want to hear, but I don’t think so.

“Repair what we have broken…” by “uplifting their voices and redistributing our power to them.” I don’t see how I (we) have broken anything. If taking care of all comers as best as one can has broken something, then I am guilty. Regarding that I need to examine how “we have eroded the trust of the very communities we care for” and that we are guilty of “medical experimentation on and exploitation of Black and Brown bodies,” what are we to examine? How have I (we) eroded the trust? Present-day physicians had nothing to do with things like the Tuskegee Institute experiment, and I hardly see how blaming us today for that abominable episode in our HISTORY is a valid point. Implying that we add to that distrust by not giving the same pain relief to certain people because of race is just preposterous. Further, asking to let others lead, for example, on the medical executive committee or in positions such as chief of service or chief of staff usually are not something one “gets” to be, but something one usually is “talked into.” There is not a racial barrier to those roles, at least at my institution, and once again the brush has inappropriately painted us all.

I understand the general gestalt of this article and agree with its basic premises. But while well meaning, this political diatribe belongs in the halls of Congress, not in the halls of our hospitals or the pages of a medical journal. I am tired of being told, directly or indirectly, that I am a racist by TV news, newspapers, social media, professional sports teams, and now by my medical journals. I would ask the authors to be careful who they throw under the bus.

Scott Peters, MD

Oak Ridge, Tennessee

Continue to: Drs. Mengesha, Arora, and Levy respond...

We appreciate the opportunity to respond to Dr. Peters. Our article brings long overdue awareness to systemic and structural problems that result in disproportionately inequitable outcomes for people of color. We are not debating the morality of individuals or talking about racism as an inherently “bad” trait that some people have, but rather recognizing the impact of social structures on health and well-being in which we all—Black, Brown, and White—live. We all have inherent biases, recognized or unrecognized, that impact our actions, decisions, and behaviors. We are humans with upbringing, backgrounds, and learned frameworks influenced by our sociocultural context that conditions our responses to a given situation. This is also woven into our hospitals, exam rooms, and even our medical journals. It constantly influences the health, well-being, and livelihood of patients—nothing that we do in medicine is in isolation of this greater context. Our health care system is steeped in this sociocultural context and impacts all patients in intersecting ways, whether that be by race, class, gender, or other social identities. And while we did not create the system in which we operate, we now have abundant evidence that shows it continually delivers inequitable outcomes particularly for people of color.

We are very clear that physicians and health care professionals strive to provide the very best care for each and every patient. We do not discount the hard work and good intentions of our colleagues. And while some individual patient behaviors may somewhat modify outcomes, we also strongly disagree with the premise that patients are to blame for poor or less desirable outcomes they face. Instead, our position is focused on the impact that the systems we work in are creating barriers to equitable care at levels of influence above a single individual, and that it is our collective professional responsibility to acknowledge and take action to lessen those barriers.

System-wide changes would not be at the expense of patient care, and physicians cannot and in fact should not shoulder these changes alone. Our current paradigm of training does not give us the capacity to do so, and a single individual cannot make such a large system change alone. The change we are advocating for requires collaboration within multidisciplinary and interprofessional teams, long-term planning, and incremental but intentional change. This is not dissimilar to the recognition over 20 years ago by the Institute of Medicine (now the National Academy of Medicine) that “to err is human.” Our eyes were opened to the structural issues resulting in medical errors, and very slowly our profession has acknowledged the necessity to recognize, report, and analyze the root causes of those errors. We do so because it is critically important to ensure that the same error never happens again. It is part of the commitment to honor our oath to “do no harm.” Similarly, racial inequities in health outcomes should also be “never events” as there is no biological basis or individual blame for these inequities, but rather systemic and structural processes (which is de facto racism) that contribute to disproportionately worse outcomes.

Disparities in COVID-19 vaccination rates for people of color is a current example that illustrates the deep distrust in our health care system that historical events, like Tuskegee, have created. In Tennessee, for example, 7% of COVID-19 vaccines have been administered to Black people despite the fact that they make up 15% of cases, 18% of deaths, and 16% of the total population.1 There are other ongoing systemic issues, including inequities in distribution, prioritization, and access, that are contributing to the lower vaccination rates among people of color; however, as physicians and advocates for our patients, it is crucial for us to acknowledge the fear of, and resistance to, government-sponsored health programs which has resulted from events like Tuskegee.

We are advocating for building our systems to help support all of the social and societal determinants of health our patients are faced with, including racism, while they are receiving care from us. Patients are faced with undue morbidity and mortality because of our health care system’s ineffectiveness in incorporating this as a part of systemic care delivery to all. We must work together alongside other health care professionals, public health and policy agencies, and community advocates to stop this deadly cycle. There will be no improvement and no end in sight unless we work together toward this common goal.

Reference 

1. Ndugga N, Pham O, Hill L, et al. Latest data on COVID-19 vaccinations: race/ethnicity. Kaiser Family Foundation website. February 1, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-covid-19-vaccinations-cases-deaths-race-ethnicity/. Accessed February 11, 2021.

Recent studies have found poor representation of darker skin types (defined as Fitzpatrick skin types V–VI) in dermatology textbooks and online resources.^1,2 We sought to evaluate representation of darker skin types in the Basic Dermatology Curriculum of the American Academy of Dermatology (AAD), an online curriculum of 35 lectures that serves as a standard curriculum for dermatologic education, particularly for medical students and residents without a home dermatology program.³ Although core dermatology knowledge was specified as a curricular goal, knowledge of how dermatologic conditions manifest across various skin types was not.³

Methods

Photographs from all Basic Dermatology Curriculum online lectures showing background skin were independently labeled by 3 investigators (B.C., R.F., and G.O.) as light skin (Fitzpatrick types I–IV) or dark skin (Fitzpatrick types V–VI), along with the associated diagnosis. Photographs without visible background skin were excluded (eg, mucous membranes, palms and soles, genitalia, scalp, dermoscopic images). Photographs with indeterminate skin type were evaluated by consensus and excluded if consensus could not be reached. Inter-rater reliability for labeling skin type was determined on an overlapping sample of 24 photographs (Fleiss’s κ, 0.80).

Results

Of 666 included photographs, 104 (15.6%) featured dark skin. Of all photographs of light skin (Fitzpatrick type I–IV), 80.8% were Fitzpatrick types I and II. One-quarter of lectures featured no photographs of dark skin (Figure 1). When the associated diagnoses of photographs were organized into 20 categories, 4 categories—pigmentary disorders, HIV infection, sexually transmitted infections and warts, and papulosquamous eruptions (Figure 2)—each featured 25% or more photographs of dark skin.

Comment

Our analysis of curricular photographs found dark skin representation in 16% of photographs, mirroring earlier findings in other educational resources.^1,2 There was little (<5%) representation of skin cancer in individuals with darker skin, which may merely reflect lower incidence, but there is concern that lack of education about skin cancer might contribute to disparities in care, such as delayed diagnosis.²

For some conditions common in darker-skinned patients, such as acne vulgaris, representation was low; the lecture “Acne vulgaris” featured only 1 photograph of dark skin. In contrast, dark skin types were well represented in photographs of sexually transmitted infections, such as HIV infection, syphilis, and warts, which may suggest bias when dark skin is chosen to represent diseases, as noted in prior findings.^1,2

Limitations of this study included individual judgment of skin type and use of the Fitzpatrick scale. Although inter-rater reliability was excellent, the validity of Fitzpatrick classification of skin color is controversial, given that it was intended to describe propensity for sunburn and that types V to VI were added later to describe darker skin.⁴

Suggestions for Improvement
Given the abundance of resources with depictions of skin of color in teaching materials (eg, Taylor and Kelly’s Dermatology for Skin of Color, Ethnic Dermatology: Principles and Practice) and digital resources (eg, VisualDx [https://www.visualdx.com]), a logical solution might be to add a greater percentage of photographs depicting darker skin from outside resources to address the imbalance. Still, this might be challenging with limited space. Often, there is only room for a single representative photograph. Therefore, greater effort must be made to consistently show how diseases might present variably on different background skin types or, at the least, to create new resources showing greater skin type diversity.

Furthermore, given the lack of representation of skin of color, authors of educational resources can prioritize capturing images of skin pathology presenting in darker skin during their clinical work. Authors who do not have access to a substantial census of patients with darker skin can collaborate with dermatologists who specialize in skin of color to gather such images.

Technical issues include difficulty capturing high-quality images of dermatologic conditions in darker skin because eruptions in these patients might have a narrower range of contrast. Although resources on taking high-quality clinical images are widely available, specific advice for photographing darker skin is lacking and warrants future research.^5-7 Collaboration with professional photographers who are experienced with clients with darker skin might be useful in developing guidelines.

Conclusion

Given recent guidance by the AAD to “include common skin disorders and diseases requiring special consideration in people with skin of color” and highlight “current disparities in health outcomes within dermatology,”⁸ our findings might guide future improvements in curricula.

Recent studies have found poor representation of darker skin types (defined as Fitzpatrick skin types V–VI) in dermatology textbooks and online resources.^1,2 We sought to evaluate representation of darker skin types in the Basic Dermatology Curriculum of the American Academy of Dermatology (AAD), an online curriculum of 35 lectures that serves as a standard curriculum for dermatologic education, particularly for medical students and residents without a home dermatology program.³ Although core dermatology knowledge was specified as a curricular goal, knowledge of how dermatologic conditions manifest across various skin types was not.³

Methods

Photographs from all Basic Dermatology Curriculum online lectures showing background skin were independently labeled by 3 investigators (B.C., R.F., and G.O.) as light skin (Fitzpatrick types I–IV) or dark skin (Fitzpatrick types V–VI), along with the associated diagnosis. Photographs without visible background skin were excluded (eg, mucous membranes, palms and soles, genitalia, scalp, dermoscopic images). Photographs with indeterminate skin type were evaluated by consensus and excluded if consensus could not be reached. Inter-rater reliability for labeling skin type was determined on an overlapping sample of 24 photographs (Fleiss’s κ, 0.80).

Results

Of 666 included photographs, 104 (15.6%) featured dark skin. Of all photographs of light skin (Fitzpatrick type I–IV), 80.8% were Fitzpatrick types I and II. One-quarter of lectures featured no photographs of dark skin (Figure 1). When the associated diagnoses of photographs were organized into 20 categories, 4 categories—pigmentary disorders, HIV infection, sexually transmitted infections and warts, and papulosquamous eruptions (Figure 2)—each featured 25% or more photographs of dark skin.

Comment

Our analysis of curricular photographs found dark skin representation in 16% of photographs, mirroring earlier findings in other educational resources.^1,2 There was little (<5%) representation of skin cancer in individuals with darker skin, which may merely reflect lower incidence, but there is concern that lack of education about skin cancer might contribute to disparities in care, such as delayed diagnosis.²

For some conditions common in darker-skinned patients, such as acne vulgaris, representation was low; the lecture “Acne vulgaris” featured only 1 photograph of dark skin. In contrast, dark skin types were well represented in photographs of sexually transmitted infections, such as HIV infection, syphilis, and warts, which may suggest bias when dark skin is chosen to represent diseases, as noted in prior findings.^1,2

Limitations of this study included individual judgment of skin type and use of the Fitzpatrick scale. Although inter-rater reliability was excellent, the validity of Fitzpatrick classification of skin color is controversial, given that it was intended to describe propensity for sunburn and that types V to VI were added later to describe darker skin.⁴

Suggestions for Improvement
Given the abundance of resources with depictions of skin of color in teaching materials (eg, Taylor and Kelly’s Dermatology for Skin of Color, Ethnic Dermatology: Principles and Practice) and digital resources (eg, VisualDx [https://www.visualdx.com]), a logical solution might be to add a greater percentage of photographs depicting darker skin from outside resources to address the imbalance. Still, this might be challenging with limited space. Often, there is only room for a single representative photograph. Therefore, greater effort must be made to consistently show how diseases might present variably on different background skin types or, at the least, to create new resources showing greater skin type diversity.

Furthermore, given the lack of representation of skin of color, authors of educational resources can prioritize capturing images of skin pathology presenting in darker skin during their clinical work. Authors who do not have access to a substantial census of patients with darker skin can collaborate with dermatologists who specialize in skin of color to gather such images.

Technical issues include difficulty capturing high-quality images of dermatologic conditions in darker skin because eruptions in these patients might have a narrower range of contrast. Although resources on taking high-quality clinical images are widely available, specific advice for photographing darker skin is lacking and warrants future research.^5-7 Collaboration with professional photographers who are experienced with clients with darker skin might be useful in developing guidelines.

Conclusion

Given recent guidance by the AAD to “include common skin disorders and diseases requiring special consideration in people with skin of color” and highlight “current disparities in health outcomes within dermatology,”⁸ our findings might guide future improvements in curricula.

Recent studies have found poor representation of darker skin types (defined as Fitzpatrick skin types V–VI) in dermatology textbooks and online resources.^1,2 We sought to evaluate representation of darker skin types in the Basic Dermatology Curriculum of the American Academy of Dermatology (AAD), an online curriculum of 35 lectures that serves as a standard curriculum for dermatologic education, particularly for medical students and residents without a home dermatology program.³ Although core dermatology knowledge was specified as a curricular goal, knowledge of how dermatologic conditions manifest across various skin types was not.³

Methods

Photographs from all Basic Dermatology Curriculum online lectures showing background skin were independently labeled by 3 investigators (B.C., R.F., and G.O.) as light skin (Fitzpatrick types I–IV) or dark skin (Fitzpatrick types V–VI), along with the associated diagnosis. Photographs without visible background skin were excluded (eg, mucous membranes, palms and soles, genitalia, scalp, dermoscopic images). Photographs with indeterminate skin type were evaluated by consensus and excluded if consensus could not be reached. Inter-rater reliability for labeling skin type was determined on an overlapping sample of 24 photographs (Fleiss’s κ, 0.80).

Results

Of 666 included photographs, 104 (15.6%) featured dark skin. Of all photographs of light skin (Fitzpatrick type I–IV), 80.8% were Fitzpatrick types I and II. One-quarter of lectures featured no photographs of dark skin (Figure 1). When the associated diagnoses of photographs were organized into 20 categories, 4 categories—pigmentary disorders, HIV infection, sexually transmitted infections and warts, and papulosquamous eruptions (Figure 2)—each featured 25% or more photographs of dark skin.

Comment

Our analysis of curricular photographs found dark skin representation in 16% of photographs, mirroring earlier findings in other educational resources.^1,2 There was little (<5%) representation of skin cancer in individuals with darker skin, which may merely reflect lower incidence, but there is concern that lack of education about skin cancer might contribute to disparities in care, such as delayed diagnosis.²

For some conditions common in darker-skinned patients, such as acne vulgaris, representation was low; the lecture “Acne vulgaris” featured only 1 photograph of dark skin. In contrast, dark skin types were well represented in photographs of sexually transmitted infections, such as HIV infection, syphilis, and warts, which may suggest bias when dark skin is chosen to represent diseases, as noted in prior findings.^1,2

Limitations of this study included individual judgment of skin type and use of the Fitzpatrick scale. Although inter-rater reliability was excellent, the validity of Fitzpatrick classification of skin color is controversial, given that it was intended to describe propensity for sunburn and that types V to VI were added later to describe darker skin.⁴

Suggestions for Improvement
Given the abundance of resources with depictions of skin of color in teaching materials (eg, Taylor and Kelly’s Dermatology for Skin of Color, Ethnic Dermatology: Principles and Practice) and digital resources (eg, VisualDx [https://www.visualdx.com]), a logical solution might be to add a greater percentage of photographs depicting darker skin from outside resources to address the imbalance. Still, this might be challenging with limited space. Often, there is only room for a single representative photograph. Therefore, greater effort must be made to consistently show how diseases might present variably on different background skin types or, at the least, to create new resources showing greater skin type diversity.

Furthermore, given the lack of representation of skin of color, authors of educational resources can prioritize capturing images of skin pathology presenting in darker skin during their clinical work. Authors who do not have access to a substantial census of patients with darker skin can collaborate with dermatologists who specialize in skin of color to gather such images.

Technical issues include difficulty capturing high-quality images of dermatologic conditions in darker skin because eruptions in these patients might have a narrower range of contrast. Although resources on taking high-quality clinical images are widely available, specific advice for photographing darker skin is lacking and warrants future research.^5-7 Collaboration with professional photographers who are experienced with clients with darker skin might be useful in developing guidelines.

Conclusion

Given recent guidance by the AAD to “include common skin disorders and diseases requiring special consideration in people with skin of color” and highlight “current disparities in health outcomes within dermatology,”⁸ our findings might guide future improvements in curricula.

Access to specialty care such as dermatology is a challenge for patients living in underserved communities.¹ In 2019, there were 29.6 million individuals without health insurance in the United States—9.2% of the population—up from 28.6 million the prior year.² Furthermore, Black and Hispanic patients, American Indian and Alaskan Natives, and Native Hawaiian and other Pacific Islanders are more likely to be uninsured than their White counterparts.³ Community service activities such as free skin cancer screenings, partnerships with community practices, and teledermatology consultations through free clinics are instrumental in mitigating health care disparities and improving access to dermatologic care. In this article, we build on existing models from dermatology residency programs across the country to propose actionable methods to expand service-learning opportunities in dermatology residency training and increase health care equity in dermatology.

Why Service Learning?

Service learning is an educational approach that combines learning objectives with community service to provide a comprehensive scholastic experience and meet societal needs.⁴ In pilot studies of family medicine residents, service-learning initiatives enhanced the standard residency curriculum by promoting clinical practice resourcefulness.⁵ Dermatology Accreditation Council for Graduate Medical Education requirements mandate that residents demonstrate an awareness of the larger context of health care, including social determinants of health.⁶ Likewise, dermatology residents must recognize the impact of socioeconomic status on health care utilization, treatment options, and patient adherence. With this understanding, residents can advocate for quality patient care and improve community-based health care systems.⁶

Service-learning projects can effectively meet the specific health needs of a community. In a service-learning environment, residents will understand a community-based health care approach and work with attending physician role models who exhibit a community service ethic.⁷ Residents also can gain interprofessional experience through collaborating with a team of social workers, community health workers, care coordinators, pharmacists, nurses, medical students, and attending physicians. Furthermore, residents can practice communicating effectively with patients and families across a range of socioeconomic and cultural backgrounds. Interprofessional, team-based care and interpersonal skill acquisition are both Accreditation Council for Graduate Medical Education requirements for dermatology training.⁶ Through increased service-learning opportunities, dermatology trainees will learn to recognize and mitigate social determinants of health with a holistic, patient-centered treatment plan.

Free or low-cost medical clinics provide health care to more than 15 million Americans, many of whom identify with marginalized racial and ethnic groups.⁸ In a dermatology access study, a sample of clinics listed in the National Association of Free and Charitable Clinics database were contacted regarding the availability of dermatologic care; however, more than half of the sites were unresponsive or closed, and the remaining clinics offered limited access to dermatology services.⁹ The scarcity of free and low-cost dermatologic services likely contributes to adverse skin health outcomes for patients in underserved communities.¹⁰ By increasing service learning within dermatology residency training programs, access to dermatologic care will improve for underserved and uninsured populations.

Actionable Methods to Increase Service Learning in Dermatology Residency Training Programs

Utilize Programming Offered Through National Dermatology Associations and Societies
The American Academy of Dermatology (AAD) has developed programming through which faculty, residents, and private practice dermatologists perform community service targeting underserved populations. SPOT me , a skin cancer screening program, is the AAD’s longest-standing public health program through which it provides complimentary screening forms, handouts, and advertisements to facilitate skin cancer screening. AccessDerm is the AAD’s philanthropic teledermatology program that delivers dermatologic care to underserved communities. Camp Discovery and the Shade Structure Grant Program are additional initiatives promoted by the AAD to support volunteer services for communities while learning about dermatology. Residents may apply for AAD grants to subsidize participation in the Native American Health Service Resident Rotation Program, the Skin Care for Developing Countries program, or an international grant.

The Women’s Dermatologic Society hosts 3 primary umbrella community outreach initiatives: Play Safe in the Sun, Coast-2-Coast, and the Transforming Interconnecting Project Program Women’s Shelter Initiative. From uplifting and educating individuals in women’s shelters about skin care, oral hygiene, self-care, nutrition, and social skills to providing complimentary skin cancer screenings, the Women’s Dermatologic Society provides easily accessible tool kits and syllabi to facilitate project composition and completion by its members.

Implement Residency Class Service-Learning Projects
Incoming dermatology residents are regularly encouraged to draft research proposals at the beginning of each academic year. Encouraging residency classes to work collectively on a dermatology service-learning project likely will increase resident camaraderie and project success while minimizing internal competition. In developing a service-learning proposal, residents should engage with community leaders and groups to best understand how to meet the skin health needs of underserved communities. The project should have clear objectives, benchmarks, and full support of the dermatology department. Short-term service-learning projects are completed when set goals are achieved, while sustainable projects continue with each new resident class.

Partner With Existing Community or Federally Funded Clinics
Establishing partnerships with free or federally funded health centers is a reliable way to increase service-learning opportunities in dermatology residency training. Personal malpractice carriers often include free clinic coverage, and most states offer limited liability or immunity for physicians who volunteer their professional services or subsidize malpractice insurance purchases.¹¹ In light of the global coronavirus disease 2019 pandemic, teledermatology options should be explored alongside in-person services. Although logistics may vary based on institutional preference, the following are our recommendations for building community partnerships for dermatology service learning (Figure):

• Secure departmental and institutional support. This includes requesting supplies, donations, and dermatopathology support

• Designate a resident or faculty community service champion to lead clinic correspondence and oversee operative logistics. This individual will establish a working partnership with the community clinic, assess the needs of the patient population, and manage the clinic schedule. The champion also will initiate and maintain open lines of communication with community providers for continuity of care. This partnership with community providers allows for shared resources and mutual learning

• Solicit residents to volunteer on a rotating schedule. Although some residents are fully committed to community service and health care justice, all residents need to participate in the service-learning program

• Participate in sustainable community engagement on a schedule that suits the needs of the community and takes into consideration resident and attending availability

Final Thoughts

Service learning in dermatology residency training is essential to improve access to equitable dermatologic care and train clinically competent dermatologists who have experience practicing in resource-limited settings. Service learning places cultural awareness and an understanding of socioeconomic determinants of health at the forefront.¹² Some dermatology residency programs treat a high percentage of medically underserved patients; others have integrated service learning into dermatology rotations, and a few programs offer community engagement–focused residency tracks.^13-16 Each dermatology program should evaluate its workforce, resources, and nearby underserved communities to strategically develop a program-specific service-learning program. Service-learning clinics often are the sole means by which patients from underserved communities receive dermatologic care.¹⁷ A commitment to service learning in dermatology residency programs will improve skin health equity and improve dermatology residency education.

Access to specialty care such as dermatology is a challenge for patients living in underserved communities.¹ In 2019, there were 29.6 million individuals without health insurance in the United States—9.2% of the population—up from 28.6 million the prior year.² Furthermore, Black and Hispanic patients, American Indian and Alaskan Natives, and Native Hawaiian and other Pacific Islanders are more likely to be uninsured than their White counterparts.³ Community service activities such as free skin cancer screenings, partnerships with community practices, and teledermatology consultations through free clinics are instrumental in mitigating health care disparities and improving access to dermatologic care. In this article, we build on existing models from dermatology residency programs across the country to propose actionable methods to expand service-learning opportunities in dermatology residency training and increase health care equity in dermatology.

Why Service Learning?

Service learning is an educational approach that combines learning objectives with community service to provide a comprehensive scholastic experience and meet societal needs.⁴ In pilot studies of family medicine residents, service-learning initiatives enhanced the standard residency curriculum by promoting clinical practice resourcefulness.⁵ Dermatology Accreditation Council for Graduate Medical Education requirements mandate that residents demonstrate an awareness of the larger context of health care, including social determinants of health.⁶ Likewise, dermatology residents must recognize the impact of socioeconomic status on health care utilization, treatment options, and patient adherence. With this understanding, residents can advocate for quality patient care and improve community-based health care systems.⁶

Service-learning projects can effectively meet the specific health needs of a community. In a service-learning environment, residents will understand a community-based health care approach and work with attending physician role models who exhibit a community service ethic.⁷ Residents also can gain interprofessional experience through collaborating with a team of social workers, community health workers, care coordinators, pharmacists, nurses, medical students, and attending physicians. Furthermore, residents can practice communicating effectively with patients and families across a range of socioeconomic and cultural backgrounds. Interprofessional, team-based care and interpersonal skill acquisition are both Accreditation Council for Graduate Medical Education requirements for dermatology training.⁶ Through increased service-learning opportunities, dermatology trainees will learn to recognize and mitigate social determinants of health with a holistic, patient-centered treatment plan.

Free or low-cost medical clinics provide health care to more than 15 million Americans, many of whom identify with marginalized racial and ethnic groups.⁸ In a dermatology access study, a sample of clinics listed in the National Association of Free and Charitable Clinics database were contacted regarding the availability of dermatologic care; however, more than half of the sites were unresponsive or closed, and the remaining clinics offered limited access to dermatology services.⁹ The scarcity of free and low-cost dermatologic services likely contributes to adverse skin health outcomes for patients in underserved communities.¹⁰ By increasing service learning within dermatology residency training programs, access to dermatologic care will improve for underserved and uninsured populations.

Actionable Methods to Increase Service Learning in Dermatology Residency Training Programs

Utilize Programming Offered Through National Dermatology Associations and Societies
The American Academy of Dermatology (AAD) has developed programming through which faculty, residents, and private practice dermatologists perform community service targeting underserved populations. SPOT me , a skin cancer screening program, is the AAD’s longest-standing public health program through which it provides complimentary screening forms, handouts, and advertisements to facilitate skin cancer screening. AccessDerm is the AAD’s philanthropic teledermatology program that delivers dermatologic care to underserved communities. Camp Discovery and the Shade Structure Grant Program are additional initiatives promoted by the AAD to support volunteer services for communities while learning about dermatology. Residents may apply for AAD grants to subsidize participation in the Native American Health Service Resident Rotation Program, the Skin Care for Developing Countries program, or an international grant.

The Women’s Dermatologic Society hosts 3 primary umbrella community outreach initiatives: Play Safe in the Sun, Coast-2-Coast, and the Transforming Interconnecting Project Program Women’s Shelter Initiative. From uplifting and educating individuals in women’s shelters about skin care, oral hygiene, self-care, nutrition, and social skills to providing complimentary skin cancer screenings, the Women’s Dermatologic Society provides easily accessible tool kits and syllabi to facilitate project composition and completion by its members.

Implement Residency Class Service-Learning Projects
Incoming dermatology residents are regularly encouraged to draft research proposals at the beginning of each academic year. Encouraging residency classes to work collectively on a dermatology service-learning project likely will increase resident camaraderie and project success while minimizing internal competition. In developing a service-learning proposal, residents should engage with community leaders and groups to best understand how to meet the skin health needs of underserved communities. The project should have clear objectives, benchmarks, and full support of the dermatology department. Short-term service-learning projects are completed when set goals are achieved, while sustainable projects continue with each new resident class.

Partner With Existing Community or Federally Funded Clinics
Establishing partnerships with free or federally funded health centers is a reliable way to increase service-learning opportunities in dermatology residency training. Personal malpractice carriers often include free clinic coverage, and most states offer limited liability or immunity for physicians who volunteer their professional services or subsidize malpractice insurance purchases.¹¹ In light of the global coronavirus disease 2019 pandemic, teledermatology options should be explored alongside in-person services. Although logistics may vary based on institutional preference, the following are our recommendations for building community partnerships for dermatology service learning (Figure):

• Secure departmental and institutional support. This includes requesting supplies, donations, and dermatopathology support

• Designate a resident or faculty community service champion to lead clinic correspondence and oversee operative logistics. This individual will establish a working partnership with the community clinic, assess the needs of the patient population, and manage the clinic schedule. The champion also will initiate and maintain open lines of communication with community providers for continuity of care. This partnership with community providers allows for shared resources and mutual learning

• Solicit residents to volunteer on a rotating schedule. Although some residents are fully committed to community service and health care justice, all residents need to participate in the service-learning program

• Participate in sustainable community engagement on a schedule that suits the needs of the community and takes into consideration resident and attending availability

Final Thoughts

Service learning in dermatology residency training is essential to improve access to equitable dermatologic care and train clinically competent dermatologists who have experience practicing in resource-limited settings. Service learning places cultural awareness and an understanding of socioeconomic determinants of health at the forefront.¹² Some dermatology residency programs treat a high percentage of medically underserved patients; others have integrated service learning into dermatology rotations, and a few programs offer community engagement–focused residency tracks.^13-16 Each dermatology program should evaluate its workforce, resources, and nearby underserved communities to strategically develop a program-specific service-learning program. Service-learning clinics often are the sole means by which patients from underserved communities receive dermatologic care.¹⁷ A commitment to service learning in dermatology residency programs will improve skin health equity and improve dermatology residency education.

Access to specialty care such as dermatology is a challenge for patients living in underserved communities.¹ In 2019, there were 29.6 million individuals without health insurance in the United States—9.2% of the population—up from 28.6 million the prior year.² Furthermore, Black and Hispanic patients, American Indian and Alaskan Natives, and Native Hawaiian and other Pacific Islanders are more likely to be uninsured than their White counterparts.³ Community service activities such as free skin cancer screenings, partnerships with community practices, and teledermatology consultations through free clinics are instrumental in mitigating health care disparities and improving access to dermatologic care. In this article, we build on existing models from dermatology residency programs across the country to propose actionable methods to expand service-learning opportunities in dermatology residency training and increase health care equity in dermatology.

Why Service Learning?

Service learning is an educational approach that combines learning objectives with community service to provide a comprehensive scholastic experience and meet societal needs.⁴ In pilot studies of family medicine residents, service-learning initiatives enhanced the standard residency curriculum by promoting clinical practice resourcefulness.⁵ Dermatology Accreditation Council for Graduate Medical Education requirements mandate that residents demonstrate an awareness of the larger context of health care, including social determinants of health.⁶ Likewise, dermatology residents must recognize the impact of socioeconomic status on health care utilization, treatment options, and patient adherence. With this understanding, residents can advocate for quality patient care and improve community-based health care systems.⁶

Service-learning projects can effectively meet the specific health needs of a community. In a service-learning environment, residents will understand a community-based health care approach and work with attending physician role models who exhibit a community service ethic.⁷ Residents also can gain interprofessional experience through collaborating with a team of social workers, community health workers, care coordinators, pharmacists, nurses, medical students, and attending physicians. Furthermore, residents can practice communicating effectively with patients and families across a range of socioeconomic and cultural backgrounds. Interprofessional, team-based care and interpersonal skill acquisition are both Accreditation Council for Graduate Medical Education requirements for dermatology training.⁶ Through increased service-learning opportunities, dermatology trainees will learn to recognize and mitigate social determinants of health with a holistic, patient-centered treatment plan.

Free or low-cost medical clinics provide health care to more than 15 million Americans, many of whom identify with marginalized racial and ethnic groups.⁸ In a dermatology access study, a sample of clinics listed in the National Association of Free and Charitable Clinics database were contacted regarding the availability of dermatologic care; however, more than half of the sites were unresponsive or closed, and the remaining clinics offered limited access to dermatology services.⁹ The scarcity of free and low-cost dermatologic services likely contributes to adverse skin health outcomes for patients in underserved communities.¹⁰ By increasing service learning within dermatology residency training programs, access to dermatologic care will improve for underserved and uninsured populations.

Actionable Methods to Increase Service Learning in Dermatology Residency Training Programs

Utilize Programming Offered Through National Dermatology Associations and Societies
The American Academy of Dermatology (AAD) has developed programming through which faculty, residents, and private practice dermatologists perform community service targeting underserved populations. SPOT me , a skin cancer screening program, is the AAD’s longest-standing public health program through which it provides complimentary screening forms, handouts, and advertisements to facilitate skin cancer screening. AccessDerm is the AAD’s philanthropic teledermatology program that delivers dermatologic care to underserved communities. Camp Discovery and the Shade Structure Grant Program are additional initiatives promoted by the AAD to support volunteer services for communities while learning about dermatology. Residents may apply for AAD grants to subsidize participation in the Native American Health Service Resident Rotation Program, the Skin Care for Developing Countries program, or an international grant.

The Women’s Dermatologic Society hosts 3 primary umbrella community outreach initiatives: Play Safe in the Sun, Coast-2-Coast, and the Transforming Interconnecting Project Program Women’s Shelter Initiative. From uplifting and educating individuals in women’s shelters about skin care, oral hygiene, self-care, nutrition, and social skills to providing complimentary skin cancer screenings, the Women’s Dermatologic Society provides easily accessible tool kits and syllabi to facilitate project composition and completion by its members.

Implement Residency Class Service-Learning Projects
Incoming dermatology residents are regularly encouraged to draft research proposals at the beginning of each academic year. Encouraging residency classes to work collectively on a dermatology service-learning project likely will increase resident camaraderie and project success while minimizing internal competition. In developing a service-learning proposal, residents should engage with community leaders and groups to best understand how to meet the skin health needs of underserved communities. The project should have clear objectives, benchmarks, and full support of the dermatology department. Short-term service-learning projects are completed when set goals are achieved, while sustainable projects continue with each new resident class.

Partner With Existing Community or Federally Funded Clinics
Establishing partnerships with free or federally funded health centers is a reliable way to increase service-learning opportunities in dermatology residency training. Personal malpractice carriers often include free clinic coverage, and most states offer limited liability or immunity for physicians who volunteer their professional services or subsidize malpractice insurance purchases.¹¹ In light of the global coronavirus disease 2019 pandemic, teledermatology options should be explored alongside in-person services. Although logistics may vary based on institutional preference, the following are our recommendations for building community partnerships for dermatology service learning (Figure):

• Secure departmental and institutional support. This includes requesting supplies, donations, and dermatopathology support

• Designate a resident or faculty community service champion to lead clinic correspondence and oversee operative logistics. This individual will establish a working partnership with the community clinic, assess the needs of the patient population, and manage the clinic schedule. The champion also will initiate and maintain open lines of communication with community providers for continuity of care. This partnership with community providers allows for shared resources and mutual learning

• Solicit residents to volunteer on a rotating schedule. Although some residents are fully committed to community service and health care justice, all residents need to participate in the service-learning program

• Participate in sustainable community engagement on a schedule that suits the needs of the community and takes into consideration resident and attending availability

Final Thoughts

Service learning in dermatology residency training is essential to improve access to equitable dermatologic care and train clinically competent dermatologists who have experience practicing in resource-limited settings. Service learning places cultural awareness and an understanding of socioeconomic determinants of health at the forefront.¹² Some dermatology residency programs treat a high percentage of medically underserved patients; others have integrated service learning into dermatology rotations, and a few programs offer community engagement–focused residency tracks.^13-16 Each dermatology program should evaluate its workforce, resources, and nearby underserved communities to strategically develop a program-specific service-learning program. Service-learning clinics often are the sole means by which patients from underserved communities receive dermatologic care.¹⁷ A commitment to service learning in dermatology residency programs will improve skin health equity and improve dermatology residency education.

A 16-minute podcast from JAMA: The Journal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.

Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.

“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.

“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” Dr. Katz said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”

Dr. Katz reiterated that both interpersonal and structural racism continue to exist in the United States, “and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”

He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”

The podcast and JAMA’s tweet promoting it were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.

B. Bobby Chiong, MD, a radiologist in New York, said although JAMA’s effort to engage with its audience about racism is laudable, it missed the mark.

“I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism,” he said. 

Perhaps the podcast’s worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, assistant professor at the University of North Carolina at Chapel Hill.

“For physicians in leadership to have the belief that structural racism does not exist in medicine, they don’t really appreciate what affects their patients and what their patients were dealing with,” Dr. Saint-Surin said in an interview. “It was a very harmful podcast and goes to show we still have so much work to do.”

Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Dr. Livingston focused on interpersonal racism rather than structural racism, she said, failing to address widespread problems such as higher rates of asthma among Black populations living in areas with poor air quality.

The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.

Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.

“I can’t submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb,” Dr. Obuobi said. “They didn’t uphold the standards they normally apply to anyone else.”

Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.

JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.

AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal, and we are deeply disturbed – and angered – by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’ ”

He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA, and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists, and it is incumbent on all of us to fix it.”

This article was updated 3/5/21.

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

A 16-minute podcast from JAMA: The Journal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.

Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.

“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.

“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” Dr. Katz said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”

Dr. Katz reiterated that both interpersonal and structural racism continue to exist in the United States, “and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”

He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”

The podcast and JAMA’s tweet promoting it were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.

B. Bobby Chiong, MD, a radiologist in New York, said although JAMA’s effort to engage with its audience about racism is laudable, it missed the mark.

“I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism,” he said. 

Perhaps the podcast’s worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, assistant professor at the University of North Carolina at Chapel Hill.

“For physicians in leadership to have the belief that structural racism does not exist in medicine, they don’t really appreciate what affects their patients and what their patients were dealing with,” Dr. Saint-Surin said in an interview. “It was a very harmful podcast and goes to show we still have so much work to do.”

Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Dr. Livingston focused on interpersonal racism rather than structural racism, she said, failing to address widespread problems such as higher rates of asthma among Black populations living in areas with poor air quality.

The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.

Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.

“I can’t submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb,” Dr. Obuobi said. “They didn’t uphold the standards they normally apply to anyone else.”

Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.

JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.

AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal, and we are deeply disturbed – and angered – by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’ ”

He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA, and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists, and it is incumbent on all of us to fix it.”

This article was updated 3/5/21.

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

A 16-minute podcast from JAMA: The Journal of the American Medical Association that attempts to discuss structural racism in the U.S. health care system has stirred conversation on social media about the handling and promotion of the episode.

Published on Feb. 23, the episode is hosted on JAMA’s learning platform for doctors and is available for continuing medical education credits.

“No physician is racist, so how can there be structural racism in health care? An explanation of the idea by doctors for doctors in this user-friendly podcast,” JAMA wrote in a Twitter post to promote the episode. That tweet has since been deleted.

“Systemic and interpersonal racism both still exist in our country — they must be rooted out. I do not share the JAMA host’s belief of doing away with the word ‘racism’ will help us be more successful in ending inequities that exists across racial and ethnic lines,” Dr. Katz said. “Further, I believe that we will only produce an equitable society when social and political structures do not continue to produce and perpetuate disparate results based on social race and ethnicity.”

Dr. Katz reiterated that both interpersonal and structural racism continue to exist in the United States, “and it is woefully naive to say that no physician is a racist just because the Civil Rights Act of 1964 forbade it.”

He also recommended JAMA use this controversy “as a learning opportunity for continued dialogue and create another podcast series as an open conversation that invites diverse experts in the field to have an open discussion about structural racism in healthcare.”

The podcast and JAMA’s tweet promoting it were widely criticized on Twitter. In interviews with WebMD, many doctors expressed disbelief that such a respected journal would lend its name to this podcast episode.

B. Bobby Chiong, MD, a radiologist in New York, said although JAMA’s effort to engage with its audience about racism is laudable, it missed the mark.

“I think the backlash comes from how they tried to make a podcast about the subject and somehow made themselves an example of unconscious bias and unfamiliarity with just how embedded in our system is structural racism,” he said. 

Perhaps the podcast’s worst offense was its failure to address the painful history of racial bias in this country that still permeates the medical community, says Tamara Saint-Surin, MD, assistant professor at the University of North Carolina at Chapel Hill.

“For physicians in leadership to have the belief that structural racism does not exist in medicine, they don’t really appreciate what affects their patients and what their patients were dealing with,” Dr. Saint-Surin said in an interview. “It was a very harmful podcast and goes to show we still have so much work to do.”

Along with a flawed premise, she says, the podcast was not nearly long enough to address such a nuanced issue. And Dr. Livingston focused on interpersonal racism rather than structural racism, she said, failing to address widespread problems such as higher rates of asthma among Black populations living in areas with poor air quality.

The number of Black doctors remains low and the lack of representation adds to an environment already rife with racism, according to many medical professionals.

Shirlene Obuobi, MD, an internal medicine doctor in Chicago, said JAMA failed to live up to its own standards by publishing material that lacked research and expertise.

“I can’t submit a clinical trial to JAMA without them combing through methods with a fine-tooth comb,” Dr. Obuobi said. “They didn’t uphold the standards they normally apply to anyone else.”

Both the editor of JAMA and the head of the American Medical Association issued statements criticizing the episode and the tweet that promoted it.

JAMA Editor-in-Chief Howard Bauchner, MD, said, “The language of the tweet, and some portions of the podcast, do not reflect my commitment as editorial leader of JAMA and JAMA Network to call out and discuss the adverse effects of injustice, inequity, and racism in society and medicine as JAMA has done for many years.” He said JAMA will schedule a future podcast to address the concerns raised about the recent episode.

AMA CEO James L. Madara, MD, said, “The AMA’s House of Delegates passed policy stating that racism is structural, systemic, cultural, and interpersonal, and we are deeply disturbed – and angered – by a recent JAMA podcast that questioned the existence of structural racism and the affiliated tweet that promoted the podcast and stated ‘no physician is racist, so how can there be structural racism in health care?’ ”

He continued: “JAMA has editorial independence from AMA, but this tweet and podcast are inconsistent with the policies and views of AMA, and I’m concerned about and acknowledge the harms they have caused. Structural racism in health care and our society exists, and it is incumbent on all of us to fix it.”

This article was updated 3/5/21.

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

The ground trembled, trees shook, and voices echoed throughout the city. I looked around in awe as the dew from my breath settled on the tip of my nose, dampening my face mask. Thousands of people with varying backgrounds, together in recognition that while the arc of the moral universe is long, it cannot bend towards justice without our help. The pain, suffering, and anger of the protestors was palpable, their chants vibrating deep in my chest, all against the backdrop of the historic Los Angeles City Hall, with rows of police officers and National Guard troops on its lawn. The countless recent racially motivated attacks and murders had driven people from all walks of life to protest for an end to systemic racism. I listened to people tell stories and challenge each other to comprehend the depths of the trauma that led us to this moment, and I went home that day curious about the history of racism in medicine.

Medicine’s roots in slavery

The uncomfortable truth is that medicine in America has some of its earliest roots in slavery. In an editorial in the New England Journal of Medicine, Evans et al¹ wrote “Slaves provided economic security for physicians and clinical material that permitted the expansion of medical research, improvement of medical care, and enhancement of medical training.”¹

In the 1830s, medical schools would publicize abundant access to “black clinical subjects” as a recruitment method. The Savannah Medical Journal, for example, proudly stated that Savannah Medical College had a Black patient census that “provided abundant clinical opportunities for studying disease.”² The dehumanization of Black people was pervasive, and while racism in medical education today may be less overt because the Black community is no longer sought after as “clinical material,” discrimination continues. Ebede and Papier³ found that patients of color are extremely underrepresented in images used in medical education.

How were trainees learning to recognize clinical findings in dark-skinned patients? Was this ultimately slowing the identification and treatment of diseases in such populations?

Racism in psychiatry

In a 2020 article in Psychiatric News, American Psychiatric Association (APA) president Jeffrey Geller, MD, MPH, provided shocking insight into the history of racism in American psychiatry.⁴ In 1773, the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Virginia, became the first public freestanding psychiatric hospital in British North America.⁴ The hospital would only accept Black patients if their admission did not interfere with the admission of White patients. Some clinicians also believed that insanity could not occur in Black people due to their “primitive nature.”⁴ John Galt, physician head of the hospital from 1841 to 1862 and one of the APA’s founding fathers, believed that Black people were “immune” to insanity because they did not experience the “mental excitement” that the free population experienced daily. Further, Benjamin Rush, considered the father of American psychiatry, was adamant that black skin itself was actually a disease, called negritude, and the only treatment involved turning a Black person white.⁴

The blasphemy is endless. John Calhoun, former vice president of the APA in the 1840s, stated “The African is incapable of self care and sinks into lunacy under the burden of freedom. It is mercy to him to give this guardianship and protection from mental health.”⁴

How could a population that was owned, sold, beaten, chained, raped, and ultimately dehumanized not develop mental illness? Race was weaponized by the powerful in order to deny the inalienable rights of Black people. Dr. Geller summarized these atrocities perfectly: “…during [the APA’s first 40 years] … Association members did not debate segregation by race. A few members said it shall be so, and the rest were silent—silent for a very long time.”⁴

While I train as a resident psychiatrist, I am learning the value of cultural sensitivity and the importance of truly understanding the background of all my patients in order to effectively treat mental illness. George Floyd’s murder is the most recent death that has shed light on systemic racism and the challenges that are largely unique to the Black community and their mental health. I recognize that combating disparities in mental health requires an honest and often uncomfortable reckoning with the role that systemic racism has played in creating these health disparities. While the trauma inflicted by centuries of injustice cannot be corrected overnight, it is our responsibility to confront these biases and barriers in medicine on a daily basis as we strive to create a more equitable society.

The ground trembled, trees shook, and voices echoed throughout the city. I looked around in awe as the dew from my breath settled on the tip of my nose, dampening my face mask. Thousands of people with varying backgrounds, together in recognition that while the arc of the moral universe is long, it cannot bend towards justice without our help. The pain, suffering, and anger of the protestors was palpable, their chants vibrating deep in my chest, all against the backdrop of the historic Los Angeles City Hall, with rows of police officers and National Guard troops on its lawn. The countless recent racially motivated attacks and murders had driven people from all walks of life to protest for an end to systemic racism. I listened to people tell stories and challenge each other to comprehend the depths of the trauma that led us to this moment, and I went home that day curious about the history of racism in medicine.

Medicine’s roots in slavery

The uncomfortable truth is that medicine in America has some of its earliest roots in slavery. In an editorial in the New England Journal of Medicine, Evans et al¹ wrote “Slaves provided economic security for physicians and clinical material that permitted the expansion of medical research, improvement of medical care, and enhancement of medical training.”¹

In the 1830s, medical schools would publicize abundant access to “black clinical subjects” as a recruitment method. The Savannah Medical Journal, for example, proudly stated that Savannah Medical College had a Black patient census that “provided abundant clinical opportunities for studying disease.”² The dehumanization of Black people was pervasive, and while racism in medical education today may be less overt because the Black community is no longer sought after as “clinical material,” discrimination continues. Ebede and Papier³ found that patients of color are extremely underrepresented in images used in medical education.

How were trainees learning to recognize clinical findings in dark-skinned patients? Was this ultimately slowing the identification and treatment of diseases in such populations?

Racism in psychiatry

In a 2020 article in Psychiatric News, American Psychiatric Association (APA) president Jeffrey Geller, MD, MPH, provided shocking insight into the history of racism in American psychiatry.⁴ In 1773, the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Virginia, became the first public freestanding psychiatric hospital in British North America.⁴ The hospital would only accept Black patients if their admission did not interfere with the admission of White patients. Some clinicians also believed that insanity could not occur in Black people due to their “primitive nature.”⁴ John Galt, physician head of the hospital from 1841 to 1862 and one of the APA’s founding fathers, believed that Black people were “immune” to insanity because they did not experience the “mental excitement” that the free population experienced daily. Further, Benjamin Rush, considered the father of American psychiatry, was adamant that black skin itself was actually a disease, called negritude, and the only treatment involved turning a Black person white.⁴

The blasphemy is endless. John Calhoun, former vice president of the APA in the 1840s, stated “The African is incapable of self care and sinks into lunacy under the burden of freedom. It is mercy to him to give this guardianship and protection from mental health.”⁴

How could a population that was owned, sold, beaten, chained, raped, and ultimately dehumanized not develop mental illness? Race was weaponized by the powerful in order to deny the inalienable rights of Black people. Dr. Geller summarized these atrocities perfectly: “…during [the APA’s first 40 years] … Association members did not debate segregation by race. A few members said it shall be so, and the rest were silent—silent for a very long time.”⁴

While I train as a resident psychiatrist, I am learning the value of cultural sensitivity and the importance of truly understanding the background of all my patients in order to effectively treat mental illness. George Floyd’s murder is the most recent death that has shed light on systemic racism and the challenges that are largely unique to the Black community and their mental health. I recognize that combating disparities in mental health requires an honest and often uncomfortable reckoning with the role that systemic racism has played in creating these health disparities. While the trauma inflicted by centuries of injustice cannot be corrected overnight, it is our responsibility to confront these biases and barriers in medicine on a daily basis as we strive to create a more equitable society.

The ground trembled, trees shook, and voices echoed throughout the city. I looked around in awe as the dew from my breath settled on the tip of my nose, dampening my face mask. Thousands of people with varying backgrounds, together in recognition that while the arc of the moral universe is long, it cannot bend towards justice without our help. The pain, suffering, and anger of the protestors was palpable, their chants vibrating deep in my chest, all against the backdrop of the historic Los Angeles City Hall, with rows of police officers and National Guard troops on its lawn. The countless recent racially motivated attacks and murders had driven people from all walks of life to protest for an end to systemic racism. I listened to people tell stories and challenge each other to comprehend the depths of the trauma that led us to this moment, and I went home that day curious about the history of racism in medicine.

Medicine’s roots in slavery

The uncomfortable truth is that medicine in America has some of its earliest roots in slavery. In an editorial in the New England Journal of Medicine, Evans et al¹ wrote “Slaves provided economic security for physicians and clinical material that permitted the expansion of medical research, improvement of medical care, and enhancement of medical training.”¹

In the 1830s, medical schools would publicize abundant access to “black clinical subjects” as a recruitment method. The Savannah Medical Journal, for example, proudly stated that Savannah Medical College had a Black patient census that “provided abundant clinical opportunities for studying disease.”² The dehumanization of Black people was pervasive, and while racism in medical education today may be less overt because the Black community is no longer sought after as “clinical material,” discrimination continues. Ebede and Papier³ found that patients of color are extremely underrepresented in images used in medical education.

How were trainees learning to recognize clinical findings in dark-skinned patients? Was this ultimately slowing the identification and treatment of diseases in such populations?

Racism in psychiatry

In a 2020 article in Psychiatric News, American Psychiatric Association (APA) president Jeffrey Geller, MD, MPH, provided shocking insight into the history of racism in American psychiatry.⁴ In 1773, the Public Hospital for Persons of Insane and Disordered Minds in Williamsburg, Virginia, became the first public freestanding psychiatric hospital in British North America.⁴ The hospital would only accept Black patients if their admission did not interfere with the admission of White patients. Some clinicians also believed that insanity could not occur in Black people due to their “primitive nature.”⁴ John Galt, physician head of the hospital from 1841 to 1862 and one of the APA’s founding fathers, believed that Black people were “immune” to insanity because they did not experience the “mental excitement” that the free population experienced daily. Further, Benjamin Rush, considered the father of American psychiatry, was adamant that black skin itself was actually a disease, called negritude, and the only treatment involved turning a Black person white.⁴

The blasphemy is endless. John Calhoun, former vice president of the APA in the 1840s, stated “The African is incapable of self care and sinks into lunacy under the burden of freedom. It is mercy to him to give this guardianship and protection from mental health.”⁴

How could a population that was owned, sold, beaten, chained, raped, and ultimately dehumanized not develop mental illness? Race was weaponized by the powerful in order to deny the inalienable rights of Black people. Dr. Geller summarized these atrocities perfectly: “…during [the APA’s first 40 years] … Association members did not debate segregation by race. A few members said it shall be so, and the rest were silent—silent for a very long time.”⁴

While I train as a resident psychiatrist, I am learning the value of cultural sensitivity and the importance of truly understanding the background of all my patients in order to effectively treat mental illness. George Floyd’s murder is the most recent death that has shed light on systemic racism and the challenges that are largely unique to the Black community and their mental health. I recognize that combating disparities in mental health requires an honest and often uncomfortable reckoning with the role that systemic racism has played in creating these health disparities. While the trauma inflicted by centuries of injustice cannot be corrected overnight, it is our responsibility to confront these biases and barriers in medicine on a daily basis as we strive to create a more equitable society.

The coronavirus disease 2019 pandemic, which as of mid-February 2021 had caused more than 486,000 deaths in the United States, has changed our lives forever. Elders and Black, Indigenous, and People of Color (BIPOC) have been overrepresented among those lost. That, when juxtaposed with the civil unrest that followed the brutal killing of George Floyd, an unarmed Black man, by a White law enforcement officer on May 25, 2020, have compelled us to talk about US race relations in unprecedented ways. These and other traumas disproportionately affect the quality of life and health of minority and underserved individuals. The international outcry about racism, serial trauma, and health disparities left the medical profession well positioned to promulgate changes that are conducive to achieving health equity.

Race is a social construct

In November 2020, the American Medical Association (AMA) Board of Trustees made several public acknowledgments about race.¹ First, race is a social, nonbiological classification that is different from biology, ethnicity, or genetic ancestry.¹ Next, race contributes to health disparities and poor health outcomes for minorities and members of underserved communities.¹ Also, racism, which includes disproportionate police brutality against Black and Indigenous people, is a driver of health inequity for them and people in marginalized communities.¹

The AMA also commented on how serial trauma and racism can affect one’s health. The AMA acknowledged that exposure to serial trauma throughout one’s life can have a cumulative effect that is “associated with chronic stress, higher rates of comorbidities and lower life expectancy” and results in increased health care costs and decreased quality of life for those who are affected.¹ Also, the AMA proclaimed that racism is a threat to public health and pledged to dismantle discriminatory practices and policies in health care, including medical education and research.²

Diversity and inclusion in psychiatry

While the AMA has been striving to reduce bias in health care systems, psychiatry has been forging its path. In March 2015, the American Psychiatric Association’s (APA) Board of Trustees approved the APA’s Strategic Initiative, which has 4 goals: 1) advancing the integration of psychiatry in health care; 2) supporting research; 3) supporting education; and 4) promoting diversity and inclusion in psychiatry.³ The latter goal includes advocating for antiracist policies that promote cultural competence and health equity in education, research and psychiatric care; increased recruitment and retention of psychiatrists from groups that historically have been underrepresented in medicine and medical leadership; and ensuring representation of these groups in APA governance at all levels.³

The APA’s antiracism agenda

In March 2020, outgoing APA President Bruce Schwartz concurred with Board members that diversity and inclusion in the APA warranted a closer review. On May 5, 2020, APA President Jeff Geller committed to authorizing a systematic study of diversity and inclusion in various branches of the APA, including councils and governance. By the end of May, with civil unrest in full swing in the United States, President Geller decided to expand the APA’s diversity agenda.

President Geller appointed the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (SR Task Force), which had its virtual inaugural meeting on June 27, 2020.⁴ The SR Task Force exists to focus on structural racism (aka institutional racism) in organized psychiatry, psychiatric patients, and those who provide psychiatric services to patients. The charge, which is subject to revision, if warranted, is clear: provide resources and education on the history of structural racism in the APA and psychiatry, explain how structural racism impacts psychiatric patients and the profession, craft actionable recommendations to dismantle structural racism in the APA and psychiatry, report those findings to the APA’s Board of Trustees, and implement a quality assurance protocol to ensure that the Task Force’s work is consistent with its charge. President Geller decided to have the Task Force focus on anti-Black racism in its inaugural year and believes that the outcome will benefit all psychiatrists, other mental health professionals, and patients who identify as members of minority and underserved groups in the United States and the profession of psychiatry.⁵

Presidential Task Forces in APA

Presidential Task Forces report directly to the Board of Trustees, which expedites the review of progress reports and deliberation on and, when favorable, implementation of recommendations. Also, Presidential Task Forces are afforded additional APA resources. For example, the SR Task Force has 16 APA staff members who have been appointed or volunteered to assist the Task Force in some way. Many APA staff have graduate degrees in law, education, and other subjects. The skill sets, networks, institutional memory, and commitment that they bring to the project are conducive to advancing the SR Task Force’s agenda at a brisk pace.

Continue to: The APA President...

The APA President decides whom to appoint to each Task Force. President Geller propitiously appointed subject matter experts and members of the Board of Trustees to serve on the SR Task Force. Subject matter experts contribute historical and contemporary content about racism, including anti-Black racism, to the discussion. The data are used to craft research questions that may yield pertinent data. (Note that not all subject matter experts are Black, nor are all Board members White.) APA staff support the Task Force by sharing their expertise, compiling data, coordinating meetings, collaborating on program development, disseminating the work product to APA members and the media, and other important tasks.

The SR Task Force’s work

The SR Task Force strives for transparency in a process that is informed by APA members. The group immediately set up a web hub that is used to communicate with APA members.⁵ Individual members also use social media to alert members to SR Task Force activities and events. Member input has been solicited by posting several brief surveys on the SR Task Force web hub. Topics have included the effect of structural racism on patient care, psychiatric practice, and organized psychiatry, including the APA. The responses, which collectively totaled >1,600, were reviewed and used to inform Task Force priorities while working within the scope of the charge.⁵

Based on member feedback, the first large project of the SR Task Force has been to examine structural racism in the APA. The SR Task Force formed workgroups to study data pertaining to diversity and inclusion in the APA Assembly, governance (the Board of Trustees), Councils and Committees, and Scientific Program Committee. As APA Publishing and the DSM Steering Committee have internal processes to address structural racism, the SR Task Force did not convene workgroups to study this. However, the SR Task Force will be meeting with leaders of those groups to learn about their protocols and will request that information be made available to APA members.

The SR Task Force reviews and interprets data that are compiled by each workgroup, deliberates on its significance, and when appropriate, drafts achievable recommendations to improve diversity and inclusion in the APA. This is where Trustee involvement is invaluable to the SR Task Force, because the report and recommendations will be presented to the Board of Trustees.

There is no guarantee that the recommendations contained in a report that is accepted by the Board of Trustees will be implemented unless they are approved. It is imperative, therefore, that SR Task Force recommendations to the Board take into consideration Board structure, processes, goals, efficiency, history, and other matters. The learning curve can be steep, especially when the first major report was due 3 months after the SR Task Force was appointed. Clarity and efficiency are key in report preparation. For example, during the Winter 2020 Board of Trustees meeting, the SR Task Force presented its report, answered questions, and offered 7 action items to the Board for deliberation and voting. The endeavor, which was completed in 20 minutes, resulted in the Board supporting 6 of the recommendations and deferring the deliberation of the seventh recommendation to the spring Board meeting, due to logistical concerns.

Continue to: Thus far, the SR Task Force Workgroups...

Thus far, the SR Task Force Workgroups on the Assembly and Governance have presented their reports. ⁵ The SR Task Force reports on the Scientific Program Committee and Councils and Committees are scheduled to be presented to the Board during the Spring 2021 meeting.

The SR Task Force has been fulfilling the commitment to provide relevant educational materials to members in several ways. There have been 4 virtual Structural Racism Town Hall meetings that featured subject matter experts. The first Town Hall session addressed the initial steps towards dismantling structural racism and included President Geller’s announcement about appointing a SR Task Force. The next Town Hall meeting addressed structural racism in medicine and psychiatry, its effect on children and individuals who identify as transgender, and its intersectionality (the cumulative effect of discrimination on a person who belongs to 2 non-dominant groups.) The panel in the third Town Hall meeting reviewed the impact of structural racism, including intersectionality, on transgenerational trauma in several minority groups. The meeting ended with an update of Task Force activities. The February 2021 Town Hall meeting focused on how structural racism affects recruitment and retention of minority psychiatry residents, and how this can undermine efforts to grow a diverse workforce. Recordings of these and other events can be accessed on the SR Task Force web hub.⁵ The SR Task Force members plan to present a review of the year’s work during the next Town Hall meeting, which is scheduled to occur on Saturday, May 1, 2021, during the APA’s Annual Meeting.

The SR Task Force web hub contains other resources, including APA position statements, press releases, and news articles, and a glossary of relevant terms. It also includes internet links to President Geller’s 9-part series on the history of Structural Racism in the APA. There are CME and other webinars, a curated list of references, videos, podcasts, and other media.⁴

The SR Task Force believes that much of the antiracism work needs to occur beyond APA headquarters. Consequently, President Geller challenged all APA Councils to work on an antiracism project to support the APA’s antiracism agenda. APA committees and caucuses have been encouraged to do the same. The SR Task Force has asked APA District Branches and Allied Organizations to share information about what they are doing to educate members about structural racism and what they are doing for input regarding their antiracist activities. Additionally, Task Force members have been speaking with these and other groups to inform them about the APA’s antiracism work.

APA’s Board of Trustees actions

It would be inappropriate for the APA to task groups with focusing on antiracism unless the organization was doing its part. In July 2020, the Board of Trustees had a 2-hour round table discussion during which each member spoke about the problem and how the APA should address it. Next, President Geller appointed a Board Workgroup to clarify the definitions of “minority” and “underrepresented.” Although the APA Assembly has defined the terms, the APA has not. Additionally, the APA Board of Trustees retained a consultant to assess all aspects of how it functions as a Board. The Board’s management of matters pertaining to diversity and inclusion was part of the examination. The recommendations are being reviewed and the Board will undergo diversity training.

Continue to: President Geller's study...

President Geller’s study of racism in the APA, which involved a review of past APA presidential addresses, brought to light a long-term pattern of racism in the organization.⁵ On January 18, 2021, Martin Luther King, Jr. Day, the APA acknowledged and apologized to psychiatrists, patients, and the public for its history of engaging in and passively condoning racist behavior.⁶ The APA has committed to being better informed about diversity and inclusion at every level. Lastly, hired consultants with expertise in diversity and inclusion are working with APA staff at every level so that the environment can be a welcoming and comfortable workspace for recruiting and retaining a diverse workforce.

Although it may seem that the APA has engaged in many antiracist activities in a brief period, there is much more to accomplish. The Task Force hopes that the work will speak for itself and will be sustained over time. It’s long overdue.

The coronavirus disease 2019 pandemic, which as of mid-February 2021 had caused more than 486,000 deaths in the United States, has changed our lives forever. Elders and Black, Indigenous, and People of Color (BIPOC) have been overrepresented among those lost. That, when juxtaposed with the civil unrest that followed the brutal killing of George Floyd, an unarmed Black man, by a White law enforcement officer on May 25, 2020, have compelled us to talk about US race relations in unprecedented ways. These and other traumas disproportionately affect the quality of life and health of minority and underserved individuals. The international outcry about racism, serial trauma, and health disparities left the medical profession well positioned to promulgate changes that are conducive to achieving health equity.

Race is a social construct

In November 2020, the American Medical Association (AMA) Board of Trustees made several public acknowledgments about race.¹ First, race is a social, nonbiological classification that is different from biology, ethnicity, or genetic ancestry.¹ Next, race contributes to health disparities and poor health outcomes for minorities and members of underserved communities.¹ Also, racism, which includes disproportionate police brutality against Black and Indigenous people, is a driver of health inequity for them and people in marginalized communities.¹

The AMA also commented on how serial trauma and racism can affect one’s health. The AMA acknowledged that exposure to serial trauma throughout one’s life can have a cumulative effect that is “associated with chronic stress, higher rates of comorbidities and lower life expectancy” and results in increased health care costs and decreased quality of life for those who are affected.¹ Also, the AMA proclaimed that racism is a threat to public health and pledged to dismantle discriminatory practices and policies in health care, including medical education and research.²

Diversity and inclusion in psychiatry

While the AMA has been striving to reduce bias in health care systems, psychiatry has been forging its path. In March 2015, the American Psychiatric Association’s (APA) Board of Trustees approved the APA’s Strategic Initiative, which has 4 goals: 1) advancing the integration of psychiatry in health care; 2) supporting research; 3) supporting education; and 4) promoting diversity and inclusion in psychiatry.³ The latter goal includes advocating for antiracist policies that promote cultural competence and health equity in education, research and psychiatric care; increased recruitment and retention of psychiatrists from groups that historically have been underrepresented in medicine and medical leadership; and ensuring representation of these groups in APA governance at all levels.³

The APA’s antiracism agenda

In March 2020, outgoing APA President Bruce Schwartz concurred with Board members that diversity and inclusion in the APA warranted a closer review. On May 5, 2020, APA President Jeff Geller committed to authorizing a systematic study of diversity and inclusion in various branches of the APA, including councils and governance. By the end of May, with civil unrest in full swing in the United States, President Geller decided to expand the APA’s diversity agenda.

President Geller appointed the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (SR Task Force), which had its virtual inaugural meeting on June 27, 2020.⁴ The SR Task Force exists to focus on structural racism (aka institutional racism) in organized psychiatry, psychiatric patients, and those who provide psychiatric services to patients. The charge, which is subject to revision, if warranted, is clear: provide resources and education on the history of structural racism in the APA and psychiatry, explain how structural racism impacts psychiatric patients and the profession, craft actionable recommendations to dismantle structural racism in the APA and psychiatry, report those findings to the APA’s Board of Trustees, and implement a quality assurance protocol to ensure that the Task Force’s work is consistent with its charge. President Geller decided to have the Task Force focus on anti-Black racism in its inaugural year and believes that the outcome will benefit all psychiatrists, other mental health professionals, and patients who identify as members of minority and underserved groups in the United States and the profession of psychiatry.⁵

Presidential Task Forces in APA

Presidential Task Forces report directly to the Board of Trustees, which expedites the review of progress reports and deliberation on and, when favorable, implementation of recommendations. Also, Presidential Task Forces are afforded additional APA resources. For example, the SR Task Force has 16 APA staff members who have been appointed or volunteered to assist the Task Force in some way. Many APA staff have graduate degrees in law, education, and other subjects. The skill sets, networks, institutional memory, and commitment that they bring to the project are conducive to advancing the SR Task Force’s agenda at a brisk pace.

Continue to: The APA President...

The APA President decides whom to appoint to each Task Force. President Geller propitiously appointed subject matter experts and members of the Board of Trustees to serve on the SR Task Force. Subject matter experts contribute historical and contemporary content about racism, including anti-Black racism, to the discussion. The data are used to craft research questions that may yield pertinent data. (Note that not all subject matter experts are Black, nor are all Board members White.) APA staff support the Task Force by sharing their expertise, compiling data, coordinating meetings, collaborating on program development, disseminating the work product to APA members and the media, and other important tasks.

The SR Task Force’s work

The SR Task Force strives for transparency in a process that is informed by APA members. The group immediately set up a web hub that is used to communicate with APA members.⁵ Individual members also use social media to alert members to SR Task Force activities and events. Member input has been solicited by posting several brief surveys on the SR Task Force web hub. Topics have included the effect of structural racism on patient care, psychiatric practice, and organized psychiatry, including the APA. The responses, which collectively totaled >1,600, were reviewed and used to inform Task Force priorities while working within the scope of the charge.⁵

Based on member feedback, the first large project of the SR Task Force has been to examine structural racism in the APA. The SR Task Force formed workgroups to study data pertaining to diversity and inclusion in the APA Assembly, governance (the Board of Trustees), Councils and Committees, and Scientific Program Committee. As APA Publishing and the DSM Steering Committee have internal processes to address structural racism, the SR Task Force did not convene workgroups to study this. However, the SR Task Force will be meeting with leaders of those groups to learn about their protocols and will request that information be made available to APA members.

The SR Task Force reviews and interprets data that are compiled by each workgroup, deliberates on its significance, and when appropriate, drafts achievable recommendations to improve diversity and inclusion in the APA. This is where Trustee involvement is invaluable to the SR Task Force, because the report and recommendations will be presented to the Board of Trustees.

There is no guarantee that the recommendations contained in a report that is accepted by the Board of Trustees will be implemented unless they are approved. It is imperative, therefore, that SR Task Force recommendations to the Board take into consideration Board structure, processes, goals, efficiency, history, and other matters. The learning curve can be steep, especially when the first major report was due 3 months after the SR Task Force was appointed. Clarity and efficiency are key in report preparation. For example, during the Winter 2020 Board of Trustees meeting, the SR Task Force presented its report, answered questions, and offered 7 action items to the Board for deliberation and voting. The endeavor, which was completed in 20 minutes, resulted in the Board supporting 6 of the recommendations and deferring the deliberation of the seventh recommendation to the spring Board meeting, due to logistical concerns.

Continue to: Thus far, the SR Task Force Workgroups...

Thus far, the SR Task Force Workgroups on the Assembly and Governance have presented their reports. ⁵ The SR Task Force reports on the Scientific Program Committee and Councils and Committees are scheduled to be presented to the Board during the Spring 2021 meeting.

The SR Task Force has been fulfilling the commitment to provide relevant educational materials to members in several ways. There have been 4 virtual Structural Racism Town Hall meetings that featured subject matter experts. The first Town Hall session addressed the initial steps towards dismantling structural racism and included President Geller’s announcement about appointing a SR Task Force. The next Town Hall meeting addressed structural racism in medicine and psychiatry, its effect on children and individuals who identify as transgender, and its intersectionality (the cumulative effect of discrimination on a person who belongs to 2 non-dominant groups.) The panel in the third Town Hall meeting reviewed the impact of structural racism, including intersectionality, on transgenerational trauma in several minority groups. The meeting ended with an update of Task Force activities. The February 2021 Town Hall meeting focused on how structural racism affects recruitment and retention of minority psychiatry residents, and how this can undermine efforts to grow a diverse workforce. Recordings of these and other events can be accessed on the SR Task Force web hub.⁵ The SR Task Force members plan to present a review of the year’s work during the next Town Hall meeting, which is scheduled to occur on Saturday, May 1, 2021, during the APA’s Annual Meeting.

The SR Task Force web hub contains other resources, including APA position statements, press releases, and news articles, and a glossary of relevant terms. It also includes internet links to President Geller’s 9-part series on the history of Structural Racism in the APA. There are CME and other webinars, a curated list of references, videos, podcasts, and other media.⁴

The SR Task Force believes that much of the antiracism work needs to occur beyond APA headquarters. Consequently, President Geller challenged all APA Councils to work on an antiracism project to support the APA’s antiracism agenda. APA committees and caucuses have been encouraged to do the same. The SR Task Force has asked APA District Branches and Allied Organizations to share information about what they are doing to educate members about structural racism and what they are doing for input regarding their antiracist activities. Additionally, Task Force members have been speaking with these and other groups to inform them about the APA’s antiracism work.

APA’s Board of Trustees actions

It would be inappropriate for the APA to task groups with focusing on antiracism unless the organization was doing its part. In July 2020, the Board of Trustees had a 2-hour round table discussion during which each member spoke about the problem and how the APA should address it. Next, President Geller appointed a Board Workgroup to clarify the definitions of “minority” and “underrepresented.” Although the APA Assembly has defined the terms, the APA has not. Additionally, the APA Board of Trustees retained a consultant to assess all aspects of how it functions as a Board. The Board’s management of matters pertaining to diversity and inclusion was part of the examination. The recommendations are being reviewed and the Board will undergo diversity training.

Continue to: President Geller's study...

President Geller’s study of racism in the APA, which involved a review of past APA presidential addresses, brought to light a long-term pattern of racism in the organization.⁵ On January 18, 2021, Martin Luther King, Jr. Day, the APA acknowledged and apologized to psychiatrists, patients, and the public for its history of engaging in and passively condoning racist behavior.⁶ The APA has committed to being better informed about diversity and inclusion at every level. Lastly, hired consultants with expertise in diversity and inclusion are working with APA staff at every level so that the environment can be a welcoming and comfortable workspace for recruiting and retaining a diverse workforce.

Although it may seem that the APA has engaged in many antiracist activities in a brief period, there is much more to accomplish. The Task Force hopes that the work will speak for itself and will be sustained over time. It’s long overdue.

The coronavirus disease 2019 pandemic, which as of mid-February 2021 had caused more than 486,000 deaths in the United States, has changed our lives forever. Elders and Black, Indigenous, and People of Color (BIPOC) have been overrepresented among those lost. That, when juxtaposed with the civil unrest that followed the brutal killing of George Floyd, an unarmed Black man, by a White law enforcement officer on May 25, 2020, have compelled us to talk about US race relations in unprecedented ways. These and other traumas disproportionately affect the quality of life and health of minority and underserved individuals. The international outcry about racism, serial trauma, and health disparities left the medical profession well positioned to promulgate changes that are conducive to achieving health equity.

Race is a social construct

In November 2020, the American Medical Association (AMA) Board of Trustees made several public acknowledgments about race.¹ First, race is a social, nonbiological classification that is different from biology, ethnicity, or genetic ancestry.¹ Next, race contributes to health disparities and poor health outcomes for minorities and members of underserved communities.¹ Also, racism, which includes disproportionate police brutality against Black and Indigenous people, is a driver of health inequity for them and people in marginalized communities.¹

The AMA also commented on how serial trauma and racism can affect one’s health. The AMA acknowledged that exposure to serial trauma throughout one’s life can have a cumulative effect that is “associated with chronic stress, higher rates of comorbidities and lower life expectancy” and results in increased health care costs and decreased quality of life for those who are affected.¹ Also, the AMA proclaimed that racism is a threat to public health and pledged to dismantle discriminatory practices and policies in health care, including medical education and research.²

Diversity and inclusion in psychiatry

While the AMA has been striving to reduce bias in health care systems, psychiatry has been forging its path. In March 2015, the American Psychiatric Association’s (APA) Board of Trustees approved the APA’s Strategic Initiative, which has 4 goals: 1) advancing the integration of psychiatry in health care; 2) supporting research; 3) supporting education; and 4) promoting diversity and inclusion in psychiatry.³ The latter goal includes advocating for antiracist policies that promote cultural competence and health equity in education, research and psychiatric care; increased recruitment and retention of psychiatrists from groups that historically have been underrepresented in medicine and medical leadership; and ensuring representation of these groups in APA governance at all levels.³

The APA’s antiracism agenda

In March 2020, outgoing APA President Bruce Schwartz concurred with Board members that diversity and inclusion in the APA warranted a closer review. On May 5, 2020, APA President Jeff Geller committed to authorizing a systematic study of diversity and inclusion in various branches of the APA, including councils and governance. By the end of May, with civil unrest in full swing in the United States, President Geller decided to expand the APA’s diversity agenda.

President Geller appointed the APA Presidential Task Force to Address Structural Racism Throughout Psychiatry (SR Task Force), which had its virtual inaugural meeting on June 27, 2020.⁴ The SR Task Force exists to focus on structural racism (aka institutional racism) in organized psychiatry, psychiatric patients, and those who provide psychiatric services to patients. The charge, which is subject to revision, if warranted, is clear: provide resources and education on the history of structural racism in the APA and psychiatry, explain how structural racism impacts psychiatric patients and the profession, craft actionable recommendations to dismantle structural racism in the APA and psychiatry, report those findings to the APA’s Board of Trustees, and implement a quality assurance protocol to ensure that the Task Force’s work is consistent with its charge. President Geller decided to have the Task Force focus on anti-Black racism in its inaugural year and believes that the outcome will benefit all psychiatrists, other mental health professionals, and patients who identify as members of minority and underserved groups in the United States and the profession of psychiatry.⁵

Presidential Task Forces in APA

Presidential Task Forces report directly to the Board of Trustees, which expedites the review of progress reports and deliberation on and, when favorable, implementation of recommendations. Also, Presidential Task Forces are afforded additional APA resources. For example, the SR Task Force has 16 APA staff members who have been appointed or volunteered to assist the Task Force in some way. Many APA staff have graduate degrees in law, education, and other subjects. The skill sets, networks, institutional memory, and commitment that they bring to the project are conducive to advancing the SR Task Force’s agenda at a brisk pace.

Continue to: The APA President...

The APA President decides whom to appoint to each Task Force. President Geller propitiously appointed subject matter experts and members of the Board of Trustees to serve on the SR Task Force. Subject matter experts contribute historical and contemporary content about racism, including anti-Black racism, to the discussion. The data are used to craft research questions that may yield pertinent data. (Note that not all subject matter experts are Black, nor are all Board members White.) APA staff support the Task Force by sharing their expertise, compiling data, coordinating meetings, collaborating on program development, disseminating the work product to APA members and the media, and other important tasks.

The SR Task Force’s work

The SR Task Force strives for transparency in a process that is informed by APA members. The group immediately set up a web hub that is used to communicate with APA members.⁵ Individual members also use social media to alert members to SR Task Force activities and events. Member input has been solicited by posting several brief surveys on the SR Task Force web hub. Topics have included the effect of structural racism on patient care, psychiatric practice, and organized psychiatry, including the APA. The responses, which collectively totaled >1,600, were reviewed and used to inform Task Force priorities while working within the scope of the charge.⁵

Based on member feedback, the first large project of the SR Task Force has been to examine structural racism in the APA. The SR Task Force formed workgroups to study data pertaining to diversity and inclusion in the APA Assembly, governance (the Board of Trustees), Councils and Committees, and Scientific Program Committee. As APA Publishing and the DSM Steering Committee have internal processes to address structural racism, the SR Task Force did not convene workgroups to study this. However, the SR Task Force will be meeting with leaders of those groups to learn about their protocols and will request that information be made available to APA members.

The SR Task Force reviews and interprets data that are compiled by each workgroup, deliberates on its significance, and when appropriate, drafts achievable recommendations to improve diversity and inclusion in the APA. This is where Trustee involvement is invaluable to the SR Task Force, because the report and recommendations will be presented to the Board of Trustees.

There is no guarantee that the recommendations contained in a report that is accepted by the Board of Trustees will be implemented unless they are approved. It is imperative, therefore, that SR Task Force recommendations to the Board take into consideration Board structure, processes, goals, efficiency, history, and other matters. The learning curve can be steep, especially when the first major report was due 3 months after the SR Task Force was appointed. Clarity and efficiency are key in report preparation. For example, during the Winter 2020 Board of Trustees meeting, the SR Task Force presented its report, answered questions, and offered 7 action items to the Board for deliberation and voting. The endeavor, which was completed in 20 minutes, resulted in the Board supporting 6 of the recommendations and deferring the deliberation of the seventh recommendation to the spring Board meeting, due to logistical concerns.

Continue to: Thus far, the SR Task Force Workgroups...

Thus far, the SR Task Force Workgroups on the Assembly and Governance have presented their reports. ⁵ The SR Task Force reports on the Scientific Program Committee and Councils and Committees are scheduled to be presented to the Board during the Spring 2021 meeting.

The SR Task Force has been fulfilling the commitment to provide relevant educational materials to members in several ways. There have been 4 virtual Structural Racism Town Hall meetings that featured subject matter experts. The first Town Hall session addressed the initial steps towards dismantling structural racism and included President Geller’s announcement about appointing a SR Task Force. The next Town Hall meeting addressed structural racism in medicine and psychiatry, its effect on children and individuals who identify as transgender, and its intersectionality (the cumulative effect of discrimination on a person who belongs to 2 non-dominant groups.) The panel in the third Town Hall meeting reviewed the impact of structural racism, including intersectionality, on transgenerational trauma in several minority groups. The meeting ended with an update of Task Force activities. The February 2021 Town Hall meeting focused on how structural racism affects recruitment and retention of minority psychiatry residents, and how this can undermine efforts to grow a diverse workforce. Recordings of these and other events can be accessed on the SR Task Force web hub.⁵ The SR Task Force members plan to present a review of the year’s work during the next Town Hall meeting, which is scheduled to occur on Saturday, May 1, 2021, during the APA’s Annual Meeting.

The SR Task Force web hub contains other resources, including APA position statements, press releases, and news articles, and a glossary of relevant terms. It also includes internet links to President Geller’s 9-part series on the history of Structural Racism in the APA. There are CME and other webinars, a curated list of references, videos, podcasts, and other media.⁴

The SR Task Force believes that much of the antiracism work needs to occur beyond APA headquarters. Consequently, President Geller challenged all APA Councils to work on an antiracism project to support the APA’s antiracism agenda. APA committees and caucuses have been encouraged to do the same. The SR Task Force has asked APA District Branches and Allied Organizations to share information about what they are doing to educate members about structural racism and what they are doing for input regarding their antiracist activities. Additionally, Task Force members have been speaking with these and other groups to inform them about the APA’s antiracism work.

APA’s Board of Trustees actions

It would be inappropriate for the APA to task groups with focusing on antiracism unless the organization was doing its part. In July 2020, the Board of Trustees had a 2-hour round table discussion during which each member spoke about the problem and how the APA should address it. Next, President Geller appointed a Board Workgroup to clarify the definitions of “minority” and “underrepresented.” Although the APA Assembly has defined the terms, the APA has not. Additionally, the APA Board of Trustees retained a consultant to assess all aspects of how it functions as a Board. The Board’s management of matters pertaining to diversity and inclusion was part of the examination. The recommendations are being reviewed and the Board will undergo diversity training.

Continue to: President Geller's study...

President Geller’s study of racism in the APA, which involved a review of past APA presidential addresses, brought to light a long-term pattern of racism in the organization.⁵ On January 18, 2021, Martin Luther King, Jr. Day, the APA acknowledged and apologized to psychiatrists, patients, and the public for its history of engaging in and passively condoning racist behavior.⁶ The APA has committed to being better informed about diversity and inclusion at every level. Lastly, hired consultants with expertise in diversity and inclusion are working with APA staff at every level so that the environment can be a welcoming and comfortable workspace for recruiting and retaining a diverse workforce.

Although it may seem that the APA has engaged in many antiracist activities in a brief period, there is much more to accomplish. The Task Force hopes that the work will speak for itself and will be sustained over time. It’s long overdue.

The Diagnosis: Epidermodysplasia Verruciformis 

Histopathologic examination of our patient's biopsy specimen revealed mild acanthosis with prominent hypergranulosis and enlarged keratinocytes with blue-gray cytoplasm (Figure). A diagnosis of acquired epidermodysplasia verruciformis (EV) was rendered. The patient was treated with photodynamic therapy utilizing 5-aminolevulinic acid. 

Epidermodysplasia verruciformis is characterized by susceptibility to human papillomavirus (HPV) infections via a defect in cellular immunity. Epidermodysplasia verruciformis was first described as an autosomal-recessive genodermatosis, but it can be acquired in immunosuppressed states with an atypical clinical appearance.¹ There are few case reports in skin of color. Acquired EV appears in patients with acquired immunodeficiencies that are susceptible to EV-causing HPVs via a similar mechanism found in inherited EV.² The most common HPV serotypes involved in EV are HPV-5 and HPV-8. The duration of immunosuppression has been found to be positively correlated with the risk for EV development, with the majority of patients developing lesions after 5 years of immunosuppression.³ There is an approximately 60% risk of malignant transformation of EV lesions into nonmelanoma skin cancer.² This risk is believed to be lower in patients with darker skin.⁴  

Preventative measures including sun protection and annual surveillance are crucial in EV patients given the high rate of malignant transformation in sun-exposed lesions.⁵ Treatment options for EV are anecdotal and have variable results, ranging from topicals including 5-fluorouracil and imiquimod to systemic medications including acitretin and interferon.³ Photodynamic therapy can be used for extensive EV. Surgical modalities and other destructive methods also have been tried.⁶ 

Epidermodysplasia verruciformis often can be confused with similar dermatoses. Porokeratosis appears as annular pink papules with waferlike peripheral scales. Tinea versicolor is a dermatophyte infection caused by Malassezia furfur and presents as multiple dyspigmented, finely scaling, thin papules and plaques. Subacute cutaneous lupus erythematosus presents as pink, scaly, annular or psoriasiform papules and plaques most commonly on the trunk. Discoid lupus erythematosus presents as pink, hypopigmented or depigmented, atrophic plaques with a peripheral rim of erythema that indicates activity. Secondary syphilis, commonly denoted as the "great mimicker," presents as psoriasiform papules and plaques among other variable morphologies. 

The Diagnosis: Epidermodysplasia Verruciformis 

Histopathologic examination of our patient's biopsy specimen revealed mild acanthosis with prominent hypergranulosis and enlarged keratinocytes with blue-gray cytoplasm (Figure). A diagnosis of acquired epidermodysplasia verruciformis (EV) was rendered. The patient was treated with photodynamic therapy utilizing 5-aminolevulinic acid. 

Epidermodysplasia verruciformis is characterized by susceptibility to human papillomavirus (HPV) infections via a defect in cellular immunity. Epidermodysplasia verruciformis was first described as an autosomal-recessive genodermatosis, but it can be acquired in immunosuppressed states with an atypical clinical appearance.¹ There are few case reports in skin of color. Acquired EV appears in patients with acquired immunodeficiencies that are susceptible to EV-causing HPVs via a similar mechanism found in inherited EV.² The most common HPV serotypes involved in EV are HPV-5 and HPV-8. The duration of immunosuppression has been found to be positively correlated with the risk for EV development, with the majority of patients developing lesions after 5 years of immunosuppression.³ There is an approximately 60% risk of malignant transformation of EV lesions into nonmelanoma skin cancer.² This risk is believed to be lower in patients with darker skin.⁴  

Preventative measures including sun protection and annual surveillance are crucial in EV patients given the high rate of malignant transformation in sun-exposed lesions.⁵ Treatment options for EV are anecdotal and have variable results, ranging from topicals including 5-fluorouracil and imiquimod to systemic medications including acitretin and interferon.³ Photodynamic therapy can be used for extensive EV. Surgical modalities and other destructive methods also have been tried.⁶ 

Epidermodysplasia verruciformis often can be confused with similar dermatoses. Porokeratosis appears as annular pink papules with waferlike peripheral scales. Tinea versicolor is a dermatophyte infection caused by Malassezia furfur and presents as multiple dyspigmented, finely scaling, thin papules and plaques. Subacute cutaneous lupus erythematosus presents as pink, scaly, annular or psoriasiform papules and plaques most commonly on the trunk. Discoid lupus erythematosus presents as pink, hypopigmented or depigmented, atrophic plaques with a peripheral rim of erythema that indicates activity. Secondary syphilis, commonly denoted as the "great mimicker," presents as psoriasiform papules and plaques among other variable morphologies. 

The Diagnosis: Epidermodysplasia Verruciformis 

Histopathologic examination of our patient's biopsy specimen revealed mild acanthosis with prominent hypergranulosis and enlarged keratinocytes with blue-gray cytoplasm (Figure). A diagnosis of acquired epidermodysplasia verruciformis (EV) was rendered. The patient was treated with photodynamic therapy utilizing 5-aminolevulinic acid. 

Epidermodysplasia verruciformis is characterized by susceptibility to human papillomavirus (HPV) infections via a defect in cellular immunity. Epidermodysplasia verruciformis was first described as an autosomal-recessive genodermatosis, but it can be acquired in immunosuppressed states with an atypical clinical appearance.¹ There are few case reports in skin of color. Acquired EV appears in patients with acquired immunodeficiencies that are susceptible to EV-causing HPVs via a similar mechanism found in inherited EV.² The most common HPV serotypes involved in EV are HPV-5 and HPV-8. The duration of immunosuppression has been found to be positively correlated with the risk for EV development, with the majority of patients developing lesions after 5 years of immunosuppression.³ There is an approximately 60% risk of malignant transformation of EV lesions into nonmelanoma skin cancer.² This risk is believed to be lower in patients with darker skin.⁴  

Preventative measures including sun protection and annual surveillance are crucial in EV patients given the high rate of malignant transformation in sun-exposed lesions.⁵ Treatment options for EV are anecdotal and have variable results, ranging from topicals including 5-fluorouracil and imiquimod to systemic medications including acitretin and interferon.³ Photodynamic therapy can be used for extensive EV. Surgical modalities and other destructive methods also have been tried.⁶ 

Epidermodysplasia verruciformis often can be confused with similar dermatoses. Porokeratosis appears as annular pink papules with waferlike peripheral scales. Tinea versicolor is a dermatophyte infection caused by Malassezia furfur and presents as multiple dyspigmented, finely scaling, thin papules and plaques. Subacute cutaneous lupus erythematosus presents as pink, scaly, annular or psoriasiform papules and plaques most commonly on the trunk. Discoid lupus erythematosus presents as pink, hypopigmented or depigmented, atrophic plaques with a peripheral rim of erythema that indicates activity. Secondary syphilis, commonly denoted as the "great mimicker," presents as psoriasiform papules and plaques among other variable morphologies. 

Dermatologists must understand the religious and cultural practices of various populations in order to provide optimal patient-centered care. In particular, patients of South Asian background have specific traditions and needs that may be unfamiliar to many providers and may affect the approach to their dermatologic care. These include the strong role of traditional garments and hair practices, the cultural emphasis on modest dress and limiting skin exposure in South Asian society, and the presence of anti–South Asian racism and religious discrimination in the United States.¹ Sikhism, Islam, and Hinduism are the predominant religions among the South Asian population, and followers of these faiths constitute nearly 40% of the world population.^2,3 By becoming familiar with the unique health care needs of this patient population, dermatologists can become key players in reducing health care disparities.

Traditional garments are particularly important in both Sikhism and Islam. Sikhs began wearing symbolic garments in the 16th century as markers of their identity during periods of religious persecution. Today, many Sikhs continue to maintain this tradition of wearing the Five Ks—kesh (uncut hair, often tied in a turban), kanga (wooden hair comb), kirpan (symbolic dagger), kachha (cotton underwear), and kara (steel bracelet).² Similarly, Islamic traditions also provide guidance for clothing. Many Muslim women wear the hijab (headscarf), a garment that originated as protective headgear for nomadic desert cultures and has come to symbolize modest dress. Traditionally, the hijab is worn in the presence of all men who are not immediate relatives, although patients may make exceptions for medical care. Some Muslim men also may cover their heads with a skullcap and/or maintain long beards (occasionally dyed with henna pigment) as a way of keeping continuity with the tradition of the Prophet Muhammad and his companions.³

Certain styles of headwear can cause high tension on hair follicles and have been associated with traction alopecia.⁴ Persistent use of the same turban, hijab, or comb also may lead to seborrheic dermatitis or fungal scalp infections. Dermatologists should advise patients about these potential challenges and suggest modifications in accordance with the patient’s religious beliefs; for example, providers can suggest removing headwear at night, using prophylactic antifungal shampoos, and/or tying the hair in a ponytail or loosening the headgear to reduce traction.

Although Hinduism does not have a unifying garment or hair tradition in the vein of Sikhism or Islam, all 3 religions share a strong emphasis on bodily modesty, which may affect dermatologic examinations. Patients from all 3 religions may seek to expose as little skin as possible during a physical examination, and many patients may be uncomfortable with a physician of the opposite gender. Dermatologists may find the following practices to be helpful⁵:

• Talk through each aspect of the skin examination while it is being performed and expose the least amount of skin necessary during the process

• Offer the patient a chaperone or a same-gender provider, if possible

• Empower patients to assist in adjusting garments themselves to help the physician visualize all parts of the skin

Some Sikhs also may have specific concerns regarding cutting their hair. One aspect of kesh is that every hair is sacred, and thus, many Sikhs refrain from removing hair on any part of the body. As such, providers should carefully obtain the patient’s informed consent before performing any procedure or physical examination maneuvers (eg, hair pull test) that may result in loss of hair.²

Physicians of all disciplines can help address these challenges through increased outreach and cultural awareness; for example, dermatologists can create skin care pamphlets translated into various South Asian languages and distribute them at houses of worship or other community centers. This may help patients identify their skin needs and seek appropriate care. The onus must be on physicians to make these patients feel comfortable seeking care by creating nonjudgmental, culturally knowledgeable clinical environments. When asking about social history, the physician might consider asking an open-ended question such as, “What role does religion/spirituality play in your life?” They can then proceed to ask specific questions about practices that might affect the patient’s care.⁵

Given the current coronavirus disease 2019 pandemic, South Asian patients may be even further discouraged from seeking dermatologic care. By understanding religious traditions and taking steps to address biases, dermatologists can help mitigate health care disparities and provide culturally competent care to South Asian patients.

Dermatologists must understand the religious and cultural practices of various populations in order to provide optimal patient-centered care. In particular, patients of South Asian background have specific traditions and needs that may be unfamiliar to many providers and may affect the approach to their dermatologic care. These include the strong role of traditional garments and hair practices, the cultural emphasis on modest dress and limiting skin exposure in South Asian society, and the presence of anti–South Asian racism and religious discrimination in the United States.¹ Sikhism, Islam, and Hinduism are the predominant religions among the South Asian population, and followers of these faiths constitute nearly 40% of the world population.^2,3 By becoming familiar with the unique health care needs of this patient population, dermatologists can become key players in reducing health care disparities.

Traditional garments are particularly important in both Sikhism and Islam. Sikhs began wearing symbolic garments in the 16th century as markers of their identity during periods of religious persecution. Today, many Sikhs continue to maintain this tradition of wearing the Five Ks—kesh (uncut hair, often tied in a turban), kanga (wooden hair comb), kirpan (symbolic dagger), kachha (cotton underwear), and kara (steel bracelet).² Similarly, Islamic traditions also provide guidance for clothing. Many Muslim women wear the hijab (headscarf), a garment that originated as protective headgear for nomadic desert cultures and has come to symbolize modest dress. Traditionally, the hijab is worn in the presence of all men who are not immediate relatives, although patients may make exceptions for medical care. Some Muslim men also may cover their heads with a skullcap and/or maintain long beards (occasionally dyed with henna pigment) as a way of keeping continuity with the tradition of the Prophet Muhammad and his companions.³

Certain styles of headwear can cause high tension on hair follicles and have been associated with traction alopecia.⁴ Persistent use of the same turban, hijab, or comb also may lead to seborrheic dermatitis or fungal scalp infections. Dermatologists should advise patients about these potential challenges and suggest modifications in accordance with the patient’s religious beliefs; for example, providers can suggest removing headwear at night, using prophylactic antifungal shampoos, and/or tying the hair in a ponytail or loosening the headgear to reduce traction.

Although Hinduism does not have a unifying garment or hair tradition in the vein of Sikhism or Islam, all 3 religions share a strong emphasis on bodily modesty, which may affect dermatologic examinations. Patients from all 3 religions may seek to expose as little skin as possible during a physical examination, and many patients may be uncomfortable with a physician of the opposite gender. Dermatologists may find the following practices to be helpful⁵:

• Talk through each aspect of the skin examination while it is being performed and expose the least amount of skin necessary during the process

• Offer the patient a chaperone or a same-gender provider, if possible

• Empower patients to assist in adjusting garments themselves to help the physician visualize all parts of the skin

Some Sikhs also may have specific concerns regarding cutting their hair. One aspect of kesh is that every hair is sacred, and thus, many Sikhs refrain from removing hair on any part of the body. As such, providers should carefully obtain the patient’s informed consent before performing any procedure or physical examination maneuvers (eg, hair pull test) that may result in loss of hair.²

Physicians of all disciplines can help address these challenges through increased outreach and cultural awareness; for example, dermatologists can create skin care pamphlets translated into various South Asian languages and distribute them at houses of worship or other community centers. This may help patients identify their skin needs and seek appropriate care. The onus must be on physicians to make these patients feel comfortable seeking care by creating nonjudgmental, culturally knowledgeable clinical environments. When asking about social history, the physician might consider asking an open-ended question such as, “What role does religion/spirituality play in your life?” They can then proceed to ask specific questions about practices that might affect the patient’s care.⁵

Given the current coronavirus disease 2019 pandemic, South Asian patients may be even further discouraged from seeking dermatologic care. By understanding religious traditions and taking steps to address biases, dermatologists can help mitigate health care disparities and provide culturally competent care to South Asian patients.

Dermatologists must understand the religious and cultural practices of various populations in order to provide optimal patient-centered care. In particular, patients of South Asian background have specific traditions and needs that may be unfamiliar to many providers and may affect the approach to their dermatologic care. These include the strong role of traditional garments and hair practices, the cultural emphasis on modest dress and limiting skin exposure in South Asian society, and the presence of anti–South Asian racism and religious discrimination in the United States.¹ Sikhism, Islam, and Hinduism are the predominant religions among the South Asian population, and followers of these faiths constitute nearly 40% of the world population.^2,3 By becoming familiar with the unique health care needs of this patient population, dermatologists can become key players in reducing health care disparities.

Traditional garments are particularly important in both Sikhism and Islam. Sikhs began wearing symbolic garments in the 16th century as markers of their identity during periods of religious persecution. Today, many Sikhs continue to maintain this tradition of wearing the Five Ks—kesh (uncut hair, often tied in a turban), kanga (wooden hair comb), kirpan (symbolic dagger), kachha (cotton underwear), and kara (steel bracelet).² Similarly, Islamic traditions also provide guidance for clothing. Many Muslim women wear the hijab (headscarf), a garment that originated as protective headgear for nomadic desert cultures and has come to symbolize modest dress. Traditionally, the hijab is worn in the presence of all men who are not immediate relatives, although patients may make exceptions for medical care. Some Muslim men also may cover their heads with a skullcap and/or maintain long beards (occasionally dyed with henna pigment) as a way of keeping continuity with the tradition of the Prophet Muhammad and his companions.³

Certain styles of headwear can cause high tension on hair follicles and have been associated with traction alopecia.⁴ Persistent use of the same turban, hijab, or comb also may lead to seborrheic dermatitis or fungal scalp infections. Dermatologists should advise patients about these potential challenges and suggest modifications in accordance with the patient’s religious beliefs; for example, providers can suggest removing headwear at night, using prophylactic antifungal shampoos, and/or tying the hair in a ponytail or loosening the headgear to reduce traction.

Although Hinduism does not have a unifying garment or hair tradition in the vein of Sikhism or Islam, all 3 religions share a strong emphasis on bodily modesty, which may affect dermatologic examinations. Patients from all 3 religions may seek to expose as little skin as possible during a physical examination, and many patients may be uncomfortable with a physician of the opposite gender. Dermatologists may find the following practices to be helpful⁵:

• Talk through each aspect of the skin examination while it is being performed and expose the least amount of skin necessary during the process

• Offer the patient a chaperone or a same-gender provider, if possible

• Empower patients to assist in adjusting garments themselves to help the physician visualize all parts of the skin

Some Sikhs also may have specific concerns regarding cutting their hair. One aspect of kesh is that every hair is sacred, and thus, many Sikhs refrain from removing hair on any part of the body. As such, providers should carefully obtain the patient’s informed consent before performing any procedure or physical examination maneuvers (eg, hair pull test) that may result in loss of hair.²

Physicians of all disciplines can help address these challenges through increased outreach and cultural awareness; for example, dermatologists can create skin care pamphlets translated into various South Asian languages and distribute them at houses of worship or other community centers. This may help patients identify their skin needs and seek appropriate care. The onus must be on physicians to make these patients feel comfortable seeking care by creating nonjudgmental, culturally knowledgeable clinical environments. When asking about social history, the physician might consider asking an open-ended question such as, “What role does religion/spirituality play in your life?” They can then proceed to ask specific questions about practices that might affect the patient’s care.⁵

Given the current coronavirus disease 2019 pandemic, South Asian patients may be even further discouraged from seeking dermatologic care. By understanding religious traditions and taking steps to address biases, dermatologists can help mitigate health care disparities and provide culturally competent care to South Asian patients.