E. Ajmal1, T. Meyer2, G. Sobol2, C. McKenney3, J. Nicastro2 1SUNY Downstate, College Of Medicine, Brooklyn, NY, USA 2Maimonides Medical Center, General Surgery, Brooklyn, NY, USA 3St.George’s University: University Centre, West Indies, Grenada
Introduction:
The historical biased treatment of people of color has led to deep-rooted “medical racism.” One example of this phenomenon is the disproportionate use of lighter skin tone illustrations in educational material. Visual representation of pathology in instructional material informs decision making in surgical disease, and can lead to misdiagnosis in underrepresented tonal groups. Our hypothesis is that visual examples of clinical pathology in major surgical texts are biased in that they are heavily weighted to Caucasian skin tones, and therefore fail to accurately represent the racial distribution of patients in the U.S. population.
Methods:
Four commonly used general surgery textbooks were screened independently by two reviewers from Maimonides Medical Center and SUNY Downstate College of Medicine. Images were assigned a Fitzpatrick skin phototype (FP) score (1-6). Human photographic and cartoon images (where skin tone could be determined), with adequate skin shown, were included. The distribution of images among the 6 FP categories were compared to the expected distribution of images in the US population, as described from a previous National Health and Nutrition Examination Survey (NHANES). Images were categorized into the 6 FP skin tone types and mean differences were compared using a chi-squared test, with p-value <0.05 considered as statistically significant.
Results:
Total images in all 4 textbooks were 556: 169 from Sabiston, 61 from Mulholland and Greenfield, 177 from Schwartz, and 149 from ACS. The majority of 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. FP score 1 accounted for most images, comprising 477 images (86.1%).
Conclusion:
Screening of general surgery textbooks showed a serious lack of diversity in images when compared to the U.S. population with most images comprised of light skin tones. Improving diversity and generating inclusive textbooks might help reduce apparent disparities in outcomes in healthcare in the future among surgical patients.