Diversity in Aesthetics

Skin is one of the key features that distinguishes appearance and is an integral part of identity, and the dermatology and aesthetic specialties should be on the frontlines when it comes to discussing issues of race and healthcare disparities.

Efforts to diversify medical specialties such as aesthetics and dermatology are gaining momentum on both a local and national level. At my own institution, Cleveland Clinic Florida, in the wake of what happened with George Floyd, we observed a moment of silence and reflection on June 12, 2020, by gathering in front of the hospital, kneeling in solidarity and united together for the cause “White Coats for Black Lives.” Other healthcare workers are participating in similar demonstrations.

However, of all the medical specialties, dermatology is second to orthopedic surgery as the least diverse, even despite studies that have found that patient populations do better when they are tended to by diverse physicians who are more representative of the patient populations they care for.¹ Yet the level of diversity in dermatology is not representative of the degree of minorities in the community. For example, while 3% of dermatologists are black, black patients represent 13% of the population. Similarly, 4% of dermatologists are Hispanic, while 16% of the population is Hispanic.¹

Here’s the problem: A lack of diversity within specialties is associated with greater healthcare disparities and poorer healthcare outcomes among patients.^2,3 So why the marked disparity and misrepresentation with the rest of the population?

While there are programs and summits being created to promote diversity, many students and candidates may feel out of place in an environment where they may wonder why “no one looks like me.” Promoters of diversity in dermatology understand and stress that when physicians mirror the population they serve, everyone around them also benefits — not just the patients or providers themselves. Research has shown that minority physicians are more likely to practice in underserved areas where there are more minority patients who are insured by Medicaid and Medicare — this is one way in which the diversity within the fields actually works to improve the health of all Americans.^2,3

And this is a significant problem that needs to be better addressed in medicine and healthcare: the lack of access to care amongst minorities. Racial differences, controlled for income and insurance factors, play a role in how likely a patient is able to get into see a dermatologist. Hispanics and black people, specifically, are less likely to be able to obtain an outpatient dermatology visit, even when controlled for the same condition.⁴ This is also affected by educational status, income and location.⁴ Studies suggest that patients report better care when they are cared for by physicians who share similar characteristics.⁵

Diagnosis and Treatment in Diverse Populations

Because dermatology and aesthetics are very visual medical specialties, certain symptoms and features such as redness, scaling and psoriasis appear differently in light vs. dark skin and manifest differently in different skin types. Regardless of race, all physicians should be well versed in the appearance of these disorders in skin of color. Since resident physicians are commonly trained to diagnose disorders in patients with lighter skin, which is what is nearly exclusively represented in the majority of medical textbooks, physicians run the risk of missing important diagnoses such as psoriasis, lichen planus and mycosis fungoides in skin of color.⁶ Tumors, such as melanomas, often get diagnosed at later stages in patients with skin of color, which increases morbidity and mortality in this group.⁶

Additionally, exposure and understanding of cultural differences is paramount. Importantly, an understanding of patient needs, wants and cultural ideals within beauty and aesthetics may vary between different cultures. For example, many Asian patients seek aesthetic alteration of large masseter muscles through surgery or neurotoxin injections to reduce a naturally prominent angle of the mandible or muscular hypertrophy.⁷

Cultural awareness, or lack thereof, also affects patient care in our specialties. For example, many black women experience hair loss from traction alopecia, which can progress to scarring alopecia, and use a variety of diverse hairstyles and camouflage methods such as extensions, braids and wigs.⁸ When treating these patients, it is important to know how they care for and style their hair as well as their haircare goals. In addition, many black women don't wash their hair more than once per week, in line with the texture and degree of moisture vs. dryness of their hair, which can affect frequency and recommendations of their treatment regimen.⁸

Diversity in aesthetics can also help to expand knowledge of topics and disease states, as researchers tend to pursue topics of personal or cultural interest. Therefore, as diversity within our specialties increase, so too does clinical knowledge.

While seeing a physician of identical culture and background isn't essential to providing competent care, a successful patient encounter largely depends on physician knowledge and cultural sensitivity.⁹ By increasing diversity within aesthetics and dermatology, we can hopefully pave the way for universal culturally competent care.

Anna H. Chacon, M.D., is a dermatologist at Cleveland Clinic Florida. She is a Miami native and a graduate of Brown University's Program in Liberal Medical Education. She completed her dermatology residency at LAC + USC Medical Center and loves all aspects of dermatology.

References:

1. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016;74(3):584-587.
2. Cooper LA, Roter DL, Johnson RL, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–915.
3. Marrast LM, Zallman L, Woolhandler S, et al. Minority physicians’ role in the care of underserved patients: diversifying the physician work-force may be key in addressing health disparities. JAMA Intern Med. 2014;174:289–291.
4. Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States. JAMA Dermatol. 2018;154(11):1286–1291.
5. Gorbatenko-Roth K, Prose N, Kundu RV, Patterson S. Assessment of Black Patients’ Perception of Their Dermatology Care. JAMA Dermatol. 2019;155(10):1129–1134.
6. Adamson AS, Smith A. Machine Learning and Health Care Disparities in Dermatology. JAMA Dermatol. 2018;154(11):1247–1248.
7. Ahn J, Horn C, Blitzer A. Botulinum toxin for masseter reduction in Asian patients. Arch Facial Plast Surg. 2004;6(3):188‐191.
8. Rucker Wright D, Gathers R, Kapke A, Johnson D, Joseph CL. Hair care practices and their association with scalp and hair disorders in African American girls. J Am Acad Dermatol. 2011;64(2):253‐262.
9. Taylor SC. Meeting the Unique Dermatologic Needs of Black Patients. JAMA Dermatol. 2019;155(10):1109–1110.

Additional Reading:

1. Granstein RD, Cornelius L, Shinkai K. Diversity in Dermatology-A Call for Action. JAMA Dermatol. 2017;153(6):499‐500.
2. Hinojosa JA, Pandya AG. Diversity in the dermatology workforce. Semin Cutan Med Surg. 2016;36(4):242‐245.
3. Imadojemu S, James WD. Increasing African American representation in dermatology. JAMA Dermatol. 2016;152:15–16.
4. Linos E, Wintroub B, Shinkai K. Diversity in the dermatology workforce: 2017 status update. Cutis. 2017 Dec;100(6):352-353.
5. Saha S. Taking diversity seriously: the merits of increasing minority representation in medicine. JAMA Intern Med. 2014;174:291–292.