Strengthening the chain of care
Dermatologists discuss their experiences with the Academy’s DEI initiatives, which help propel the specialty toward more comprehensive care for all patients.
By Allison Evans, Assistant Managing Editor, December 1, 2023
The American Academy of Dermatology (AAD) has taken an active role in addressing health inequities by increasing racial and ethnic diversity in the specialty of dermatology. Studies have shown that diversity in medical school enhances the preparation of all students to serve diverse populations; and diversity in the physician workforce improves outcomes not only for minoritized groups but for all patients. Although dermatology has done well in reducing gender disparities, persistent disparities remain when it comes to race and ethnicity.
Underrepresented in medicine (UIM) is defined by the American Association of Medical Colleges as racial and ethnic groups that are not represented in medicine relative to their numbers in the general population. Most commonly, these groups are Black/African American, Latinos/Hispanics, Indigenous People/Native Americans, and Pacific Islanders, which are considered UIM in dermatology.
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Key takeaways from this article:
The Academy has taken an active role in addressing the lack of racial and ethnic diversity in the specialty of dermatology through its three-year DEI plan, which includes critical programming including Pathways: Inclusivity in Dermatology and the Diversity Champion Workshop.
Starting in 2022, the Academy, in collaboration with Johnson & Johnson Consumer Health and Janssen, is working to increase the number of practicing dermatologists who are UIM in medicine over the next five years through the Pathways: Inclusivity in Dermatology program.
The Pathways program is comprised of an array of programs, including the Academy’s Diversity Mentorship Program, Skin Science, Nth dimensions programs, which include bioskills workshops, the Medical Student Symposium, and the scholar program.
The Diversity Champion Workshop, another Academy DEI initiative although not technically part of Pathways, takes place twice per year — once at the Academy’s Annual Meeting and again before the Association of Professors of Dermatology Annual Meeting where dermatology faculty, and even residents, share success stories, discuss outreach programs and initiatives, and exchange ideas.
A lack of diversity
In the United States, racial/ethnic minorities consistently experience high rates of morbidity and mortality when compared to non-minorities, even when accounting for factors known to contribute to health disparities. This problem may become increasingly relevant as the racial and ethnic composition of the U.S. population becomes increasingly diverse. According to U.S. Census data, by the year 2044 more than half of the population is projected to belong to a new majority group. The largest change will be among Latino/Hispanic Americans, who will increase from 53.3 million in 2012 to 128.8 million in 2060, comprising 31% of the population. By 2060, 15% of Americans will be Black/African American, and 8.2% will be Asian American.
“This underscores the importance of diversifying the dermatology workforce, providing culturally competent care, reducing bias in the health care setting, and ensuring ethical and inclusive research,” said Cindy Kuhn, the Academy’s vice president of member relations and engagement.
“Dermatology is currently one of the least diverse medical specialties,” said Katrina Abuabara, MD, FAAD, chair of the Academy’s Diversity Committee. “A diversity of experience and ideas has been shown to lead to stronger and more responsive organizations, which is important for the AAD to meet the needs of trainees, clinicians, and the patients that they serve.”
According to a 2015 article, Black/African American dermatologists comprise only 3% of all dermatologists, even though 12.8% of Americans are of African descent. Only 4.2% of dermatologists are of Latino/Hispanic origin compared with 16.3% in the general population, wrote Amit G. Pandya, MD, FAAD, and colleagues in a JAAD commentary.
“Dermatology remains one of the least diverse medical specialties, which is the result of multiple factors,” said Kandice Bailey, MD, a PGY-4 dermatology resident at Washington University of St. Louis.
“An important factor contributing to the lack of diversity is the narrow and stagnant number of UIM college students entering medical school,” noted Starling Tolliver, MD, a PGY-4 dermatology resident at Wayne State University in Michigan. Other factors contributing to this disparity in the field of dermatology include unconscious bias, late exposure to the specialty of dermatology during medical school training, lack of mentorship, and emphasis on criteria for resident selection, such as United States Medical Licensing Examination scores (doi: https://doi.org/10.1016/j.jaad.2018.04.003).
Pathways: Inclusivity in Dermatology
The Academy, in collaboration with Johnson & Johnson Consumer Health and Janssen, is working to increase the number of practicing dermatologists who are UIM in medicine over the next five years through the Pathways: Inclusivity in Dermatology program. “The initiatives under the Pathways umbrella, which launched in 2022, represent a comprehensive pipeline strategy,” said Brian Williams, the Academy’s senior manager of member diversity, equity, and inclusion. “The program goal is to increase diverse representation in the field of dermatology by creating opportunities for UIM from high school through residency programs to learn about and prepare for a career in dermatology.”
“Over the next five years, we hope to double the number of physicians who are UIM in dermatology residency programs, increase the number of UIM dermatologists by 3%, and increase the number of UIM faculty by 2%,” said Dr. Abuabara.
“The Pathways programs encompass the Academy’s Diversity Mentorship Program, sponsorship of Nth Dimensions pipeline programs, and resources which includes scholarships, expertise, mentorship, and hands-on experiences such as bioskills workshops, and the Medical Student Symposium,” said Brittany Whaley, the Academy’s manager of member engagement and programs. “There is also an AAD-SID gap-year fellowship and a high school outreach program called Skin Science, which debuted this year,” she added.
“Pathways is about addressing the comprehensive student journey to become a dermatologist, including high school, undergraduate, medical school, and residency,” Williams said. “We want to avoid people dropping out of the pathway by providing quality resources for individuals to be successful.”
“The Pathways program increases visibility of the Academy’s DEI efforts,” said Rebecca Vasquez, MD, FAAD, associate professor in the Department of Dermatology at UT Southwestern Medical Center, director of the department’s Health Equity Building (HEB) Committee, and deputy chair of the Academy’s Diversity Committee.
“We had all these programs, and they were kind of all over the place, and we didn’t really know what impact they were having on particular populations. Now we have these programs and we can start to look at the population that they’re having an impact on. Eventually, the goal is to have measurable data,” Dr. Vasquez said. “Ultimately, this program is about providing the best possible patient care and making sure we’re addressing historical gaps in that patient care. Also, it’s about ensuring our physicians have the best possible education of being able to diagnose and treat a wide variety of skin conditions on every skin type,” she added.
“When you talk about increasing diversity of a specialty or changing the face of a specialty, it can be daunting,” said Dr. Bailey. “There are so many moving pieces. The Pathways program gives us structure and resources where there just wasn’t before.”
Derm Career Prep
This past summer, the Academy hosted its first Derm Career Prep program, which included five days of supporting high school and undergraduate students in their exploration of dermatology at George Washington University. “The program immerses students into the field of dermatology and engages them with different aspects and knowledge around what is required to enter the specialty through medical school and matching as a resident,” Williams said.
“We hosted 27 high school and undergraduate participants over three days,” said Dr. Abuabara. “The program was run by five physician volunteers, four residents, four medical students, two guest speakers, and the program director Dr. Jaracus Copes, the president and executive director of The Applied Learning Academy, Inc. One hundred percent of attendees said they would recommend the program. Next year, we’re hoping to expand to two sites.”
“In addition to exposure to the specialty, students also received tips on how to successfully apply to medical school and continue on the pathway to a career in medicine as well as trying out typical procedures performed routinely by dermatologists,” Whaley said.
“I’m really excited to see how many of these students who’ve been participating since our entry point — the Skin Science high school outreach program — follow through the Derm Career Prep program, the Medical Student Symposium, and other medical student efforts, and end up matching as dermatology residents,” Williams said.
“The Pathways program supports our overall mission to advance dermatology,” Williams said. “We need to make sure that our workforce is representative of our patient needs throughout the United States.”
Diversity in dermatology
In August of 2020, the AAD Board of Directors approved a three-year comprehensive plan to address diversity in dermatology. View the plan at www.aad.org/DEI-plan. The plan was based on research and data that consistently show that:
In the United States, racial/ethnic minorities consistently experience higher rates of morbidity and mortality when compared to non-minorities, even when accounting for factors known to contribute to health disparities. This problem will become increasingly relevant as the racial and ethnic composition of the U.S. population becomes increasingly diverse. Racial/ethnic health disparities, in particular, occur in the context of broader current and historic social and economic inequities and involve contributing factors such as bias, discrimination, and systemic racism at the individual, institutional, and broader health care system.
Interventions to eliminate health disparities must be comprehensive and integrated into the education of FAAD dermatologists and trainees. Educational training on important concepts including cultural competence/humility, implicit bias, structural competence/humility, and health disparities is important in bridging sociocultural differences between patients and FAAD dermatologists.
Physicians who do not work with patients with skin of color in their residency or haven’t been trained with images that show diseases on individuals with darker pigmented skin are more likely to misdiagnose cutaneous disorders in people with skin of color.
Diversity in the physician workforce improves outcomes not only for minorities but for all patients. Compared to other specialties, dermatology ranks in the lower third from the standpoint of racial and ethnic diversity.
Diversity Mentorship Program
While the grouping of Academy DEI programs under Pathways is relatively new, many of these programs have been part of AAD programming for years. The Diversity Mentorship Program, for example, began in 1994. “In fact, about one-third of our medical students who have participated in this mentorship program are now practicing dermatologists,” added Whaley.
“Growing up, my interest in dermatology came from seeing loved ones and neighbors endure various dermatologic conditions,” said Dr. Bailey, a resident member of the Academy’s Diversity Committee. “Our rural community had limited access to any physician or health care provider, especially one as specialized as a dermatologist. If someone had a skin issue, it went unaddressed.”
“Unfortunately, my interest in dermatology was often met with discouragement,” said Dr. Bailey. “Many cited the specialty’s competitiveness, insinuating that I might not fit the mold. Others advised I could better serve my community through primary care. Over time, others’ opinions overpowered my own self-perception.”
But things changed for Dr. Bailey during her fourth year as a medical student when she participated in the Academy’s Diversity Mentorship Program with Dr. Robert Brodell. Pathways played a significant role in leading Dr. Tolliver to dermatology as well. “I was one of the only Black students in my science classes at Ohio State. I had significant imposter syndrome and questioned whether this path was for me. After I was introduced to the specialty of dermatology and read Dr. Pandya’s JAAD article that was a call to action to increase diversity in the specialty, I was brought to tears and realized there were people on the other side paving a way for me.”
A mentor from Ohio State connected Dr. Tolliver with Andrew Alexis, MD, MPH, FAAD, who is prominent in skin of color and DEI work within dermatology. “Through the Diversity Mentorship Program, as a medical student, I was able to spend a month at Mount Sinai and spend lots of time at their Skin of Color Institute. This was the first time I had been mentored by a Black dermatologist. Having that connection to culture and having him motivating and inspiring me, really helped me along my journey.”
“In addition to the experience, the connections forged can lead to stellar letters of recommendation, which can be the difference between someone with good grades and test scores and someone with good grades and dermatologists standing behind them,” Dr. Tolliver noted.
Become a mentor
Take part in the AAD’s Diversity Mentorship Program to provide UIM medical students with hands-on exposure to the field of dermatology. Learn more.
Diversity Champion Workshop
The Diversity Champion Workshop is the first program that came from Dr. Henry Lim’s Presidential Summit on Diversity in 2017. It now takes place twice per year — once at the Academy’s Annual Meeting and again before the Association of Professors of Dermatology Annual Meeting. Geared toward residency faculty and program directors, the workshop provides participants with an opportunity to share success stories, discuss outreach programs and initiatives, and exchange ideas. “The purpose is to drive awareness of the important role residency programs have in improving diversity in the dermatology workforce,” Whaley said.
The program aids in facilitating the establishment of diversity outreach programs and discusses what other programs are doing to improve diversity in dermatology. Some of the topics discussed include perspectives from various individuals from underrepresented communities, creating and supporting safe and inclusive spaces, and discussing the root cause of workforce diversity and health disparities.
“For a while we focused on addressing resident recruitment. Now, there’s a movement in that workshop not just to recruit, but to retain. While it’s rare for dermatology residents to fail out, if they do, they tend to be students from underrepresented backgrounds in medicine. We have to thoughtfully ask ourselves why that is, so we talk about these kinds of things and work toward mitigation strategies,” Dr. Vasquez said.
“You can get wonderful, brilliant candidates for dermatology, but if residency programs aren’t open to the possibility of assessing more than test scores, you miss a lot,” said Kuhn. “The Diversity Champion Workshop has truly helped pull the best and the brightest from all backgrounds into dermatology residency programs.”
Dr. Bailey’s first time attending the workshop, a virtual experience, was during her first year of residency. “It was amazing! I had the opportunity to speak about my experience as a Black person matching into dermatology.” She was so nervous to speak about such vulnerabilities that she turned off her camera because she didn’t want anyone to see her while talking.
“After I was done, there was an outpouring of support and encouragement from practicing dermatologists, some who knew me, and a lot who did not,” Dr. Bailey said. “It was a moment where I felt more optimistic about where our specialty can go — and where it is going.”
The workshop was instrumental in asserting Dr. Bailey’s place within the specialty. “I was encouraged to use my voice and share my story, take up space, and share my experiences without fear of negative responses.”
For Dr. Tolliver, what she took away from the experience was sheer inspiration from diversity champions like Drs. Susan Taylor and Amit Pandya. “There are so many greats out there putting so many people on their shoulders, which just inspires me to go back to my program and give back however I can.”
“While the Diversity Champion Workshop is not part of the official Pathways program, it is a critical part of our comprehensive pathway plan,” Kuhn said. “You must be able to prepare, mentor, and recruit candidates, and then pull them through and retain them in residency programs.”
“These programs are truly needed,” Dr. Tolliver stated. “They are helping facilitate closing and repairing leaky pathways so that we can get underrepresented minoritized groups into the field of dermatology. We need more programs and more resources so that we can better serve our patients. There are a lot of patient groups out there that need extra care, and this is one of the ways we can start to dismantle systemic racism, which has eroded a lot of trust in the medical community.”
While a lot of work has been accomplished in the last five or so years, there is still a long way to go, Dr. Bailey added. “There is such amazing work being done for our specialty in this space. I can’t even fathom how this will continue to evolve even just five years from now,” Dr. Bailey said.
“Increasing diversity is a means to an end: To enhance culturally competent physicians who can better serve a growing diverse patient population and expand the health care research agenda,” said Dr. Vasquez.
Become a Diversity Champion
A Diversity Champion is a dermatologist who is committed to improving diversity in dermatology and gets involved in activities to achieve this goal. Find out more.