Skin Color Representation in Thyroid Textbooks: Lack of Imaging Diversity

Racial and ethnic disparities in the diagnosis and treatment of thyroid disease have been identified with various contributing factors, including delays in diagnosis and care, limited access to health care, and potential underlying provider bias. Individuals from racially and ethnically diverse backgrounds, particularly those with darker skin tones, have been historically underrepresented in medical textbooks; this underrepresentation contributes to the development of inherent racial biases in medical trainees when considering certain diagnoses. The potential impact that educational resources have on provider bias related to thyroid disease is limited. This study aims to assess the representation of thyroid disease in textbooks, specifically focusing on the depiction of various skin tones.

We conducted a review analyzing skin color in thyroid images from the latest editions of major textbooks with sections on thyroid disease. There were no restrictions based on language, country of publication, or patient age. We excluded images depicting thyroid trauma, black-and-white images, and illustrations. Skin color was assessed using the Fitzpatrick constitutive scale.

We analyzed 139 pictures from 22 textbooks. Most images depicted adults (95%) with benign noninfectious thyroid conditions such as goiter, hypothyroidism, and Graves' disease (46.7%). The Fitzpatrick constitutive scale depicted a predominance of lighter skin tones across all textbooks. Overall, 88% of the images depicted lighter skin tones, while only 12% showed darker skin tones. Notably, darker skin color images were absent from internal medicine books.

The underrepresentation of patients with darker skin tones in thyroid disease images is prevalent across various medical textbooks. The relative absence of depicting patients with darker skin tones in educational resources potentially contributes to provider bias in their understanding of thyroid disease. To address this disparity, we recommend a more diverse range of patient skin tones in textbook images. This approach may help mitigate disparities in the diagnosis and treatment of thyroid disease by lessening implicit bias that may develop during training.