What happens when medical teaching consistently defaults to a certain type of patient?
In recent weeks, an online petition has been circulating lobbying for the inclusion of BAME representation in clinical teaching in UK Medical schools. This comes off the back of the Black Lives Matter movement which has made waves not only in the USA and the UK but all over the world, galvanising people from all racial backgrounds like never before in recent history to hold systems and institutions to account for the ways in which they perpetuate racism in our respective societies. The healthcare system in the UK is one that is not exempt from this, evidenced most recently by the public outcry regarding the most recently released COVID-19 report which attributes racism as a contributing factor to the disproportionate impact of COVID-19 experienced by Black, Asian and Minority Ethnic communities. Medical education, just like other institutions, is a part of this and is long overdue for being held accountable for its shortcomings in relation to addressing BAME populations.
There are 33 Medical schools in the UK which currently produce approximately 7000 doctors each year. These doctors enter the UK healthcare workforce and eventually receive their licence to practise on the basis they possess what is considered the rudimentary skillset and knowledge base needed to treat patients and prescribe medicines. Medical schools determine what constitutes these basic competencies which the doctors they produce should have in order to effectively treat patients in the curation of curricula. What happens when medical teaching consistently defaults to a certain type of patient?
For medical students nationwide, clinical signs and manifestations of disease are taught nearly always on one particular type of patient: the white patient. Erythema, changes in pallor, cyanosis, jaundice and more are portrayed using images of white bodies as our only frame of reference. There is no frame of reference provided for patients of colour, whose increased melanin production means that the appearances of these clinical manifestations can be altered or obscured. In practical examinations, it is very rare to be met with a Black or Brown patient actor on whom you need to perform a clinical examination. This means that the first time a doctor will have to identify these physical manifestations of disease on a person of colour is beyond their stage of training; on a real-life patient in need of medical attention. How do we expect our doctors to be able to accurately identify signs of disease on people of colour if they have never been taught or received the appropriate training to do so? With people from BAME backgrounds constituting almost 20% of our national population, this is a significant incompetency which can no longer be ignored. Failure to identify signs of disease means that diagnoses are not made until a later (thus often more critical) stage of the disease process which directly impacts disease outcomes and prognoses. Frankly, it is dangerous that our nation’s doctors are not as equipped to identify dermatological manifestations of disease on people of colour compared to their white counterparts and the medical education system seems to not consider this as a major shortcoming that needs urgent rectification to improve health outcomes for such a significant proportion of our population.
The problem goes beyond the dermatological picture of disease and is a serious health matter when we consider that we live in a population that is multicultural and multi-ethnic. In my personal experience of medical school so far, the only time patients from diverse ethnic backgrounds are mentioned are in relation to FGM, tropical and infectious diseases as well as certain diseases to which they confer an increased susceptibility such as diabetes, hypertension or sickle cell anaemia. The lack of diversity in clinical teaching unconsciously limits the scope in which we view the health of people from BAME communities and enforces the notion that the health needs of people from BAME backgrounds is different and separate to the ‘rest’ of the population; that is the white population. Yes, people of minority backgrounds can get tuberculosis (as can anyone if exposed) but they are also able to suffer from asthma. It is important that, beyond their ethnic background, clinicians are able to take the entire picture of their health into consideration with the appropriate cultural sensitivity and contextualisation. The impact of not doing so can be as severe as death. When patients from diverse ethnic backgrounds are treated as though they are the exception rather than integrated into the mainframe of understanding illness and disease, it creates a disparaging difference in patient management as well as their health outcomes.
Medical schools are doing a disservice by their students and ultimately the wider population in relegating BAME people to being an afterthought in patient care. It is about time that the inability to identify signs of disease in patients of colour is considered an incompetency so fundamental that doctors in training cannot get their licence to practise. It must be considered so crucial that those who govern medical teaching and examinations would ensure that all medical students can identify disease in patients of all ethnic backgrounds, from eczema to Kawasaki’s disease. The health and ultimately the lives of people from BAME communities depend on having doctors who are able to diagnose and treat disease in them.
The British Association of Dermatology, who currently have very little by the way of references for the manifestations of dermatological conditions on darker skin complexions, have expressed they have discussed producing materials with NHS Digital to address the lack of representation of darker skin complexions in resources for dermatological conditions. While we wait for this representation to become more mainstream, resources such as @BrownSkinMatters on Twitter and Instagram have a wealth of images accessible to all that medical students and professionals can use to inform themselves of how skin changes caused by disease may appear on darker skin tones compared to white skin.
The rise of this petition, as with countless others, shows that there is power in the collective voice to evoke change in our institutions. While we cannot undo the impact which decades of oversight caused by incomplete medical training has had on patients from BAME communities, we can hope that bodies such as the General Medical Council and Medical schools all over the country will pay attention to the needs of population it serves, ensuring that our healthcare professionals are given the appropriate training which enables them to effectively treat all members of the population, no matter the colour of their skin.