Bridging the gap: diversifying education in primary healthcare

This blog post is written by Sara Thompson (GP), Morounkeji Ogunrinde (GP), Zenni Emeka-Enechi (Medical student) and Natalie Amavih-Mensah (Medical student).

Racism in healthcare concerns everyone

Racism and racial inequality are deeply rooted in societies and institutions worldwide. Britain is no exception.

For many, 2020 was a clarion call to address various ills plaguing our society. Although the time in isolation and lockdown brought significant emotional stress, it also forced us to confront long-standing systemic concerns based on race and our misconceptions of one another. In 2020, the BMJ published its first special report on racism in healthcare since its inauguration in the 1800s.¹ In the UK, racial disparities occur in fields as varied as genetic counselling, artificial intelligence, and medical school admissions.² These inequalities expose ethnic minorities to a higher risk of chronic conditions.³

Racism, not race, perpetuates health disparities

The NHS is regarded as a fair and equitable tool for distributing health care services, and its accomplishments have been praised worldwide. Yet, despite this, one in five black women in the UK die in and around childbirth.⁴ Black men are ten times more likely to face discrimination when presenting with a mental health illness.⁵

Training on microaggressions and implicit bias have minimal effect on outcomes and cannot facilitate change without a corresponding shift in the system.⁶ Attempts to haphazardly reduce these disparities without addressing the root causes have been problematic e.g. the #NotsoNICE campaign.⁷ NICE proposed draft guidelines to reduce maternal mortality among Black, Asian and minority ethnic people by encouraging inducing labour.⁸ The guideline did not address the principal factors of racism and neglect, sparking outcry and disillusionment. Race-based medicine provides crude shortcuts to clinical judgement that is harmful to patients from BAME communities.⁹

World-renowned science journalist Angela Saini refers to race as a social construct that we should challenge. She reports that we “tailor” clinical decisions about patient treatment considering race without any substantial scientific basis of delineating what terms like “Caucasian” or “Black” mean¹⁰; we have created a subjective ‘science’ that is not scientific at all.

The healthcare and minority ethnic groups divide

Patients of colour are disproportionately vulnerable to misdiagnosis and undertreatment. Consequently, patients from ethnic minorities have poorer outcomes in healthcare and fewer opportunities to access healthy living.³

A lack of diverse, inclusive education precipitates insidious doubt and mistrust recently exemplified by the suspicion and hesitation of the ethnic minorities communities towards the COVID-19 vaccine.¹¹

Health Care Professionals (HCPs) and students come to accept racial biases and aggressions as the norm. Some  professionals from ethnic minority groups are reticent to voice concerns for fear of being undermined or receiving backlash. HCPs from ethnic minority groups are more likely to be blamed for errors and are victim to disproportionately more disciplinary action.¹²

Students from ethnic minority groups may not report racial aggressions because they believe their medical school will not take them seriously.¹³ There is a performance gap in UK medical schools. Black students are more likely to underperform compared to their white counterparts.¹⁴

People from ethnic minority communities are less likely to participate in research studies and initiatives to improve health outcomes. Thus, there is less data available, biasing research and policy.¹⁵

Natalie’s experiences as an ethnic minority patient

Feeling unheard and misunderstood is debilitating. I struggled with acne since high school. I was only referred to dermatology after three years. I cannot be sure if my race played a part intentionally, or unintentionally; however, significant distress was caused.

Insecurities, caused by acne, stifled my confidence. I believed that the condition defined me. My GP practice consistently dismissed my concerns making me think that the acne was my fault. I felt powerless and alone. Understanding the variations in presentation among different skin tones is not just about treating a single condition; it is also about preventing and remedying the subsequent destructive psychological thinking patterns.

The Diversifying Dermatology in Primary Care Working Group

We aim to understand the patient experience and to increase the diversity of educational resources available, we want to raise awareness that conditions as common as acne and eczema present differently on different skin tones and educate on how to better diagnose and manage these conditions on darker skin. We won a “Listen and “Learn” grant, with which we held interviews to understand service users’ experience. Mimms Learning has developed an e-learning module addressing several questions on how and when black skin will look significantly different. ¹⁶ Our collaboration with Black & Brown Skin aims to facilitate community members to continue to support each other by creating a forum for shared experiences and a growing image library accessible to clinicians worldwide.

We hope that, by increasing the variety of resources available, the quality of education will improve, leading to higher quality care for patients thus enhancing patients’ trust in the health care service created to treat and serve them.

Conclusion

Reform takes time. We need to overturn and redefine ideas about race that have persisted for centuries. There will be uncomfortable conversations and we will have to overcome indifference and resistance to change.

Decolonising the curriculum is not a fad; it is something that we must continue, even when the world is not watching. With dedication, persistence and unity, there is hope for a better future – for all skin tones.

Additional Information

Quiz on Dermatology in Black and Brown Skin

Bimpe and Zainab: Bimpe (UCL medical student) talking to Zainab about atopic dermatitis.mp4

Zenni and Malone:Zenni (UCL medical student) interviewing Malone Mukwende (Founder of blackandbrownskin.co.uk).MOV

Honey and Natalie:Honey (UCL medical student) talking to Natalie about acne vulgaris.mp4

References

1. https://www.bmj.com/racism-in-medicine
2. Adebowale, V., Rao M. Racism in medicine: why equality matters to everyone. BMJ [online] 2020;368:m530 . Available from: doi: https://doi.org/10.1136/bmj.m530
3. McKenna, H., 2019. Professor David Williams on racism, discrimination and the impact they have on health. [podcast] The King’s Fund. Available from: <https://www.kingsfund.org.uk/audio-video/podcast/david-williams-racism-discrimination-health>
4. https://www.bmj.com/content/372/bmj.n152
5. https://www.mind.org.uk/news-campaigns/legal-news/legal-newsletter-june-2019/discrimination-in-mental-health-services
6. Sharda S, Dhara A. It’s Time To Talk: Gender and Race in Medicine. CMAJ Blogs July 2019
7. Lewin, L. The #NotSoNice Campaign [online]. The OBS: England; 2021 [Accessed 30th August 2021] Available from: https://the-obs.co.uk/your-doula/
8. National Institute for Health and Care Excellence. ​​NICE recommends offering women induced labour earlier in new draft guidance [online]. NICE: London; 2021 [Accessed 20th August 2021]. Available from:https://www.nice.org.uk/news/article/nice-recommends-inducing-women-in-labour-earlier-in-new-draft-guidance
9. Chadha, N., Lim, B., Kane, M., et al. Toward the Abolition of Biological Race in Medicine. UC Berkeley [online] 2020; 4-6, 16-19. Available at: <https://escholarship.org/uc/item/4gt3n0dd>
10. https://www.angelasaini.co.uk/
11. Lockyer, B, Islam, S,  Rahman, A, et al;  the Bradford Institute for Health Research Covid-19 Scientific Advisory Group.  Understanding COVID-19 misinformation and vaccine hesitancy in context: Findings from a qualitative study involving citizens in Bradford, UK. [online]. Health Expect.  2021; 24: 1158– 1167. Available from: https://doi.org/10.1111/hex.13240
12. Majid, A. What lies beneath: getting under the skin of GMC referrals BMJ [online] 2020;368:m338 . Available from: doi: https://doi.org/10.1136/bmj.m338
13. Kmietowicz, Z. Are medical schools turning a blind eye to racism? BMJ [online] 2020;368:m420 . Available from: doi: https://doi.org/10.1136/bmj.m420
14. Jones, A. C. , Nichols, A. C. , McNicholas, C. M. & Stanford, F. C. Admissions Is Not Enough: The Racial Achievement Gap in Medical Education. Acad Med [online]  2021;96 (2):176-181. Available from: doi:10.1097/ACM.0000000000003837.
15. Smart, A., Harrison, E. The under-representation of minority ethnic groups in UK medical research. Ethnicity & Health [online] 2017;22(1): 65-82. Available from: doi: 1080/13557858.2016.1182126
16. https://www.mimslearning.co.uk/learning-paths/skin-of-colour-disorders-of-pigmentation-and-hair-and-scalp-conditions