Image Innovation: Q&A With Dr Nada Elbuluk on Project IMPACT

As a thought leader in dermatology and expert in skin of color (SOC), Nada Elbuluk, MD, MSc, FAAD saw a need to improve others knowledge of diseases in darker skin types. She is an associate professor in the department of dermatology, the founder and director of the USC Skin of Color Center and Pigmentary Disorders Program, and the founder and director of the Dermatology Diversity and Inclusion Program at the University of Southern California Keck School of Medicine in Los Angeles, CA. In addition, she serves as the Director of clinical impact for VisualDx, a clinical decision support system that combines images with a search function, and was integral in the creation of Project IMPACT, a collaborative effort to reduce health care disparities and improve care through education.

In an interview with The Dermatologist, Dr Elbuluk discussed health equity, Project IMPACT, and how clinical images can pave the way to improve dermatologic care for racial-ethnic minorities.

What would you say is the largest cause of disparities in health care among racial-ethnic minority groups?
I think that the cause is multifactorial and cannot be pinned down to one cause to account for all the disparities that affect people of color. Some of the major players, though, include unconscious and conscious bias. We have racism that exists in our society, and there are systemic issues that perpetuate that. I think that is a fact that just cannot be denied. There are also social determinants of health, things that various demographic groups may deal with disproportionately that also contribute to disparities: living in impoverished areas or lower socioeconomic status, having less access to care, having delayed diagnoses, etc. Then there are other types of biases in medicine that can also contribute to health disparities, such as representative bias and premature closure.

One of the things we focus on a lot at VisualDx is medical education. We have multiple gaps in medical education when it comes to people of color and how their health care conditions and needs can differ from individuals who are not of color. In dermatology specifically, we talk about how skin diseases can look different in darker skin vs lighter skin. If somebody is not educated or trained on that, then they may miss a diagnosis completely, or they may underdiagnose disease severity in a patient. The lack of education can directly translate into health care disparities.

How can dermatologists be more sensitive to the specific concerns of their patients with SOC?
This question begins to hit on the broader topic of cultural competence or cultural humility, which are being familiar with the practices, beliefs, ideologies, and things that exist within that person's culture and background. For example, if a patient says to their doctor, "My skin is really ashy," and the physician has no idea what that means, the unfamiliarity with that term, which is culturally used among certain patients, is a disconnect in that patient-provider relationship.

Cultural competency has multiple layers in dermatology. It can be hair care practices, including how often one washes their hair, how they style their hair, what kind of products they use, and so on. It is so important for us as physicians and health care providers to be culturally competent with our patients of all different backgrounds. When that disconnect exists, then we lose the patient and the trust that really leads to compliance. Compliance and trust can significantly change outcomes.

Education is relevant no matter the specialty in medicine. In dermatology, we need to make sure we are comfortable with treating all skin types. If you did not train in a place where you saw patients of color, then it is imperative that you get that education through multiple other routes, whether can include using a platform such as VisualDx, reading literature, or going to conferences with lectures related to these topics. It is really the responsibility of every physician and provider to be proactive in filling those knowledge gaps to become culturally competent, so that they can provide the best, and hopefully equitable, care.

Can you talk a bit about Project IMPACT and its mission?
Project IMPACT was created because we were looking at the work we were doing at VisualDx in terms of health equity and we wanted to connect with others working in this space in similar and different capacities to create a global community and umbrella initiative for resources and programming to improve health equity. As I mentioned earlier, our work focuses on improving knowledge gaps related to medical education and in SOC specifically. We have this amazing database of images, where over a third of the images are of SOC. We're really focused on making sure that people have access to this diverse database, so that they can really be comfortable with what diseases look like across all skin types.

We realize that health equity involves a multipronged approach. Medical education is part of that, but there are so many things that we need to address to try to reach that point of health equity and to try to really decrease disparities. We decided that we needed to band together with others trying to improve health equity and create something bigger than us, something truly impactful, as the name says.

IMPACT actually is an acronym, and it stands for improving medicine's power to address care and treatment. The goal is basically to work together with other like-minded organizations and individuals to really move the needle in terms of health equity. Our inaugural collaborators are New England Journal of Medicine and the Skin of Color Society, but we have since been joined by the American Academy of Dermatology, American Medical Women’s Association, Society for Investigative Dermatology, Association of Professors of Dermatology, The National Medical Association Dermatology Section and more. We continue to grow and we are excited to have a couple other collaborators who are going to be signing on soon. We look forward to working together with our collaborators to address all those factors and issues and try to make a difference in this arena.

What do you want your colleagues in dermatology to take away from your insights?
The issues and disparities that I talked about today are known, but knowing them is not enough to change them or make a difference about them. We need to take that knowledge and translate it into action. That is what we are really trying to do with Project IMPACT. We want to make a difference, and we want to work with other people who are doing that.

Change always starts with first acknowledging the problem, but then the next step is addressing it. That is where we’re at right now with Project IMPACT. At VisualDx, we are doing educational work in terms of continuing to increase our diverse database of images, creating Kodachrome teaching slide sets and other resources, to really build upon what is already out there for improving those knowledge gaps for people. Our collaborators are doing great work as well to improve research efforts, increasing recruitment of diverse populations into clinical trials, implicit bias training, among other arenas that are so important to health equity.

What I want to emphasize is this is a new effort toward change, and I encourage other physicians and health care providers to join us as well as other organizations dedicated to improving health equity. We want people and groups to join us on this journey. People can join Project IMPACT as an individual, and organizations can join us as collaborators. Industry and other for-profit groups can join us as sponsors. There are a multitude of ways to be part of this effort and make an impact on SOC health care.