Representation in Figures Depicting Penile Pathology in Urologic Textbooks

Lack of Racial Diversity in Surgery and Pathology Textbooks Depicting Diseases of the Breast

INTRODUCTION

The lack of racial diversity depicted in medical education texts may contribute to an implicit racial bias among clinicians. This bias influences outcomes, as familiarity with the various cutaneous manifestations of disease is essential to making an accurate diagnosis. To better understand the racial disparities in breast surgery, we sought to determine the extent of skin tone representation depicted in images of breast surgery and pathology textbooks.

METHODS

Textbooks were screened for color images of conditions with sufficient skin tissue present to assign the Fitzpatrick skin phototype (FSP). Figures were independently assigned an FP score (range: 1-6), and subdivided into "light skin" (FP 1-3) and "dark skin" (FP 4-6). Number of figures in each category and percentage of patients with each skin tone were calculated.

RESULTS

557 figures were included. Among 12 textbooks reviewed, seven textbooks were from the discipline of surgery, while five were pathology-related. Textbook year of publication spanned from 1996 to 2018. Overall, 533 (95.7%) figures depicted patients with light skin color versus 24 (4.3%) with dark skin color. There was no association between FP score and year of textbook publication (P = 0.69).

CONCLUSIONS

Patient images in breast textbooks are overwhelmingly of light skin tones, excluding patients with darker skin tones. The dearth of images depicting dark skinned individuals did not improve over time. Inclusion of patients of color in future textbooks may help reduce racial disparities within breast cancer care.

Expanding Understanding of Thyroid Eye Disease Manifestations to Include Hispanic and Black Patients

PURPOSE

Knowledge of thyroid eye disease (TED) is based on predominantly Caucasian populations. To date, no studies in the United States examine the presentation in Black and Hispanic patients. The purpose of this study is to introduce the presentation of TED in two previously undescribed populations.

METHODS

This is a retrospective, cross-sectional, chart review study of patients with TED at a tertiary center using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. The main outcome measure for severity was the European Group on Graves' Orbitopathy 2016 Severity Scale.

RESULTS

Of the 2905 charts reviewed, 99 met the inclusion criteria. The mean age was 51 (standard deviation 16) years with 78% women. Race was 49.4% Black, 39.1% Hispanic, 9.2% Caucasian, and 2.3% Asian. Smoking rates were 25% current smokers and 14% former smokers. Manifestations were proptosis (94% Hispanic and 91% Black), eyelid retraction (85% Hispanic and 79% Black), extraocular muscle (EOM) restriction (79% Hispanic and 63% Black), eyelid edema (41% Hispanic and 30% Black), chemosis (24% Hispanic and 14% Black), and optic neuropathy (18% Hispanic and 9% Black). Overall, disease severity was 22% mild, 65% moderate to severe, and 13% sight-threatening. Older patients had increased rates of optic neuropathy (P = 0.04). Younger patients had increased rates of proptosis (P = 0.02). Socioeconomic status was not associated with disease severity (P = 0.67).

CONCLUSION

Hispanic and Black patients with TED presented with higher than previously established rates of proptosis, EOM restriction, and optic neuropathy. Including research of different races broadens understanding of presentation and management, improving patient outcomes.

Skin Color Representation in Ophthalmology Textbooks

OBJECTIVE

Inadequate diversity in dermatologic images has been associated with diagnostic delays and poorer health outcomes. This underrepresentation of darker skin tones has also been demonstrated across various fields of medicine, including rheumatology, urology, and in the COVID-19 pandemic. The distribution of skin tones has not been examined in educational ophthalmology texts. The authors aimed to quantify the representation of skin tones across three leading ophthalmology textbooks.

METHODS

Two independent investigators utilized the Fitzpatrick's skin phototype scale to code images containing skin as either "light" (Fitz. I-IV) or "dark" (Fitz. V-VI) in three fundamental ophthalmology textbooks: Clinical Ophthalmology (Salmon and Kanski), Ophthalmology (Yanoff and Duker), and the 13 Basic and Clinical Science Course texts by the American Academy of Ophthalmology. Images without discernible skin color were excluded.

RESULTS

Of the 9766 images reviewed, 2305 images met inclusion criteria. The three textbooks combined were found to have 2123 (92.1%) images of light skin tones and 182 images (7.9%) of dark skin tones. When compared to national data that found 12.6% of individuals to have dark skin tones, the proportion of images with darker skin tones in ophthalmology textbooks was statistically significantly lower (χ ² _corr(1, N = 4996) = 211.7, p < 0.001).

CONCLUSIONS

Darker skin tones are statistically significantly underrepresented in textbooks that are central to education of trainees in ophthalmology. Acknowledgement and inclusion of skin tone diversity in ophthalmology educational materials are necessary to ensure that physicians in the field are equipped with the knowledge and training to provide the highest level of care to all patients.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01636-4.

Skin Color and Skin Tone Diversity in Human Sexuality Textbook Anatomical Diagrams

Little is known about skin tone and skin color representation within sexuality education materials. A content analysis was performed to assess skin tone and skin color diversity among anatomical images (n = 182) within eight contemporary, college-level human sexuality textbooks. Of these images, 1.1% represented dark skin tones while 83.5% represented light skin tones. Skin colors commonly associated with Black and Brown people were underrepresented in comparison to colors generally associated with white or white-presenting people such as conch, which comprised 42.3% (n = 77) of anatomical images. We encourage sex therapists to use racially conscious and inclusive imagery and educational materials when serving clients.