Maimonides Evening of Research
Gene Sobol, MPH
Department of Surgery
Racial and Ethnic Diversity in Surgical Education as Reflected by Skin Tone in General Surgery Textbooks
Objectives
Disparity in healthcare is an important and timely topic. One example of such disparity appears to be the disproportionate use of lighter skin tone illustrations in surgical educational material. Visual representation of pathology in instructional material is one key element that informs decision making in surgical disease and could contribute to disparity in outcomes in underrepresented tonal groups. Our hypothesis is that visual examples of clinical pathology in surgical texts are biased as they are weighted to Caucasian skin tones and don’t accurately represent the racial distribution in the U.S. population.
Methods
Images from four commonly used general surgery textbooks were screened independently by two reviewers. Human photographic and cartoon images with adequate skin shown were included. These images were assigned a Fitzpatrick skin photo type (FP) score (1-6). The distribution of images among the 6 FP categories were compared to the expected distribution of images in the US (United States) population, as described from a previous National Health and Nutrition Examination Survey (NHANES). Differences in distribution were compared using a chi-squared test, with p-value <0.05.
Results
There were 556 total images deemed adequate for assessment from the four textbooks chosen. 169 from Sabiston, 61 from Mulholland and Greenfield, 177 from Schwartz, and 149 from ACS. 539 of these images (96.9%) were depictions of patients with light skin tone (FP scores 1-3.) while less than 4% of images were of dark-skinned individuals (FP score between 4-6.) An FP score 1 accounted for most images, comprising 477 images (86.1%). There was a 1.8% analytical discrepancy noted between the textbook reviewers. The distribution on the general US population (NHANES) is: FP score 1: 1.6%, FP score 2: 33.1%, FP score 3: 47.8%, FP score 4: 4.9%, FP score 5: 3.6%, FP score 6: 9.0%.
Conclusion And Implication
Images in the commonly used general surgery textbooks included in this study do not accurately represent the U.S. population in terms of skin tone distribution. Given that appropriate care is predicated on adequate medical knowledge, and that this knowledge is largely dependent on academic curriculum, a more accurate population-based distribution of skin tones in surgical texts’ is warranted.