The New England Journal of Medicine
LaShyra Nolen, B.S.
Moving through the world as a black woman, I am accustomed to not being represented as “the norm.” Everything from the hue of the Band-Aids that cover my wounds to the heroes in the movies I watch makes me acutely aware of my deviation from what is typical and expected: I am black and female, whereas the world represented around me is often white and male. For me and for many members of minority groups in the United States, this realization does not come as an epiphany but is instead an essential fact that we must come to understand to navigate the world in which we live. It was not until I started medical school, however, that I realized the ways in which the standard representation of white and male might affect medical education — and consequently the quality of care that my peers and I will provide to our future patients.
I began to ponder this issue after taking my school’s mandatory in-person CPR training course. The paramedics walked in with large bags filled with plastic mannequins and opened them to reveal that all our “patients” were white male bodies. I left the 2-hour course without any knowledge of the nuances of performing CPR on patients with breasts or the potential precautions we should consider for pregnant women. These gaps are particularly troubling since women are less likely than men to receive bystander CPR because of fears regarding inappropriate touching, potential accusations of sexual assault, and causing injury.1
I had a similar feeling during a microbiology class as our professor swiftly moved through the final points of a lecture. The topic of the day was extracellular pathogens, and the star of the lesson was Borrelia burgdorferi, the bacterium known to cause Lyme disease. “A hallmark of stage 1 Lyme disease is a bull’s-eye rash, erythema migrans, which typically appears 3 days after infection,” the professor explained confidently. Behind him was an image from the Centers for Disease and Control and Prevention of a prominent red bull’s-eye rash on white skin. Shortly after the explanation, a classmate raised his hand and asked the professor, “How do you recognize this rash in patients with darker skin?” The professor responded that it is more difficult to see the rash on melanated skin (see figure) and moved on to the next slide.
Class ended and I felt unsatisfied with the idea that the answer could be so simple: “Stage 1 Lyme disease is hard to see in patients who are not white, so therefore we don’t depend on rash recognition for diagnosis.” It didn’t feel right, so I decided to look for answers. My first stop: Google. I searched “bull’s-eye Lyme disease” and the first page of images was populated with photos similar to the ones I had seen in class: a homogeneous representation of the rash on white skin. I was not surprised, but I was disappointed.
My mind started racing with questions: “Is the diagnosis of Lyme disease in black and brown patients delayed? Do these patients therefore present with more advanced symptoms, such as neurologic disorders and arthritis, than white patients?” More research revealed that my hypotheses were correct. One study of patients with Lyme disease found that there was a higher proportion of diagnoses of arthritis (late-stage Lyme disease) and a lower proportion of diagnoses of erythema migrans (stage 1 Lyme disease) among black patients than among white patients.2 The authors concluded that this difference could be attributed to a failure to recognize early signs of the disease in black patients.
From the images in textbooks used in medical schools to the photos displayed at medical conferences, patients of color are grossly underrepresented in medical educational material.3 If medical students and trainees are taught to recognize symptoms of disease in only white patients and learn to perform lifesaving maneuvers on only male-bodied mannequins, medical educators may be unwittingly contributing to health disparities instead of mitigating them. Most worrisome, the United States may be in danger of graduating large numbers of physicians who are unable to serve the needs of our ever-diversifying patient population.
Many medical schools throughout the country have integrated courses about health disparities into their curricula and have made diversity and community engagement key pillars of their institutional missions. Such efforts may fall flat, however, if we don’t ask ourselves important questions: What is the true value of these institutional reforms if we continue to underrepresent minority populations and women in our foundational learning material — or exclude them altogether? How might this lack of representation indirectly contribute to the disparities we seek to address? And, what moral responsibility do medical schools have to ensure that students graduate with the tools and experience necessary to equitably treat these patient populations?
As a first-year medical student, I have considered steps we can take to address these inequities during the early stages of medical education. First, it is essential that medical schools obtain female-bodied mannequins so that students can comfortably learn about the nuances of performing CPR on patients with breasts. Schools could also develop a complementary curriculum addressing common misconceptions about female bodies, appropriate touching, and follow-up conversations about consent. Second, medical educators should strive to include images of more than one skin type in their learning material. Reference photos of patients with nonwhite skin have already begun to be collected on online platforms such as Brown Skin Matters and VisualDx; such collections could be used as a starting point for developing new material.4 Finally, these reforms cannot be merely isolated changes, but should be part of broader policy changes and ongoing requirements implemented at all medical institutions. This approach will ensure that these changes are lasting and become ingrained in competencies for medical practice.
Medical education is missing the bull’s-eye. The current standardized, homogeneous representation of white males in medical education is exclusionary and puts patients of color and women at risk for adverse health outcomes. These exclusionary practices are pervasive throughout medicine and are indicative of a larger problem: the systemic exclusion of these patients from clinical trials, like their underrepresentation in anatomy courses, affects the quality of care we provide to these populations.5
As a black woman and future health care practitioner, I believe that educators should reevaluate their learning material and develop curricula for all levels of medical education that ensure equal representation of all people. The existing antiquated standard of white male representation may lead even the most well-meaning medical students to perpetuate health care disparities in their future practices. Our inaction will be especially harmful for patients with intersecting marginalized identities, such as women of color, who already bear the brunt of some of our most pressing health disparities. We must act expeditiously — going beyond written commitments to diversity and inclusion — if we seek to advocate for and equitably serve these patients.
I decided to become a physician because of my goal of advocating for and serving patients of all backgrounds — including those who look like me. My hope now is that the institutions that have pledged to teach me and my peers to become mission-driven physicians will provide us with adequate tools to achieve this goal.
Disclosure forms provided by the author are available at NEJM.org.