Diversity in Medical Education: The Past, Present and Future
By Naabil Khan - Exeter Medical Student
In the medical curricula, students are faced with a multitude of cases and ailments as part of teaching and learning materials. Within the field of dermatology, images of atopic eczema, diabetic rashes or chicken pox scars can be witnessed over the course of medical education. A defining similarity has been noted between these images and learning tools. Most of them present with light/ white skin, posing a challenge for the future generation of doctors and healthcare workers to identify the presence of diseases in darker skin tones.
As a medical student, I have seen how diversity and representation are considered and discussed within our learning resources, and healthcare system. From Malone Mukwende’s educational site surrounding dermatology on darker skin, Mind the Gap (Malone, M., Peter, T. and Margot, T., 2020) to the comprehensive and in-depth analysis of racial bias in our healthcare system manifested in the book, Divided, by Annabel Sowemimo (Farooki, R., 2023). Leaps have been taken to reach the position we are currently facing when it comes to the movement surrounding ethnic minority representation in healthcare as a whole.
In order for a movement to continue to grow and reach larger communities, fueling steps and actions must be taken. Therefore, when I decided to create the online learning resource, Skin For All (Skin For All, 2023) my aim was focused and clear. This website will represent everyone who uses it and will support them in the process of diagnosis, treatment and further reading. This required months of careful research, engagement from other initiatives I have been involved with and a passion to help others find themselves on this platform and feel like they are seen and represented within a health-focused resource.Websites like this are vital in helping the culture of healthcare shift towards a more representative and diverse space. As seen in Salma Gilman’s paper about the issue of ill-representation in healthcare; this issue can have real-life consequences that may prove fatal. The most alarming conclusion was that the lack of diversity in medical training and dermatology textbooks had led to misdiagnoses for patients of colour. Medical professionals are often trained to focus on white patients, which can make it difficult for them to recognise symptoms of diseases on various skin tones.
One notable story referenced Lyme disease and how early recognition, diagnosis and treatment are essential in improving the prognosis. However, due to the lack of knowledge and awareness surrounding its presentation on skin of colour, these clinical milestones were missed, worsening the patient’s prognosis (Gilman, S., 2021). Thus, my resolve to create a resource like Skin For All was solidified with the presence of articles like this one adding to the already growing discussion surrounding representation in healthcare.
When looking at the NHS website, descriptions of symptoms heavily focus on lighter skin tones with a rash being described as ‘red’ or ‘pink’ and the colouration of jaundice being ‘orange tinted’. During the COVID-19 pandemic, patients were asked if their skin had gone ‘pale’ or their lips had turned ‘blue’. These descriptions are accurate, but only when observing lighter skin (Baines, 2020). Again, this lack of information given to readers means those with darker skin cannot identify with the written symptoms- therefore, failing to recognise certain conditions and thus leading to future complications regarding late diagnosis and infection.To face this issue, I made the decision to include representative language within the image descriptions and paragraphs within the disease profiles. Paired with this, the skin conditions seen on the website are split into certain sections according to the level of medical knowledge held by the user. One is for medical students (early and later years) and another focuses on “patients” who may have the condition, know someone who has the condition or wants to know more. Medical jargon is defined for non-medical users and simplified sentences are written to improve accessibility to the website’s content. Therefore, increasing the level of semantic accessibility amongst different racial groups and groups with differing medical knowledge.
The Power of Images
In 2018, the University of Washington published the first study into racial diversity in textbooks. The results highlighted the immense lack of representation of BAME groups within the medical education system. The Atlas of Human Anatomy; a popular learning tool utilised by medical schools globally, holds less than 1% of images featuring dark skin. The highest percentage reached 8%, in Bate’s Guide to Physical Examination and History Taking (McFarling, 2020). These poor results truly magnify the issue of ill-representation in medical education. In response to this issue within educational resources, Skin For All contains images chosen to represent multiple skin tones and types. It also includes a variety of condition stages to understand how these conditions impact differently on a range of skin tones. Therefore, the website aims to represent all users at every stage of their condition in an equal and clear manner.
Misinformation, confusion and distortion are commonly present when skin conditions are poorly represented among certain groups. This leads to inaccurate information being spread or no information at all; failing to adequately support and comfort patients who may be suffering from certain conditions. Therefore, the website includes an imperative feature that highlights commonly heard myths about certain conditions as well as leading questions the patient could use to help guide their conversations with their doctors. This allows the user to research further into conditions they are interested in with helpful and relevant links. Based on conversations, the use of questions for each condition has proven useful for everyone. By providing a list of recommended questions, the consultations with doctors can also be less intimidating and more structured and informative to the patient/individual.
A Call to Action
In this movement towards diversifying the medical sphere, it is important to equip readers and aspiring activists with the tools needed to continue this journey and ensure it is as sustainable as possible. Students can help support this movement by calling for more cases regarding ethnic minority patients to be integrated within their course material. Another call for the inclusion of images and recommended reading lists will further enable the normalisation of diversity. By encouraging those to engage with the conversations, speeches, materials, articles and people dedicated to the cause, we can create a culture within medical education that not only includes diversity in its teaching but accepts it as commonplace means that students from a multitude of backgrounds and ethnicities can be educated in an environment where they feel represented and a sense of belonging.
Creating Skin For All was truly an amazing experience where I learnt so much about the importance of representation, how this translates to healthcare and what components of a patient’s care should be rendered diverse, clear and accessible.
Skin For All is only one of the steps we can take to ensure the movement and conversation about ethnic minority representation continues. It is within the power of the people, non-medical and medical groups alike. We are the future of healthcare and we have the capability to ensure patients feel seen and respected; and medical students feel as supported as possible in their academic/clinical journeys.
 Mukwende, Malone; Tamony, Peter; Turner, Margot (2020). Mind the Gap: A handbook of clinical signs in Black and Brown skin. St George's, University of London. Online resource. https://doi.org/10.24376/rd.sgul.12769988.v1https://doi.org/10.24376/rd.sgul.12769988.v1
 Roopa Farooki (2023). Divided by Annabel Sowemimo review – the roots of racism in medicine. [online] the Guardian. Available at: https://www.theguardian.com/books/2023/apr/10/divided-by-annabel-sowemimo-review-the-roots-of-racism-in-medicine [Accessed 30 Aug. 2023].
 Skin For All (2023). Skin For All. [online] Skin For All. Available at: https://skinforall.co.uk/ [Accessed 30 Aug. 2023].
 Salma Abdelnour Gilman (2021). Why Doctors Misdiagnose Skin of Color. [online] EverydayHealth.com. Available at: https://www.everydayhealth.com/black-health/too-many-doctors-are-misdiagnosing-disease-on-skin-of-color/ [Accessed 30 Aug. 2023].
 Bains, C. Lack of racial diversity in medical textbooks could mean inequity in care, studies suggests. CBC website 2018; Available at: https://www.cbc.ca/news/health/racial-diversity-medical-textbooks-1.4562352
 Usha Lee McFarling. Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of colour. STAT 2020. Available at: https://www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/