Diversity in Medicine

The issue of race and survival in patients with clear cell renal cell carcinoma (ccRCC) has been debated in the literature.

Some studies have shown worse survival for Black patients, while others have suggested that Black race is instead a stand-in for social determinants, including access to care.

New research suggests that Black race is not correlated with increased mortality from ccRCC. These results were published in Urology.

“Despite well documented racial biases and race-specific outcomes in the health care landscape, our study found race was not associated with 5-year cause-specific survival from ccRCC,” wrote investigator Dhaval Jivanji, a medical student at Florida International University, Miami, and colleagues.

In their retrospective study, the investigators examined 5-year survival in ccRCC patients, comparing results across races. The team used data from the Surveillance Epidemiology, and End Results (SEER) database, which collects cancer data from 13 states using population-based cancer registries. They extracted data on demographics, prevalence, and mortality, in relation to ccRCC.

A total of 8,421 subjects with ccRCC were included in the analysis, which covered the years 2007-2015. The primary outcome was 5-year survival, defined as cause-specific mortality up to the first 60 months from time of cancer diagnosis.

In addition to race, variables included in the statistical model were age (18-50, 51-60, 61-70,71-80, >80), sex (male/female), SEER Summary tumor staging (localized, regionalized, distant), insurance status (uninsured, insured, insured not specific, Medicaid), and marital status (single, married/partner, separated/divorced/widowed).
 

Demographic determinism

In the adjusted analysis, the researchers found no association between race and 5-year cause-specific survival in patients with ccRCC.

The hazard ratios for death were 0.96 for Black patients, 1.01 for American Indian/Alaska Native patients, and 0.99 for Asian/Pacific Islander patients, with White patients as the comparator.

In terms of the other covariates studied, the researchers found that older age (>50 years) and the presence of regional or distant tumors were associated with an increased hazard of death, while female sex and having insurance were associated with a decreased hazard of death.

“Our study found that age, tumor stage, and insurance status are significantly associated with 5-year cause-specific survival. Future studies will benefit from complete assessment of other demographic factors, including income, medical comorbidities, and access to care. These are negative predictors, and [their] potential impact on overall survival should be considered by the clinician in treatment and management plans for RCC patients,” the researchers concluded.

In an editorial commentary published within the main article, Paul Russo, MD, of Weill Cornell Medicine, New York, stated: “Investigations such as this utilizing the SEER registries provide a 30,000-foot demographic view of some disease elements but lack important granularity, such as tumor size and grade, family income, critical medical comorbidities, and patient access to hospitals with surgical and medical oncologic expertise.”

Dr. Russo said it is well known that disparate access to diagnosis, surgical intervention, and expert treatment have an impact on survival.

He went on to ask: “Could African Americans have had superior outcomes if the data was controlled for these important variables? As urologic surgeons, we must join the greater medical community in understanding the root causes leading to structural racial and economic disparities, inequities in access to care, and the profound negative impact these disparities have on health outcomes in general and cancer outcomes specifically.”

The authors did not disclose funding or conflicts of interest.

[email protected]

SOURCE: Jivanji D et al. Urology. 2020. doi: 10.1016/j.urology.2020.10.055.

The issue of race and survival in patients with clear cell renal cell carcinoma (ccRCC) has been debated in the literature.

Some studies have shown worse survival for Black patients, while others have suggested that Black race is instead a stand-in for social determinants, including access to care.

New research suggests that Black race is not correlated with increased mortality from ccRCC. These results were published in Urology.

“Despite well documented racial biases and race-specific outcomes in the health care landscape, our study found race was not associated with 5-year cause-specific survival from ccRCC,” wrote investigator Dhaval Jivanji, a medical student at Florida International University, Miami, and colleagues.

In their retrospective study, the investigators examined 5-year survival in ccRCC patients, comparing results across races. The team used data from the Surveillance Epidemiology, and End Results (SEER) database, which collects cancer data from 13 states using population-based cancer registries. They extracted data on demographics, prevalence, and mortality, in relation to ccRCC.

A total of 8,421 subjects with ccRCC were included in the analysis, which covered the years 2007-2015. The primary outcome was 5-year survival, defined as cause-specific mortality up to the first 60 months from time of cancer diagnosis.

In addition to race, variables included in the statistical model were age (18-50, 51-60, 61-70,71-80, >80), sex (male/female), SEER Summary tumor staging (localized, regionalized, distant), insurance status (uninsured, insured, insured not specific, Medicaid), and marital status (single, married/partner, separated/divorced/widowed).
 

Demographic determinism

In the adjusted analysis, the researchers found no association between race and 5-year cause-specific survival in patients with ccRCC.

The hazard ratios for death were 0.96 for Black patients, 1.01 for American Indian/Alaska Native patients, and 0.99 for Asian/Pacific Islander patients, with White patients as the comparator.

In terms of the other covariates studied, the researchers found that older age (>50 years) and the presence of regional or distant tumors were associated with an increased hazard of death, while female sex and having insurance were associated with a decreased hazard of death.

“Our study found that age, tumor stage, and insurance status are significantly associated with 5-year cause-specific survival. Future studies will benefit from complete assessment of other demographic factors, including income, medical comorbidities, and access to care. These are negative predictors, and [their] potential impact on overall survival should be considered by the clinician in treatment and management plans for RCC patients,” the researchers concluded.

In an editorial commentary published within the main article, Paul Russo, MD, of Weill Cornell Medicine, New York, stated: “Investigations such as this utilizing the SEER registries provide a 30,000-foot demographic view of some disease elements but lack important granularity, such as tumor size and grade, family income, critical medical comorbidities, and patient access to hospitals with surgical and medical oncologic expertise.”

Dr. Russo said it is well known that disparate access to diagnosis, surgical intervention, and expert treatment have an impact on survival.

He went on to ask: “Could African Americans have had superior outcomes if the data was controlled for these important variables? As urologic surgeons, we must join the greater medical community in understanding the root causes leading to structural racial and economic disparities, inequities in access to care, and the profound negative impact these disparities have on health outcomes in general and cancer outcomes specifically.”

The authors did not disclose funding or conflicts of interest.

[email protected]

SOURCE: Jivanji D et al. Urology. 2020. doi: 10.1016/j.urology.2020.10.055.

The issue of race and survival in patients with clear cell renal cell carcinoma (ccRCC) has been debated in the literature.

Some studies have shown worse survival for Black patients, while others have suggested that Black race is instead a stand-in for social determinants, including access to care.

New research suggests that Black race is not correlated with increased mortality from ccRCC. These results were published in Urology.

“Despite well documented racial biases and race-specific outcomes in the health care landscape, our study found race was not associated with 5-year cause-specific survival from ccRCC,” wrote investigator Dhaval Jivanji, a medical student at Florida International University, Miami, and colleagues.

In their retrospective study, the investigators examined 5-year survival in ccRCC patients, comparing results across races. The team used data from the Surveillance Epidemiology, and End Results (SEER) database, which collects cancer data from 13 states using population-based cancer registries. They extracted data on demographics, prevalence, and mortality, in relation to ccRCC.

A total of 8,421 subjects with ccRCC were included in the analysis, which covered the years 2007-2015. The primary outcome was 5-year survival, defined as cause-specific mortality up to the first 60 months from time of cancer diagnosis.

In addition to race, variables included in the statistical model were age (18-50, 51-60, 61-70,71-80, >80), sex (male/female), SEER Summary tumor staging (localized, regionalized, distant), insurance status (uninsured, insured, insured not specific, Medicaid), and marital status (single, married/partner, separated/divorced/widowed).
 

Demographic determinism

In the adjusted analysis, the researchers found no association between race and 5-year cause-specific survival in patients with ccRCC.

The hazard ratios for death were 0.96 for Black patients, 1.01 for American Indian/Alaska Native patients, and 0.99 for Asian/Pacific Islander patients, with White patients as the comparator.

In terms of the other covariates studied, the researchers found that older age (>50 years) and the presence of regional or distant tumors were associated with an increased hazard of death, while female sex and having insurance were associated with a decreased hazard of death.

“Our study found that age, tumor stage, and insurance status are significantly associated with 5-year cause-specific survival. Future studies will benefit from complete assessment of other demographic factors, including income, medical comorbidities, and access to care. These are negative predictors, and [their] potential impact on overall survival should be considered by the clinician in treatment and management plans for RCC patients,” the researchers concluded.

In an editorial commentary published within the main article, Paul Russo, MD, of Weill Cornell Medicine, New York, stated: “Investigations such as this utilizing the SEER registries provide a 30,000-foot demographic view of some disease elements but lack important granularity, such as tumor size and grade, family income, critical medical comorbidities, and patient access to hospitals with surgical and medical oncologic expertise.”

Dr. Russo said it is well known that disparate access to diagnosis, surgical intervention, and expert treatment have an impact on survival.

He went on to ask: “Could African Americans have had superior outcomes if the data was controlled for these important variables? As urologic surgeons, we must join the greater medical community in understanding the root causes leading to structural racial and economic disparities, inequities in access to care, and the profound negative impact these disparities have on health outcomes in general and cancer outcomes specifically.”

The authors did not disclose funding or conflicts of interest.

[email protected]

SOURCE: Jivanji D et al. Urology. 2020. doi: 10.1016/j.urology.2020.10.055.

The poorer survival rates in Black women compared with White women with breast cancer could be explained to some extent by the finding of much higher rates of  obesity, obesity-related comorbidities, and overall comorbidities in Black women, say researchers reporting a retrospective chart review from their clinic.

Kirsten A. Nyrop, PhD, deputy director for research for the Geriatric Oncology Program at the University of North Carolina, Chapel Hill, and colleagues analyzed medical charts for 144 Black women and 404 White women with early breast cancer.

Obesity rates were nearly double among Black women, at 62% vs 32%.

In addition, significantly more Black women had two or more total comorbidities (62% vs 47%), two or more obesity-related comorbidities (33% vs 10%), hypertension (60% vs 32%), type 2 diabetes (23% vs 6%), and hypercholesterolemia or hyperlipidemia (28% vs 18%).

These racial disparities persisted after adjustment for age and body mass index, both independent predictors of chronic diseases.

The difference in obesity and comorbidity did not translate to differences in treatment decisions such as surgery type, chemotherapy regimen, radiation, or endocrine treatment, the researchers note.

The findings were published online December 7 in the journal Cancer.

They underscore the likely role of obesity and related complications in the racial disparities seen in breast cancer survival outcomes, the authors conclude.

Experts writing in an accompanying editorial agree, while emphasizing the well documented differences in survival.

Compared with White women with breast cancer, Black women with breast cancer have a 42% higher mortality rate and a greater likelihood of dying from breast cancer regardless of their age at diagnosis, note Caitlin E. Taylor, MD, and Jane Lowe Meisel, MD, of Emory University, Atlanta, Georgia.

“Although it is clear that the causes of such disparities are complex and multifactorial, questions remain regarding to what extent patient comorbidities, and specifically obesity, may be playing a role,” they write.

The obesity- and comorbidity-related disparities identified by Nyrop et al “undoubtedly contribute to the overall disparities noted in breast cancer outcomes among Black women,” they add.
 

Takeaway messages

Nyrop and colleagues say their findings have two important takeaway messages:

1) It is important to manage comorbidities in women with newly diagnosed early breast cancer to reduce the risk of mortality from competing causes, and

2) Excess weight at diagnosis and weight gain after primary treatment increase the risk of obesity-related disease that can affect survival, and patients should be educated about the association.

Such conversations should be “patient-centered and culturally appropriate,” they note.

In their editorial, Taylor and Meisel agree with the authors’ conclusions. “Given the higher prevalence of obesity and related comorbidities among Black patients, addressing these issues must become an integral part of early breast cancer management to prolong overall survival and continue improving outcomes for these women.”

In fact, addressing comorbidities early in breast cancer management is important for patients of all racial and ethnic backgrounds, the editorialists add, concluding that the role of obesity as “a critical player underlying breast cancer mortality” is increasingly clear, and that its management is crucial for improved outcomes and quality of life.

This study was supported by the Breast Cancer Research Foundation, the National Cancer Institute’s Breast Cancer Specialized Program of Research Excellence, and the University of North Carolina Lineberger Comprehensive Cancer Center/University Cancer Research Fund. The study authors have disclosed no relevant financial relationships. Meisel has received research support from Pfizer, Eli Lilly, and Seattle Genetics and has served as a paid advisor for Pfizer, PUMA, Novartis, and Clovis Oncology. Taylor has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The poorer survival rates in Black women compared with White women with breast cancer could be explained to some extent by the finding of much higher rates of  obesity, obesity-related comorbidities, and overall comorbidities in Black women, say researchers reporting a retrospective chart review from their clinic.

Kirsten A. Nyrop, PhD, deputy director for research for the Geriatric Oncology Program at the University of North Carolina, Chapel Hill, and colleagues analyzed medical charts for 144 Black women and 404 White women with early breast cancer.

Obesity rates were nearly double among Black women, at 62% vs 32%.

In addition, significantly more Black women had two or more total comorbidities (62% vs 47%), two or more obesity-related comorbidities (33% vs 10%), hypertension (60% vs 32%), type 2 diabetes (23% vs 6%), and hypercholesterolemia or hyperlipidemia (28% vs 18%).

These racial disparities persisted after adjustment for age and body mass index, both independent predictors of chronic diseases.

The difference in obesity and comorbidity did not translate to differences in treatment decisions such as surgery type, chemotherapy regimen, radiation, or endocrine treatment, the researchers note.

The findings were published online December 7 in the journal Cancer.

They underscore the likely role of obesity and related complications in the racial disparities seen in breast cancer survival outcomes, the authors conclude.

Experts writing in an accompanying editorial agree, while emphasizing the well documented differences in survival.

Compared with White women with breast cancer, Black women with breast cancer have a 42% higher mortality rate and a greater likelihood of dying from breast cancer regardless of their age at diagnosis, note Caitlin E. Taylor, MD, and Jane Lowe Meisel, MD, of Emory University, Atlanta, Georgia.

“Although it is clear that the causes of such disparities are complex and multifactorial, questions remain regarding to what extent patient comorbidities, and specifically obesity, may be playing a role,” they write.

The obesity- and comorbidity-related disparities identified by Nyrop et al “undoubtedly contribute to the overall disparities noted in breast cancer outcomes among Black women,” they add.
 

Takeaway messages

Nyrop and colleagues say their findings have two important takeaway messages:

1) It is important to manage comorbidities in women with newly diagnosed early breast cancer to reduce the risk of mortality from competing causes, and

2) Excess weight at diagnosis and weight gain after primary treatment increase the risk of obesity-related disease that can affect survival, and patients should be educated about the association.

Such conversations should be “patient-centered and culturally appropriate,” they note.

In their editorial, Taylor and Meisel agree with the authors’ conclusions. “Given the higher prevalence of obesity and related comorbidities among Black patients, addressing these issues must become an integral part of early breast cancer management to prolong overall survival and continue improving outcomes for these women.”

In fact, addressing comorbidities early in breast cancer management is important for patients of all racial and ethnic backgrounds, the editorialists add, concluding that the role of obesity as “a critical player underlying breast cancer mortality” is increasingly clear, and that its management is crucial for improved outcomes and quality of life.

This study was supported by the Breast Cancer Research Foundation, the National Cancer Institute’s Breast Cancer Specialized Program of Research Excellence, and the University of North Carolina Lineberger Comprehensive Cancer Center/University Cancer Research Fund. The study authors have disclosed no relevant financial relationships. Meisel has received research support from Pfizer, Eli Lilly, and Seattle Genetics and has served as a paid advisor for Pfizer, PUMA, Novartis, and Clovis Oncology. Taylor has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

The poorer survival rates in Black women compared with White women with breast cancer could be explained to some extent by the finding of much higher rates of  obesity, obesity-related comorbidities, and overall comorbidities in Black women, say researchers reporting a retrospective chart review from their clinic.

Kirsten A. Nyrop, PhD, deputy director for research for the Geriatric Oncology Program at the University of North Carolina, Chapel Hill, and colleagues analyzed medical charts for 144 Black women and 404 White women with early breast cancer.

Obesity rates were nearly double among Black women, at 62% vs 32%.

In addition, significantly more Black women had two or more total comorbidities (62% vs 47%), two or more obesity-related comorbidities (33% vs 10%), hypertension (60% vs 32%), type 2 diabetes (23% vs 6%), and hypercholesterolemia or hyperlipidemia (28% vs 18%).

These racial disparities persisted after adjustment for age and body mass index, both independent predictors of chronic diseases.

The difference in obesity and comorbidity did not translate to differences in treatment decisions such as surgery type, chemotherapy regimen, radiation, or endocrine treatment, the researchers note.

The findings were published online December 7 in the journal Cancer.

They underscore the likely role of obesity and related complications in the racial disparities seen in breast cancer survival outcomes, the authors conclude.

Experts writing in an accompanying editorial agree, while emphasizing the well documented differences in survival.

Compared with White women with breast cancer, Black women with breast cancer have a 42% higher mortality rate and a greater likelihood of dying from breast cancer regardless of their age at diagnosis, note Caitlin E. Taylor, MD, and Jane Lowe Meisel, MD, of Emory University, Atlanta, Georgia.

“Although it is clear that the causes of such disparities are complex and multifactorial, questions remain regarding to what extent patient comorbidities, and specifically obesity, may be playing a role,” they write.

The obesity- and comorbidity-related disparities identified by Nyrop et al “undoubtedly contribute to the overall disparities noted in breast cancer outcomes among Black women,” they add.
 

Takeaway messages

Nyrop and colleagues say their findings have two important takeaway messages:

1) It is important to manage comorbidities in women with newly diagnosed early breast cancer to reduce the risk of mortality from competing causes, and

2) Excess weight at diagnosis and weight gain after primary treatment increase the risk of obesity-related disease that can affect survival, and patients should be educated about the association.

Such conversations should be “patient-centered and culturally appropriate,” they note.

In their editorial, Taylor and Meisel agree with the authors’ conclusions. “Given the higher prevalence of obesity and related comorbidities among Black patients, addressing these issues must become an integral part of early breast cancer management to prolong overall survival and continue improving outcomes for these women.”

In fact, addressing comorbidities early in breast cancer management is important for patients of all racial and ethnic backgrounds, the editorialists add, concluding that the role of obesity as “a critical player underlying breast cancer mortality” is increasingly clear, and that its management is crucial for improved outcomes and quality of life.

This study was supported by the Breast Cancer Research Foundation, the National Cancer Institute’s Breast Cancer Specialized Program of Research Excellence, and the University of North Carolina Lineberger Comprehensive Cancer Center/University Cancer Research Fund. The study authors have disclosed no relevant financial relationships. Meisel has received research support from Pfizer, Eli Lilly, and Seattle Genetics and has served as a paid advisor for Pfizer, PUMA, Novartis, and Clovis Oncology. Taylor has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

In January in many states, the start of a new year also means the start of a new legislative session. For LGBTQ youth and their families, these sessions can create a significant amount of anxiety, as legislators in several states introduce legislation to curtail the rights of this population. In some cases, legislators have attempted to criminalize the provision of gender-affirming medical care to the trans and gender-diverse adolescents that many of us provide care to on a daily basis. As pediatricians, we have an important role in advocating for legislation at the local, state, and federal level that improves the lives of the LGBTQ patients we serve.

2020 started on a positive note for LGBTQ children and adolescents, with Virginia becoming the 20th state to ban conversion therapy for minors. Legislation was introduced in several other states to prohibit this practice, including Kentucky, Missouri, and Ohio, and but they ultimately died in committee or were never referred. While there is not yet a nationwide ban on conversion therapy, legislation was introduced in the last three U.S. Congress sessions to ban this harmful practice. In June 2020, the Supreme Court decision in Bostock vs. Clayton County stated that employers could not fire an employee solely because of that person’s sexual orientation and/or gender identity.

However, 19 separate bills were introduced in 2020 alone in states across the United States that would prohibit gender-affirming care for adolescents under age 18.¹ Many of these bills also would make the provision of gender-affirming medical care codified as felony child abuse, with loss of licensure, fines and/or jail time a possibility for physicians who prescribe hormones or puberty blockers for gender-affirming care to minors. Fortunately, these bills either died in committee or never had a hearing. However, legislation has been prefiled in several states for their 2021 session to again attempt to prohibit minors from obtaining gender-affirming medical care and/or criminalizing the provision of this care by physicians. Other bills were filed or have been prefiled again to allow various medical and mental health providers to refuse to treat LGBTQ patients because of their personal religious beliefs and/or forcing these same providers to tell a parent if a minor reveals to that provider that they are LGBTQ.

Even if this legislation does not pass or get a hearing, the fact that the bills were introduced can have a profound impact on LGBTQ patients and their families. After a bill was introduced in Texas in their 2017 legislative session that would require trans and gender-diverse (TGD) people to use the bathroom based on their sex assigned at birth, the Trevor Project reported that it had an increase of 34% in crisis calls from trans youth who were in distress.² This was similar, but slightly less, than was reported by the Trevor Project in September 2015 when in the run-up to a vote on Houston’s Equal Rights Ordinance, advertising was run equating trans women as predators who could be lying in wait in bathrooms. On the converse, when LGBTQ youth feel supported in the media, courts, and legislatures, this can have a positive impact on their mental health. A 2017 study found that, in states who enacted same-sex marriage laws prior to the 2015 Supreme Court decision in Obergefell, compared with those who did not, there was a 7% relative reduction in the proportion of high school students who attempted suicide.³

The American Academy of Pediatrics published its policy statement in September 2018 outlining suggestions for pediatricians to provide support to TGD youth.⁴ In this position statement, recommendation No. 7 states “that pediatricians have a role in advocating for policies and laws that protect youth who identify as TGD from discrimination and violence.” Therefore, it is incumbent upon us to use our voices to support our LGBTQ youth. In 2020, several pediatricians from the South Dakota chapter of the AAP provided testimony – and organized public rallies – against legislation in that state which would have made gender-affirming care to minors under age 16 punishable by a fine and/or up to 10 years in prison.⁵

So what can you do? First, get to know your local and state legislators. While it was difficult to meet them in person for much of 2020, you can always call their district and/or Capitol offices, email them, or fill out their constituent contact form typically found on their website. Let them know that you oppose bills which introduce discrimination against your LGBTQ patients or threaten to criminalize the care that you provide to these patients.

Second, work with your state medical association or state AAP chapter to encourage them to oppose these harmful laws and support laws that improve the lives of LGBTQ patients. Third, you can write op-eds to your local newspaper, expressing your support for your patients and outlining the detrimental effects that anti-LGBTQ laws have on your patients. Lastly, you can be active on Twitter, Facebook, or other social media platforms sharing stories of how harmful or helpful certain pieces of legislation can be for your patients.

Dr. Cooper is assistant professor of pediatrics at the University of Texas, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. He has no relevant financial disclosures. Email Dr. Cooper at [email protected].

References

1. “Leglislation affecting LGBT rights across country.” www.aclu.org.

2. “Bathroom Bills Fuel Spike In Calls From Trans Youth To Suicide Hotline.” www.outsmartmagazine.com. 2017 Aug.

3. JAMA Pediatr. 2017 Apr 1. doi: 10.1001/jamapediatrics.2016.4529.

4. Pediatrics. 2018 Oct. doi: 10.1542/peds.2018-2162.

5. Wyckoff AS. “State bills seek to place limits on transgender care, ‘punish’ physicians.” AAP News. 2020 Feb 18.

In January in many states, the start of a new year also means the start of a new legislative session. For LGBTQ youth and their families, these sessions can create a significant amount of anxiety, as legislators in several states introduce legislation to curtail the rights of this population. In some cases, legislators have attempted to criminalize the provision of gender-affirming medical care to the trans and gender-diverse adolescents that many of us provide care to on a daily basis. As pediatricians, we have an important role in advocating for legislation at the local, state, and federal level that improves the lives of the LGBTQ patients we serve.

2020 started on a positive note for LGBTQ children and adolescents, with Virginia becoming the 20th state to ban conversion therapy for minors. Legislation was introduced in several other states to prohibit this practice, including Kentucky, Missouri, and Ohio, and but they ultimately died in committee or were never referred. While there is not yet a nationwide ban on conversion therapy, legislation was introduced in the last three U.S. Congress sessions to ban this harmful practice. In June 2020, the Supreme Court decision in Bostock vs. Clayton County stated that employers could not fire an employee solely because of that person’s sexual orientation and/or gender identity.

However, 19 separate bills were introduced in 2020 alone in states across the United States that would prohibit gender-affirming care for adolescents under age 18.¹ Many of these bills also would make the provision of gender-affirming medical care codified as felony child abuse, with loss of licensure, fines and/or jail time a possibility for physicians who prescribe hormones or puberty blockers for gender-affirming care to minors. Fortunately, these bills either died in committee or never had a hearing. However, legislation has been prefiled in several states for their 2021 session to again attempt to prohibit minors from obtaining gender-affirming medical care and/or criminalizing the provision of this care by physicians. Other bills were filed or have been prefiled again to allow various medical and mental health providers to refuse to treat LGBTQ patients because of their personal religious beliefs and/or forcing these same providers to tell a parent if a minor reveals to that provider that they are LGBTQ.

Even if this legislation does not pass or get a hearing, the fact that the bills were introduced can have a profound impact on LGBTQ patients and their families. After a bill was introduced in Texas in their 2017 legislative session that would require trans and gender-diverse (TGD) people to use the bathroom based on their sex assigned at birth, the Trevor Project reported that it had an increase of 34% in crisis calls from trans youth who were in distress.² This was similar, but slightly less, than was reported by the Trevor Project in September 2015 when in the run-up to a vote on Houston’s Equal Rights Ordinance, advertising was run equating trans women as predators who could be lying in wait in bathrooms. On the converse, when LGBTQ youth feel supported in the media, courts, and legislatures, this can have a positive impact on their mental health. A 2017 study found that, in states who enacted same-sex marriage laws prior to the 2015 Supreme Court decision in Obergefell, compared with those who did not, there was a 7% relative reduction in the proportion of high school students who attempted suicide.³

The American Academy of Pediatrics published its policy statement in September 2018 outlining suggestions for pediatricians to provide support to TGD youth.⁴ In this position statement, recommendation No. 7 states “that pediatricians have a role in advocating for policies and laws that protect youth who identify as TGD from discrimination and violence.” Therefore, it is incumbent upon us to use our voices to support our LGBTQ youth. In 2020, several pediatricians from the South Dakota chapter of the AAP provided testimony – and organized public rallies – against legislation in that state which would have made gender-affirming care to minors under age 16 punishable by a fine and/or up to 10 years in prison.⁵

So what can you do? First, get to know your local and state legislators. While it was difficult to meet them in person for much of 2020, you can always call their district and/or Capitol offices, email them, or fill out their constituent contact form typically found on their website. Let them know that you oppose bills which introduce discrimination against your LGBTQ patients or threaten to criminalize the care that you provide to these patients.

Second, work with your state medical association or state AAP chapter to encourage them to oppose these harmful laws and support laws that improve the lives of LGBTQ patients. Third, you can write op-eds to your local newspaper, expressing your support for your patients and outlining the detrimental effects that anti-LGBTQ laws have on your patients. Lastly, you can be active on Twitter, Facebook, or other social media platforms sharing stories of how harmful or helpful certain pieces of legislation can be for your patients.

Dr. Cooper is assistant professor of pediatrics at the University of Texas, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. He has no relevant financial disclosures. Email Dr. Cooper at [email protected].

References

1. “Leglislation affecting LGBT rights across country.” www.aclu.org.

2. “Bathroom Bills Fuel Spike In Calls From Trans Youth To Suicide Hotline.” www.outsmartmagazine.com. 2017 Aug.

3. JAMA Pediatr. 2017 Apr 1. doi: 10.1001/jamapediatrics.2016.4529.

4. Pediatrics. 2018 Oct. doi: 10.1542/peds.2018-2162.

5. Wyckoff AS. “State bills seek to place limits on transgender care, ‘punish’ physicians.” AAP News. 2020 Feb 18.

In January in many states, the start of a new year also means the start of a new legislative session. For LGBTQ youth and their families, these sessions can create a significant amount of anxiety, as legislators in several states introduce legislation to curtail the rights of this population. In some cases, legislators have attempted to criminalize the provision of gender-affirming medical care to the trans and gender-diverse adolescents that many of us provide care to on a daily basis. As pediatricians, we have an important role in advocating for legislation at the local, state, and federal level that improves the lives of the LGBTQ patients we serve.

2020 started on a positive note for LGBTQ children and adolescents, with Virginia becoming the 20th state to ban conversion therapy for minors. Legislation was introduced in several other states to prohibit this practice, including Kentucky, Missouri, and Ohio, and but they ultimately died in committee or were never referred. While there is not yet a nationwide ban on conversion therapy, legislation was introduced in the last three U.S. Congress sessions to ban this harmful practice. In June 2020, the Supreme Court decision in Bostock vs. Clayton County stated that employers could not fire an employee solely because of that person’s sexual orientation and/or gender identity.

However, 19 separate bills were introduced in 2020 alone in states across the United States that would prohibit gender-affirming care for adolescents under age 18.¹ Many of these bills also would make the provision of gender-affirming medical care codified as felony child abuse, with loss of licensure, fines and/or jail time a possibility for physicians who prescribe hormones or puberty blockers for gender-affirming care to minors. Fortunately, these bills either died in committee or never had a hearing. However, legislation has been prefiled in several states for their 2021 session to again attempt to prohibit minors from obtaining gender-affirming medical care and/or criminalizing the provision of this care by physicians. Other bills were filed or have been prefiled again to allow various medical and mental health providers to refuse to treat LGBTQ patients because of their personal religious beliefs and/or forcing these same providers to tell a parent if a minor reveals to that provider that they are LGBTQ.

Even if this legislation does not pass or get a hearing, the fact that the bills were introduced can have a profound impact on LGBTQ patients and their families. After a bill was introduced in Texas in their 2017 legislative session that would require trans and gender-diverse (TGD) people to use the bathroom based on their sex assigned at birth, the Trevor Project reported that it had an increase of 34% in crisis calls from trans youth who were in distress.² This was similar, but slightly less, than was reported by the Trevor Project in September 2015 when in the run-up to a vote on Houston’s Equal Rights Ordinance, advertising was run equating trans women as predators who could be lying in wait in bathrooms. On the converse, when LGBTQ youth feel supported in the media, courts, and legislatures, this can have a positive impact on their mental health. A 2017 study found that, in states who enacted same-sex marriage laws prior to the 2015 Supreme Court decision in Obergefell, compared with those who did not, there was a 7% relative reduction in the proportion of high school students who attempted suicide.³

The American Academy of Pediatrics published its policy statement in September 2018 outlining suggestions for pediatricians to provide support to TGD youth.⁴ In this position statement, recommendation No. 7 states “that pediatricians have a role in advocating for policies and laws that protect youth who identify as TGD from discrimination and violence.” Therefore, it is incumbent upon us to use our voices to support our LGBTQ youth. In 2020, several pediatricians from the South Dakota chapter of the AAP provided testimony – and organized public rallies – against legislation in that state which would have made gender-affirming care to minors under age 16 punishable by a fine and/or up to 10 years in prison.⁵

So what can you do? First, get to know your local and state legislators. While it was difficult to meet them in person for much of 2020, you can always call their district and/or Capitol offices, email them, or fill out their constituent contact form typically found on their website. Let them know that you oppose bills which introduce discrimination against your LGBTQ patients or threaten to criminalize the care that you provide to these patients.

Second, work with your state medical association or state AAP chapter to encourage them to oppose these harmful laws and support laws that improve the lives of LGBTQ patients. Third, you can write op-eds to your local newspaper, expressing your support for your patients and outlining the detrimental effects that anti-LGBTQ laws have on your patients. Lastly, you can be active on Twitter, Facebook, or other social media platforms sharing stories of how harmful or helpful certain pieces of legislation can be for your patients.

Dr. Cooper is assistant professor of pediatrics at the University of Texas, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas. He has no relevant financial disclosures. Email Dr. Cooper at [email protected].

References

1. “Leglislation affecting LGBT rights across country.” www.aclu.org.

2. “Bathroom Bills Fuel Spike In Calls From Trans Youth To Suicide Hotline.” www.outsmartmagazine.com. 2017 Aug.

3. JAMA Pediatr. 2017 Apr 1. doi: 10.1001/jamapediatrics.2016.4529.

4. Pediatrics. 2018 Oct. doi: 10.1542/peds.2018-2162.

5. Wyckoff AS. “State bills seek to place limits on transgender care, ‘punish’ physicians.” AAP News. 2020 Feb 18.

Black race is the most important risk factor for patients with acute myeloid leukemia (AML) and is associated with poor survival, according to new findings.

Among patients with AML younger than 60 years, the rate of overall 3-year survival was significantly less among Black patients than White patients (34% vs. 43%). The risk for death was 27% higher for Black patients compared with White patients.

“Our study demonstrates the delicate interplay between a variety of factors that influence survival disparities, particularly for younger Black AML patients,” said first author Bhavana Bhatnagar, DO, of the Ohio State University’s Comprehensive Cancer Center, Columbus. “We were able to confirm the impact of socioeconomic factors while also demonstrating that being Black is, in and of itself, an independent poor prognostic variable for survival.”

She noted that the persistently poor outcomes of young Black patients that were seen despite similar treatments in clinical trials strongly suggest that additional factors have a bearing on their survival.

The findings of the study were presented during the plenary session of the annual meeting of the American Society of Hematology, which was held online this year. The study was simultaneously published in Cancer Discovery.

Racial disparities in cancer outcomes remain a challenge. The term “health disparities” describes the differences of health outcomes among different groups, said Chancellor Donald, MD, of Tulane University, New Orleans, who introduced the article at the meeting. “Racial health disparities usually result from an unequal distribution of power and resources, not genetics.

“The examination of health disparities is certainly a worthwhile endeavor,” he continued. “For generations, differences in key health outcomes have negatively impacted the quality of life and shortened the life span of countless individuals. As scientists, clinicians, and invested members of our shared society, we are obligated to obtain a profound understanding of the mechanisms and impact of this morbid reality.”
 

Black race a risk factor

For their study, Dr. Bhatnagar and colleagues conducted a nationwide population analysis using data from the Surveillance Epidemiology End Results (SEER) Program of the National Cancer Institute to identify 11,190 adults aged 18-60 years who were diagnosed with AML between 1986 and 2015.

To characterize molecular features, they conducted targeted sequencing of 81 genes in 1,339 patients with AML who were treated on frontline Cancer and Leukemia Group B/Alliance for Clinical Trials in Oncology (Alliance) protocols based on standard-intensity cytarabine/anthracycline induction followed by consolidation between 1986 and 2016. None of these patients received an allogeneic stem cell transplant when they achieved complete remission.

Although overall survival has improved during the past 3 decades, survival disparities between Black and White patients has widened over time (P < .001). The authors found a nonstatistically significant difference in survival between 1986 and 1995 (White patients, n = 1,365; Black patients, n = 160; P = .19). However, the difference was significant between 1996 and 2005 (White patients, n = 2,994; Black patients, n = 480; P = .004). “And it became even more noticeable in the most recent decade,” said Dr. Bhatnagar. “Furthermore, younger Black AML patients were found to have worse survival compared with younger White AML patients.”

Results from the second analysis of patients treated on Alliance protocols did not show any significant differences in early death rates (10% vs. 46%; P = .02) and complete remission rates (71% vs. 71%; P = 1.00). “While relapse rates were slightly higher in Black compared to White patients, this difference did not reach statistical significance,” said Dr. Bhatnagar. “There was also no significant difference in the number of cycles of consolidation chemotherapy administered to these patients.”

However, both disease-free and overall survival were significantly worse for Black patients, suggesting that factors other than treatment selection were likely at play in influencing the survival disparity. The median disease-free survival for Black patients was 0.8 years, vs. 1.4 years for White patients (P = .02). Overall survival was 1.2 years vs. 1.8 years (P = .02).

Relapse rates were slightly higher in Black patients than in White patients, at 71% vs. 59%, but this difference did not reach statistical significance (P = .14).
 

Differences in biomarkers

With regard to underlying molecular differences between Black and White patients, the investigators found that the most common mutations were in NPM1, FLT3-ITD, and DNM3TA. Mutations were detected in more than 20% of Black patients. Other commonly mutated genes were IDH2, NRAS, TET2, IDH1, and TP53, which were mutated in more than 10% of patients. “All of these genes are established commonly mutated genes in AML,” said Bhatnagar.

On univariable and multivariable outcome analyses, which were used to identify clinical or molecular features that had a bearing on outcome, FLT3-ITD and IDH2 mutations were the only mutations associated with a higher risk for death among Black patients.

“This is actually a very important finding, as both FLT3 and IDH2 are now targetable with small-molecule inhibitors,” said Dr. Bhatnagar. “In addition, it is also worth noting that other gene mutations that have known prognostic significance in AML, such as NPM1, as well as RUNX1 and TP53, did not remain in the final statistical model.

“Importantly, our study provides powerful evidence that suggests differences in underlying disease biology between young Black and White AML patients, as evidenced by differences in the frequencies of recurrent gene mutations, “ she said.
 

Understudied disparities

Although the study showed that Black patients had worse outcomes, “surprisingly, the authors found these outcomes hold even when the patients are participating in clinical trials,” noted Elisa Weiss, PhD, senior vice president of education, services, and health research for the Leukemia and Lymphoma Society.

“The study makes clear that the medical and science community need to do more to better understand the social, economic, environmental, and biological causes of these disparities,” she said in an interview. “In fact, the findings suggest that there are myriad complex and understudied causes of the identified disparities, and they are likely to lie at the intersection of all levels of the social ecology that impact an individual’s ability to access timely and unbiased care, maintain their mental and physical health, and receive needed social support and resources.”

She noted that the Leukemia and Lymphoma Society has an Equity in Access research program that aims to “advance study of underlying causes of inequitable access to care and identify policies, strategies, and interventions that have the potential to reduce inequities and increase access to health care, services, and programs for blood cancer patients and survivors.”

The research was supported in part by the National Cancer Institute of the National Institutes of Health, other institutions, and through several scholar awards. Dr. Bhatnagar has received advisory board honoraria from Novartis, Kite Pharma, Celgene, Astellas, and Cell Therapeutics. Dr. Weiss has disclosed no relevant financial relationships.

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

Black race is the most important risk factor for patients with acute myeloid leukemia (AML) and is associated with poor survival, according to new findings.

Among patients with AML younger than 60 years, the rate of overall 3-year survival was significantly less among Black patients than White patients (34% vs. 43%). The risk for death was 27% higher for Black patients compared with White patients.

“Our study demonstrates the delicate interplay between a variety of factors that influence survival disparities, particularly for younger Black AML patients,” said first author Bhavana Bhatnagar, DO, of the Ohio State University’s Comprehensive Cancer Center, Columbus. “We were able to confirm the impact of socioeconomic factors while also demonstrating that being Black is, in and of itself, an independent poor prognostic variable for survival.”

She noted that the persistently poor outcomes of young Black patients that were seen despite similar treatments in clinical trials strongly suggest that additional factors have a bearing on their survival.

The findings of the study were presented during the plenary session of the annual meeting of the American Society of Hematology, which was held online this year. The study was simultaneously published in Cancer Discovery.

Racial disparities in cancer outcomes remain a challenge. The term “health disparities” describes the differences of health outcomes among different groups, said Chancellor Donald, MD, of Tulane University, New Orleans, who introduced the article at the meeting. “Racial health disparities usually result from an unequal distribution of power and resources, not genetics.

“The examination of health disparities is certainly a worthwhile endeavor,” he continued. “For generations, differences in key health outcomes have negatively impacted the quality of life and shortened the life span of countless individuals. As scientists, clinicians, and invested members of our shared society, we are obligated to obtain a profound understanding of the mechanisms and impact of this morbid reality.”
 

Black race a risk factor

For their study, Dr. Bhatnagar and colleagues conducted a nationwide population analysis using data from the Surveillance Epidemiology End Results (SEER) Program of the National Cancer Institute to identify 11,190 adults aged 18-60 years who were diagnosed with AML between 1986 and 2015.

To characterize molecular features, they conducted targeted sequencing of 81 genes in 1,339 patients with AML who were treated on frontline Cancer and Leukemia Group B/Alliance for Clinical Trials in Oncology (Alliance) protocols based on standard-intensity cytarabine/anthracycline induction followed by consolidation between 1986 and 2016. None of these patients received an allogeneic stem cell transplant when they achieved complete remission.

Although overall survival has improved during the past 3 decades, survival disparities between Black and White patients has widened over time (P < .001). The authors found a nonstatistically significant difference in survival between 1986 and 1995 (White patients, n = 1,365; Black patients, n = 160; P = .19). However, the difference was significant between 1996 and 2005 (White patients, n = 2,994; Black patients, n = 480; P = .004). “And it became even more noticeable in the most recent decade,” said Dr. Bhatnagar. “Furthermore, younger Black AML patients were found to have worse survival compared with younger White AML patients.”

Results from the second analysis of patients treated on Alliance protocols did not show any significant differences in early death rates (10% vs. 46%; P = .02) and complete remission rates (71% vs. 71%; P = 1.00). “While relapse rates were slightly higher in Black compared to White patients, this difference did not reach statistical significance,” said Dr. Bhatnagar. “There was also no significant difference in the number of cycles of consolidation chemotherapy administered to these patients.”

However, both disease-free and overall survival were significantly worse for Black patients, suggesting that factors other than treatment selection were likely at play in influencing the survival disparity. The median disease-free survival for Black patients was 0.8 years, vs. 1.4 years for White patients (P = .02). Overall survival was 1.2 years vs. 1.8 years (P = .02).

Relapse rates were slightly higher in Black patients than in White patients, at 71% vs. 59%, but this difference did not reach statistical significance (P = .14).
 

Differences in biomarkers

With regard to underlying molecular differences between Black and White patients, the investigators found that the most common mutations were in NPM1, FLT3-ITD, and DNM3TA. Mutations were detected in more than 20% of Black patients. Other commonly mutated genes were IDH2, NRAS, TET2, IDH1, and TP53, which were mutated in more than 10% of patients. “All of these genes are established commonly mutated genes in AML,” said Bhatnagar.

On univariable and multivariable outcome analyses, which were used to identify clinical or molecular features that had a bearing on outcome, FLT3-ITD and IDH2 mutations were the only mutations associated with a higher risk for death among Black patients.

“This is actually a very important finding, as both FLT3 and IDH2 are now targetable with small-molecule inhibitors,” said Dr. Bhatnagar. “In addition, it is also worth noting that other gene mutations that have known prognostic significance in AML, such as NPM1, as well as RUNX1 and TP53, did not remain in the final statistical model.

“Importantly, our study provides powerful evidence that suggests differences in underlying disease biology between young Black and White AML patients, as evidenced by differences in the frequencies of recurrent gene mutations, “ she said.
 

Understudied disparities

Although the study showed that Black patients had worse outcomes, “surprisingly, the authors found these outcomes hold even when the patients are participating in clinical trials,” noted Elisa Weiss, PhD, senior vice president of education, services, and health research for the Leukemia and Lymphoma Society.

“The study makes clear that the medical and science community need to do more to better understand the social, economic, environmental, and biological causes of these disparities,” she said in an interview. “In fact, the findings suggest that there are myriad complex and understudied causes of the identified disparities, and they are likely to lie at the intersection of all levels of the social ecology that impact an individual’s ability to access timely and unbiased care, maintain their mental and physical health, and receive needed social support and resources.”

She noted that the Leukemia and Lymphoma Society has an Equity in Access research program that aims to “advance study of underlying causes of inequitable access to care and identify policies, strategies, and interventions that have the potential to reduce inequities and increase access to health care, services, and programs for blood cancer patients and survivors.”

The research was supported in part by the National Cancer Institute of the National Institutes of Health, other institutions, and through several scholar awards. Dr. Bhatnagar has received advisory board honoraria from Novartis, Kite Pharma, Celgene, Astellas, and Cell Therapeutics. Dr. Weiss has disclosed no relevant financial relationships.

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

Black race is the most important risk factor for patients with acute myeloid leukemia (AML) and is associated with poor survival, according to new findings.

Among patients with AML younger than 60 years, the rate of overall 3-year survival was significantly less among Black patients than White patients (34% vs. 43%). The risk for death was 27% higher for Black patients compared with White patients.

“Our study demonstrates the delicate interplay between a variety of factors that influence survival disparities, particularly for younger Black AML patients,” said first author Bhavana Bhatnagar, DO, of the Ohio State University’s Comprehensive Cancer Center, Columbus. “We were able to confirm the impact of socioeconomic factors while also demonstrating that being Black is, in and of itself, an independent poor prognostic variable for survival.”

She noted that the persistently poor outcomes of young Black patients that were seen despite similar treatments in clinical trials strongly suggest that additional factors have a bearing on their survival.

The findings of the study were presented during the plenary session of the annual meeting of the American Society of Hematology, which was held online this year. The study was simultaneously published in Cancer Discovery.

Racial disparities in cancer outcomes remain a challenge. The term “health disparities” describes the differences of health outcomes among different groups, said Chancellor Donald, MD, of Tulane University, New Orleans, who introduced the article at the meeting. “Racial health disparities usually result from an unequal distribution of power and resources, not genetics.

“The examination of health disparities is certainly a worthwhile endeavor,” he continued. “For generations, differences in key health outcomes have negatively impacted the quality of life and shortened the life span of countless individuals. As scientists, clinicians, and invested members of our shared society, we are obligated to obtain a profound understanding of the mechanisms and impact of this morbid reality.”
 

Black race a risk factor

For their study, Dr. Bhatnagar and colleagues conducted a nationwide population analysis using data from the Surveillance Epidemiology End Results (SEER) Program of the National Cancer Institute to identify 11,190 adults aged 18-60 years who were diagnosed with AML between 1986 and 2015.

To characterize molecular features, they conducted targeted sequencing of 81 genes in 1,339 patients with AML who were treated on frontline Cancer and Leukemia Group B/Alliance for Clinical Trials in Oncology (Alliance) protocols based on standard-intensity cytarabine/anthracycline induction followed by consolidation between 1986 and 2016. None of these patients received an allogeneic stem cell transplant when they achieved complete remission.

Although overall survival has improved during the past 3 decades, survival disparities between Black and White patients has widened over time (P < .001). The authors found a nonstatistically significant difference in survival between 1986 and 1995 (White patients, n = 1,365; Black patients, n = 160; P = .19). However, the difference was significant between 1996 and 2005 (White patients, n = 2,994; Black patients, n = 480; P = .004). “And it became even more noticeable in the most recent decade,” said Dr. Bhatnagar. “Furthermore, younger Black AML patients were found to have worse survival compared with younger White AML patients.”

Results from the second analysis of patients treated on Alliance protocols did not show any significant differences in early death rates (10% vs. 46%; P = .02) and complete remission rates (71% vs. 71%; P = 1.00). “While relapse rates were slightly higher in Black compared to White patients, this difference did not reach statistical significance,” said Dr. Bhatnagar. “There was also no significant difference in the number of cycles of consolidation chemotherapy administered to these patients.”

However, both disease-free and overall survival were significantly worse for Black patients, suggesting that factors other than treatment selection were likely at play in influencing the survival disparity. The median disease-free survival for Black patients was 0.8 years, vs. 1.4 years for White patients (P = .02). Overall survival was 1.2 years vs. 1.8 years (P = .02).

Relapse rates were slightly higher in Black patients than in White patients, at 71% vs. 59%, but this difference did not reach statistical significance (P = .14).
 

Differences in biomarkers

With regard to underlying molecular differences between Black and White patients, the investigators found that the most common mutations were in NPM1, FLT3-ITD, and DNM3TA. Mutations were detected in more than 20% of Black patients. Other commonly mutated genes were IDH2, NRAS, TET2, IDH1, and TP53, which were mutated in more than 10% of patients. “All of these genes are established commonly mutated genes in AML,” said Bhatnagar.

On univariable and multivariable outcome analyses, which were used to identify clinical or molecular features that had a bearing on outcome, FLT3-ITD and IDH2 mutations were the only mutations associated with a higher risk for death among Black patients.

“This is actually a very important finding, as both FLT3 and IDH2 are now targetable with small-molecule inhibitors,” said Dr. Bhatnagar. “In addition, it is also worth noting that other gene mutations that have known prognostic significance in AML, such as NPM1, as well as RUNX1 and TP53, did not remain in the final statistical model.

“Importantly, our study provides powerful evidence that suggests differences in underlying disease biology between young Black and White AML patients, as evidenced by differences in the frequencies of recurrent gene mutations, “ she said.
 

Understudied disparities

Although the study showed that Black patients had worse outcomes, “surprisingly, the authors found these outcomes hold even when the patients are participating in clinical trials,” noted Elisa Weiss, PhD, senior vice president of education, services, and health research for the Leukemia and Lymphoma Society.

“The study makes clear that the medical and science community need to do more to better understand the social, economic, environmental, and biological causes of these disparities,” she said in an interview. “In fact, the findings suggest that there are myriad complex and understudied causes of the identified disparities, and they are likely to lie at the intersection of all levels of the social ecology that impact an individual’s ability to access timely and unbiased care, maintain their mental and physical health, and receive needed social support and resources.”

She noted that the Leukemia and Lymphoma Society has an Equity in Access research program that aims to “advance study of underlying causes of inequitable access to care and identify policies, strategies, and interventions that have the potential to reduce inequities and increase access to health care, services, and programs for blood cancer patients and survivors.”

The research was supported in part by the National Cancer Institute of the National Institutes of Health, other institutions, and through several scholar awards. Dr. Bhatnagar has received advisory board honoraria from Novartis, Kite Pharma, Celgene, Astellas, and Cell Therapeutics. Dr. Weiss has disclosed no relevant financial relationships.

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

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most recently identified member of the zoonotic pathogens of coronaviruses. It caused an outbreak of pneumonia in December 2019 in Wuhan, China.¹ Among all related acute respiratory syndromes (SARS-CoV, Middle East respiratory syndrome coronavirus), SARS-CoV-2 remains to be the most infectious, has the highest potential for human transmission, and can eventually result in acute respiratory distress syndrome.^2,3

Only 15% of coronavirus disease 2019 (COVID-19) cases progress to pneumonia, and approximately 5% of these cases develop acute respiratory distress syndrome, septic shock, and/or multiple organ failure. The majority of cases only exhibit mild to moderate symptoms.^4,5 A wide array of skin manifestations in COVID-19 infection have been reported, including maculopapular eruptions, morbilliform rashes, urticaria, chickenpoxlike lesions, livedo reticularis, COVID toes, erythema multiforme, pityriasis rosea, and several other patterns.⁶ We report a case of herpes zoster (HZ) complication in a COVID-19–positive woman who was 27 weeks pregnant.

Case Report

A 36-year-old woman who was 27 weeks pregnant was referred by her obstetrician to the dermatology clinic. She presented with a low-grade fever and a vesicular painful rash. Physical examination revealed painful, itchy, dysesthetic papules and vesicles on the left side of the forehead along with mild edema of the left upper eyelid but no watering of the eye or photophobia. She reported episodes of fever (temperature, 38.9°C), fatigue, and myalgia over the last week. She had bouts of dyspnea and tachycardia that she thought were related to being in the late second trimester of pregnancy. The area surrounding the vesicular eruption was tender to touch. No dry cough or any gastrointestinal or urinary tract symptoms were noted. She reported a burning sensation when splashing water on the face or when exposed to air currents. One week following the initial symptoms, she experienced a painful vesicular rash along the upper left forehead (Figure) associated with eyelid edema. Oral and ocular mucosae were free of any presentations. She had no relevant history and had not experienced any complications during pregnancy. A diagnosis of HZ was made, and she was prescribed valacyclovir 1 g 3 times daily for 7 days, acetaminophen for the fever, and calamine lotion. We recommended COVID-19 testing based on her symptoms. A chest radiograph and a positive nasopharyngeal smear were consistent with COVID-19 infection. She reported via telephone follow-up 1 week after presentation that her skin condition had improved following the treatment course and that the vesicles eventually dried, leaving a crusting appearance after 5 to 7 days. Regarding her SARS-CoV-2 condition, her oxygen saturation was 95% at presentation; she self-quarantined at home; and she was treated with oseltamivir 75 mg orally every 12 hours for 5 days, azithromycin 500 mg orally daily, acetaminophen, and vitamin C. Electronic fetal heart rate monitoring and ultrasound examinations were performed to assess the condition of the fetus and were reported normal. At the time of writing this article, she was 32 weeks pregnant and tested negative to 2 consecutive nasopharyngeal swabs for COVID-19 and was in good general condition. She continued her pregnancy according to her obstetrician’s recommendations.

Comment

The incubation time of COVID-19 can be up to 14 days. Fever, dry cough, fatigue, and diarrhea have been speculated to be clinical symptoms; however, many cases may be asymptomatic. Aside from a medical or travel history at risk for COVID-19, diagnosis can be confirmed by detection of viral RNA by reverse transcriptase–polymerase chain reaction for nasopharyngeal swabs or bronchoalveolar fluid. Patients who are immunocompromised, older, or male or who have a history of cardiovascular conditions or debilitating chronic conditions are at an increased risk for severe disease and poor outcome compared to younger healthy individuals.⁷

The vesicular rash of COVID-19 has been reported to have different forms of presentation. A diffuse widespread pattern resembling hand-foot-and-mouth disease and a localized monomorphic pattern resembling chickenpox but with predilection to the trunk has been described.⁸

Physiologic changes in the immune and cardiopulmonary systems during pregnancy (eg, diaphragm elevation, increased oxygen consumption, edema of the respiratory tract mucosae) make pregnant women intolerant to hypoxia. The mortality rate of the 1918 influenza pandemic was 2.6% in the overall population but 37% among pregnant women.⁹ In 2009, pregnant women were reported to be at an increased risk for complications from the H1N1 influenza virus pandemic, with a higher estimated rate of hospital admission than the general population.¹⁰ In 2003, approximately 50% of pregnant women who received a diagnosis of SARS-CoV were admitted to the intensive care unit, approximately 33% of pregnant women with SARS-CoV required mechanical ventilation, and the mortality rate was as high as 25% for these women.¹¹ To date, data on the effects of COVID-19 in pregnancy are limited to small case series.^12-15

It was confirmed that COVID-19 infection is accompanied by a reduction in lymphocytes, monocytes, and eosinophils, along with a notable reduction of CD4/CD8 T cells, B cells, and natural killer cells. It was further revealed that nonsurvivor COVID-19 patients continued to show a decrease in lymphocyte counts along the course of their disease until death.^16-18

Different mechanisms for lymphocyte depletion and deficiency were speculated among COVID-19 patients and include direct lymphocyte death through coronavirus angiotensin-converting enzyme 2–lymphocyte-expressed receptors; direct damage to lymphatic organs, such as the thymus and spleen, but this theory needs to be further investigated; direct lymphocyte apoptosis mediated by tumor necrosis factor α, IL-6, and other proinflammatory cytokines; and direct inhibition of lymphocytes by metabolic upset, such as acidosis.^19,20

These causes may precipitate lymphopenia and impaired antiviral responses.²¹ It also has been postulated that the functional damage of CD4⁺ T cells may predispose patients with COVID-19 to severe disease.²² Such immune changes can render a patient more susceptible to developing shingles by reactivating varicella-zoster virus, which could be a sign of undiagnosed COVID-19 infection in younger age groups.

Two earlier reports discussed HZ among COVID-19–diagnosed patients. Shors²³ presented a case of a patient who developed varicella-zoster virus reactivation of the V2 dermatome during the course of COVID-19 infection. In addition, the patient developed severe acute herpetic neuralgia despite the early initiation of antiviral therapy.²³ Elsaie et al²⁴ described 2 cases of patients during the pandemic who first presented with HZ before later being diagnosed with COVID-19 infection.

New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. We report a pregnant female presenting with HZ during the course of COVID-19 infection, which suggests that the clinical presentation of HZ at the time of the current pandemic, especially if associated with other signs of COVID-19 infection, should be carefully monitored and reported for further assessment.

Acknowledgment
The authors would like to thank all the health care workers who have been fighting COVID-19 in Egypt and worldwide.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most recently identified member of the zoonotic pathogens of coronaviruses. It caused an outbreak of pneumonia in December 2019 in Wuhan, China.¹ Among all related acute respiratory syndromes (SARS-CoV, Middle East respiratory syndrome coronavirus), SARS-CoV-2 remains to be the most infectious, has the highest potential for human transmission, and can eventually result in acute respiratory distress syndrome.^2,3

Only 15% of coronavirus disease 2019 (COVID-19) cases progress to pneumonia, and approximately 5% of these cases develop acute respiratory distress syndrome, septic shock, and/or multiple organ failure. The majority of cases only exhibit mild to moderate symptoms.^4,5 A wide array of skin manifestations in COVID-19 infection have been reported, including maculopapular eruptions, morbilliform rashes, urticaria, chickenpoxlike lesions, livedo reticularis, COVID toes, erythema multiforme, pityriasis rosea, and several other patterns.⁶ We report a case of herpes zoster (HZ) complication in a COVID-19–positive woman who was 27 weeks pregnant.

Case Report

A 36-year-old woman who was 27 weeks pregnant was referred by her obstetrician to the dermatology clinic. She presented with a low-grade fever and a vesicular painful rash. Physical examination revealed painful, itchy, dysesthetic papules and vesicles on the left side of the forehead along with mild edema of the left upper eyelid but no watering of the eye or photophobia. She reported episodes of fever (temperature, 38.9°C), fatigue, and myalgia over the last week. She had bouts of dyspnea and tachycardia that she thought were related to being in the late second trimester of pregnancy. The area surrounding the vesicular eruption was tender to touch. No dry cough or any gastrointestinal or urinary tract symptoms were noted. She reported a burning sensation when splashing water on the face or when exposed to air currents. One week following the initial symptoms, she experienced a painful vesicular rash along the upper left forehead (Figure) associated with eyelid edema. Oral and ocular mucosae were free of any presentations. She had no relevant history and had not experienced any complications during pregnancy. A diagnosis of HZ was made, and she was prescribed valacyclovir 1 g 3 times daily for 7 days, acetaminophen for the fever, and calamine lotion. We recommended COVID-19 testing based on her symptoms. A chest radiograph and a positive nasopharyngeal smear were consistent with COVID-19 infection. She reported via telephone follow-up 1 week after presentation that her skin condition had improved following the treatment course and that the vesicles eventually dried, leaving a crusting appearance after 5 to 7 days. Regarding her SARS-CoV-2 condition, her oxygen saturation was 95% at presentation; she self-quarantined at home; and she was treated with oseltamivir 75 mg orally every 12 hours for 5 days, azithromycin 500 mg orally daily, acetaminophen, and vitamin C. Electronic fetal heart rate monitoring and ultrasound examinations were performed to assess the condition of the fetus and were reported normal. At the time of writing this article, she was 32 weeks pregnant and tested negative to 2 consecutive nasopharyngeal swabs for COVID-19 and was in good general condition. She continued her pregnancy according to her obstetrician’s recommendations.

Comment

The incubation time of COVID-19 can be up to 14 days. Fever, dry cough, fatigue, and diarrhea have been speculated to be clinical symptoms; however, many cases may be asymptomatic. Aside from a medical or travel history at risk for COVID-19, diagnosis can be confirmed by detection of viral RNA by reverse transcriptase–polymerase chain reaction for nasopharyngeal swabs or bronchoalveolar fluid. Patients who are immunocompromised, older, or male or who have a history of cardiovascular conditions or debilitating chronic conditions are at an increased risk for severe disease and poor outcome compared to younger healthy individuals.⁷

The vesicular rash of COVID-19 has been reported to have different forms of presentation. A diffuse widespread pattern resembling hand-foot-and-mouth disease and a localized monomorphic pattern resembling chickenpox but with predilection to the trunk has been described.⁸

Physiologic changes in the immune and cardiopulmonary systems during pregnancy (eg, diaphragm elevation, increased oxygen consumption, edema of the respiratory tract mucosae) make pregnant women intolerant to hypoxia. The mortality rate of the 1918 influenza pandemic was 2.6% in the overall population but 37% among pregnant women.⁹ In 2009, pregnant women were reported to be at an increased risk for complications from the H1N1 influenza virus pandemic, with a higher estimated rate of hospital admission than the general population.¹⁰ In 2003, approximately 50% of pregnant women who received a diagnosis of SARS-CoV were admitted to the intensive care unit, approximately 33% of pregnant women with SARS-CoV required mechanical ventilation, and the mortality rate was as high as 25% for these women.¹¹ To date, data on the effects of COVID-19 in pregnancy are limited to small case series.^12-15

It was confirmed that COVID-19 infection is accompanied by a reduction in lymphocytes, monocytes, and eosinophils, along with a notable reduction of CD4/CD8 T cells, B cells, and natural killer cells. It was further revealed that nonsurvivor COVID-19 patients continued to show a decrease in lymphocyte counts along the course of their disease until death.^16-18

Different mechanisms for lymphocyte depletion and deficiency were speculated among COVID-19 patients and include direct lymphocyte death through coronavirus angiotensin-converting enzyme 2–lymphocyte-expressed receptors; direct damage to lymphatic organs, such as the thymus and spleen, but this theory needs to be further investigated; direct lymphocyte apoptosis mediated by tumor necrosis factor α, IL-6, and other proinflammatory cytokines; and direct inhibition of lymphocytes by metabolic upset, such as acidosis.^19,20

These causes may precipitate lymphopenia and impaired antiviral responses.²¹ It also has been postulated that the functional damage of CD4⁺ T cells may predispose patients with COVID-19 to severe disease.²² Such immune changes can render a patient more susceptible to developing shingles by reactivating varicella-zoster virus, which could be a sign of undiagnosed COVID-19 infection in younger age groups.

Two earlier reports discussed HZ among COVID-19–diagnosed patients. Shors²³ presented a case of a patient who developed varicella-zoster virus reactivation of the V2 dermatome during the course of COVID-19 infection. In addition, the patient developed severe acute herpetic neuralgia despite the early initiation of antiviral therapy.²³ Elsaie et al²⁴ described 2 cases of patients during the pandemic who first presented with HZ before later being diagnosed with COVID-19 infection.

New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. We report a pregnant female presenting with HZ during the course of COVID-19 infection, which suggests that the clinical presentation of HZ at the time of the current pandemic, especially if associated with other signs of COVID-19 infection, should be carefully monitored and reported for further assessment.

Acknowledgment
The authors would like to thank all the health care workers who have been fighting COVID-19 in Egypt and worldwide.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the most recently identified member of the zoonotic pathogens of coronaviruses. It caused an outbreak of pneumonia in December 2019 in Wuhan, China.¹ Among all related acute respiratory syndromes (SARS-CoV, Middle East respiratory syndrome coronavirus), SARS-CoV-2 remains to be the most infectious, has the highest potential for human transmission, and can eventually result in acute respiratory distress syndrome.^2,3

Only 15% of coronavirus disease 2019 (COVID-19) cases progress to pneumonia, and approximately 5% of these cases develop acute respiratory distress syndrome, septic shock, and/or multiple organ failure. The majority of cases only exhibit mild to moderate symptoms.^4,5 A wide array of skin manifestations in COVID-19 infection have been reported, including maculopapular eruptions, morbilliform rashes, urticaria, chickenpoxlike lesions, livedo reticularis, COVID toes, erythema multiforme, pityriasis rosea, and several other patterns.⁶ We report a case of herpes zoster (HZ) complication in a COVID-19–positive woman who was 27 weeks pregnant.

Case Report

A 36-year-old woman who was 27 weeks pregnant was referred by her obstetrician to the dermatology clinic. She presented with a low-grade fever and a vesicular painful rash. Physical examination revealed painful, itchy, dysesthetic papules and vesicles on the left side of the forehead along with mild edema of the left upper eyelid but no watering of the eye or photophobia. She reported episodes of fever (temperature, 38.9°C), fatigue, and myalgia over the last week. She had bouts of dyspnea and tachycardia that she thought were related to being in the late second trimester of pregnancy. The area surrounding the vesicular eruption was tender to touch. No dry cough or any gastrointestinal or urinary tract symptoms were noted. She reported a burning sensation when splashing water on the face or when exposed to air currents. One week following the initial symptoms, she experienced a painful vesicular rash along the upper left forehead (Figure) associated with eyelid edema. Oral and ocular mucosae were free of any presentations. She had no relevant history and had not experienced any complications during pregnancy. A diagnosis of HZ was made, and she was prescribed valacyclovir 1 g 3 times daily for 7 days, acetaminophen for the fever, and calamine lotion. We recommended COVID-19 testing based on her symptoms. A chest radiograph and a positive nasopharyngeal smear were consistent with COVID-19 infection. She reported via telephone follow-up 1 week after presentation that her skin condition had improved following the treatment course and that the vesicles eventually dried, leaving a crusting appearance after 5 to 7 days. Regarding her SARS-CoV-2 condition, her oxygen saturation was 95% at presentation; she self-quarantined at home; and she was treated with oseltamivir 75 mg orally every 12 hours for 5 days, azithromycin 500 mg orally daily, acetaminophen, and vitamin C. Electronic fetal heart rate monitoring and ultrasound examinations were performed to assess the condition of the fetus and were reported normal. At the time of writing this article, she was 32 weeks pregnant and tested negative to 2 consecutive nasopharyngeal swabs for COVID-19 and was in good general condition. She continued her pregnancy according to her obstetrician’s recommendations.

Comment

The incubation time of COVID-19 can be up to 14 days. Fever, dry cough, fatigue, and diarrhea have been speculated to be clinical symptoms; however, many cases may be asymptomatic. Aside from a medical or travel history at risk for COVID-19, diagnosis can be confirmed by detection of viral RNA by reverse transcriptase–polymerase chain reaction for nasopharyngeal swabs or bronchoalveolar fluid. Patients who are immunocompromised, older, or male or who have a history of cardiovascular conditions or debilitating chronic conditions are at an increased risk for severe disease and poor outcome compared to younger healthy individuals.⁷

The vesicular rash of COVID-19 has been reported to have different forms of presentation. A diffuse widespread pattern resembling hand-foot-and-mouth disease and a localized monomorphic pattern resembling chickenpox but with predilection to the trunk has been described.⁸

Physiologic changes in the immune and cardiopulmonary systems during pregnancy (eg, diaphragm elevation, increased oxygen consumption, edema of the respiratory tract mucosae) make pregnant women intolerant to hypoxia. The mortality rate of the 1918 influenza pandemic was 2.6% in the overall population but 37% among pregnant women.⁹ In 2009, pregnant women were reported to be at an increased risk for complications from the H1N1 influenza virus pandemic, with a higher estimated rate of hospital admission than the general population.¹⁰ In 2003, approximately 50% of pregnant women who received a diagnosis of SARS-CoV were admitted to the intensive care unit, approximately 33% of pregnant women with SARS-CoV required mechanical ventilation, and the mortality rate was as high as 25% for these women.¹¹ To date, data on the effects of COVID-19 in pregnancy are limited to small case series.^12-15

It was confirmed that COVID-19 infection is accompanied by a reduction in lymphocytes, monocytes, and eosinophils, along with a notable reduction of CD4/CD8 T cells, B cells, and natural killer cells. It was further revealed that nonsurvivor COVID-19 patients continued to show a decrease in lymphocyte counts along the course of their disease until death.^16-18

Different mechanisms for lymphocyte depletion and deficiency were speculated among COVID-19 patients and include direct lymphocyte death through coronavirus angiotensin-converting enzyme 2–lymphocyte-expressed receptors; direct damage to lymphatic organs, such as the thymus and spleen, but this theory needs to be further investigated; direct lymphocyte apoptosis mediated by tumor necrosis factor α, IL-6, and other proinflammatory cytokines; and direct inhibition of lymphocytes by metabolic upset, such as acidosis.^19,20

These causes may precipitate lymphopenia and impaired antiviral responses.²¹ It also has been postulated that the functional damage of CD4⁺ T cells may predispose patients with COVID-19 to severe disease.²² Such immune changes can render a patient more susceptible to developing shingles by reactivating varicella-zoster virus, which could be a sign of undiagnosed COVID-19 infection in younger age groups.

Two earlier reports discussed HZ among COVID-19–diagnosed patients. Shors²³ presented a case of a patient who developed varicella-zoster virus reactivation of the V2 dermatome during the course of COVID-19 infection. In addition, the patient developed severe acute herpetic neuralgia despite the early initiation of antiviral therapy.²³ Elsaie et al²⁴ described 2 cases of patients during the pandemic who first presented with HZ before later being diagnosed with COVID-19 infection.

New information and cutaneous manifestations possibly related to COVID-19 are emerging every day. We report a pregnant female presenting with HZ during the course of COVID-19 infection, which suggests that the clinical presentation of HZ at the time of the current pandemic, especially if associated with other signs of COVID-19 infection, should be carefully monitored and reported for further assessment.

Acknowledgment
The authors would like to thank all the health care workers who have been fighting COVID-19 in Egypt and worldwide.

Although physicians commit themselves to providing equitable treatment to all patients, significant disparities remain in the dermatologic care of Black patients, who constitute 13% of the US population, which continues to grow increasingly diverse.¹ Despite these changes in the population, the literature demonstrates that dermatologic training does not adequately focus on unique presentations of cutaneous pathology in the Black population.^2,3 Accordingly, medical students lack proper training in how skin disorders manifest in people of color. Compounding the problem, only 3% of dermatologists are Black, creating a cultural barrier that can compromise care for Black patients.^2,4 Racial disparities in dermatology training can compromise treatment, patient satisfaction, and outcomes.³

Issues in Medical Education Training and Resources

Lack of diversity in the resources used for dermatology training in medical schools affects diagnosis and treatment, as skin manifestations such as hypersensitivity reactions, rashes, and cancer can appear differently on different skin tones.⁵ A study of medical students’ ability to diagnose common dermatologic pathologies found that when trainees were presented with photographs of dark skin, their accuracy in identifying urticaria, squamous cell carcinoma, and even atopic dermatitis was reduced, despite these diseases being more prevalent in children of African American ancestry.^4,6

Dermatologic diseases also can have different distributions in different races; for example, on non–sun-exposed sites, squamous cell carcinoma in Black patients occurs at 8.5 times the frequency of White patients.⁷ Failure to identify diseases accurately due to insufficient training can have grave consequences for patients. Although skin cancer is less common in individuals with skin of color, it is associated with greater morbidity and mortality, in part due to delayed diagnosis.⁷

Inadequate research, reporting, and instruction on dermatologic findings in patients with darker complexions further compound racial disparities in dermatology. A 2006 study of the representation of darker skin in major dermatology educational resources found that only 2% of teaching events at American Academy of Dermatology annual meetings focused on skin of color. Furthermore, the study determined that many common diseases in patients with dark skin, such as acne vulgaris and pityriasis rosea, were completely absent or limited in dermatology textbooks.⁸

Impact on the Black Patient Experience

Patients’ therapeutic relationship with their physician also is damaged by limitations in training in diverse skin color. A study that assessed Black patients seen in a skin of color clinic (SOCC) compared to Black patients seen in a non-SOCC found that non-SOCC patients reported a lower degree of respect, dignity, understanding, and trust compared to the patients seen in a SOCC. Black patients expressed specific concerns about non-SOCC dermatologists’ knowledge of abnormalities that present in darker skin and Black hair.³ These findings are compounded by reports suggesting that, independent of care, structural racism contributes to dermatologic disease severity by influencing patient education level, household income, and degree of exposure to harmful environmental irritants.⁶

Racial disparities continue to be seen in the makeup of the universe of dermatologists and skin researchers. As of 2016, only 3% of dermatologists were Black, making dermatology one of the least diverse medical specialties.² Increasing the diversity of the dermatology workforce is important to improve patient satisfaction and treatment, both for minority and nonminority patients. Compared to race-discordant medical visits, race-concordant visits were shown to have a higher rate of satisfaction and better shared decision-making.⁹ Also, minority physicians are more likely to practice health care in areas that are traditionally underserved and to care for patients who do not have health insurance, making their participation essential in addressing some of the baseline disparities Black patients face in securing quality dermatologic care.¹

Structural Racism in Medicine

Changing dermatology training to ensure improved treatment of Black patients requires not only increased attention to differences in disease presentation but also heightened awareness of underlying genetic, environmental, and structural factors that contribute to the disease course.⁶ For example, there is evidence suggesting that structural racism in the form of residential segregation, lower socioeconomic status, and lower educational attainment contribute to disease severity in conditions such as atopic dermatitis. There is additional evidence suggesting that White patients are more readily offered therapeutic options than Black patients. A study of racial disparities in psoriasis treatment found that Black patients with moderate to severe psoriasis were 70% less likely to receive treatment with a biologic than White patients, independent of socioeconomic factors, comorbidities, and insurance plans.¹⁰

Moving Forward

Although research continues to underscore racial disparities in dermatology, some leaders in the field are actively combating these problems. A recent study that looked at representations of dark skin images in medical educational resources found far greater representation of dark pigmented skin in web-based resources than in traditional printed texts. Specifically, the online resource VisualDx (https://www.visualdx.com/) features 28.5% dark skin images compared to 10.3% (on average) in printed dermatology books.¹¹ There also is increasing public awareness of these issues, with organizations such as the Skin of Color Society (http://skinofcolorsociety.org/) helping to promote interest in racial disparities in dermatology. Physicians also have created textbooks and social media accounts focused on dermatologic manifestations in skin of color.¹² The Instagram account Brown Skin Matters (@brownskinmatters) has created a publicly accessible online resource where physicians and patients can see and post dermatologic diseases in skin of color.⁵

Final Thoughts

It is critical that physicians be trained to identify skin and hair manifestations of disease and disorders in Black patients. Training can be improved by including more images of skin manifestations in dark skin, both in medical school curricula and in new editions of dermatology textbooks. Training also must teach students about hair in Black individuals and how to properly treat it as well as related conditions of the hair and scalp.¹³ More research also is needed to better understand how dermatologists can improve the patient experience for Black patients. Residency programs must work to increase diversity among dermatology trainees.

Lastly, dermatology education should increasingly be supplemented with newer, web-based resources that show dermatologic manifestations across the spectrum of skin tones. Dermatology training must be adapted to better account for diverse patient populations and increase its focus on the systems that produce baseline disparities in disease morbidity and mortality.

Although physicians commit themselves to providing equitable treatment to all patients, significant disparities remain in the dermatologic care of Black patients, who constitute 13% of the US population, which continues to grow increasingly diverse.¹ Despite these changes in the population, the literature demonstrates that dermatologic training does not adequately focus on unique presentations of cutaneous pathology in the Black population.^2,3 Accordingly, medical students lack proper training in how skin disorders manifest in people of color. Compounding the problem, only 3% of dermatologists are Black, creating a cultural barrier that can compromise care for Black patients.^2,4 Racial disparities in dermatology training can compromise treatment, patient satisfaction, and outcomes.³

Issues in Medical Education Training and Resources

Lack of diversity in the resources used for dermatology training in medical schools affects diagnosis and treatment, as skin manifestations such as hypersensitivity reactions, rashes, and cancer can appear differently on different skin tones.⁵ A study of medical students’ ability to diagnose common dermatologic pathologies found that when trainees were presented with photographs of dark skin, their accuracy in identifying urticaria, squamous cell carcinoma, and even atopic dermatitis was reduced, despite these diseases being more prevalent in children of African American ancestry.^4,6

Dermatologic diseases also can have different distributions in different races; for example, on non–sun-exposed sites, squamous cell carcinoma in Black patients occurs at 8.5 times the frequency of White patients.⁷ Failure to identify diseases accurately due to insufficient training can have grave consequences for patients. Although skin cancer is less common in individuals with skin of color, it is associated with greater morbidity and mortality, in part due to delayed diagnosis.⁷

Inadequate research, reporting, and instruction on dermatologic findings in patients with darker complexions further compound racial disparities in dermatology. A 2006 study of the representation of darker skin in major dermatology educational resources found that only 2% of teaching events at American Academy of Dermatology annual meetings focused on skin of color. Furthermore, the study determined that many common diseases in patients with dark skin, such as acne vulgaris and pityriasis rosea, were completely absent or limited in dermatology textbooks.⁸

Impact on the Black Patient Experience

Patients’ therapeutic relationship with their physician also is damaged by limitations in training in diverse skin color. A study that assessed Black patients seen in a skin of color clinic (SOCC) compared to Black patients seen in a non-SOCC found that non-SOCC patients reported a lower degree of respect, dignity, understanding, and trust compared to the patients seen in a SOCC. Black patients expressed specific concerns about non-SOCC dermatologists’ knowledge of abnormalities that present in darker skin and Black hair.³ These findings are compounded by reports suggesting that, independent of care, structural racism contributes to dermatologic disease severity by influencing patient education level, household income, and degree of exposure to harmful environmental irritants.⁶

Racial disparities continue to be seen in the makeup of the universe of dermatologists and skin researchers. As of 2016, only 3% of dermatologists were Black, making dermatology one of the least diverse medical specialties.² Increasing the diversity of the dermatology workforce is important to improve patient satisfaction and treatment, both for minority and nonminority patients. Compared to race-discordant medical visits, race-concordant visits were shown to have a higher rate of satisfaction and better shared decision-making.⁹ Also, minority physicians are more likely to practice health care in areas that are traditionally underserved and to care for patients who do not have health insurance, making their participation essential in addressing some of the baseline disparities Black patients face in securing quality dermatologic care.¹

Structural Racism in Medicine

Changing dermatology training to ensure improved treatment of Black patients requires not only increased attention to differences in disease presentation but also heightened awareness of underlying genetic, environmental, and structural factors that contribute to the disease course.⁶ For example, there is evidence suggesting that structural racism in the form of residential segregation, lower socioeconomic status, and lower educational attainment contribute to disease severity in conditions such as atopic dermatitis. There is additional evidence suggesting that White patients are more readily offered therapeutic options than Black patients. A study of racial disparities in psoriasis treatment found that Black patients with moderate to severe psoriasis were 70% less likely to receive treatment with a biologic than White patients, independent of socioeconomic factors, comorbidities, and insurance plans.¹⁰

Moving Forward

Although research continues to underscore racial disparities in dermatology, some leaders in the field are actively combating these problems. A recent study that looked at representations of dark skin images in medical educational resources found far greater representation of dark pigmented skin in web-based resources than in traditional printed texts. Specifically, the online resource VisualDx (https://www.visualdx.com/) features 28.5% dark skin images compared to 10.3% (on average) in printed dermatology books.¹¹ There also is increasing public awareness of these issues, with organizations such as the Skin of Color Society (http://skinofcolorsociety.org/) helping to promote interest in racial disparities in dermatology. Physicians also have created textbooks and social media accounts focused on dermatologic manifestations in skin of color.¹² The Instagram account Brown Skin Matters (@brownskinmatters) has created a publicly accessible online resource where physicians and patients can see and post dermatologic diseases in skin of color.⁵

Final Thoughts

It is critical that physicians be trained to identify skin and hair manifestations of disease and disorders in Black patients. Training can be improved by including more images of skin manifestations in dark skin, both in medical school curricula and in new editions of dermatology textbooks. Training also must teach students about hair in Black individuals and how to properly treat it as well as related conditions of the hair and scalp.¹³ More research also is needed to better understand how dermatologists can improve the patient experience for Black patients. Residency programs must work to increase diversity among dermatology trainees.

Lastly, dermatology education should increasingly be supplemented with newer, web-based resources that show dermatologic manifestations across the spectrum of skin tones. Dermatology training must be adapted to better account for diverse patient populations and increase its focus on the systems that produce baseline disparities in disease morbidity and mortality.

Although physicians commit themselves to providing equitable treatment to all patients, significant disparities remain in the dermatologic care of Black patients, who constitute 13% of the US population, which continues to grow increasingly diverse.¹ Despite these changes in the population, the literature demonstrates that dermatologic training does not adequately focus on unique presentations of cutaneous pathology in the Black population.^2,3 Accordingly, medical students lack proper training in how skin disorders manifest in people of color. Compounding the problem, only 3% of dermatologists are Black, creating a cultural barrier that can compromise care for Black patients.^2,4 Racial disparities in dermatology training can compromise treatment, patient satisfaction, and outcomes.³

Issues in Medical Education Training and Resources

Lack of diversity in the resources used for dermatology training in medical schools affects diagnosis and treatment, as skin manifestations such as hypersensitivity reactions, rashes, and cancer can appear differently on different skin tones.⁵ A study of medical students’ ability to diagnose common dermatologic pathologies found that when trainees were presented with photographs of dark skin, their accuracy in identifying urticaria, squamous cell carcinoma, and even atopic dermatitis was reduced, despite these diseases being more prevalent in children of African American ancestry.^4,6

Dermatologic diseases also can have different distributions in different races; for example, on non–sun-exposed sites, squamous cell carcinoma in Black patients occurs at 8.5 times the frequency of White patients.⁷ Failure to identify diseases accurately due to insufficient training can have grave consequences for patients. Although skin cancer is less common in individuals with skin of color, it is associated with greater morbidity and mortality, in part due to delayed diagnosis.⁷

Inadequate research, reporting, and instruction on dermatologic findings in patients with darker complexions further compound racial disparities in dermatology. A 2006 study of the representation of darker skin in major dermatology educational resources found that only 2% of teaching events at American Academy of Dermatology annual meetings focused on skin of color. Furthermore, the study determined that many common diseases in patients with dark skin, such as acne vulgaris and pityriasis rosea, were completely absent or limited in dermatology textbooks.⁸

Impact on the Black Patient Experience

Patients’ therapeutic relationship with their physician also is damaged by limitations in training in diverse skin color. A study that assessed Black patients seen in a skin of color clinic (SOCC) compared to Black patients seen in a non-SOCC found that non-SOCC patients reported a lower degree of respect, dignity, understanding, and trust compared to the patients seen in a SOCC. Black patients expressed specific concerns about non-SOCC dermatologists’ knowledge of abnormalities that present in darker skin and Black hair.³ These findings are compounded by reports suggesting that, independent of care, structural racism contributes to dermatologic disease severity by influencing patient education level, household income, and degree of exposure to harmful environmental irritants.⁶

Racial disparities continue to be seen in the makeup of the universe of dermatologists and skin researchers. As of 2016, only 3% of dermatologists were Black, making dermatology one of the least diverse medical specialties.² Increasing the diversity of the dermatology workforce is important to improve patient satisfaction and treatment, both for minority and nonminority patients. Compared to race-discordant medical visits, race-concordant visits were shown to have a higher rate of satisfaction and better shared decision-making.⁹ Also, minority physicians are more likely to practice health care in areas that are traditionally underserved and to care for patients who do not have health insurance, making their participation essential in addressing some of the baseline disparities Black patients face in securing quality dermatologic care.¹

Structural Racism in Medicine

Changing dermatology training to ensure improved treatment of Black patients requires not only increased attention to differences in disease presentation but also heightened awareness of underlying genetic, environmental, and structural factors that contribute to the disease course.⁶ For example, there is evidence suggesting that structural racism in the form of residential segregation, lower socioeconomic status, and lower educational attainment contribute to disease severity in conditions such as atopic dermatitis. There is additional evidence suggesting that White patients are more readily offered therapeutic options than Black patients. A study of racial disparities in psoriasis treatment found that Black patients with moderate to severe psoriasis were 70% less likely to receive treatment with a biologic than White patients, independent of socioeconomic factors, comorbidities, and insurance plans.¹⁰

Moving Forward

Although research continues to underscore racial disparities in dermatology, some leaders in the field are actively combating these problems. A recent study that looked at representations of dark skin images in medical educational resources found far greater representation of dark pigmented skin in web-based resources than in traditional printed texts. Specifically, the online resource VisualDx (https://www.visualdx.com/) features 28.5% dark skin images compared to 10.3% (on average) in printed dermatology books.¹¹ There also is increasing public awareness of these issues, with organizations such as the Skin of Color Society (http://skinofcolorsociety.org/) helping to promote interest in racial disparities in dermatology. Physicians also have created textbooks and social media accounts focused on dermatologic manifestations in skin of color.¹² The Instagram account Brown Skin Matters (@brownskinmatters) has created a publicly accessible online resource where physicians and patients can see and post dermatologic diseases in skin of color.⁵

Final Thoughts

It is critical that physicians be trained to identify skin and hair manifestations of disease and disorders in Black patients. Training can be improved by including more images of skin manifestations in dark skin, both in medical school curricula and in new editions of dermatology textbooks. Training also must teach students about hair in Black individuals and how to properly treat it as well as related conditions of the hair and scalp.¹³ More research also is needed to better understand how dermatologists can improve the patient experience for Black patients. Residency programs must work to increase diversity among dermatology trainees.

Lastly, dermatology education should increasingly be supplemented with newer, web-based resources that show dermatologic manifestations across the spectrum of skin tones. Dermatology training must be adapted to better account for diverse patient populations and increase its focus on the systems that produce baseline disparities in disease morbidity and mortality.

OBG Management takes the issues of systemic and structural racism incredibly seriously--not just by talking about it but by trying to highlight areas in medicine, particularly in obstetrics and gynecology, that are barriers to progress. In this new series for OBG Management, Board Member Barbara Levy, MD, faces the issues head-on, beginning with this peer-to-peer interview with Pierre Johnson, MD, ObGyn in Chicago, Illinois. Watch for future installments in upcoming issues of OBG Management.

Finding inspiration among life’s challenges

Barbara Levy, MD: I am fortunate to have met Pierre serendipitously at a training that we were both attending and was impressed by Dr. Johnson’s life story, his passion and commitment, and his dedication—not only to his personal career but also to raising up other young men of color by trying to break down barriers that face them. His life story highlights those areas of systemic and structural problems that all of us together need to address if we are going to make any progress.

Pierre Johnson, MD: Thank you, Barbara. A little about myself: I am a board-certified ObGyn, and I specialize in minimally invasive surgery. I was born on the South side of Chicago, experiencing gang violence, drugs, and substandard, underserved schools. Long story short, I had a very rough upbringing. I had a single mom and several different issues at home. I am the oldest of 5 siblings, and life was tough.

But I knew that I wanted to do something different with my life. I saw that there was a need in my community as far as health care was concerned, in particular women’s health and childbirth. I knew early on that I wanted to be an ObGyn, and the reason had a lot to do with The Cosby Show. It was the only example of a positive, successful Black man that I saw. No one graduated from college in my family. There weren’t any models of young Black excellence around me. Saying that I wanted to be a doctor planted a seed. I was 9 when my mom became pregnant with my first sibling, and it was fascinating to me. The physiology of pregnancy, and eventually childbirth, was extremely fascinating to me; it set me off on my journey to be an ObGyn.

As I got older, things didn’t get any easier. I went to high school in one of the toughest areas on the South side of Chicago. Gang violence, and violence in and of itself, were all around me, but I was able to stay focused. I went on to Xavier University in Louisiana.

Dr. Levy: There are some important things that I learned from your book and from talking to you at our first meeting. Your mom’s ObGyn, when she was pregnant with your next youngest sibling, was also a Black ObGyn. He took some time to take you under wing?

Dr. Johnson: He did. My mom’s ObGyn was a Black man. Other than The Cosby Show, that’s the only time I saw something like that. When I spoke to him, he really took the time to answer my questions and show me that he was like me; he wasn’t just a far-off mythical person, or something that I could not obtain.

Continue to: Seeing is believing when it comes to success...

Seeing is believing when it comes to success

Dr. Levy: Do you think it was important to have a role model who wasn’t a sports star?

Dr. Johnson: If you can’t see it, you can’t achieve it. He took his time to really talk to me, and it’s the little things for kids that go a long way in their life experience. I still have a relationship with him to this day. How he handled me as a kid made me realize that this is something that I could do. That was extremely important for me.

Dr. Levy: One of the structural things I think we need to point out is that the ability to see yourself as someone successful is critical. When we see 1,000 images a day and they are all White, and they are all so different from where we are that it gets incorporated into our sense of being. I think that’s really difficult for those of us of with privilege to understand what that privilege is.

Dr. Johnson: Absolutely, and I’ll even go further. In residency, 2 White females were my classmates, and both of their parents were doctors. They had grandparents who were doctors. My mom was addicted to drugs; my father was not around. They had been talking medicine since they were 5. You have to make things equitable, but in medicine it’s really not equitable. In medicine, what we don’t realize is that there is an importance for all aspects of someone’s upbringing and environment, and it’s not just what they can regurgitate on a standardized test. If a patient can’t relate to you and tell you what is wrong with them, how can you adequately treat them?

Dr. Levy: Even if they are trying to tell me, but I can’t hear it because I don’t have the language and I don’t have the background. There are really good data to show, in fact, that Black male physicians do a better job at engaging Black men to manage their hypertension.¹ When we look at the inequities in birth outcomes for women of color, indigenous women and Black women, there’s evidence that providers who come from a similar background do a better job.

Dr. Johnson: There was the study of Black infants that just came out about them dying at a 3-time higher rate in non-Black physicians’ hands.² These things need to be recognized. They need to be discussed, and they need to be identified as issues and then, realistically, we need to start talking about solutions, not get offended by what actual statistics are saying.

Foundational inequities in education

Dr. Levy: To address some of the barriers that you faced: I know that you went to a high school that was not geared toward pushing students into professional careers. Your colleagues, however, had educations that prepared them for the standardized tests and other things that they would face academically.

Dr. Johnson: People think I am kidding when I say it, but when I went into college, I didn’t know what a periodic table was. I saw it, but I had no idea what these things meant. I didn’t have any sciences or any AP classes in high school. I did well, but grades are smoke and mirrors. The true test of medicine comes with testing. From the MCATs to the boards, every step of the way there is a standardized test.

Knowledge is something that you can obtain, but test taking is a cultivated skill that happens from a very early age. Trying to teach an adult or someone in their late teens a skill that they should have learned as a kid is difficult. For me, I did not have that, so I had to program myself. I had to learn how to fundamentally take tests as an adult, where most people understand how to do that going into college and professional school.

Dr. Levy: I was impressed with your resilience. I think all of us as human beings, if we fail a test, we take it personally and think it’s about our lack of knowledge. One of the insights that you came to was that failure on those things was not that you didn’t study hard enough. In fact, you probably studied 4 times harder than most other people. You had the knowledge. Being able to get that knowledge into a standardized structured test score was the huge challenge for you.

Dr. Johnson: That’s it. I can remember taking the MCAT, and if you looked at the step 1 book, I could regurgitate to you everything on that page. However, it’s not a test about do you know it or not. It’s an understanding of the English language and how to break things down to make things fit into particular scenarios.

Continue to: A college experience focused on growth and exposure...

Dr. Levy: I was impressed by the distinction between your experience at Xavier University where there was a lot of support and guidance and help in your premed program, and what happened to you when you hit medical school.

Dr. Johnson: Xavier University in Louisiana is the number 1 institution in the country for getting minorities into professional school. They understand that they have kids that are brilliant but underprepared, and just have not had the background to actually tackle some of these tough curriculums. I always had good grades in school. But by not being challenged, I didn’t know what I didn’t really know. So now that I was seeing biology, chemistry for the first time, and trying to tackle it; there’s a failure point. I didn’t know how to take tests, and I didn’t know how to study properly. The harder I tried, the worse things got for me.

Xavier has seen that story a multitude of times. If I went to a bigger or predominantly White university, a counselor would have told me, “Well, medicine’s maybe not for you. You can’t handle a premed curriculum.” Instead, I said, “Listen, I’m studying. I’m doing all of these things, and I’m not hacking it.” And they broke it down: “Let’s get you into study groups with kids that have had these type of AP classes before. We’ll have you watch how they study,” and everything started to click. That facilitation of how to adjust to this curriculum was a godsend. It’s the only reason I’m here. I am a prime example of being brilliant enough to be able to do it, but needing the infrastructure and a system set up.

Dr. Levy: There’s a great book by Carol Dweck called Mindset that talks about education of young kids and putting them into silos so early in life; the brilliant kids go into the AP courses and the rest are labeled as inadequate. It’s assumed in a fixed mindset based on their heredity and IQ, and not based on the fact that they have not been exposed to the right things.

Xavier was growing you into the man who could, in fact, do all of those things. I think that is one of the systemic and structural issues that we have—that fixed mindset that frames a kid who is not succeeding as therefore unable to succeed, as opposed to framing that child as not having the correct tools.

New tribulations of medical school

Dr. Johnson: Absolutely. I think what Xavier did for me is to at least let me understand what I needed to do, how to comprehend and retain information, which I never had been exposed to before. Those years were very important to establishing a foundation. When going to medical school, it was like, “There’s no more excuses. What could be the problem now?” Well, now let’s talk about taking tests—a whole different skill. Xavier focused on getting me to understand how to structure my thought process and knowledge base. In medical school I had to apply those skills (because if you can’t apply them, there’s no fit).

My second through fourth year of medical school, I was the only African-American kid in my class. I was spending 20-hour days sometimes just studying, trying to overcompensate by knowing as much as I possibly could and thinking that would propel me from the test-taking standpoint. Even though I didn’t have a lot of classmates in medical school that looked like me, I did have mentors that looked similarly, who really saw potential in me. Dr. Frederick Horvath, a nephrologist in Peoria said, “What are you doing? I want you to get out of these books, and let’s go out to lunch.”

He ended up buying me some instrumental books, really talked to me, listening to my background and understanding how driven I was as a person. He took me under his wing for the rest of medical school and said, “This is how you navigate through these spaces. Yes, you need to have a fund of knowledge to be able to take these tests, but you need to start understanding how to apply it to these questions.” I’m forever grateful to Dr. Horvath for doing that because it was a point in time where I was lost and struggling.

Continue to: Hitting a stride but facing racism head-on...

Dr. Levy: You talk about the systemic and pervasive racism that was on the wards when you hit them in fourth year. If you don’t mind sharing just a little bit of that, it would help people reading this to have a better understanding of the kinds of barriers that are out there.

Dr. Johnson: Even when I talk about it today, it bothers me.

I went to medical school in Peoria, Illinois, not far from the home of the Ku Klux Klan. At that time, once you got out of Chicago it was a very brutal place, with systemic racism throughout. I was a young Black kid going through a process that not many young Black kids from the South side of Chicago go through, and you had people who had never seen anyone like me. When I was going through my clinical rotations, I knew what I was up against. I was dressed “to the T” every day, arriving early, leaving late, trying to answer questions. I would look at the evaluations, and they would be disparaging. I would look at my counterparts, how their evaluations were, and how people would respond to them, and it would be completely different.

Surgery was the part of ObGyn that I really grew to love more than anything, even more than obstetrics. When general surgery came, I wanted to take it very seriously and learn as much as I possibly could. From the beginning, I knew there was a problem because the chief resident, an older White man, wouldn’t look me in the eye or talk to me. He would make disparaging remarks. The thing that stuck out in my mind the most was when I was in the operating room transporting patients, just like a medical student did, and he came up behind me and said, “You know, Pierre, this is where a small mind and a strong back come into play.” For me, it took me to a place where I had to corral my emotions and thoughts because I just wanted to lash out and just tell him how racist and horrible that was for him to say that to me. I explained this to the powers that be, the director of the department, and they basically blew it off to the side.

When it came down to the end of the evaluation period, I passed with flying colors. But they gave me an incomplete because of that chief resident and his remarks on my evaluations. He had 3 pages of report about me as a person and as a student. He said that he had difficulty in expressing his opinions about me because of possible cultural biases that he may have had. He put “cultural biases” in an evaluation, and they looked at that and said that was enough for me to have to remediate my time. I was required to do an extra month in Pontiac, Illinois, which is even more rural than Peoria, because of a racist person that did not give me a fair opportunity because I was Black.

Like everything else in life, it was a learning experience. It’s why I fight so hard today. It’s why I’m so passionate about equity, not only in medicine but also in all aspects of society. It shows why we have police brutality and Black men dying in the streets. It shows how this happens because there are cultural and implicit biases that play out in every part of life, and we are not honest about it. Until we are honest about it and until we say that this is happening and there is something that needs to be done to address it, it’s going to continue to happen. That is my fight.

Exposing the unspoken power struggle

Dr. Levy: I couldn’t agree more. Attributing things like that to the individual, where you talk about a White man in power and a power structure that didn’t literally physically beat you but did beat you into submission. You talk about how to succeed in medical school, and how you had to suck it up and submit to something that was incredibly unfair. You understood, you were old enough, mature enough, to understand that if you fought back, you were going to lose. The only opportunity you had was to submit to that inequity and push forward.

Dr. Johnson: When I did try to fight, the chair of the department told me that either I accept the consequences or I would not graduate from medical school and be forced to do another year. That struck a chord with me. I think that happens a lot in our society, and it needs to be exposed.

Past experiences reflected in today’s society

Dr. Levy: Can you talk about what you faced in your ObGyn residency in terms of the systemic pushback, people not taking your orders, people questioning you. I know that I have heard that a great deal, and I experienced that myself as a woman.

Dr. Johnson: We look at the things that are happening now, everything from George Floyd’s murder to Colin Kaepernick taking a knee. These things are 10 years past when I first started residency. The year before I started residency, there was a noose hanging on the capitol lawn of Springfield, Illinois’ capital city. There’s systemic racism and hatred there. When I first started on the wards of my first year of ObGyn, again, I was the very first Black resident of my program’s history. Nobody could relate to me.

I went from a year-long general surgery internship at Washington Hospital Center in Washington, DC, to ObGyn residency. In the first 2 months, there were complaints of, “He’s not answering his pages. He’s not being prompt.” I went to my program director and said, “Listen, I have never had one complaint like this. There’s a problem here. And there’s a problem when I’m on the floor: When trying to give orders to nurses, they’re not taking them. I had to tell a couple of nurses, ‘I’m Dr. Johnson. Don’t call me by my first name, especially not in front of patients.’”

My director was just not hearing me, because the entire scenario was something they had never been exposed to. Systemic racism is real, and unless you experience it, it’s very difficult to accept that it is happening. But biases happen when you are not cognizant. People are used to things a certain way. Things play out in the media that make your mind think a certain way, and you don’t even realize it. You may not even want to be that way.

Continue to: Unconscious bias is a barrier to ensuring equity...

Dr. Levy: One very important point you just made is that we as the system need to be able to recognize those unconscious things, the language that we use, the disparaging remarks, the things that put people down, as well as the things that keep people out of promotion.

There are some interesting data about both race and gender and the language that we use when we write recommendations for people, that we do things unconsciously. The big message to all of us at the end is to open our minds to where those things can occur. For myself, professionally, I keep a list of words that I use when I write recommendations. I measure myself to ensure that I am using the same language for men and women, for Black and White. I think we need to overcome the system and the structure to create real equity—not equality but equity.

It begins with being real about the issues

Dr. Johnson: It’s a bigger problem than the existence of bias and racism. I think these are systemic issues that have been cultivated over centuries that have never been addressed. The true issue is that we deny that these are problems and refuse to talk about it because it makes us uncomfortable. To truly make things more equitable, we have to push our levels of comfort to be able to talk about things in a healthy manner, be open and transparent, and to start to understand how we are thinking about certain things. When you can see it, you can start to implement changes and start to change mentalities and thought processes.

For me, people say, “You don’t look like a doctor.” I get that all the time—because I have tattoos and earrings. I wear my hair in a mohawk. The image of what success looks like has been manifested through our media and culture, and it has imprinted on our minds as to how things are supposed to be. If someone doesn’t fit those molds, we start to shun them out, or we start to exhibit biases against those things. What I am trying to do is change that thought process of what a successful or a professional person looks like. It doesn’t have a look. It is not a White or Black thing. It’s an intellect, a mindset, a way of living. You have to treat every person as an individual and take all the biases out of it and understand where they are coming from and what they have to offer to the profession.

Dr. Levy: I personally was so impressed by you when I met you. I was impressed by the tattoos and the earrings, and my initial response to them was exactly that biased, “Oh, who is this person?” I checked that at the door, listened to you, and was really impressed at your surgical skill, your knowledge, your background. I am really grateful that you have been willing to spend the time to share that with everyone.

Dr. Johnson: Thank you for this discussion.

To watch the full interview between Drs. Levy and Johnson, visit: https://www.mdedge.com/obgyn/article/228507/facing-systemic-racism-health-care-inequities-medical-education. ●

OBG Management takes the issues of systemic and structural racism incredibly seriously--not just by talking about it but by trying to highlight areas in medicine, particularly in obstetrics and gynecology, that are barriers to progress. In this new series for OBG Management, Board Member Barbara Levy, MD, faces the issues head-on, beginning with this peer-to-peer interview with Pierre Johnson, MD, ObGyn in Chicago, Illinois. Watch for future installments in upcoming issues of OBG Management.

Finding inspiration among life’s challenges

Barbara Levy, MD: I am fortunate to have met Pierre serendipitously at a training that we were both attending and was impressed by Dr. Johnson’s life story, his passion and commitment, and his dedication—not only to his personal career but also to raising up other young men of color by trying to break down barriers that face them. His life story highlights those areas of systemic and structural problems that all of us together need to address if we are going to make any progress.

Pierre Johnson, MD: Thank you, Barbara. A little about myself: I am a board-certified ObGyn, and I specialize in minimally invasive surgery. I was born on the South side of Chicago, experiencing gang violence, drugs, and substandard, underserved schools. Long story short, I had a very rough upbringing. I had a single mom and several different issues at home. I am the oldest of 5 siblings, and life was tough.

But I knew that I wanted to do something different with my life. I saw that there was a need in my community as far as health care was concerned, in particular women’s health and childbirth. I knew early on that I wanted to be an ObGyn, and the reason had a lot to do with The Cosby Show. It was the only example of a positive, successful Black man that I saw. No one graduated from college in my family. There weren’t any models of young Black excellence around me. Saying that I wanted to be a doctor planted a seed. I was 9 when my mom became pregnant with my first sibling, and it was fascinating to me. The physiology of pregnancy, and eventually childbirth, was extremely fascinating to me; it set me off on my journey to be an ObGyn.

As I got older, things didn’t get any easier. I went to high school in one of the toughest areas on the South side of Chicago. Gang violence, and violence in and of itself, were all around me, but I was able to stay focused. I went on to Xavier University in Louisiana.

Dr. Levy: There are some important things that I learned from your book and from talking to you at our first meeting. Your mom’s ObGyn, when she was pregnant with your next youngest sibling, was also a Black ObGyn. He took some time to take you under wing?

Dr. Johnson: He did. My mom’s ObGyn was a Black man. Other than The Cosby Show, that’s the only time I saw something like that. When I spoke to him, he really took the time to answer my questions and show me that he was like me; he wasn’t just a far-off mythical person, or something that I could not obtain.

Continue to: Seeing is believing when it comes to success...

Seeing is believing when it comes to success

Dr. Levy: Do you think it was important to have a role model who wasn’t a sports star?

Dr. Johnson: If you can’t see it, you can’t achieve it. He took his time to really talk to me, and it’s the little things for kids that go a long way in their life experience. I still have a relationship with him to this day. How he handled me as a kid made me realize that this is something that I could do. That was extremely important for me.

Dr. Levy: One of the structural things I think we need to point out is that the ability to see yourself as someone successful is critical. When we see 1,000 images a day and they are all White, and they are all so different from where we are that it gets incorporated into our sense of being. I think that’s really difficult for those of us of with privilege to understand what that privilege is.

Dr. Johnson: Absolutely, and I’ll even go further. In residency, 2 White females were my classmates, and both of their parents were doctors. They had grandparents who were doctors. My mom was addicted to drugs; my father was not around. They had been talking medicine since they were 5. You have to make things equitable, but in medicine it’s really not equitable. In medicine, what we don’t realize is that there is an importance for all aspects of someone’s upbringing and environment, and it’s not just what they can regurgitate on a standardized test. If a patient can’t relate to you and tell you what is wrong with them, how can you adequately treat them?

Dr. Levy: Even if they are trying to tell me, but I can’t hear it because I don’t have the language and I don’t have the background. There are really good data to show, in fact, that Black male physicians do a better job at engaging Black men to manage their hypertension.¹ When we look at the inequities in birth outcomes for women of color, indigenous women and Black women, there’s evidence that providers who come from a similar background do a better job.

Dr. Johnson: There was the study of Black infants that just came out about them dying at a 3-time higher rate in non-Black physicians’ hands.² These things need to be recognized. They need to be discussed, and they need to be identified as issues and then, realistically, we need to start talking about solutions, not get offended by what actual statistics are saying.

Foundational inequities in education

Dr. Levy: To address some of the barriers that you faced: I know that you went to a high school that was not geared toward pushing students into professional careers. Your colleagues, however, had educations that prepared them for the standardized tests and other things that they would face academically.

Dr. Johnson: People think I am kidding when I say it, but when I went into college, I didn’t know what a periodic table was. I saw it, but I had no idea what these things meant. I didn’t have any sciences or any AP classes in high school. I did well, but grades are smoke and mirrors. The true test of medicine comes with testing. From the MCATs to the boards, every step of the way there is a standardized test.

Knowledge is something that you can obtain, but test taking is a cultivated skill that happens from a very early age. Trying to teach an adult or someone in their late teens a skill that they should have learned as a kid is difficult. For me, I did not have that, so I had to program myself. I had to learn how to fundamentally take tests as an adult, where most people understand how to do that going into college and professional school.

Dr. Levy: I was impressed with your resilience. I think all of us as human beings, if we fail a test, we take it personally and think it’s about our lack of knowledge. One of the insights that you came to was that failure on those things was not that you didn’t study hard enough. In fact, you probably studied 4 times harder than most other people. You had the knowledge. Being able to get that knowledge into a standardized structured test score was the huge challenge for you.

Dr. Johnson: That’s it. I can remember taking the MCAT, and if you looked at the step 1 book, I could regurgitate to you everything on that page. However, it’s not a test about do you know it or not. It’s an understanding of the English language and how to break things down to make things fit into particular scenarios.

Continue to: A college experience focused on growth and exposure...

Dr. Levy: I was impressed by the distinction between your experience at Xavier University where there was a lot of support and guidance and help in your premed program, and what happened to you when you hit medical school.

Dr. Johnson: Xavier University in Louisiana is the number 1 institution in the country for getting minorities into professional school. They understand that they have kids that are brilliant but underprepared, and just have not had the background to actually tackle some of these tough curriculums. I always had good grades in school. But by not being challenged, I didn’t know what I didn’t really know. So now that I was seeing biology, chemistry for the first time, and trying to tackle it; there’s a failure point. I didn’t know how to take tests, and I didn’t know how to study properly. The harder I tried, the worse things got for me.

Xavier has seen that story a multitude of times. If I went to a bigger or predominantly White university, a counselor would have told me, “Well, medicine’s maybe not for you. You can’t handle a premed curriculum.” Instead, I said, “Listen, I’m studying. I’m doing all of these things, and I’m not hacking it.” And they broke it down: “Let’s get you into study groups with kids that have had these type of AP classes before. We’ll have you watch how they study,” and everything started to click. That facilitation of how to adjust to this curriculum was a godsend. It’s the only reason I’m here. I am a prime example of being brilliant enough to be able to do it, but needing the infrastructure and a system set up.

Dr. Levy: There’s a great book by Carol Dweck called Mindset that talks about education of young kids and putting them into silos so early in life; the brilliant kids go into the AP courses and the rest are labeled as inadequate. It’s assumed in a fixed mindset based on their heredity and IQ, and not based on the fact that they have not been exposed to the right things.

Xavier was growing you into the man who could, in fact, do all of those things. I think that is one of the systemic and structural issues that we have—that fixed mindset that frames a kid who is not succeeding as therefore unable to succeed, as opposed to framing that child as not having the correct tools.

New tribulations of medical school

Dr. Johnson: Absolutely. I think what Xavier did for me is to at least let me understand what I needed to do, how to comprehend and retain information, which I never had been exposed to before. Those years were very important to establishing a foundation. When going to medical school, it was like, “There’s no more excuses. What could be the problem now?” Well, now let’s talk about taking tests—a whole different skill. Xavier focused on getting me to understand how to structure my thought process and knowledge base. In medical school I had to apply those skills (because if you can’t apply them, there’s no fit).

My second through fourth year of medical school, I was the only African-American kid in my class. I was spending 20-hour days sometimes just studying, trying to overcompensate by knowing as much as I possibly could and thinking that would propel me from the test-taking standpoint. Even though I didn’t have a lot of classmates in medical school that looked like me, I did have mentors that looked similarly, who really saw potential in me. Dr. Frederick Horvath, a nephrologist in Peoria said, “What are you doing? I want you to get out of these books, and let’s go out to lunch.”

He ended up buying me some instrumental books, really talked to me, listening to my background and understanding how driven I was as a person. He took me under his wing for the rest of medical school and said, “This is how you navigate through these spaces. Yes, you need to have a fund of knowledge to be able to take these tests, but you need to start understanding how to apply it to these questions.” I’m forever grateful to Dr. Horvath for doing that because it was a point in time where I was lost and struggling.

Continue to: Hitting a stride but facing racism head-on...

Dr. Levy: You talk about the systemic and pervasive racism that was on the wards when you hit them in fourth year. If you don’t mind sharing just a little bit of that, it would help people reading this to have a better understanding of the kinds of barriers that are out there.

Dr. Johnson: Even when I talk about it today, it bothers me.

I went to medical school in Peoria, Illinois, not far from the home of the Ku Klux Klan. At that time, once you got out of Chicago it was a very brutal place, with systemic racism throughout. I was a young Black kid going through a process that not many young Black kids from the South side of Chicago go through, and you had people who had never seen anyone like me. When I was going through my clinical rotations, I knew what I was up against. I was dressed “to the T” every day, arriving early, leaving late, trying to answer questions. I would look at the evaluations, and they would be disparaging. I would look at my counterparts, how their evaluations were, and how people would respond to them, and it would be completely different.

Surgery was the part of ObGyn that I really grew to love more than anything, even more than obstetrics. When general surgery came, I wanted to take it very seriously and learn as much as I possibly could. From the beginning, I knew there was a problem because the chief resident, an older White man, wouldn’t look me in the eye or talk to me. He would make disparaging remarks. The thing that stuck out in my mind the most was when I was in the operating room transporting patients, just like a medical student did, and he came up behind me and said, “You know, Pierre, this is where a small mind and a strong back come into play.” For me, it took me to a place where I had to corral my emotions and thoughts because I just wanted to lash out and just tell him how racist and horrible that was for him to say that to me. I explained this to the powers that be, the director of the department, and they basically blew it off to the side.

When it came down to the end of the evaluation period, I passed with flying colors. But they gave me an incomplete because of that chief resident and his remarks on my evaluations. He had 3 pages of report about me as a person and as a student. He said that he had difficulty in expressing his opinions about me because of possible cultural biases that he may have had. He put “cultural biases” in an evaluation, and they looked at that and said that was enough for me to have to remediate my time. I was required to do an extra month in Pontiac, Illinois, which is even more rural than Peoria, because of a racist person that did not give me a fair opportunity because I was Black.

Like everything else in life, it was a learning experience. It’s why I fight so hard today. It’s why I’m so passionate about equity, not only in medicine but also in all aspects of society. It shows why we have police brutality and Black men dying in the streets. It shows how this happens because there are cultural and implicit biases that play out in every part of life, and we are not honest about it. Until we are honest about it and until we say that this is happening and there is something that needs to be done to address it, it’s going to continue to happen. That is my fight.

Exposing the unspoken power struggle

Dr. Levy: I couldn’t agree more. Attributing things like that to the individual, where you talk about a White man in power and a power structure that didn’t literally physically beat you but did beat you into submission. You talk about how to succeed in medical school, and how you had to suck it up and submit to something that was incredibly unfair. You understood, you were old enough, mature enough, to understand that if you fought back, you were going to lose. The only opportunity you had was to submit to that inequity and push forward.

Dr. Johnson: When I did try to fight, the chair of the department told me that either I accept the consequences or I would not graduate from medical school and be forced to do another year. That struck a chord with me. I think that happens a lot in our society, and it needs to be exposed.

Past experiences reflected in today’s society

Dr. Levy: Can you talk about what you faced in your ObGyn residency in terms of the systemic pushback, people not taking your orders, people questioning you. I know that I have heard that a great deal, and I experienced that myself as a woman.

Dr. Johnson: We look at the things that are happening now, everything from George Floyd’s murder to Colin Kaepernick taking a knee. These things are 10 years past when I first started residency. The year before I started residency, there was a noose hanging on the capitol lawn of Springfield, Illinois’ capital city. There’s systemic racism and hatred there. When I first started on the wards of my first year of ObGyn, again, I was the very first Black resident of my program’s history. Nobody could relate to me.

I went from a year-long general surgery internship at Washington Hospital Center in Washington, DC, to ObGyn residency. In the first 2 months, there were complaints of, “He’s not answering his pages. He’s not being prompt.” I went to my program director and said, “Listen, I have never had one complaint like this. There’s a problem here. And there’s a problem when I’m on the floor: When trying to give orders to nurses, they’re not taking them. I had to tell a couple of nurses, ‘I’m Dr. Johnson. Don’t call me by my first name, especially not in front of patients.’”

My director was just not hearing me, because the entire scenario was something they had never been exposed to. Systemic racism is real, and unless you experience it, it’s very difficult to accept that it is happening. But biases happen when you are not cognizant. People are used to things a certain way. Things play out in the media that make your mind think a certain way, and you don’t even realize it. You may not even want to be that way.

Continue to: Unconscious bias is a barrier to ensuring equity...

Dr. Levy: One very important point you just made is that we as the system need to be able to recognize those unconscious things, the language that we use, the disparaging remarks, the things that put people down, as well as the things that keep people out of promotion.

There are some interesting data about both race and gender and the language that we use when we write recommendations for people, that we do things unconsciously. The big message to all of us at the end is to open our minds to where those things can occur. For myself, professionally, I keep a list of words that I use when I write recommendations. I measure myself to ensure that I am using the same language for men and women, for Black and White. I think we need to overcome the system and the structure to create real equity—not equality but equity.

It begins with being real about the issues

Dr. Johnson: It’s a bigger problem than the existence of bias and racism. I think these are systemic issues that have been cultivated over centuries that have never been addressed. The true issue is that we deny that these are problems and refuse to talk about it because it makes us uncomfortable. To truly make things more equitable, we have to push our levels of comfort to be able to talk about things in a healthy manner, be open and transparent, and to start to understand how we are thinking about certain things. When you can see it, you can start to implement changes and start to change mentalities and thought processes.

For me, people say, “You don’t look like a doctor.” I get that all the time—because I have tattoos and earrings. I wear my hair in a mohawk. The image of what success looks like has been manifested through our media and culture, and it has imprinted on our minds as to how things are supposed to be. If someone doesn’t fit those molds, we start to shun them out, or we start to exhibit biases against those things. What I am trying to do is change that thought process of what a successful or a professional person looks like. It doesn’t have a look. It is not a White or Black thing. It’s an intellect, a mindset, a way of living. You have to treat every person as an individual and take all the biases out of it and understand where they are coming from and what they have to offer to the profession.

Dr. Levy: I personally was so impressed by you when I met you. I was impressed by the tattoos and the earrings, and my initial response to them was exactly that biased, “Oh, who is this person?” I checked that at the door, listened to you, and was really impressed at your surgical skill, your knowledge, your background. I am really grateful that you have been willing to spend the time to share that with everyone.

Dr. Johnson: Thank you for this discussion.

To watch the full interview between Drs. Levy and Johnson, visit: https://www.mdedge.com/obgyn/article/228507/facing-systemic-racism-health-care-inequities-medical-education. ●

OBG Management takes the issues of systemic and structural racism incredibly seriously--not just by talking about it but by trying to highlight areas in medicine, particularly in obstetrics and gynecology, that are barriers to progress. In this new series for OBG Management, Board Member Barbara Levy, MD, faces the issues head-on, beginning with this peer-to-peer interview with Pierre Johnson, MD, ObGyn in Chicago, Illinois. Watch for future installments in upcoming issues of OBG Management.

Finding inspiration among life’s challenges

Barbara Levy, MD: I am fortunate to have met Pierre serendipitously at a training that we were both attending and was impressed by Dr. Johnson’s life story, his passion and commitment, and his dedication—not only to his personal career but also to raising up other young men of color by trying to break down barriers that face them. His life story highlights those areas of systemic and structural problems that all of us together need to address if we are going to make any progress.

Pierre Johnson, MD: Thank you, Barbara. A little about myself: I am a board-certified ObGyn, and I specialize in minimally invasive surgery. I was born on the South side of Chicago, experiencing gang violence, drugs, and substandard, underserved schools. Long story short, I had a very rough upbringing. I had a single mom and several different issues at home. I am the oldest of 5 siblings, and life was tough.

But I knew that I wanted to do something different with my life. I saw that there was a need in my community as far as health care was concerned, in particular women’s health and childbirth. I knew early on that I wanted to be an ObGyn, and the reason had a lot to do with The Cosby Show. It was the only example of a positive, successful Black man that I saw. No one graduated from college in my family. There weren’t any models of young Black excellence around me. Saying that I wanted to be a doctor planted a seed. I was 9 when my mom became pregnant with my first sibling, and it was fascinating to me. The physiology of pregnancy, and eventually childbirth, was extremely fascinating to me; it set me off on my journey to be an ObGyn.

As I got older, things didn’t get any easier. I went to high school in one of the toughest areas on the South side of Chicago. Gang violence, and violence in and of itself, were all around me, but I was able to stay focused. I went on to Xavier University in Louisiana.

Dr. Levy: There are some important things that I learned from your book and from talking to you at our first meeting. Your mom’s ObGyn, when she was pregnant with your next youngest sibling, was also a Black ObGyn. He took some time to take you under wing?

Dr. Johnson: He did. My mom’s ObGyn was a Black man. Other than The Cosby Show, that’s the only time I saw something like that. When I spoke to him, he really took the time to answer my questions and show me that he was like me; he wasn’t just a far-off mythical person, or something that I could not obtain.

Continue to: Seeing is believing when it comes to success...

Seeing is believing when it comes to success

Dr. Levy: Do you think it was important to have a role model who wasn’t a sports star?

Dr. Johnson: If you can’t see it, you can’t achieve it. He took his time to really talk to me, and it’s the little things for kids that go a long way in their life experience. I still have a relationship with him to this day. How he handled me as a kid made me realize that this is something that I could do. That was extremely important for me.

Dr. Levy: One of the structural things I think we need to point out is that the ability to see yourself as someone successful is critical. When we see 1,000 images a day and they are all White, and they are all so different from where we are that it gets incorporated into our sense of being. I think that’s really difficult for those of us of with privilege to understand what that privilege is.

Dr. Johnson: Absolutely, and I’ll even go further. In residency, 2 White females were my classmates, and both of their parents were doctors. They had grandparents who were doctors. My mom was addicted to drugs; my father was not around. They had been talking medicine since they were 5. You have to make things equitable, but in medicine it’s really not equitable. In medicine, what we don’t realize is that there is an importance for all aspects of someone’s upbringing and environment, and it’s not just what they can regurgitate on a standardized test. If a patient can’t relate to you and tell you what is wrong with them, how can you adequately treat them?

Dr. Levy: Even if they are trying to tell me, but I can’t hear it because I don’t have the language and I don’t have the background. There are really good data to show, in fact, that Black male physicians do a better job at engaging Black men to manage their hypertension.¹ When we look at the inequities in birth outcomes for women of color, indigenous women and Black women, there’s evidence that providers who come from a similar background do a better job.

Dr. Johnson: There was the study of Black infants that just came out about them dying at a 3-time higher rate in non-Black physicians’ hands.² These things need to be recognized. They need to be discussed, and they need to be identified as issues and then, realistically, we need to start talking about solutions, not get offended by what actual statistics are saying.

Foundational inequities in education

Dr. Levy: To address some of the barriers that you faced: I know that you went to a high school that was not geared toward pushing students into professional careers. Your colleagues, however, had educations that prepared them for the standardized tests and other things that they would face academically.

Dr. Johnson: People think I am kidding when I say it, but when I went into college, I didn’t know what a periodic table was. I saw it, but I had no idea what these things meant. I didn’t have any sciences or any AP classes in high school. I did well, but grades are smoke and mirrors. The true test of medicine comes with testing. From the MCATs to the boards, every step of the way there is a standardized test.

Knowledge is something that you can obtain, but test taking is a cultivated skill that happens from a very early age. Trying to teach an adult or someone in their late teens a skill that they should have learned as a kid is difficult. For me, I did not have that, so I had to program myself. I had to learn how to fundamentally take tests as an adult, where most people understand how to do that going into college and professional school.

Dr. Levy: I was impressed with your resilience. I think all of us as human beings, if we fail a test, we take it personally and think it’s about our lack of knowledge. One of the insights that you came to was that failure on those things was not that you didn’t study hard enough. In fact, you probably studied 4 times harder than most other people. You had the knowledge. Being able to get that knowledge into a standardized structured test score was the huge challenge for you.

Dr. Johnson: That’s it. I can remember taking the MCAT, and if you looked at the step 1 book, I could regurgitate to you everything on that page. However, it’s not a test about do you know it or not. It’s an understanding of the English language and how to break things down to make things fit into particular scenarios.

Continue to: A college experience focused on growth and exposure...

Dr. Levy: I was impressed by the distinction between your experience at Xavier University where there was a lot of support and guidance and help in your premed program, and what happened to you when you hit medical school.

Dr. Johnson: Xavier University in Louisiana is the number 1 institution in the country for getting minorities into professional school. They understand that they have kids that are brilliant but underprepared, and just have not had the background to actually tackle some of these tough curriculums. I always had good grades in school. But by not being challenged, I didn’t know what I didn’t really know. So now that I was seeing biology, chemistry for the first time, and trying to tackle it; there’s a failure point. I didn’t know how to take tests, and I didn’t know how to study properly. The harder I tried, the worse things got for me.

Xavier has seen that story a multitude of times. If I went to a bigger or predominantly White university, a counselor would have told me, “Well, medicine’s maybe not for you. You can’t handle a premed curriculum.” Instead, I said, “Listen, I’m studying. I’m doing all of these things, and I’m not hacking it.” And they broke it down: “Let’s get you into study groups with kids that have had these type of AP classes before. We’ll have you watch how they study,” and everything started to click. That facilitation of how to adjust to this curriculum was a godsend. It’s the only reason I’m here. I am a prime example of being brilliant enough to be able to do it, but needing the infrastructure and a system set up.

Dr. Levy: There’s a great book by Carol Dweck called Mindset that talks about education of young kids and putting them into silos so early in life; the brilliant kids go into the AP courses and the rest are labeled as inadequate. It’s assumed in a fixed mindset based on their heredity and IQ, and not based on the fact that they have not been exposed to the right things.

Xavier was growing you into the man who could, in fact, do all of those things. I think that is one of the systemic and structural issues that we have—that fixed mindset that frames a kid who is not succeeding as therefore unable to succeed, as opposed to framing that child as not having the correct tools.

New tribulations of medical school

Dr. Johnson: Absolutely. I think what Xavier did for me is to at least let me understand what I needed to do, how to comprehend and retain information, which I never had been exposed to before. Those years were very important to establishing a foundation. When going to medical school, it was like, “There’s no more excuses. What could be the problem now?” Well, now let’s talk about taking tests—a whole different skill. Xavier focused on getting me to understand how to structure my thought process and knowledge base. In medical school I had to apply those skills (because if you can’t apply them, there’s no fit).

My second through fourth year of medical school, I was the only African-American kid in my class. I was spending 20-hour days sometimes just studying, trying to overcompensate by knowing as much as I possibly could and thinking that would propel me from the test-taking standpoint. Even though I didn’t have a lot of classmates in medical school that looked like me, I did have mentors that looked similarly, who really saw potential in me. Dr. Frederick Horvath, a nephrologist in Peoria said, “What are you doing? I want you to get out of these books, and let’s go out to lunch.”

He ended up buying me some instrumental books, really talked to me, listening to my background and understanding how driven I was as a person. He took me under his wing for the rest of medical school and said, “This is how you navigate through these spaces. Yes, you need to have a fund of knowledge to be able to take these tests, but you need to start understanding how to apply it to these questions.” I’m forever grateful to Dr. Horvath for doing that because it was a point in time where I was lost and struggling.

Continue to: Hitting a stride but facing racism head-on...

Dr. Levy: You talk about the systemic and pervasive racism that was on the wards when you hit them in fourth year. If you don’t mind sharing just a little bit of that, it would help people reading this to have a better understanding of the kinds of barriers that are out there.

Dr. Johnson: Even when I talk about it today, it bothers me.

I went to medical school in Peoria, Illinois, not far from the home of the Ku Klux Klan. At that time, once you got out of Chicago it was a very brutal place, with systemic racism throughout. I was a young Black kid going through a process that not many young Black kids from the South side of Chicago go through, and you had people who had never seen anyone like me. When I was going through my clinical rotations, I knew what I was up against. I was dressed “to the T” every day, arriving early, leaving late, trying to answer questions. I would look at the evaluations, and they would be disparaging. I would look at my counterparts, how their evaluations were, and how people would respond to them, and it would be completely different.

Surgery was the part of ObGyn that I really grew to love more than anything, even more than obstetrics. When general surgery came, I wanted to take it very seriously and learn as much as I possibly could. From the beginning, I knew there was a problem because the chief resident, an older White man, wouldn’t look me in the eye or talk to me. He would make disparaging remarks. The thing that stuck out in my mind the most was when I was in the operating room transporting patients, just like a medical student did, and he came up behind me and said, “You know, Pierre, this is where a small mind and a strong back come into play.” For me, it took me to a place where I had to corral my emotions and thoughts because I just wanted to lash out and just tell him how racist and horrible that was for him to say that to me. I explained this to the powers that be, the director of the department, and they basically blew it off to the side.

When it came down to the end of the evaluation period, I passed with flying colors. But they gave me an incomplete because of that chief resident and his remarks on my evaluations. He had 3 pages of report about me as a person and as a student. He said that he had difficulty in expressing his opinions about me because of possible cultural biases that he may have had. He put “cultural biases” in an evaluation, and they looked at that and said that was enough for me to have to remediate my time. I was required to do an extra month in Pontiac, Illinois, which is even more rural than Peoria, because of a racist person that did not give me a fair opportunity because I was Black.

Like everything else in life, it was a learning experience. It’s why I fight so hard today. It’s why I’m so passionate about equity, not only in medicine but also in all aspects of society. It shows why we have police brutality and Black men dying in the streets. It shows how this happens because there are cultural and implicit biases that play out in every part of life, and we are not honest about it. Until we are honest about it and until we say that this is happening and there is something that needs to be done to address it, it’s going to continue to happen. That is my fight.

Exposing the unspoken power struggle

Dr. Levy: I couldn’t agree more. Attributing things like that to the individual, where you talk about a White man in power and a power structure that didn’t literally physically beat you but did beat you into submission. You talk about how to succeed in medical school, and how you had to suck it up and submit to something that was incredibly unfair. You understood, you were old enough, mature enough, to understand that if you fought back, you were going to lose. The only opportunity you had was to submit to that inequity and push forward.

Dr. Johnson: When I did try to fight, the chair of the department told me that either I accept the consequences or I would not graduate from medical school and be forced to do another year. That struck a chord with me. I think that happens a lot in our society, and it needs to be exposed.

Past experiences reflected in today’s society

Dr. Levy: Can you talk about what you faced in your ObGyn residency in terms of the systemic pushback, people not taking your orders, people questioning you. I know that I have heard that a great deal, and I experienced that myself as a woman.

Dr. Johnson: We look at the things that are happening now, everything from George Floyd’s murder to Colin Kaepernick taking a knee. These things are 10 years past when I first started residency. The year before I started residency, there was a noose hanging on the capitol lawn of Springfield, Illinois’ capital city. There’s systemic racism and hatred there. When I first started on the wards of my first year of ObGyn, again, I was the very first Black resident of my program’s history. Nobody could relate to me.

I went from a year-long general surgery internship at Washington Hospital Center in Washington, DC, to ObGyn residency. In the first 2 months, there were complaints of, “He’s not answering his pages. He’s not being prompt.” I went to my program director and said, “Listen, I have never had one complaint like this. There’s a problem here. And there’s a problem when I’m on the floor: When trying to give orders to nurses, they’re not taking them. I had to tell a couple of nurses, ‘I’m Dr. Johnson. Don’t call me by my first name, especially not in front of patients.’”

My director was just not hearing me, because the entire scenario was something they had never been exposed to. Systemic racism is real, and unless you experience it, it’s very difficult to accept that it is happening. But biases happen when you are not cognizant. People are used to things a certain way. Things play out in the media that make your mind think a certain way, and you don’t even realize it. You may not even want to be that way.

Continue to: Unconscious bias is a barrier to ensuring equity...

Dr. Levy: One very important point you just made is that we as the system need to be able to recognize those unconscious things, the language that we use, the disparaging remarks, the things that put people down, as well as the things that keep people out of promotion.

There are some interesting data about both race and gender and the language that we use when we write recommendations for people, that we do things unconsciously. The big message to all of us at the end is to open our minds to where those things can occur. For myself, professionally, I keep a list of words that I use when I write recommendations. I measure myself to ensure that I am using the same language for men and women, for Black and White. I think we need to overcome the system and the structure to create real equity—not equality but equity.

It begins with being real about the issues

Dr. Johnson: It’s a bigger problem than the existence of bias and racism. I think these are systemic issues that have been cultivated over centuries that have never been addressed. The true issue is that we deny that these are problems and refuse to talk about it because it makes us uncomfortable. To truly make things more equitable, we have to push our levels of comfort to be able to talk about things in a healthy manner, be open and transparent, and to start to understand how we are thinking about certain things. When you can see it, you can start to implement changes and start to change mentalities and thought processes.

For me, people say, “You don’t look like a doctor.” I get that all the time—because I have tattoos and earrings. I wear my hair in a mohawk. The image of what success looks like has been manifested through our media and culture, and it has imprinted on our minds as to how things are supposed to be. If someone doesn’t fit those molds, we start to shun them out, or we start to exhibit biases against those things. What I am trying to do is change that thought process of what a successful or a professional person looks like. It doesn’t have a look. It is not a White or Black thing. It’s an intellect, a mindset, a way of living. You have to treat every person as an individual and take all the biases out of it and understand where they are coming from and what they have to offer to the profession.

Dr. Levy: I personally was so impressed by you when I met you. I was impressed by the tattoos and the earrings, and my initial response to them was exactly that biased, “Oh, who is this person?” I checked that at the door, listened to you, and was really impressed at your surgical skill, your knowledge, your background. I am really grateful that you have been willing to spend the time to share that with everyone.

Dr. Johnson: Thank you for this discussion.

To watch the full interview between Drs. Levy and Johnson, visit: https://www.mdedge.com/obgyn/article/228507/facing-systemic-racism-health-care-inequities-medical-education. ●

Many laser and light-based technologies fall short when it comes to treating people of color, according to Haley L. Marks, PhD.

For one thing, melanin’s extinction overlaps with common laser lines, which affects the safety and efficacy of laser treatments in dermatology, but also in imaging and wearable devices that use LEDs in the visible range. “Pheomelanin and eumelanin are chemically very similar and both have this property of having very high extinction coefficients in the visible range, meaning that melanins both absorb and scatter light which we commonly use for laser treatments and for wearable medical devices,” Dr. Marks, a research scientist in dermatology at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Melanins also shadow a number of other biological signals that we look for in the skin, such as those from hemoglobin.”

A number of different scales can be used to estimate the amount of eumelanin, or darkly pigmented melanin, in the skin, but the most famous is Fitzpatrick skin typing, the classification system that ranges from I to VI originally intended to quantify the skin’s response to UV light. “It’s so famous that it’s used in the emoji modifier of the Unicode Consortium lookup table,” said Dr. Marks, who spoke on behalf of the Wellman Anti-Racism Effort (WARE), a grassroots working group within the Wellman Center for Photomedicine at Massachusetts General Hospital. (The mission of the group is to eradicate racism in STEM, medicine, and academia starting with its own research and Center.)

Dr. Marks referred to a Northwestern University study published in 2013, which found that both patients and dermatologists failed to accurately determine Fitzpatrick skin type (FST) when compared with reflectance spectrophotometry used to measure melanin index objectively. “There is a need to classify skin type with reliable questions with responses suitable for all skin types,” the authors concluded.

Plenty more can go wrong when clinicians ignore or misunderstand the role of melanin as a background contrast agent, Dr. Marks continued. She cited the common misconception that melanomas do not occur in darker pigmented skin, a topic discussed in an article published online in January 2020 in Cancer Cytopathology.

“While they do occur at a lower rate, this misconception leads to an alarmingly low survival rate for black melanoma patients,” Dr. Marks said. “Acral lentiginous melanoma is one example of this. It is not related to sun exposure, yet it occurs in 30% to 70% of melanomas in black patients. This also exposes a mortality rate of 1 in 3 for Black melanoma patients, compared with 1 in 11 for White patients. In fact, Black patients face a lower survival for most cancers, often attributed to social and economic disparities rather than biological differences.”

Another significant contributing factor may be the lack of data and awareness of clinical research related to patients with skin of color. The Skin of Color Society’s “Find a Doctor” database is attempting to address this by improving patients’ access to board-certified dermatologists who specialize in skin of color. “Some of the discrepancies in dermatology education, screening, and treatment for Black, indigenous, and people of color is likely attributed to the fact that only 4.5% of images in general medical textbooks show darker skin, as they are only 5% of clinical trial participants despite making up 17% of the U.S. population,” Dr. Marks said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. Mind The Gap, a handbook of clinical signs and symptoms in black and brown skin, was published in 2020 by students and staff at St. George’s University of London. It can be downloaded for free.

Some 40 years after Kodak was criticized for not acknowledging inherent biases in their film stocks based on its “Kodak Shirley” color correction card, Dr. Marks said that camera makers are still ignoring racial bias in their technologies. “This is likely a ‘garbage in, garbage out’ phenomenon,” she said. “Due to the lack of diverse images, these biases get ingrained into machine learning models themselves, either because patients were not served in the first place, resulting in missing data, or because of mislabeling due to a lack of knowledge in properly classifying these images. So, while machine learning has the potential to step in where dermatologists fall short, we must be very diligent about recognizing any bias we are ingraining into these algorithms,” she said.

“That said, no technology is ‘born racist,’ of course; it is up to us to prevent history from repeating itself and prevent these biases from being ingrained in our work,” she added. “We can start by holding ourselves and others accountable when designing studies that have exclusion criteria, by challenging our sponsors on the exclusion of Fitzpatrick V and VI if you feel it is not scientifically sound, and by ensuring inclusive algorithm development. If these things are not possible, please use a disclaimer to make these limitations clear.”

According to Dr. Marks and WARE, clinicians can increase diversity in clinical trials by widening eligibility criteria, tapping into community-based medical centers, connecting with patient advocacy groups, using point-of-care and telemedicine technologies, supporting diversity-focused public policy on a larger scale, and making diversity an internal mandate, “within your institution, and within yourselves.”

Some community efforts stemming from Wellman inventions so far include the Texas-based Removery INK-nitiative program, which removes racist and hateful tattoos for free via laser tattoo removal technology that was invented at Wellman. Dr. Marks and her WARE colleagues also work with the Dream Beam Foundation, which is a global initiative bringing laser-based technologies to children in Vietnam, Armenia, Israel, Brazil, and Lebanon.

Dr. Marks reported having no financial disclosures.

[email protected]

Many laser and light-based technologies fall short when it comes to treating people of color, according to Haley L. Marks, PhD.

For one thing, melanin’s extinction overlaps with common laser lines, which affects the safety and efficacy of laser treatments in dermatology, but also in imaging and wearable devices that use LEDs in the visible range. “Pheomelanin and eumelanin are chemically very similar and both have this property of having very high extinction coefficients in the visible range, meaning that melanins both absorb and scatter light which we commonly use for laser treatments and for wearable medical devices,” Dr. Marks, a research scientist in dermatology at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Melanins also shadow a number of other biological signals that we look for in the skin, such as those from hemoglobin.”

A number of different scales can be used to estimate the amount of eumelanin, or darkly pigmented melanin, in the skin, but the most famous is Fitzpatrick skin typing, the classification system that ranges from I to VI originally intended to quantify the skin’s response to UV light. “It’s so famous that it’s used in the emoji modifier of the Unicode Consortium lookup table,” said Dr. Marks, who spoke on behalf of the Wellman Anti-Racism Effort (WARE), a grassroots working group within the Wellman Center for Photomedicine at Massachusetts General Hospital. (The mission of the group is to eradicate racism in STEM, medicine, and academia starting with its own research and Center.)

Dr. Marks referred to a Northwestern University study published in 2013, which found that both patients and dermatologists failed to accurately determine Fitzpatrick skin type (FST) when compared with reflectance spectrophotometry used to measure melanin index objectively. “There is a need to classify skin type with reliable questions with responses suitable for all skin types,” the authors concluded.

Plenty more can go wrong when clinicians ignore or misunderstand the role of melanin as a background contrast agent, Dr. Marks continued. She cited the common misconception that melanomas do not occur in darker pigmented skin, a topic discussed in an article published online in January 2020 in Cancer Cytopathology.

“While they do occur at a lower rate, this misconception leads to an alarmingly low survival rate for black melanoma patients,” Dr. Marks said. “Acral lentiginous melanoma is one example of this. It is not related to sun exposure, yet it occurs in 30% to 70% of melanomas in black patients. This also exposes a mortality rate of 1 in 3 for Black melanoma patients, compared with 1 in 11 for White patients. In fact, Black patients face a lower survival for most cancers, often attributed to social and economic disparities rather than biological differences.”

Another significant contributing factor may be the lack of data and awareness of clinical research related to patients with skin of color. The Skin of Color Society’s “Find a Doctor” database is attempting to address this by improving patients’ access to board-certified dermatologists who specialize in skin of color. “Some of the discrepancies in dermatology education, screening, and treatment for Black, indigenous, and people of color is likely attributed to the fact that only 4.5% of images in general medical textbooks show darker skin, as they are only 5% of clinical trial participants despite making up 17% of the U.S. population,” Dr. Marks said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. Mind The Gap, a handbook of clinical signs and symptoms in black and brown skin, was published in 2020 by students and staff at St. George’s University of London. It can be downloaded for free.

Some 40 years after Kodak was criticized for not acknowledging inherent biases in their film stocks based on its “Kodak Shirley” color correction card, Dr. Marks said that camera makers are still ignoring racial bias in their technologies. “This is likely a ‘garbage in, garbage out’ phenomenon,” she said. “Due to the lack of diverse images, these biases get ingrained into machine learning models themselves, either because patients were not served in the first place, resulting in missing data, or because of mislabeling due to a lack of knowledge in properly classifying these images. So, while machine learning has the potential to step in where dermatologists fall short, we must be very diligent about recognizing any bias we are ingraining into these algorithms,” she said.

“That said, no technology is ‘born racist,’ of course; it is up to us to prevent history from repeating itself and prevent these biases from being ingrained in our work,” she added. “We can start by holding ourselves and others accountable when designing studies that have exclusion criteria, by challenging our sponsors on the exclusion of Fitzpatrick V and VI if you feel it is not scientifically sound, and by ensuring inclusive algorithm development. If these things are not possible, please use a disclaimer to make these limitations clear.”

According to Dr. Marks and WARE, clinicians can increase diversity in clinical trials by widening eligibility criteria, tapping into community-based medical centers, connecting with patient advocacy groups, using point-of-care and telemedicine technologies, supporting diversity-focused public policy on a larger scale, and making diversity an internal mandate, “within your institution, and within yourselves.”

Some community efforts stemming from Wellman inventions so far include the Texas-based Removery INK-nitiative program, which removes racist and hateful tattoos for free via laser tattoo removal technology that was invented at Wellman. Dr. Marks and her WARE colleagues also work with the Dream Beam Foundation, which is a global initiative bringing laser-based technologies to children in Vietnam, Armenia, Israel, Brazil, and Lebanon.

Dr. Marks reported having no financial disclosures.

[email protected]

Many laser and light-based technologies fall short when it comes to treating people of color, according to Haley L. Marks, PhD.

For one thing, melanin’s extinction overlaps with common laser lines, which affects the safety and efficacy of laser treatments in dermatology, but also in imaging and wearable devices that use LEDs in the visible range. “Pheomelanin and eumelanin are chemically very similar and both have this property of having very high extinction coefficients in the visible range, meaning that melanins both absorb and scatter light which we commonly use for laser treatments and for wearable medical devices,” Dr. Marks, a research scientist in dermatology at Massachusetts General Hospital, Boston, said during a virtual course on laser and aesthetic skin therapy. “Melanins also shadow a number of other biological signals that we look for in the skin, such as those from hemoglobin.”

A number of different scales can be used to estimate the amount of eumelanin, or darkly pigmented melanin, in the skin, but the most famous is Fitzpatrick skin typing, the classification system that ranges from I to VI originally intended to quantify the skin’s response to UV light. “It’s so famous that it’s used in the emoji modifier of the Unicode Consortium lookup table,” said Dr. Marks, who spoke on behalf of the Wellman Anti-Racism Effort (WARE), a grassroots working group within the Wellman Center for Photomedicine at Massachusetts General Hospital. (The mission of the group is to eradicate racism in STEM, medicine, and academia starting with its own research and Center.)

Dr. Marks referred to a Northwestern University study published in 2013, which found that both patients and dermatologists failed to accurately determine Fitzpatrick skin type (FST) when compared with reflectance spectrophotometry used to measure melanin index objectively. “There is a need to classify skin type with reliable questions with responses suitable for all skin types,” the authors concluded.

Plenty more can go wrong when clinicians ignore or misunderstand the role of melanin as a background contrast agent, Dr. Marks continued. She cited the common misconception that melanomas do not occur in darker pigmented skin, a topic discussed in an article published online in January 2020 in Cancer Cytopathology.

“While they do occur at a lower rate, this misconception leads to an alarmingly low survival rate for black melanoma patients,” Dr. Marks said. “Acral lentiginous melanoma is one example of this. It is not related to sun exposure, yet it occurs in 30% to 70% of melanomas in black patients. This also exposes a mortality rate of 1 in 3 for Black melanoma patients, compared with 1 in 11 for White patients. In fact, Black patients face a lower survival for most cancers, often attributed to social and economic disparities rather than biological differences.”

Another significant contributing factor may be the lack of data and awareness of clinical research related to patients with skin of color. The Skin of Color Society’s “Find a Doctor” database is attempting to address this by improving patients’ access to board-certified dermatologists who specialize in skin of color. “Some of the discrepancies in dermatology education, screening, and treatment for Black, indigenous, and people of color is likely attributed to the fact that only 4.5% of images in general medical textbooks show darker skin, as they are only 5% of clinical trial participants despite making up 17% of the U.S. population,” Dr. Marks said at the meeting, which was sponsored by Harvard Medical School, Massachusetts General Hospital, and the Wellman Center for Photomedicine. Mind The Gap, a handbook of clinical signs and symptoms in black and brown skin, was published in 2020 by students and staff at St. George’s University of London. It can be downloaded for free.

Some 40 years after Kodak was criticized for not acknowledging inherent biases in their film stocks based on its “Kodak Shirley” color correction card, Dr. Marks said that camera makers are still ignoring racial bias in their technologies. “This is likely a ‘garbage in, garbage out’ phenomenon,” she said. “Due to the lack of diverse images, these biases get ingrained into machine learning models themselves, either because patients were not served in the first place, resulting in missing data, or because of mislabeling due to a lack of knowledge in properly classifying these images. So, while machine learning has the potential to step in where dermatologists fall short, we must be very diligent about recognizing any bias we are ingraining into these algorithms,” she said.

“That said, no technology is ‘born racist,’ of course; it is up to us to prevent history from repeating itself and prevent these biases from being ingrained in our work,” she added. “We can start by holding ourselves and others accountable when designing studies that have exclusion criteria, by challenging our sponsors on the exclusion of Fitzpatrick V and VI if you feel it is not scientifically sound, and by ensuring inclusive algorithm development. If these things are not possible, please use a disclaimer to make these limitations clear.”

According to Dr. Marks and WARE, clinicians can increase diversity in clinical trials by widening eligibility criteria, tapping into community-based medical centers, connecting with patient advocacy groups, using point-of-care and telemedicine technologies, supporting diversity-focused public policy on a larger scale, and making diversity an internal mandate, “within your institution, and within yourselves.”

Some community efforts stemming from Wellman inventions so far include the Texas-based Removery INK-nitiative program, which removes racist and hateful tattoos for free via laser tattoo removal technology that was invented at Wellman. Dr. Marks and her WARE colleagues also work with the Dream Beam Foundation, which is a global initiative bringing laser-based technologies to children in Vietnam, Armenia, Israel, Brazil, and Lebanon.

Dr. Marks reported having no financial disclosures.

[email protected]

Black patients with extensive-stage small cell lung cancer (ES-SCLC) are less likely to receive chemotherapy but have better survival, compared with White patients, according to a study published in JTO Clinical Research and Reports.

This study provides a large-scale analysis of real-world data identifying racial and socioeconomic factors impacting systemic therapy delivery and survival in ES-SCLC.

“The most important finding was the significant disparity in receipt of chemotherapy,” said study author Umit Tapan, MD, of Boston Medical Center.

“Black individuals with ES-SCLC were less likely to receive chemotherapy compared to Whites and other racial groups. Similarly, elderly, uninsured patients, patients with nonprivate health insurance, and those with lower education levels were less likely to be treated with chemotherapy,” Dr. Tapan said.

Using the National Cancer Data Base (NCDB), Dr. Tapan and colleagues identified 148,961 patients who were diagnosed with stage IV ES-SCLC during 2004-2016. In all, 82,592 patients were included in the study.
 

Results: Treatment and survival

Compared with White patients, Black patients (adjusted odds ratio, 0.85; P = .0004) and patients from other racial groups (aOR, 0.87; P = .126) had lower odds of receiving chemotherapy on multivariate analysis.

However, survival was superior in Black patients (adjusted hazard ratio, 0.92; P < .0001) and other non-White patients (aHR 0.86; P < .0001).

“We speculate that additional factors, such as performance status, which is not captured by NCDB, might have accounted for better survival for Black patients,” Dr. Tapan said, noting that the analysis was adjusted for known possible confounding factors, such as age, gender, and comorbidity status.

Black patients had higher odds of receiving chemotherapy between 2010 and 2016 compared with 2004 and 2009. “This suggests a positive impact of the Patient Protection and Affordable Care Act (ACA) in 2010,” Dr. Tapan said.

Another surprising finding pertained to patients with nonprivate insurance. These patients had even lower odds of getting chemotherapy after the implementation of ACA, Dr. Tapan said. Patients who had private insurance had higher survival compared with those who were uninsured.

Higher level of education, measured by percentage of residents with a high school degree, increased the odds of receiving chemotherapy.

Age also had a significant impact on receipt of chemotherapy. About 83% of patients over age 80 years received chemotherapy, compared with 94% of patients aged 40-64 years.
 

Real-world data

Minorities are underrepresented in cancer clinical trials in the United States, with only 2% of National Cancer Institute trials having sufficient minority participants, Dr. Tapan said. A study published in Academic Medicine in 2018 showed that only 13% of 782 National Institute of Health–sponsored clinical trials reported outcomes by race and ethnicity.

As a result, we are missing data on patient care in minority populations, Dr. Tapan said. “Collecting and analyzing real-world data becomes critical to study treatment patterns and outcomes,” he added.

The current real-world study had a somewhat diverse patient population, but 90.6% of patients were White, 7.8% were Black, and 1.7% were other races.

“We would have expected a higher percentage of Black patients considering the most recent U.S. Census Bureau estimates that 76.3% of the U.S. population is White and 13.4% is Black,” Dr. Tapan said. “There are conflicting results in the literature regarding racial disparities in SCLC and survival. Many of these studies were performed via state-based cancer registries instead of on a national level, making prior reports less generalizable.”
 

‘More work to do’

While the new study showed patients with nonprivate insurance or those with no insurance were less likely to receive chemotherapy, studies have shown that chemotherapy administration was not impacted by insurance status in limited-stage SCLC.

This is in contrast to radiotherapy delivery. Studies have revealed a lower likelihood of radiotherapy delivery in limited-stage SCLC for patients with government health insurance such as Medicare/Medicaid, Dr. Tapan said.

“Access to cancer care has been shown to be one of the most important barriers in racial disparity. Studies analyzing outcomes in the equal access health systems, such as the Veteran Administration, have revealed less racial disparities,” Dr. Tapan said.

Even when Black patients have equal access to care, they might receive suboptimal treatment, Dr. Tapan noted.

“Studies have shown that Black patients are not only more likely to refuse surgery, but also are more likely to be given a negative recommendation by a surgeon as compared to Whites, suggesting potential involvement of miscommunication or bias during patient-physician encounters,” Dr. Tapan said. “In the same vein, physicians would need to acknowledge their patients’ beliefs. Not doing so may lead to unsatisfactory physician-patient interactions and suboptimal decision-making.”

“Measures to reduce physician bias are an important step to reduce disparities,” Dr. Tapan continued. “Studies have shown that Black patients are perceived to be less intelligent and educated, less likely to have social support, and more likely to be at risk of noncompliance. For some patients and oncologists, extra effort is needed so that every patient can access the best possible treatments and outcomes. It is the oncologist’s responsibility to advocate for patients, but, ultimately, further legislative actions are needed to mitigate the disparities around cancer care.”

Dr. Tapan noted that, in 1966, Martin Luther King Jr., PhD, stated that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Tapan said: “We have overcome some barriers since 1966, but we have more work to do.” He and colleagues had no disclosures related to this study.

SOURCE: Tapan U et al. JTO Clin Res Rep. 2020. doi: 10.1016/j.jtocrr.2020.100109.

Black patients with extensive-stage small cell lung cancer (ES-SCLC) are less likely to receive chemotherapy but have better survival, compared with White patients, according to a study published in JTO Clinical Research and Reports.

This study provides a large-scale analysis of real-world data identifying racial and socioeconomic factors impacting systemic therapy delivery and survival in ES-SCLC.

“The most important finding was the significant disparity in receipt of chemotherapy,” said study author Umit Tapan, MD, of Boston Medical Center.

“Black individuals with ES-SCLC were less likely to receive chemotherapy compared to Whites and other racial groups. Similarly, elderly, uninsured patients, patients with nonprivate health insurance, and those with lower education levels were less likely to be treated with chemotherapy,” Dr. Tapan said.

Using the National Cancer Data Base (NCDB), Dr. Tapan and colleagues identified 148,961 patients who were diagnosed with stage IV ES-SCLC during 2004-2016. In all, 82,592 patients were included in the study.
 

Results: Treatment and survival

Compared with White patients, Black patients (adjusted odds ratio, 0.85; P = .0004) and patients from other racial groups (aOR, 0.87; P = .126) had lower odds of receiving chemotherapy on multivariate analysis.

However, survival was superior in Black patients (adjusted hazard ratio, 0.92; P < .0001) and other non-White patients (aHR 0.86; P < .0001).

“We speculate that additional factors, such as performance status, which is not captured by NCDB, might have accounted for better survival for Black patients,” Dr. Tapan said, noting that the analysis was adjusted for known possible confounding factors, such as age, gender, and comorbidity status.

Black patients had higher odds of receiving chemotherapy between 2010 and 2016 compared with 2004 and 2009. “This suggests a positive impact of the Patient Protection and Affordable Care Act (ACA) in 2010,” Dr. Tapan said.

Another surprising finding pertained to patients with nonprivate insurance. These patients had even lower odds of getting chemotherapy after the implementation of ACA, Dr. Tapan said. Patients who had private insurance had higher survival compared with those who were uninsured.

Higher level of education, measured by percentage of residents with a high school degree, increased the odds of receiving chemotherapy.

Age also had a significant impact on receipt of chemotherapy. About 83% of patients over age 80 years received chemotherapy, compared with 94% of patients aged 40-64 years.
 

Real-world data

Minorities are underrepresented in cancer clinical trials in the United States, with only 2% of National Cancer Institute trials having sufficient minority participants, Dr. Tapan said. A study published in Academic Medicine in 2018 showed that only 13% of 782 National Institute of Health–sponsored clinical trials reported outcomes by race and ethnicity.

As a result, we are missing data on patient care in minority populations, Dr. Tapan said. “Collecting and analyzing real-world data becomes critical to study treatment patterns and outcomes,” he added.

The current real-world study had a somewhat diverse patient population, but 90.6% of patients were White, 7.8% were Black, and 1.7% were other races.

“We would have expected a higher percentage of Black patients considering the most recent U.S. Census Bureau estimates that 76.3% of the U.S. population is White and 13.4% is Black,” Dr. Tapan said. “There are conflicting results in the literature regarding racial disparities in SCLC and survival. Many of these studies were performed via state-based cancer registries instead of on a national level, making prior reports less generalizable.”
 

‘More work to do’

While the new study showed patients with nonprivate insurance or those with no insurance were less likely to receive chemotherapy, studies have shown that chemotherapy administration was not impacted by insurance status in limited-stage SCLC.

This is in contrast to radiotherapy delivery. Studies have revealed a lower likelihood of radiotherapy delivery in limited-stage SCLC for patients with government health insurance such as Medicare/Medicaid, Dr. Tapan said.

“Access to cancer care has been shown to be one of the most important barriers in racial disparity. Studies analyzing outcomes in the equal access health systems, such as the Veteran Administration, have revealed less racial disparities,” Dr. Tapan said.

Even when Black patients have equal access to care, they might receive suboptimal treatment, Dr. Tapan noted.

“Studies have shown that Black patients are not only more likely to refuse surgery, but also are more likely to be given a negative recommendation by a surgeon as compared to Whites, suggesting potential involvement of miscommunication or bias during patient-physician encounters,” Dr. Tapan said. “In the same vein, physicians would need to acknowledge their patients’ beliefs. Not doing so may lead to unsatisfactory physician-patient interactions and suboptimal decision-making.”

“Measures to reduce physician bias are an important step to reduce disparities,” Dr. Tapan continued. “Studies have shown that Black patients are perceived to be less intelligent and educated, less likely to have social support, and more likely to be at risk of noncompliance. For some patients and oncologists, extra effort is needed so that every patient can access the best possible treatments and outcomes. It is the oncologist’s responsibility to advocate for patients, but, ultimately, further legislative actions are needed to mitigate the disparities around cancer care.”

Dr. Tapan noted that, in 1966, Martin Luther King Jr., PhD, stated that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Tapan said: “We have overcome some barriers since 1966, but we have more work to do.” He and colleagues had no disclosures related to this study.

SOURCE: Tapan U et al. JTO Clin Res Rep. 2020. doi: 10.1016/j.jtocrr.2020.100109.

Black patients with extensive-stage small cell lung cancer (ES-SCLC) are less likely to receive chemotherapy but have better survival, compared with White patients, according to a study published in JTO Clinical Research and Reports.

This study provides a large-scale analysis of real-world data identifying racial and socioeconomic factors impacting systemic therapy delivery and survival in ES-SCLC.

“The most important finding was the significant disparity in receipt of chemotherapy,” said study author Umit Tapan, MD, of Boston Medical Center.

“Black individuals with ES-SCLC were less likely to receive chemotherapy compared to Whites and other racial groups. Similarly, elderly, uninsured patients, patients with nonprivate health insurance, and those with lower education levels were less likely to be treated with chemotherapy,” Dr. Tapan said.

Using the National Cancer Data Base (NCDB), Dr. Tapan and colleagues identified 148,961 patients who were diagnosed with stage IV ES-SCLC during 2004-2016. In all, 82,592 patients were included in the study.
 

Results: Treatment and survival

Compared with White patients, Black patients (adjusted odds ratio, 0.85; P = .0004) and patients from other racial groups (aOR, 0.87; P = .126) had lower odds of receiving chemotherapy on multivariate analysis.

However, survival was superior in Black patients (adjusted hazard ratio, 0.92; P < .0001) and other non-White patients (aHR 0.86; P < .0001).

“We speculate that additional factors, such as performance status, which is not captured by NCDB, might have accounted for better survival for Black patients,” Dr. Tapan said, noting that the analysis was adjusted for known possible confounding factors, such as age, gender, and comorbidity status.

Black patients had higher odds of receiving chemotherapy between 2010 and 2016 compared with 2004 and 2009. “This suggests a positive impact of the Patient Protection and Affordable Care Act (ACA) in 2010,” Dr. Tapan said.

Another surprising finding pertained to patients with nonprivate insurance. These patients had even lower odds of getting chemotherapy after the implementation of ACA, Dr. Tapan said. Patients who had private insurance had higher survival compared with those who were uninsured.

Higher level of education, measured by percentage of residents with a high school degree, increased the odds of receiving chemotherapy.

Age also had a significant impact on receipt of chemotherapy. About 83% of patients over age 80 years received chemotherapy, compared with 94% of patients aged 40-64 years.
 

Real-world data

Minorities are underrepresented in cancer clinical trials in the United States, with only 2% of National Cancer Institute trials having sufficient minority participants, Dr. Tapan said. A study published in Academic Medicine in 2018 showed that only 13% of 782 National Institute of Health–sponsored clinical trials reported outcomes by race and ethnicity.

As a result, we are missing data on patient care in minority populations, Dr. Tapan said. “Collecting and analyzing real-world data becomes critical to study treatment patterns and outcomes,” he added.

The current real-world study had a somewhat diverse patient population, but 90.6% of patients were White, 7.8% were Black, and 1.7% were other races.

“We would have expected a higher percentage of Black patients considering the most recent U.S. Census Bureau estimates that 76.3% of the U.S. population is White and 13.4% is Black,” Dr. Tapan said. “There are conflicting results in the literature regarding racial disparities in SCLC and survival. Many of these studies were performed via state-based cancer registries instead of on a national level, making prior reports less generalizable.”
 

‘More work to do’

While the new study showed patients with nonprivate insurance or those with no insurance were less likely to receive chemotherapy, studies have shown that chemotherapy administration was not impacted by insurance status in limited-stage SCLC.

This is in contrast to radiotherapy delivery. Studies have revealed a lower likelihood of radiotherapy delivery in limited-stage SCLC for patients with government health insurance such as Medicare/Medicaid, Dr. Tapan said.

“Access to cancer care has been shown to be one of the most important barriers in racial disparity. Studies analyzing outcomes in the equal access health systems, such as the Veteran Administration, have revealed less racial disparities,” Dr. Tapan said.

Even when Black patients have equal access to care, they might receive suboptimal treatment, Dr. Tapan noted.

“Studies have shown that Black patients are not only more likely to refuse surgery, but also are more likely to be given a negative recommendation by a surgeon as compared to Whites, suggesting potential involvement of miscommunication or bias during patient-physician encounters,” Dr. Tapan said. “In the same vein, physicians would need to acknowledge their patients’ beliefs. Not doing so may lead to unsatisfactory physician-patient interactions and suboptimal decision-making.”

“Measures to reduce physician bias are an important step to reduce disparities,” Dr. Tapan continued. “Studies have shown that Black patients are perceived to be less intelligent and educated, less likely to have social support, and more likely to be at risk of noncompliance. For some patients and oncologists, extra effort is needed so that every patient can access the best possible treatments and outcomes. It is the oncologist’s responsibility to advocate for patients, but, ultimately, further legislative actions are needed to mitigate the disparities around cancer care.”

Dr. Tapan noted that, in 1966, Martin Luther King Jr., PhD, stated that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

Dr. Tapan said: “We have overcome some barriers since 1966, but we have more work to do.” He and colleagues had no disclosures related to this study.

SOURCE: Tapan U et al. JTO Clin Res Rep. 2020. doi: 10.1016/j.jtocrr.2020.100109.

Patients self-identified as non-White are far more likely to express a preference for dermatologic care from a physician of their own race or ethnicity, according to a patient survey.

In the survey, 42% of self-identified Black patients and 44% of self-identified Hispanic patients assigned some level of importance to the race or ethnicity of their dermatologist. Of patients self-identified as White, the figure was 2%, which was significantly lower (P less than .001).

Responses to the survey indicated that there is concern among non-White patients that White physicians are not fully sensitive to the clinical issues presented by their skin type. For example, 22% of Hispanic patients and 21% of Black patients agreed that a race-concordant physician would be better trained to treat their skin.

The results of the survey were recently published in a Research Letter in the Journal of the American Academy of Dermatology.

When patients were asked to agree or disagree with the statement that non-White patients receive the same quality of care as White patients, about a third disagreed, “but about half said they were unsure, which I interpret basically as a negative answer,” reported the lead author, Adam Friedman, MD, professor and interim chair of the department of dermatology at George Washington University, Washington.

“These data are a call to action. Certainly, we need to diversify our workforce to mirror the overall population, but we can also do more to improve training for dermatologic diseases across skin types,” Dr. Friedman said in an interview.

“Ensuring all skin types are represented in all dermatologic education, from resident book clubs to the national stage is but one step to making dermatology more inclusive and prepared to care for all patients,” he added.

Ninety-two patients receiving dermatology care at Dr. Friedman’s institution completed the survey. Fifty identified themselves as White, nine as Hispanic, and 33 as Black. Allowing patients to self-identify race was an important feature of this survey, according to Dr. Friedman.

“Something I really struggle with is terminology. Are race and ethnicity the appropriate terms when discussing different skin types and tones? It is so easy to misuse even validated tools. The Fitzpatrick Scale, for example, requires patients to relay how easily they burn, but reveals nothing about how patients refer to their skin tone,” Dr. Friedman explained. “We need to reset how we characterize and categorize skin types.”

Among those who assigned at least some importance to having a dermatologist of the same race or ethnicity, the most common reason was that such physicians “are better able to listen and relate to me.” Thirty percent of Black patients and 22% of Hispanic patients agreed with this statement. The perception that such physicians are better trained to treat non-White skin was the next most common reason.

The results of the survey emphasize the importance of ensuring that there is comprehensive training in managing all skin types and that physicians receive rigorous implicit bias and cultural sensitivity training in order to win patient trust, according to Dr. Friedman. He suggested that the perception that White physicians might not provide optimal care to non-White patients by study participants “has some validity. Structural racism in medicine is well-documented, and dermatologists have already begun to combat this on several fronts.”

In fact, the process of conducting and analyzing data from this survey proved to be its own lesson in sociocultural sensitivity, he said.

After a draft completed peer review and was accepted for publication, Dr. Friedman was confronted with numerous criticisms of the language that was used. In particular, one of his former residents, Misty Eleryan, MD, who is now a Mohs Fellow at the University of California, Los Angeles, was instrumental in pointing out problems. Ultimately, he withdrew the paper to rephrase the findings.

“It was not until then that I also learned that there is a JAAD Sensitivity Workgroup, which was very helpful in identifying issues we had overlooked,” Dr. Friedman said. For example, he had used the term “minorities” for non-White populations, which is not only inaccurate in many situations but has a pejorative undertone.

“It is important to recognize that the impact is more important than the intention,” said Dr. Friedman, who reported that he learned a lot in this process.

It is the need for this type of augmented sensitivity that the survey underscores, he added. He called for cultural sensitivity to be part of medical training to undo unrecognized bias, and said, “We need to understand how our patients perceive us.”

SOURCE: Friedman A et al. J Am Acad Dermatol. 2020 Sep 16;S0190-9622(20)32620-7. doi: 10.1016/j.jaad.2020.09.032.

Patients self-identified as non-White are far more likely to express a preference for dermatologic care from a physician of their own race or ethnicity, according to a patient survey.

In the survey, 42% of self-identified Black patients and 44% of self-identified Hispanic patients assigned some level of importance to the race or ethnicity of their dermatologist. Of patients self-identified as White, the figure was 2%, which was significantly lower (P less than .001).

Responses to the survey indicated that there is concern among non-White patients that White physicians are not fully sensitive to the clinical issues presented by their skin type. For example, 22% of Hispanic patients and 21% of Black patients agreed that a race-concordant physician would be better trained to treat their skin.

The results of the survey were recently published in a Research Letter in the Journal of the American Academy of Dermatology.

When patients were asked to agree or disagree with the statement that non-White patients receive the same quality of care as White patients, about a third disagreed, “but about half said they were unsure, which I interpret basically as a negative answer,” reported the lead author, Adam Friedman, MD, professor and interim chair of the department of dermatology at George Washington University, Washington.

“These data are a call to action. Certainly, we need to diversify our workforce to mirror the overall population, but we can also do more to improve training for dermatologic diseases across skin types,” Dr. Friedman said in an interview.

“Ensuring all skin types are represented in all dermatologic education, from resident book clubs to the national stage is but one step to making dermatology more inclusive and prepared to care for all patients,” he added.

Ninety-two patients receiving dermatology care at Dr. Friedman’s institution completed the survey. Fifty identified themselves as White, nine as Hispanic, and 33 as Black. Allowing patients to self-identify race was an important feature of this survey, according to Dr. Friedman.

“Something I really struggle with is terminology. Are race and ethnicity the appropriate terms when discussing different skin types and tones? It is so easy to misuse even validated tools. The Fitzpatrick Scale, for example, requires patients to relay how easily they burn, but reveals nothing about how patients refer to their skin tone,” Dr. Friedman explained. “We need to reset how we characterize and categorize skin types.”

Among those who assigned at least some importance to having a dermatologist of the same race or ethnicity, the most common reason was that such physicians “are better able to listen and relate to me.” Thirty percent of Black patients and 22% of Hispanic patients agreed with this statement. The perception that such physicians are better trained to treat non-White skin was the next most common reason.

The results of the survey emphasize the importance of ensuring that there is comprehensive training in managing all skin types and that physicians receive rigorous implicit bias and cultural sensitivity training in order to win patient trust, according to Dr. Friedman. He suggested that the perception that White physicians might not provide optimal care to non-White patients by study participants “has some validity. Structural racism in medicine is well-documented, and dermatologists have already begun to combat this on several fronts.”

In fact, the process of conducting and analyzing data from this survey proved to be its own lesson in sociocultural sensitivity, he said.

After a draft completed peer review and was accepted for publication, Dr. Friedman was confronted with numerous criticisms of the language that was used. In particular, one of his former residents, Misty Eleryan, MD, who is now a Mohs Fellow at the University of California, Los Angeles, was instrumental in pointing out problems. Ultimately, he withdrew the paper to rephrase the findings.

“It was not until then that I also learned that there is a JAAD Sensitivity Workgroup, which was very helpful in identifying issues we had overlooked,” Dr. Friedman said. For example, he had used the term “minorities” for non-White populations, which is not only inaccurate in many situations but has a pejorative undertone.

“It is important to recognize that the impact is more important than the intention,” said Dr. Friedman, who reported that he learned a lot in this process.

It is the need for this type of augmented sensitivity that the survey underscores, he added. He called for cultural sensitivity to be part of medical training to undo unrecognized bias, and said, “We need to understand how our patients perceive us.”

SOURCE: Friedman A et al. J Am Acad Dermatol. 2020 Sep 16;S0190-9622(20)32620-7. doi: 10.1016/j.jaad.2020.09.032.

Patients self-identified as non-White are far more likely to express a preference for dermatologic care from a physician of their own race or ethnicity, according to a patient survey.

In the survey, 42% of self-identified Black patients and 44% of self-identified Hispanic patients assigned some level of importance to the race or ethnicity of their dermatologist. Of patients self-identified as White, the figure was 2%, which was significantly lower (P less than .001).

Responses to the survey indicated that there is concern among non-White patients that White physicians are not fully sensitive to the clinical issues presented by their skin type. For example, 22% of Hispanic patients and 21% of Black patients agreed that a race-concordant physician would be better trained to treat their skin.

The results of the survey were recently published in a Research Letter in the Journal of the American Academy of Dermatology.

When patients were asked to agree or disagree with the statement that non-White patients receive the same quality of care as White patients, about a third disagreed, “but about half said they were unsure, which I interpret basically as a negative answer,” reported the lead author, Adam Friedman, MD, professor and interim chair of the department of dermatology at George Washington University, Washington.

“These data are a call to action. Certainly, we need to diversify our workforce to mirror the overall population, but we can also do more to improve training for dermatologic diseases across skin types,” Dr. Friedman said in an interview.

“Ensuring all skin types are represented in all dermatologic education, from resident book clubs to the national stage is but one step to making dermatology more inclusive and prepared to care for all patients,” he added.

Ninety-two patients receiving dermatology care at Dr. Friedman’s institution completed the survey. Fifty identified themselves as White, nine as Hispanic, and 33 as Black. Allowing patients to self-identify race was an important feature of this survey, according to Dr. Friedman.

“Something I really struggle with is terminology. Are race and ethnicity the appropriate terms when discussing different skin types and tones? It is so easy to misuse even validated tools. The Fitzpatrick Scale, for example, requires patients to relay how easily they burn, but reveals nothing about how patients refer to their skin tone,” Dr. Friedman explained. “We need to reset how we characterize and categorize skin types.”

Among those who assigned at least some importance to having a dermatologist of the same race or ethnicity, the most common reason was that such physicians “are better able to listen and relate to me.” Thirty percent of Black patients and 22% of Hispanic patients agreed with this statement. The perception that such physicians are better trained to treat non-White skin was the next most common reason.

The results of the survey emphasize the importance of ensuring that there is comprehensive training in managing all skin types and that physicians receive rigorous implicit bias and cultural sensitivity training in order to win patient trust, according to Dr. Friedman. He suggested that the perception that White physicians might not provide optimal care to non-White patients by study participants “has some validity. Structural racism in medicine is well-documented, and dermatologists have already begun to combat this on several fronts.”

In fact, the process of conducting and analyzing data from this survey proved to be its own lesson in sociocultural sensitivity, he said.

After a draft completed peer review and was accepted for publication, Dr. Friedman was confronted with numerous criticisms of the language that was used. In particular, one of his former residents, Misty Eleryan, MD, who is now a Mohs Fellow at the University of California, Los Angeles, was instrumental in pointing out problems. Ultimately, he withdrew the paper to rephrase the findings.

“It was not until then that I also learned that there is a JAAD Sensitivity Workgroup, which was very helpful in identifying issues we had overlooked,” Dr. Friedman said. For example, he had used the term “minorities” for non-White populations, which is not only inaccurate in many situations but has a pejorative undertone.

“It is important to recognize that the impact is more important than the intention,” said Dr. Friedman, who reported that he learned a lot in this process.

It is the need for this type of augmented sensitivity that the survey underscores, he added. He called for cultural sensitivity to be part of medical training to undo unrecognized bias, and said, “We need to understand how our patients perceive us.”

SOURCE: Friedman A et al. J Am Acad Dermatol. 2020 Sep 16;S0190-9622(20)32620-7. doi: 10.1016/j.jaad.2020.09.032.