By Mary Butler
Early research has found ample evidence that COVID-19 has been disproportionately impacting communities of color.
Black COVID-19 patients are almost three times as likely to be hospitalized as their white counterparts, according to a Health Affairs study.
This disparity isn’t exactly a surprise to providers who have been studying the impact of social determinants of health (SDOH) for decades and who have seen firsthand how a person’s race impacts their health outcomes.
Art Papier, MD, a practicing dermatologist in Rochester, NY, and CEO of VisualDx, a diagnostic clinical decision support system. VisualDx provides a photographic database of dermatologic conditions and what they look like on a variety of skin tones. The database is intended to help emergency physicians and primary care providers—who have less experience diagnosing dermatologic conditions on darker skin tones—better address racial disparities in their practice settings. Papier spoke with the Journal about his research into racial disparities in healthcare, the role of clinical decision support, and the impact of COVID-19 in minority populations.
JAHIMA: Did your interest in racial disparities arise from your focus on dermatology or what were you seeing impacts of disparities in your own practice that made you want to study it more?
Papier: We have a fairly large African-American patient population in Rochester, where I’ve been a practicing dermatologist for 27 years. With this interest in diagnostic accuracy, it became something I was immediately attuned to. Even during my residency in the early 90s people were missing diagnoses in people of color. The problem is, if you’re white and you get a rash or inflammation of the blood vessels, your skin gets red because of blood flow. When you get that dilation in brown skin it doesn’t look red, it looks deeper brown and it can be very subtle.
So I’ve seen in my career cases of infectious disease, drug reactions, and dermatologic diseases where individuals clearly have a rash if you know how to illuminate the skin correctly. But most non-dermatologists don’t have enough experience or weren’t trained well enough. It’s really a blind spot in medical education—resources and training have been on white skin.
JAHIMA: How can training and education address this?
Papier: If you’re training in Chicago, which has a fairly large African-American population, you’re evaluating more people who have dark skin and you’re exposed to that. But if you’re going to the University of Vermont or Dartmouth in New Hampshire with a much smaller population of people of color and you do residency there, you weren’t exposed in your training to lots of cases of rashes and dark skin. Part of the solution is virtual education and using tools for the training—visual information tools that show you examples of dark skin and having those tools available as you practice.
JAHIMA: Can you talk about some of the consequences of having delayed diagnoses and inadequate training?
Papier: There’s a myth that people with dark skin can’t get skin cancer or cancer that’s life threatening. There have been stories of horrendous delays of diagnosis or diagnostic error where melanoma is missed in someone of color because of intrinsic bias—thinking that people of color don’t get skin cancer. Missing signs of inflammation in dark skin therefore delays the diagnosis in a lot of diseases. There are horrible outcomes when you miss skin cancer.
Certainly, if someone has a multi-year delay to diagnosis it can make their disease more severe. You can miss a drug reaction if a patient comes in with a rash you think will go away and you sent them home. That kind of rash can result in blistering. There are real consequences to diagnostic error and diagnostic delay.
JAHIMA: There have been well-documented racial disparities in COVID-19 infection and death rates. Can you talk a bit about racial disparities and the phenomenon of “COVID toes?”
Papier: Well COVID-19 originally was thought to be a respiratory illness, with a fever and cough. Then we realized patients might have severe diarrhea, headaches, flu symptoms, loss of taste or smell. In the last six weeks we heard about patients with skin findings, including people with reddened toes or purple toes, which is something we see in a skin condition called perniosis that’s associated with cold, damp climates in the winter.
A lot of cases were first reported in Spain or Europe two and then two and a half or three months ago we started seeing cases here in the US. We have a network of contributors so we’ve added in pictures of ‘COVID toes’ [to the VisualDx database] and we’ve also seen pictures of other rashes coming with COVID, like a viral rash of pink spots all over your body.
With these new presentations of COVID, one of the things doctors know is that diagnoses don’t often present just like the textbook and there’s lots of variation. A key to improving diagnosis is making sure doctors appreciate variation, and that goes back to the dark skin training.
You can’t just train on white skin, you have to train on dark skin. I haven’t seen any photos of COVID toes in people of color. Is that because it doesn’t happen or because doctors aren’t noticing redness of toes because skin is brown? Why don’t we have pictures of that yet?
JAHIMA: Given your studies in racial disparities, are you surprised at all with how the pandemic is unfolding and disproportionately impacting communities of color?
Papier: I’m not surprised because science is pointing to indoor transmission and crowding. The most densely populated cities, New York City being the most populated city in the country, had the worst outbreak. We’re seeing that crowded environments, such as are multi-generational families living together in tight quarters, makes for easy spread. This goes to poverty and social determinants of health. Layer on top the problem of morbidity and any pre-existing medical conditions like diabetes and hypertension, which disproportionately affect people of color. We’ve known for a long time that many African Americans have hypertension and it’s not well treated. And diabetes is a disease that affects people of poverty more frequently than people of means. Physicians that have been talking about social determinants of health and social justice and looking at our problems holistically—none of them are surprised.
Mary Butler ([email protected]) is senior editor at the Journal of AHIMA.
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