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If you want to be it, it helps to see it: Examining the need for diversity in dermatology

https://doi.org/10.1016/j.ijwd.2020.01.007 2352-6475/ 2020 The Author(s). Published by Elsevier Inc. on behalf of Women’s Dermatologic Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ‘‘The strength of our nation —and the field of medicine—is rooted in diversity.” [Dr. Barbara McAneny, American Medical Association President (McAneny, 2019)]

There are myriad possible reasons for this lack of representation in dermatology that merit examination. This article explores this predicament through my personal lens of the underrepresented medical student considering the specialty. This is by no means an attempt to generalize the experience of marginalized groups or individuals. It is meant to shine a light on some of these issues and critically reflect on the next steps for every one of us. In July 2019 at the Summer AAD meeting, the WDS held a Diversity Inclusion Networking Breakfast for UIM students interested in dermatology. This event fostered a space for networking with professors and peers, developing mentorships, and gathering advice from a carefully curated group of panelists. At one point, the audience of approximately 20 students was asked about the specific challenges of being a minority pursuing a path toward dermatology. One student questioned if program directors were aware of the unreported intangibles of adversity faced by UIM students.
This brought to mind the instances in which some minority students, worried about socioeconomic stability, are forced to juggle the demands of both work and school. We can experience a sense of imposter syndrome that is perpetuated by being the first in many of our families to enter into medical school and the lack of representation illustrated by our peers and physicians in a clinical setting. We can encounter the persistence of racially charged medical beliefs transmitted inadvertently in the classroom through our medical school curriculum. For instance, students are often asked to pathologize race by associating race with specific diseases without social contextualization or justification, perpetuating bias and influencing decision making (Tsai et al., 2016).
Many UIM students continuously face, directly or indirectly, experiences of discrimination, negative stereotyping, and exclusion within an unjust racial hierarchy that remains deeply embedded in the conscious and unconscious attitudes of our society as explicit and implicit bias. This can manifest as drastically as racebased differences in health care delivery and outcomes, such as differences in medical pain management wherein nonwhite patients who present with abdominal pain are 22% to 30% less likely to receive analgesic medication and 17% to 30% less likely to receive narcotic analgesics compared with white patients (Shah et al., 2015).
The bias can also be as subtle as a statement of comparison between students based on assumed shared cultural backgrounds https://doi.org/10.1016/j.ijwd.2020.01.007 2352-6475/Ó 2020 The Author(s). Published by Elsevier Inc. on behalf of Women's Dermatologic Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). International Journal of Women's Dermatology 6 (2020) 206-208

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International Journal of Women's Dermatology or experiences. Although personal and interpersonal factors influence all students' performance, UIM students often shoulder additional burdens as we strive to learn and demonstrate our abilities in the clinical environment. We hope that program directors are aware of the increased cognitive and emotional loads of learning and performing that are not addressed in the current educational environment or considered in assessment and grading.
A brief review of articles available in the literature on diversity in dermatology revealed that, although limited data exist, several editorials demonstrate the need for and significance of increasing racial and ethnic diversity in the field (Pandya et al., 2016;Pritchett et al., 2018a;2018b). A recent study in 2019 by students at the Albert Einstein College of Medicine used a survey to understand barriers for students pursuing a career in dermatology. The students reported that all survey participants cited U.S. Medical Licensing Examination Step 1, clinical grades, and the risk of not matching as the most important barriers to applying for a dermatology residency.
A subgroup analysis that examined minority students specifically reported the ''lack of diversity, perceived negative perceptions of minority students by residencies, socioeconomic factors, and lack of mentors" as additional major barriers (Soliman et al., 2019). In combination with the data that illustrate bias in medical student performance evaluations and licensing examinations based on race (Gardner et al., 2019;Ross et al., 2017), the challenges can often feel insurmountable.
A shared forum, such as the WDS sponsored event, provides a necessary support. Sharing feelings of doubt, finding comfort in community, and discovering that there are advocates and mentors working toward representation and diversity within the field of dermatology was reaffirming. The energy after the event can only be described as electric. Students passed down words of wisdom about specific programs, such as UIM visiting clerkship programs, and joined shared social media platforms that provided encouragement and support for prospective UIM applicants.
Students also had the opportunity to connect with dermatology residents and attending physicians at a variety of institutions to begin developing professional mentorships. Dr. Pearl Grimes, former president of the WDS, attended the event. She shared that similar programs, such as the Champions of Diversity meeting, are ''profoundly moving and insightful. More than 90 participants from multiple dermatology residency programs were in attendance. The presentations and panel discussions regarding the need to increase underrepresented minorities in Dermatology truly resonated with all the participants." There are countless benefits of increasing minority representation in dermatology, including but not limited to providing a more robust educational experience, improving the patient-provider relationship, becoming more representative of the population, and leaning into our longstanding social justice movement for equality. A more diverse training body creates a more vigorous learning environment, patients can have improved interactions with physicians from various backgrounds, institutions can appear more approachable and trustworthy when they include a workforce reflective of the community they serve, and those who have been purposefully excluded for many years can now be included (Saha et al., 2015).
Likewise, the literature continues to demonstrate that increased ethnic diversity of physicians is associated with increased access to health care for underserved communities (Bae et al., 2016;Saha et al., 2015). A 1995 national survey found that minority physicians provided care for poor and uninsured Americans at higher rates than their nonminority counterparts (Moy and Bartman, 1995). Numerous studies have continued to validate these early findings. For example, a 2014 cross-sectional analysis in the Journal of the American Medical Association found that nonwhite physicians cared for 53.5% of minority and 70.4% of non-English-speaking patients (Marrast et al., 2014).
The recommendations put forth by leading academic societies are not only a call to action, but a challenge and an opportunity. Dermatology departments can prioritize diversity as a program mission, adopt the diversity champion program, and build on existing mentorship programs by encouraging engagement among both UIM and non-UIM mentors in programs such as the AAD's Diversity Mentorship program and WDS networking event. Dermatology departments can also examine their existing data on diversity and reflect on both strengths and weaknesses in recruitment and retention. Residency programs can make diversity an explicit goal of resident recruitment by expanding the criteria used in the residency selection process. This may include the addition of several measurements such as personal and professional journey, likelihood to address health care disparities, and assessment of grit, cultural competence, and emotional intelligence as recommended by the AAD (Pritchett et al., 2018b).
These objectives will test our imagination and determination, but with active engagement, dermatology can become a role model for other medical fields for diversity and inclusion. By sharing these insights, we hope that programs and organizations can have a better understanding of the obstacles encountered by minority medical students, as shared at the WDS event and ways that organizations have begun to make waves. I have repeatedly witnessed the significance of representation from the academic classroom to the wards of the hospital and benefited from meaningful mentorships with UIM physicians throughout my education. One saying still rings true: ''If you want to be it, it helps to see it."