The Skin I am In: A Need for Better Black Dermatology

As an admirer of my skin, I often survey it, and one day I noticed something unusual—a slightly raised section on my right inner arm near the crease. I made an appointment with my doctor who referred me to their practice’s dermatologist. 

When he first walked in the room, he looked me up and down. He may or may not have said hi to me. I remembered he uttered a sound from his mouth, but no eye contact was made; it didn’t feel like a true greeting. I was a bit uncomfortable by this but just let that part go. He then started asking me a slew of questions, which started off as normal enough. 

“N-Nkech—….So how do you pronounce your name.” This didn’t even feel like a real question.

“It’s Nkechi,” I responded hopefully. 

“And the last name?”

“It’s N-jock-uh,” I suddenly remembered all of the situations where in the doctor’s office, I hadn’t been addressed by my name or heard my name pronounced correctly. I felt that this was symbolic of his interest in me as a person. 

“Oh, so what IS THAT?” Any feelings of optimism quickly disappeared. His tone was a mix of aggression and confusion. 

I opened my mouth to respond.

“Japanese.” He stated matter of factly and frowned.

I was confused but also amused since there are no traces of Asian ancestry in my being and it felt ignorant. “No, it’s not actually, it’s—”

“It’s Japanese.” He stated again, this time, more aggressively.

“I’m Nigerian, not Japanese.” I met his firmness and now his scowl and I looked at him with why are you challenging me? eyes. I blinked slowly. We had only been in the room together for three minutes.

“Oh. Oh. OK. Well then.” he looked over his glasses. “Welcome to this country.”

“Actually, I was born here.” 

The medical practice I go to is a teaching practice, so there were four medical students that joined him after he asked me questions about where I grew up, if I had a job, where I live, and what I do for work that didn’t actually feel like small talk by his condescending tone and the perpetual scowl.

When the students came in, they lined up against the wall with their clipboards, nervously taking notes and darting their eyes between his scowl, me, and their paper.

This doctor asked me to share why I made the appointment. I explained to the group that I keep a close watch on my skin,  noticed a raised bump, and was curious about it. I was questioned about how much time I spend in the sun and if I had any other skin concerns. I said that I also had a growing mole on my left butt cheek.

I was then asked to “drop my pants.” Yet, he didn’t leave the room and neither did the medical students. I wasn’t given a gown either. I was a little confused by the request; it definitely made me even more uncomfortable than I already was and I wasn’t sure what to do. I ultimately decided that it was way easier and far more efficient to just remove my jeans in front of everyone rather than have everyone leave and come back. I don’t know if my sense of urgency was because I was embarrassed or humiliated but I wish I had paused and said something to the effect of, “Proper bedside manner would have you leave the room.” I didn’t. Instead I struggled to quickly get out of my skinny jeans while everyone watched me.

The doctor hastily told me to turn around so they could all examine my mole closely. 

“OK, we’re done with you,” he finally said in a bored voice after explaining the different types of moles and raised skin to the students. And then he says as much to them as he does to me: “So, it’s really important that you know people with this skin color don’t get skin cancer.”

Of all the horrible things I encountered with this man in the 20 minutes of this agonizing appointment, this was the most dangerous one. Above his racism, sexism, classism, and xenophobia, his racialization of medicine was the most disturbing.

What he said was simply false. Just because a person has melanin doesn’t mean that they can’t get melanoma.

People with my skin tone can get skin cancer—and they do. In fact, while non-hispanic Blacks have the lowest rates of melanoma diagnoses, they are also the most likely to be diagnosed at a later stage according to a 2016 Journal of the American Academy of Dermatology research study. So I’ll say it again: Black people can get skin cancer. What’s more is that when we do, we’re far more likely to die from it. Based on the most recent data that the American Cancer Society published, the five-year melanoma survival rate is 93 percent for white people, but only 69 percent for Black people. These findings from the 2016 study suggest that a greater emphasis is needed for melanoma screening and awareness in non-white populations to improve survival outcomes for Black skin cancer patients. 

I am incredibly inspired by the work of young Black medical student Malone Mukwende who is publishing a book titled  “Mind the Gap: A Handbook of Clinical Signs in Black and Brown Skin.” At 20-years-old, he discovered a curriculum gap in the teachings around skin diagnoses and how certain symptoms appear differently in those who aren’t white. His work highlights how problematic is to have medical text books that overrepresent white skin while not acknowledging skin differences in the presentation of disease.

When I left the doctor’s office, I felt peculiar about my experience. I was relieved that there wasn’t anything for me to worry about in terms of my skin, but I also felt the need for a second option just in case. (I did get one, and my skin is healthy.) I also felt embarrassed to share my experience with friends who followed up with me about my appointment. I was encouraged to report it to the clinic, which I did, and the doctor is no longer practicing there. I felt both strange about and disturbed by how I was treated and also how inappropriate that treatment was. 

I spoke with Dr. Tiffany Lester, a functional medicine physician, to get her perspective on doctor-patient relationships and provide modelship for what it could and should be. I started by asking about bedside manner, a term describing a doctor’s approach or attitude toward a patient, and asked her for her definition.

Dr. Tiffany Lester: It’s the unquantifiable thing you have as a healthcare professional to make someone feel safe to express their pain, their grief, their ailments with you as essentially a stranger. To meet them where they are and offer them the empathy they need in that moment. To treat them with the same care you would your dearest friend or family member.

NDN : What is appropriate protocol when asking patients to undress? 

Dr. Tiffany Lester: I typically lay out a gown or appropriate covering and then remove myself from the room while the person changes. And then knock after a few minutes before re-entering.

NDN: What sort of race/class/nationality training do doctors receive in medical school? 

Dr. Tiffany Lester: None that I am aware of. You are taught that Black people have a higher incidence of stroke and hypertension and it is assumed it is due to their Blackness. Rather than taking into affect other social determinants of health— like food inequities and access to health insurance. 

NDN: What is the most common myth about skin cancer that you know of for POC? 

Dr. Tiffany Lester: That [Black people] don’t need sunscreen and that melanin protects us from skin cancer. That we can’t get sunburns.

The entire situation made me wonder how prepared dermatologists are to care for people who exist in the margins and how much or little preparedness affects a bias. And, as was the case with my dermatologist (which was not unlike other encounters I have endured in Wester Medicine), a bias can not only be incredibly harmful; it pollutes the truth. The American Psychological Association (APA), describes implicit bias as an unconsciously held negative feeling about a person or group of people, but the person’s conscious attitude differs. This means, too, that implicit biases can be shown through a doctor’s language, actions, and worst of all, through the level of care that they provide to their patients. A few examples of his bias were the assumptions he made based on my race, gender, class and nationality. Others can include education, weight, age, ability, and gender assignment, to simply name a few. This can and does show up when they see a patient and have patient interactions. 

When we go to the doctor, we expect to be treated for our reason for being there, regardless of who we are, regardless of skin tone or race. I expect my concerns to be heard and acknowledged and investigated equitably. It is also in the Hippocratic oath that doctors  be unbiased about who they care for. So when doctors hold biases, and therefore diminish a patient’s concern or experience, not only is it physically harmful to the patient, but it can also cause emotional harm as well.

While all professionals in health care should be professional without bias (implicit or otherwise), that wasn’t the case for me. And I imagine I am not the only patient of his who has not been treated like a human being when seeking professional health care. 

This needs to change. Western medicine needs to do better for Black women and WOC.

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