A group of medical students organized a review of all pre-clerkship learning materials related to dermatological conditions in the Undergraduate Medical Education (UGME) to determine whether those conditions were shown on more than just white skin. Now, they’re sharing their recommendations for change in the curriculum.
“I just noticed that the majority of our lectures were only showing skin conditions on white skin tones,” Iku Nwosu, Med ’22, said in an interview with The Journal. “There were sometimes entire lectures where every single photo was only on white people and, as a Black person, it obviously was unsettling for me to see that.”
“I really just thought to myself: how would I be able to treat myself, my family members, my community members, my Black peers, Black people in general, or even just people who are of a darker complexion if we’re only being taught how things look on white people.”
She joined efforts with Aquila Akingbade, Med ’22, and Eric Zhang, Med ’23, who had both identified similar concerns with the curriculum.
“As someone who has not been able to do the dermatology block, there’s a lot of extrapolating that students are forced to do, or it feels that I’m forced to do, towards people that are not white, which is such a growing proportion of our population,” Zhang told The Journal.
“Things like that skew our ability to understand the other components and the social determinants of health that integrate into someone’s wellbeing and makes it difficult to help.”
They started their work last May and spent the summer collecting signatures on a letter they’d written about the importance of this issue—which received support
from students in every year of the program, as well as from those who had already graduated and were completing their residency—and submitting a plan to the UGME about how they wanted to
review the curriculum.
The group then enlisted the help of more than 120 student volunteers to review over 900 pieces of learning material related to dermatological conditions, marking down whether skin presentations were only shown on white skin. Their review encompassed the entire pre-clerkship curriculum, which constitutes the first two years of medical school.
“I think the vast majority of photos were the lighter skin tones,” Akingbade told The Journal. He referenced the Fitzpatrick scale, a classification system for skin colour, to explain the disparity.
“It goes from a one to a six with a one being a very pale-ish white that burns very easily to a six being the darkest skin phenotype,” Akingbade said. “We noticed that the vast majority of photos used in the curriculum were Fitzpatrick one or two, maybe three, but there were very few sixes, or fives, or fours—which obviously shows an inequity in our medical education.”
Medicine is a speciality that’s dependent upon pattern recognition, especially dermatology, he said.
“Seeing something before is what determines your ability to recognize it in the future,” Akingbade said. “If we’re not exposed to something in our pre-clerkship years or even in residency, then how in the world would you be able to diagnose that condition when you’re a practicing physician?”
“That’s why this is a huge issue. Data shows that a lot of physicians miss skin conditions in darker skinned people.”
He used melanoma as an example.
“What happens is darker skinned people have higher mortality from melanomas because they’re caught at a much later stage compared to white patients,” he said. “That has the complication of death. There’s increased death in that population of people.”
Nwosu said it’s important the medical curriculum covers these topics because physicians often make up for what they didn’t learn in the classroom through what they encounter with their patients. This learning environment varies depending on the population.
“With the Kingston-specific patient population, it’s mostly white. So, if students aren’t taught these things during our pre-clerkship, there’s not a lot of opportunity for us to fill in those gaps in clerkship,” Nwosu said.
“With that being said, it’s an issue across Canada in pre-clerkship curriculums. This is not a Queen’s specific issue. It’s a medicine issue. It’s a systemic-racism issue.”
After the review was complete, they began advocating for the UGME to get access to Visual Dx, a medical image database with a digital repository of diverse images for various skin conditions.
Access to this repository also prevents professors from encountering issues with copyright, which Akingbade said has been an issue in the past when trying to obtain photos.
They said Dr. Michelle Gibson, Assistant Dean of curriculum in the UGME, and Sarah Wickett, Head Health Sciences Librarian, were also advocates for securing access to Visual Dx for the entire Faculty of Health Sciences (FHS) through the Bracken Health Sciences Library.
The group is also making course package recommendations for individual courses, which will be sent to program directors so they can make the necessary changes for the upcoming school year.
The recommendations will include the standards that all learning material should meet and where instructors can find images to meet the criteria.
Akingbade said they created a framework that’s being used by other Canadian medical schools to review their curriculum as well.
“This entire project has really shown that students are able to organize and implement things when they decide it’s important to them, even though in an ideal world our administration—our UGME—would be the people to do this work, I think the learners—the people who are feeling it the most and who can see the gaps the most—are the best people to lead the initiative and get it off the ground to start with,” Nwosu said.
Jane Philpott, Dean of the FHS, said she’s “proud” of the work done by students to improve skin representation.
“I am incredibly proud of our students’ initiatives around skin representations, both as it relates to diversifying skin representations in the curriculum of our medical school, and building learning tools for healthcare professionals,” Philpott wrote in a statement to The Journal.
Philpott said the FHS intends to continue this kind of work through its Dean’s Action Table on Equity, Diversity and Inclusion, which has a working group tasked focused on curricular reform across the entire faculty.
“All of our curricula need to be inclusive and reflect the diversity and lived experiences of the Canadian population; work like this is not just important, it is critical. As our students have pointed out, it can save lives.”
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