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“I Don’t Go Blue.” Why Representation in Medical Education Matters.

The racial disparities with the Rona (aka COVID-19) and the global resurgence of the #BlackLivesMatter movement have somewhat forced us all to open up the dialogue about systemic and institutionalised racism. One statement that has circulated a lot in this time is: “A system cannot fail those it was never designed to protect.” – W.E.B Du Bois.

I am realising more and more the many ways in which medical education isn’t really designed with black and brown people in mind. In medical textbooks, white skin is often the default and they rarely show what skin manifestations of a disease look like on darker skin tones. A number of signs of certain conditions do not present in darker skinned people in the same way that they do in white patients or are not as easily identifiable.

If this representation is left out of medical education, how can we then expect these medical students to go on and confidently recognise these signs when they become medical doctors?

There was a day in A&E where I took notes whilst my colleague, a more senior doctor, did the talking. Just as we were about to discharge the patient, the other doctor started reeling off red flags to look out for, “If you feel short of breath or if you go blue...-” Immediately the patient interjected, “I don’t go blue.”

The term for going blue is ‘cyanosis’ and is a result of hypoxia (low oxygen supply in the body/a region of the body). In many cases, it can be a sign of a medical emergency.

I watched as my colleague backtracked, encouraging the patient to focus instead on the plethora of other signs they could look out for. But I could see the fear in the patient’s eyes. They were fixated on their hands, wondering what the dark hue of their skin would look like if it turned a potentially fatal cyanotic blue.

There were countless times in medical school, I recall learning about these terms: cyanosis (bluish skin discolouration), ’jaundice’ (yellow skin discolouration), “pallor” (becoming pale) “erythema” (redness of the skin), wondering how I would identify it on darker skin. On the rare occasion medical texts alluded to differences in certain signs and symptoms on darker skin tones, there were hardly ever images, examples or illustrations to highlight this. The first time I brought it up in an anatomy class, the response was basically ‘lol, you’ll know.’ Would I though?! You know, the first time I googled “hypoxia black skin” I came across a black dog about the same time I did a black person. (Although arguably “cyanosis black skin” would have been a better search, I was still a bit taken aback.)

One branch of medicine where this issue is particularly obvious is dermatology, the branch of medicine dealing with the skin. Studies show that “minorities are more likely than whites to have common dermatologic conditions such as psoriasis go undiagnosed.” And whilst skin cancer in Black ethnic groups is much less common when compared to their white/Caucasian counterparts, when it does happen the outcomes tend to be worse. For a common form of skin cancer, melanoma, the five-year survival rate for a Black patient is only 65% compared to 90% for white patients. This “may be attributed to skin cancers being diagnosed at a more advanced stage.” To combat this, we are seeing the introduction of concepts like ‘ethnic dermatology.’ A branch of dermatology dedicated to pigmented skin or ‘skin of colour’. But non-white skin types are not new so having to introduce this idea of ‘ethnic dermatology’ feels somewhat suggestive that non-white skin colours are an aberration that deviate from the norm.

Representation in medical textbooks and medical education is not simply a matter of wanting to feel seen or a cheeky bit of diversity and inclusion. It’s about patient safety. My colleague and I should have been trained to be confidently able to explain to that patient that a bluish tinge may have been noticeable in places like the gums, the eyes, the nail beds. Or that darker skin ‘going blue’ might be akin to dusky or ‘ashy’ skin. Or maybe we should have just not bothered bringing it up at all given that it can be difficult to explain to a layperson and is actually a somewhat late sign.

In truth, this issue really speaks to the need for increased representation across the board! Research also shows a lack of gender, age and body type diversity. This all serves as entry points for bias. The lack of representation in textbooks and curricula designed for medical education means that future and current healthcare professionals are not as well-equipped to deal with their patient populations as they should be. That is dangerous.

Okay, so what can you do?

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