Lack of Racial and Ethnic Diversity in Surgical Education, as Reflected by Skin Tone in General Surgery Textbooks

Disparity in healthcare is an important and timely topic. One example of such disparity appears to be the disproportionate use of lighter skin tone illustrations in medical and surgical educational material.¹ Visual representation of pathology in instructional material is one key element that informs decision making in surgical disease and could contribute to disparity in outcomes in underrepresented tonal groups. Our hypothesis is that visual examples (illustrations) 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 United States population.

Images from 4 commonly used general surgery textbooks were screened independently by 2 reviewers from Maimonides Medical Center and SUNY (State University of New York) Downstate College of Medicine. Human photographic and cartoon images (where skin tone could be determined), with adequate skin shown, were included. These images were assigned a Fitzpatrick skin photo type (FP) score (1-6). The distribution of images among the 6 FP categories were compared to the expected distribution of images in the United States population, as described from a previous National Health and Nutrition Examination Survey (NHANES). Differences in distribution were compared using a chi-squared test, with p-value <0.05 considered as statistically significant.

There were 556 total images deemed adequate for assessment from the 4 textbooks chosen. 169 from Sabiston, 61 from Mulholland and Greenfield, 177 from Schwartz, and 149 from ACS. About 539 of these 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 and 6.) An FP score 1 accounted for most images, comprising 477 images (86.1%). There was a 1.8% analytical discrepancy noted between the textbook reviewers. The distribution on the general US population (NHANES) is: FP score 1: 1.6%, FP score 2: 33.1%, FP score 3: 47.8%, FP score 4: 4.9%, FP score 5: 3.6%, FP score 6: 9.0%.

Screening of commonly used general surgery textbooks showed a significant lack of diversity in image-based skin tone representation when compared to the United States population at large. The overwhelming majority of images were of light skin tones. Improving diversity of imagery in educational material, such as basic textbooks, might help reduce observed disparities in outcomes among surgical patients in the future.