Why Aren't There More Black Dermatologists?

When Danielle* walked into the clinic where Laura Scott, MD, was a resident, it was the fourth time she had tried and failed to diagnose the rash on her hairline. None of the other dermatologists she’d seen could determine what was going on, but after asking a few pointed questions, Dr. Scott quickly identified the issue: tinted edge-control gel. “Everyone was blaming her wig, but she just wanted to hook up her edges with her wig. It was a mystery because no one understood the product she used,” says Dr. Scott. What led Dr. Scott to the right diagnosis? Well, for one, Dr. Scott knows what edge-control gel is. In this case, she was the first dermatologist to ask more about a product that many black women keep stocked in their hair kits.

Stories like these are common for Dr. Scott, one of the few black female dermatologists in a field dominated by white doctors. Recent data shows that only three percent of dermatologists are black, which is especially low considering that African-American people make up about 13.4% of the American population. In fact, black physicians only comprise six percent of the entire medical profession, and of all the specialties, dermatology is one of the least diverse. As a result, among the many health disparities that black women face — like being more likely to die in childbirth and less likely to be given medicine for pain management — there are also gaps in care in dermatology, where the five-year survival rate for a black patient diagnosed with melanoma, a common form of skin cancer, is only 65%, versus 90% for white patients.

In order to better serve black patients — a subset of the population that will grow to 15% by 2060 — there is a need to increase the number of black dermatologists overall, which requires taking down some of the barriers to entry for the field. “On a daily basis, I hear from my patients that they found me because they were looking for a black dermatologist,” says Andrew Alexis, MD, MPH, director of the Skin of Color Center at Mount Sinai hospital in NYC, who notes that there's a comfort level when you see a doctor that looks like you. “Patients are demanding a physician that has the cultural awareness and can empathise with their condition.” More importantly, regardless of race, dermatologists must educate themselves on the proper ways to treat brown skin and the cultural practices that affect the way we approach beauty, all while recognising the deeply-rooted biases that make black women feel overlooked.

The simple solution would be to recruit more black dermatologists to treat black women, especially since it’s been proven that visits where the doctor and patient share an ethnic background leave the patient more satisfied. But ask any medical student and they will tell you that dermatology is one of the most competitive specialties to pursue. A typical applicant’s résumé includes published research, stellar exam scores, glowing recommendation letters from dermatologists, an away rotation (where the student works at another college for a month), and an honour society membership. And even if you meet all those requirements, you could still end up not getting into a dermatology program.

“Getting into derm is like The Amazing Race or The Apprentice. It’s a constant hustle,” says Heather Woolery-Lloyd, MD, who serves as the Director of Ethnic Skin Care for the University of Miami Department of Dermatology and Cutaneous Surgery. “You can be a straight-A student and not get in. Some people have to try three times to get in, and that is discouraging.”

But even before the application process begins, many black medical students are discouraged from considering dermatology and steered toward primary-care specialties like family practice and paediatrics. “Mentors will say that primary care, obstetrics, or emergency medicine are where you see the patients who really need you,” says Dr. Scott. “But then I thought, ‘Wait, everyone needs good care.’ Disparities in dermatology are even more magnified because people don’t have dermatologists who look like them. You can still serve your community and give back in a meaningful way.”

Once a student decides to go into dermatology, it’s a long and financially draining road. There are application fees, flights for interviews, and summer research programs with little pay. “Most [minorities] are at a disadvantage,” says Dr. Scott. “In dermatology, you are expected to leave your med school and spend a month at another program working. I couldn’t do that.” Some minority students don't have extra funds to spare for private tutoring or away rotations when there are more pressing expenses, like rent. And if you don’t get into dermatology on your first try, you take a year to do more research, which strengthens your application. However, it also means postponing a full-time pay-check, which is a hardship some aspiring derms can’t afford. This financial burden disproportionately affects black students, who take on 85% more education debt than their white counterparts and face more challenges when it comes to debt repayment.

Like with many career paths, a student’s success is also greatly influenced by mentorship. If black children grow up seeing black dermatologists, they are more likely to consider the field and have a resource or advocate should they pursue a similar career. Fortunately, many health organisations have recognised this disparity, and the American Academy of Dermatology’s Minority Mentorship Program works to pair medical students from underrepresented populations with practicing dermatologists. “We try to reach out to students to shadow derms early in their medical school career so they can be exposed to it and have a cheerleader — that way it feels attainable,” says Dr. Woolery-Lloyd. There are even attempts to reach students at the high school and undergraduate levels. Some programs also offer stipends that help pay for away rotations and summer research, minimising the financial barriers to entry for minority doctors.

Even though that is a start, the power to diversify the field of dermatology lies mostly with the faculty that are reviewing the residency applications. There is a push to make the application review less about test scores and more about qualitative factors. “We promote a more holistic way to look at applicants,” says Amit Pandya, MD, former chair of the AAD Diversity Taskforce and faculty member at UT Southwestern. “Did the person grow up with a silver spoon in their mouth or are they the first to go to college? Do they speak different languages? Do they have sustained volunteerism? None of those things are grades.”

This application process will be one of the topics discussed at the first-ever Diversity Champion Workshop this September in Chicago. The event, hosted by an intersociety Work Group on Diversity in Dermatology, will bring together five major dermatology organisations and representatives from dermatology programs across the country to discuss actionable steps to increase diversity in the field.

For the three percent of black dermatologists out there, there is a high demand for their services. Oftentimes, there’s a months-long waiting list which is not only frustrating for patients, but also puts unfair pressure on the few black dermatologists who are servicing this community well. “I feel a duty to make sure [my patients] see someone who looks like me because the hospital I work at has an 80% minority population. So, I go into every patient room,” says Dr. Scott. “It’s hard. Increasing diversity so you are not one of the only ones holding up that weight is certainly going to help.”

Another thing that would help is increasing the cultural competency of all dermatologists. You don’t have to be black to give black patients the best care. However, many skin diseases and hair conditions present differently in darker skin tones, and all dermatologists have to be able to recognise the nuances. In a recent study, only 12.2% of program directors reported a rotation in which residents gained specific experience in treating patients with skin of colour. Another survey shows that 47% of dermatologists felt that their medical training didn’t prepare them to treat Black skin.

“If it’s a program that doesn’t have any black faculty, but they are seeing patients every day in Brooklyn, those residents would be very competent overall,” says Dr. Woolery-Lloyd. “Now let’s say you practice in Idaho, and in that residency, they don’t have a skin-of-colour specialty or resident who is interested [in diverse populations] — those residents aren’t going to be as well trained.” This lack of training can lead to serious misdiagnoses for black women, like mistaking a cancerous mole for an innocuous skin tag.

Part of the problem also goes back to research and curriculum; currently, there are fewer studies on darker skin tones for dermatologists to learn from. This is due to many factors, including a need for more black researchers and less representation of non-white patients in clinical trials overall. As a result, the drugs and treatments that are often praised as the latest advancements are not always deemed safe and efficacious for darker skin tones.

But in addition to a lack of formal training and research, there are also more subtle offences that fall into the “cultural competency” category. For example, Josina Reaves, 45, scheduled a dermatology appointment ahead of her wedding in order to manage her acne, but she left the Park Avenue office feeling belittled. “There was this assumption that I couldn’t afford the medication. [The doctor] immediately started off with, ‘This is probably going to be too expensive.’ Then, she added insult to injury by offering me skin-lightening treatments, even though I didn’t mention acne scars or hyperpigmentation.” For Reaves, the whole situation was pulling on a common stereotype. “There is a bias that black women automatically want to lighten their skin or that we all rolled in off the street from panhandling.”

If the dermatologists providing care or clinical trials looked like their patients, or at least demonstrated that they have the cultural competence to understand and be empathetic to their conditions and their communities, things would change for the better, says Dr. Alexis. “Thankfully there are more resources for the entire derm community to advance their skills for treating patients of colour,” he says. “At the national AAD meeting, there was an unprecedented amount of educational sessions on issues that are more prevalent in skin of colour, like hyperpigmentation and hair disorders.” Dr. Scott agrees that education is the key. "Every patient can’t come to my clinic, but we can give lectures to dermatologists at large that highlight things like hair-care practices, products people are using, and how to have these conversations," she adds.

Organizations like the Skin of Color Society also serve as a resource, providing lectures and information on how to treat certain disorders that are common among those with melanin-rich skin tones, as well as matching patients with dermatologists who specialise in treating diverse skin tones.

For Laila Fiason, 36, it’s not so much about ethnicity — it’s about being treated like a human being. When she went to the dermatologist to treat a dark rash that was creeping up her neck and face, she felt like an experiment. “They looked at me strange, I felt judged and embarrassed. [The doctor] didn’t really touch me, and they started taking pictures of me without asking,” she says. Now, she’s found a new dermatologist who takes the time to hear her concerns and treat her atopic dermatitis. “She sat down and talked with me and gave me eye contact. She touched me and assured me that everything was going to be OK. I don’t care what [the doctor’s] ethnicity is as long as they can help me in healing. Treat me as a person, not just this disease.”

*Names have been changed to protect patient privacy.