Short communicationRepresentations of race and skin tone in medical textbook imagery
Introduction
While most physicians believe that they treat patients equally, race-based treatment inequities pervade the U.S. health care system (Feagin and Bennefield, 2014; Williams, 2012). Black dialysis patients are less likely than their White counterparts to be told about transplantation, family donation, or to receive a referral to a transplant waiting list (Rangrass et al. 2015; van Ryn and Fu, 2003). Black and Latino children receive fewer bacterial diagnoses than White children, even with the presentation of the same set of symptoms (Mangione-Smith et al. 2004). Women of color are less likely to be asked about a family history of breast cancer or to be referred for a screening mammogram than White women (Hawley et al., 2000; Murff et al., 2005). Thus, it is no surprise that, relative to Whites, Latinos, Asians, and Blacks report lower quality communication (Ngo-Metzger et al., 2004) and overall interaction with physicians (Saha et al., 2003). These accounts, as well as other reports of unequal treatment based on discrimination (Rangrass et al. 2015), cannot simply be reduced to a perception problem. Random assignment experiments show that physicians treat patients with identical symptoms differently based on race (Green et al., 2007).
For this reason, scholars are now paying increasing attention to the role of the “hidden curriculum” in medical training. The hidden curriculum consists of the uncritical aspects of medical training that impact medical practice. In the case of race, while the formal curriculum emphasizes equality of care, this message is undermined when there is unequal representation in lectures, textbooks, case studies, and clinical training (Karnieli-Miller et al. 2011). Regardless of whether the underrepresentation of racial minorities in the hidden curriculum is intentional or unintentional, the result is the marginalization of racial minorities in medical education. Further, the representation of different groups sends a normative message about the kinds of patients that practitioners are likely to encounter. The presence or absence of certain racial groups may inform the association doctors make between race and disease risk. Since illness only loosely maps on to the phenotypic expression of race (Duster, 2003), groups that are underrepresented or are represented only in conjunction with particular topics could experience differential diagnoses and treatment (King and Domin, 2007).
In the current study, we define race as a social construct used to capture the experience of race relations rooted in broader structures of racial oppression and domination (Braun, 2002). Prior research on the hidden curriculum has primarily focused on the representation of race in course materials at specific medical schools (Martin et al., 2016; Tsai et al., 2016; Turbes et al. 2002). This includes an investigation into the depiction of race and gender in course slides at the University of Washington School of Medicine (Martin et al., 2016), in preclinical lecture slides at Warren Alpert Medical School of Brown University (Tsai et al., 2016), and in case studies used at the University of Minnesota Medical School (Turbes et al. 2002). These studies find that, compared to Whites, People of Color are underrepresented in both the visual and textual content of preclinical course materials (Martin et al., 2016; Tsai et al., 2016; Turbes et al. 2002). More specifically, Martin et al. (2016) found that the representation of race in lecture slides does not reflect the racial demographics of the U.S. population, with images predominantly depicting White people. Tsai et al. (2016) found that race was most frequently discussed in relation to biological “risk factors”, 14 while Turbes and colleagues (2002) state that a lack of attention to race/ethnicity in case examples reinforces whiteness as the assumed norm. We build on this body of research in a number of ways.
First, we examine the depiction of race as well as skin tone in the imagery provided in medical textbooks. An emerging literature has called attention to vast social inequalities that exist based on skin tone (Monk, 2014, 2015; Telles et al. 2015; Uzogara, 2017). Because humans are highly visual creatures, skin tone continues to serve as a significant marker of difference (Jablonski, 2012). That said, evolutionary differences in skin tone is not a claim about biological race, but merely a statement about skin color (Jablonski, 2012). Notably, darker skin, even within the same racial group, is associated with greater exposure to discrimination (Monk, 2014, 2015), an important risk-factor for many health outcomes including poorer self-rated physical and mental health, depression, and hypertension (Monk, 2015). Scholars have also found darker skin tone to be a significant and powerful predictor of higher allostatic load and higher blood pressure (Cobb et al., 2016; Harburg et al., 1978; Monk, 2015; Perreira and Telles, 2014; Veenstra, 2011), as well as lower levels of coping resources such as self-esteem (Thompson and Keith 2001). Further, the vast majority of medical imagery consists of decontextualized images of body parts where skin tone, which may be related to disease presentation, is the only phenotypical marker. These images may have been excluded from previous work because they cannot be coded for race. As Monk (2014, 2015) has forcefully argued, a focus on race alone obscures significant skin tone stratification within and across ethnoracial categories. While gradational differences in skin color within a racial group can have a profound impact on the life chances of particular group members (Monk, 2014, 2015; Murguia and Telles, 1996; Perreira and Telles, 2014), less is known about how skin tone operates in the realm of medical education.
Second, we use a sample of preclinical textbooks from medical schools across North America. The analysis of medical curriculum material beyond that provided by specific medical schools provides important information about the technical information provided to thousands of medical professionals.
Third, we consider whether racial and skin tone diversity occurs at multiple levels of the curriculum. Even if there is diversity overall, there may still be an absence of representation at some levels of the curriculum. Therefore, we consider representation not only at the textbook but also at the chapter and topic level. A singular focus on representation within a textbook may mask important complexities in the patterning of race and skin tone at the chapter (e.g., the skin) and topic levels of analysis (e.g., skin cancer).
We make these contributions by examining the representation of race and skin tone in the imagery contained in four preclinical anatomy textbooks. We are guided by two research questions: 1) To what extent is the representation of race and skin tone in the images in each of the four textbooks proportional to the distribution of race and skin tone in the U.S. population? 2) How are race and skin tone represented at the textbook, chapter, and topic-level of analysis?
Section snippets
Sample
We selected the U.S. editions of Atlas of Human Anatomy (2014), Bates' Guide to Physical Examination and History Taking (2013), Clinically Oriented Anatomy (2014), and Gray's Anatomy for Students (2015). The 2015–2016 syllabi at 20 top-ranked North American medical schools most frequently assign these books in first and second year preclinical anatomy courses. While publishers do not release sales information about books in current print, Gray's (originally published in 1858) is described as
Results
We compare the distribution of race and skin tone in the textbooks to the racial and skin tone demographics of the U.S. population where 72.4% identifies as White, 12.6% identifies as Black, and 15% identifies as Asian, American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, some other race or two or more races (Humes et al., 2011). In terms of skin tone, the 2012 American National Election Survey (ANES), which also used the Massey-Martin scale, determined that 63.4% of the
Discussion
Uneven representation in the curriculum has been identified as an important contributor to racial inequality in health care experience, treatment, and outcomes (Martin et al., 2016). On the one hand, this study shows that the overall representation of race in three out of four best-selling textbooks –Bates’, Clinically, and Gray's - is proportional to that in the population. While previous studies document an underrepresentation of racial minorities in medical curriculum (Martin et al., 2016;
Acknowledgments
We would like to thank Richard Carpiano, Sylvia Fuller, Melissa Milkie, Wendy Roth, Markus Schafer, Arjumand Siddiqi, Gerry Veenstra, Blair Wheaton, Cary Wu, and the anonymous reviewers for helpful comments.
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