Investigating the changes in skin color representation within US medical textbook imagery

Medical education traditionally relies on textbooks with limited representation of dark skin tones, contributing to "visual racism." This study sought to answer: "To what extent has skin-of-color representation changed in widely used U.S. medical textbooks over twenty years?" Older and newer editions of four widely used medical textbooks were reviewed: Bates' Guide to Physical Examination and History Taking, Katzung's Basic & Clinical Pharmacology, Netter's Atlas of Human Anatomy, and Basic Immunology. Images (teaching photographs and illustrations) depicting human skin were evaluated independently by trained coders using the Fitzpatrick scale. Images were classified as skin of color when coded as Fitzpatrick Types IV-VI. Proportions of skin of color images were compared across editions. Intercoder reliability was maintained below 15%. An independent two-sided t-test was used to assess representation of darker skin tones in images over time. A total of 1222 teaching photographs and 926 illustrations met inclusion criteria. The representation of darker skin tones increased from 12.4% in earlier editions to 32.1% in later editions. Bates' (8th and 13th editions) demonstrated the largest increase and was the only text to show statistically significant improvement in photographic representation of darker skin tones (p < 0.05). Illustration-based resources (Bates' and Netter's) demonstrated modest gains (5.2% to 17.7% and 2.4% to 4.6%, respectively) but continued to underrepresent darker skin tones. The total image counts for each text varied across editions. Continued advocacy, publisher accountability, and standardized guidance for inclusive medical imagery are needed to support equitable healthcare education.