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Cultural competence in dermatology
- 1. CULTURAL COMPETENCE IN DERMATOLOGY Lindsey Lawrence, PA-S
- 2. INTRODUCTION The purpose of my literature review is to bring awareness to the gaps in the education that practitioners receive with regards to dermatology and ethnic populations.
- 3. QUESTION Does a culturally competent curriculum for clinical students improve healthcare outcomes for patients with skin tones IV-VI?
- 4. METHODOLOGY My literature review covered the following topics: - summarizing dermatologic education and training - detailing the usage of primary care for skin disease - cultural competence - the cost of dermatologic healthcare - patient education Search terms: Health care disparities, Healthcare inequities, Dermatology, cultural competence, dermatology in primary care, ethnicities, race, dermatology in emergency care, dermatology education, skin cancer, ethnic dermatology Inclusion: Skin types IV-VI, Exclusion: Skin types I-III and Articles not in English Databases: PubMed, Google Scholarly Articles, peer-reviewed articles, online magazines, government websites and databases
- 5. DEFINITIONS Acral Lentiginous Melanoma (ALM) Breslow Depth Cultural Competence Fitzpatrick Skin Phototypescale/Fitzpatrick Scale Malignant Melanoma (MM)/Melanoma
- 6. BACKGROUND The average medical school student spends about 20.5 classroom hours on dermatology (Drucker et al., 2013) The top five most common skin diseases seen by non-dermatologists are: contact dermatitis, cellulitis/abscess, rash, epidermoid cyst and tinea (Wilmer et al., 2014) Dermatologists treat only 30%–40% of patients with skin disease (Awadalla et al., 2008) The mean wait time for a new patient visit to a dermatologist is approximately 33 days (Jack et al., 2011) 47% of dermatologists and dermatology residents reported that their medical training was inadequate in training them on skin conditions in blacks (Buster et al., 2012)
- 8. SKIN CANCER RISK PERCEPTIONS: A COMPARISON ACROSS ETHNICITY, AGE, EDUCATION, GENDER, AND INCOME Objective: We evaluated skin cancer (SC) risk perceptions across race and other demographic markers and compared them to discover differences in perception that may contribute to the disparities in SC diagnosis and treatment. Methods: Respondents with no history of SC were randomly selected to answer questions assessing perceived risk and knowledge of preventive strategies of SC. Results: Blacks, the elderly, and people with less education perceived themselves as at lower risk of developing SC. Conclusion: Uncertainty and altered perceptions are more common in the SC risk perceptions of ethnic minorities, the elderly, and those with less education.
- 9. MALIGNANT MELANOMA IN PIGMENTED SKIN: DOES THE CURRENT INTERVENTIONAL MODEL FIT A DIFFERENT CLINICAL, HISTOLOGIC, AND MOLECULAR ENTITY?BACKGROUND Although the incidence of malignant melanoma in African Americans is considerably lower than in Caucasians, African Americans have a less-favorable prognosis related to later presentation and more deeply invasive lesions at diagnosis OBJECTIVE To review the current literature addressing the specific clinical, histopathologic, and molecular features of melanoma in darkly pigmented individuals RESULTS Several studies have suggested differences between lightly and darkly pigmented populations with regard to clinicopathologic character and the underlying genetic processes affecting its pathogenesis. CONCLUSION Such research may help to ameliorate the disparities in melanoma outcomes through improved screening, public health
- 10. DERMATOLOGIC DISEASE IN FAMILY MEDICINE Background and Objectives: Because dermatologic complaints are encountered frequently in primary care, the education of PCPs about skin disorders is important Methods: Study researchers analyzed the National Ambulatory Medical Care Survey data from 2002 to 2005 for dermatologic diagnoses and most common prescriptions by family physicians. The data from 2002–2005 were compared to data from 1990–1994 Results: Skin conditions accounted for 8% of all visits to family physicians in 2002–2005 Conclusions: Family physicians diagnose a wide range of skin disorders and prescribe drugs to treat them. Family physicians make more dermatologic diagnoses and prescribe more treatments than previously
- 11. TEACHING DERMATOLOGY TO INTERNAL MEDICINE RESIDENTS: NEEDS ASSESSMENT SURVEY AND POSSIBLE DIRECTIONS Background: Internal medicine trainees receive limited teaching and training in dermatology and may feel inadequately prepared to assess and manage patients with dermatologic complaints. Objective: To determine internal medicine residents’ comfort in assessing and managing dermatologic issues and their educational needs in dermatology. Methods: An electronic survey was conducted of first-, second-, and third- year internal medicine residents at the University of Toronto. Results: Fifty-four of 186 internal medicine trainees responded to our survey (response rate 5 29%). Each respondent did not answer every question. Residents were generally uncomfortable or very uncomfortable assessing and managing dermatologic issues in the emergency department (40 of 47, 85%), ward or intensive care unit (39 of 47, 83%), and ambulatory clinic (40 of 47, 85%). Conclusions: An effort should be made to increase the availability of relevant dermatology teaching and clinical exposures for internal medicine residents.
- 12. MEDICAL SCHOOL DERMATOLOGY CURRICULUM: ARE WE ADEQUATELY PREPARING PRIMARY CARE PHYSICIANS? Background: There is a lack of information regarding the dermatology learning needs of primary care physicians and residents. Objective: To determine dermatologic topics that primary care physicians consider important and to determine primary care residents’ ratings of the teaching adequacy of these topics in the undergraduate medical curriculum. Methods: Primary care physicians and residents were surveyed regarding the importance and teaching adequacy of 17 dermatologic content areas Conclusion: Seventeen content areas can be divided into 3 categories: dermatologic topics that are important and adequately taught, topics that are unimportant, and a group of important, yet inadequately taught content areas. This latter group should be further integrated
- 14. SKIN OF COLOR – A BASIC OUTLINE Darker skin differs from white skin in presentation, a tendency toward pronounced scarring, and pathophysiology of skin diseases common to those with skin of color. Recent studies highlight differences beyond the surface, which include issues of treatment, scar formation, collagen production, basic structure, and skin cancer development. Cultural Competence: being familiar with the healthcare beliefs, practices and needs of diverse patients in order to close the gap in healthcare outcomes
- 15. THE BURDEN OF SKIN DISEASES: A JOINT PROJECT OF THE AMERICAN ACADEMY OF DERMATOLOGY ASSOCIATION AND THE SOCIETY FOR INVESTIGATIVE DERMATOLOGY Background: Skin disease is one of the top 15 groups of medical conditions for which prevalence and health care spending increased the most between 1987 and 2000 Objective: This study closes the gap by estimating the prevalence, economic burden, and impact on quality of life for 22 leading categories of skin disease. Method: Data for estimating the clinical and economic burden of skin diseases were obtained primarily from several nationally representative public and private databases, including the National Health Interview Survey (NHIS), the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Surveillance, Epidemiology, and End Results database of the National Cancer Institute (NCI) Conclusion: Many of the 22 categories of skin disease addressed here disproportionately affect women, minorities, and the elderly in their prevalence, severity, and costs. Also disproportionately affected are those without health insurance coverage or who lack access to health care services
- 16. THE COST OF INITIATING APPROPRIATE THERAPY FOR SKIN DISEASES: A COMPARISON OF DERMATOLOGISTS AND FAMILY PHYSICIANSA prospective survey examining how forty-one dermatologists and forty-one family practitioners manage patients with skin diseases. The results show that dermatologists diagnose more conditions accurately, refer patients less often, charge more in professional fees, prescribe more medicines at higher cost to the patient but order laboratory tests costing less than do family physicians.
- 17. LIMITATIONS OF RESEARCH There is little research on the adequacy of current dermatologic training to produce dermatologists with cross cultural competence, confidence, and skill in treating patients from diverse backgrounds. A PubMed search of the terms dermatology, residency, and education reveals just 1 manuscript since 2000 that addresses residency training and ethnic skin There is also very little research that has been done that includes ethnic populations as part of the test groups for common dermatologic conditions
- 18. AREAS FOR FURTHER RESEARCH Didactic Education Multi-tonal photos References and Presentations Discussion Clinical Education Increased exposure to rotations diverse patient populations Confidence Surveys Clinicians and Patients
- 19. WHY IS THIS IMPORTANT FOR ME AS A PA? The importance of cultural competence for physician assistants entering and currently in the field is that PA’s are the future of primary care. Growing Diversity Financial Patient Satisfaction Provider Time
- 20. CONCLUSION Cultural competency is an important and growing facet of American healthcare. You cannot treat effectively a person you don’t understand. If patients don’t trust that you understand them and can help them they will find a practitioner that does.
- 21. REFERENCESAlexandrescu, D. T., Maslin, B., Kauffman, C. L., Ichim, T. E., & Dasanu, C. A. (2013). Malignant melanoma in pigmented skin: does the current interventional model fit a different clinical, histologic, and molecular entity? Dermatol Surg, 39(9), 1291-1303. doi: 10.1111/dsu.12251 Awadalla, F., Rosenbaum, D. A., Camacho, F., Fleischer, A. B., Jr., & Feldman, S. R. (2008). Dermatologic disease in family medicine. Fam Med, 40(7), 507-511. Bickers, D. R., Lim, H. W., Margolis, D., Weinstock, M. A., Goodman, C., Faulkner, E., . . . Dall, T. (2006). The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. J Am Acad Dermatol, 55(3), 490-500. doi: 10.1016/j.jaad.2006.05.048 Buster, K. J., You, Z., Fouad, M., & Elmets, C. (2012). Skin cancer risk perceptions: a comparison across ethnicity, age, education, gender, and income. J Am Acad Dermatol, 66(5), 771-779. doi: 10.1016/j.jaad.2011.05.021 Clark, R. A., & Rietschel, R. L. (1983). The cost of initiating appropriate therapy for skin diseases: a comparison of dermatologists and family physicians. J Am Acad Dermatol, 9(5), 787-796. Czerkasij, V. (2013). Skin of color: a basic outline of unique differences. Nurse Pract, 38(5), 34-40; quiz 40-31. doi: 10.1097/01.npr.0000428813.26762.66 Drucker, A. M., Cavalcanti, R. B., Wong, B. M., & Walsh, S. R. (2013). Teaching dermatology to internal medicine residents: needs assessment survey and possible directions. J Cutan Med Surg, 17(1), 39-45. Hansra, N. K., O'Sullivan, P., Chen, C. L., & Berger, T. G. (2009). Medical school dermatology curriculum: are we adequately preparing primary care physicians? J Am Acad Dermatol, 61(1), 23-29.e21. doi: 10.1016/j.jaad.2008.11.912 Jack, A. R., Spence, A. A., Nichols, B. J., Chong, S., Williams, D. T., Swadron, S. P., & Peng, D. H. (2011). Cutaneous conditions leading to dermatology consultations in the emergency department. West J Emerg Med, 12(4), 551-555. doi: 10.5811/westjem.2010.4.1653 Ramsay, D. L., & Weary, P. E. (1996). Primary care in dermatology: whose role should it be? J Am Acad Dermatol, 35(6), 1005- 1008. Wilmer, E. N., Gustafson, C. J., Ahn, C. S., Davis, S. A., Feldman, S. R., & Huang, W. W. (2014). Most common dermatologic conditions encountered by dermatologists and nondermatologists. Cutis, 94(6), 285-292.
- 22. QUESTIONS?
Editor's Notes
- The purpose of my literature review is to bring awareness to the gaps in the education that practitioners receive with regards to dermatology and ethnic populations. By assessing the areas for academic improvement future research in dermatologic education of health care practitioners, a more culturally competent educational curriculum can be established to account for the growing diversity in healthcare, specifically dermatology.
- Acral Lentiginous Melanoma (ALM): Melanoma affecting body protrusions; finger tips, knuckles, elbows, knees, buttocks, toes, heels and ears misdiagnosed at initial presentation as benign common skin conditions, such as warts, ulcers, fungal infections, foreign bodies, and hematomas Breslow Depth: measures in millimeters (1 mm equals 0.04 inch) the distance between the upper layer of the epidermis and the deepest point of tumor penetration. The thinner the melanoma, the better the chance of a cure Cultural Competence: being familiar with the healthcare beliefs, practices and needs of diverse patients in order to close the gap in healthcare outcomes Fitzpatrick Skin Phototypescale/Fitzpatrick Scale: A scale to classify skin tone. White skin contains various levels of pigmentation on the scale from I to III. The scale states that an individual in this range can either “always burn” or “tan slowly.” Ethnic skin types classified as IV, V, or VI are, defined as sun insensitive skin, uncommonly burns, and contains high pigmentation. Malignant Melanoma (MM)/Melanoma: a rare and serious type of cancer that begins in the skin and can spread to other organs in the body.
- the hypothesis for the study was that poor risk perception status contributes to health disparity skin cancer (SC) risk perceptions were evaluated across race and other demographic markers compared to discover differences in perception that may contribute to the disparities in SC diagnosis and treatment Results: Blacks, the elderly, and people with less education perceived themselves as at lower risk of developing SC. They, along with Hispanics, were also more likely to believe that one cannot lower their SC risk and that there are so many different recommendations on how to prevent SC that it makes it difficult to know which ones to follow. Lower education also correlated with greater reluctance to have a skin examination. Conclusion: Uncertainty and altered perceptions are more common in the SC risk perceptions of ethnic minorities, the elderly, and those with less education. These are the same groups that are subject to disparities in SC outcomes. Educational programs directed at these demographic groups may help to reduce the SC-related health disparities.
- The article looked at the presentation of MM in Caucasians and African Americans. The article found that Caucasians have great occurrence of MM in sun exposed areas and the ABCDE protocol is better applied to these patients Assymetry Border Color Diameter Evolution Family Hx Ethnic populations including AA which were studied, Puerto Ricans and Asians were shown to have greater occurrence of ALM and lesions were hidden to regular screening protocols Better protocols for providers on how to screen ethnic patients and greater patient education that highlights not only the ABCDE for lighter skinned patients but being inclusive for darker skinned patients to educate them on ethnic specific areas to look for MM lesions.
- This article looks at finding out what is seen clinically by PCPs and what medications are commonly used for treatment The article found that there was a shift in the way that PCPs were prescribing. In the 1990s prednisone, a corticosteroid, was the most commonly used drug followed by sunscreen. In the early 2000s prednisone was #3, Keflex had become #1 followed by Zyrtec. Prescribing for dermatologic conditions has become more complex since the 1990s into the early 2000s which suggests that primary care is seeing and treating more difficult skin infections
- An electronic survey was distributed to 1st, 2nd and 3rd internal medicine residents to determine their comfort with assessing and managing dermatologic issues and their educational needs in dermatology. Residents were generally uncomfortable or very uncomfortable assessing and managing dermatologic issues in the emergency department (40 of 47, 85%), ward or intensive care unit (39 of 47, 83%), and ambulatory clinic (40 of 47, 85%). Residents thought that various clinical and didactic dermatology exposures would be useful to their training as internists. Case based teaching and ambulatory clinical rotations were felt to be particularly valuable. Additionally, 38 of 46 (83%) respondents wanted to learn how to perform punch biopsies. One intervention mentioned was a recently instituted program at the University of Toronto is Dermatology Consult Case Rounds. These rounds are led by dermatology residents who prepare interactive presentations based on recent inpatient consultations from internal medicine services. The aim is to recreate relevant clinical encounters in a classroom setting as a platform for dermatology teaching to a larger group of learners. These presentations teach internal medicine trainees approaches to the assessment and management of dermatologic conditions, along with disease-specific teaching.
- Primary care physicians and residents were surveyed regarding the importance and teaching adequacy of 17 dermatologic content areas To determine dermatologic topics that primary care physicians consider important and to determine primary care residents’ ratings of the teaching adequacy of these topics in the undergraduate medical curriculum.
- The green and red circles show areas that 50% of PCPs thought were important Skin infections, NMSC, Psoriasis, acne, rosacea and warts were thought to be inadequately taught by more resident’s who did not participate in dermatology rotations but than resident’s who did participate in a rotation Resident’s who participated in rotations felt better prepared to diagnose, treat and manage more conditions than those without exposure to rotations.
- Darker skin differs from white skin in presentation, a tendency toward pronounced scarring, and pathophysiology of skin diseases common to those with skin of color. There has been a growing sense of frustration among descendants of Hispanics, Latin Americans, Asians, American Indians (which also includes Pacific Islanders), and Africans, who make up the majority of the population worldwide, that healthcare providers in the United States do not understand the particular needs of their unique backgrounds. In particular, the diagnosis and care of patients with darker skin
- In 2009 the direct medical costs associated with skin-related diseases, including health services and prescriptions, was approximately $22 billion; the annual total economic burden was estimated to be closer to $96 billion when factoring in the cost of lost productivity and pay for symptom relief The five most economically burdensome, based on direct and indirect costs, are skin ulcers and wounds, melanoma, acne, non-melanoma skin cancer, and contact dermatitis, comprising a total of $22.8 billion Skin conditions also have indirect costs that are associated with lost productivity. Patients with skin conditions report experiencing significant deficits in quality of life, an intangible cost, which can exceed many non-skin related conditions because their disease process is visible to the world. Major types of symptoms include debilitating itching, mobility impairment, and severe psychosocial effects. Of those surveyed five disease areas accounted for 73% of the total willingness to pay for symptom relief: hair and nail disorders, acne, seborrheic keratosis, atopic dermatitis and human papillomavirus. The total amount that patients would be willing to pay was $40.8 billion for symptom relief
- A prospective survey examining how forty-one dermatologists and forty-one family practitioners manage patients with skin diseases. This limited study provides data which suggests that dermatologists provide more appropriate care than family practitioners in the treatment of skin diseases at no greater cost. Higher prescription costs and professional fees by the dermatologists were offset by increased laboratory testing, treatment of incorrect diagnosis and increased referrals by family physicians Feldman, et. al. extrapolated from their data that 5 million inappropriate biopsies would be performed during the 30 million outpatient visits seen by non-dermatologist at a cost of more than $765 million where dermatologists only needed to see the condition to properly diagnose What does this mean? If PCPs can be taught what to look for in their patients including those with ethnic skin they can better treat at a lower cost as the first provider to make contact with the patients.
- The goal was to determine if improvements in the areas of education could lead to an increased familiarity with dermatologic diagnoses in darker skin tones and increased confidence of clinicians to appropriately manage skin disease in ethnic populations. At this time there is further research that needs to be done.
- Cultural competency is an important and growing facet of American healthcare. As a diverse population, that is increasingly becoming more diverse, and with more patients seeking healthcare due to a changing healthcare landscape and laws it is important for clinicians to also change. Clinicians should be encouraged to incorporate more understanding of other cultures to help better treat their patient populations. You cannot treat effectively a person you don’t understand. If patients don’t trust that you understand them and can help them they will find a practitioner that does.