I remember being in my gastrointestinal block as a second-year medical student and receiving a call from my mother that her PCP told her that she had jaundice. Immediately, I FaceTimed her to see for myself, but could not detect any abnormal yellowing of her skin or eyes over the phone. In my head, I ran through the list of differentials for adult jaundice that I had just learned: gallstones, hemolytic anemia, hepatitis, an autoimmune cholangitis, etc. I already knew my mother’s social history: she did not do drugs, drank on celebratory occasions but not often, and had not traveled anywhere recently. We had no family history of liver disease. My mother had simply gone to the doctor for her annual checkup, and though there seemed to be no cause for my mother’s jaundice, as someone so early in my training, I figured that there must be something that the board-certified doctor had caught that I had missed.
I went home that weekend to do some further digging. I looked into the whites of my mother’s eyes and the mucous membranes of her mouth, but could not find anything remotely yellow. I went so far as to do a Murphy’s sign, but the further I went into the physical exam, the more I became convinced that my mother was and looked exactly how I remembered — perfectly healthy.
When her bilirubin levels finally came back from the lab as normal, I realized that my mother did not have jaundice, she was just Asian. It baffled me that something so simple and obvious as a difference in skin color could become a red herring. Though such a mistake can seem laughable, it had real consequences for my mother, causing her much unnecessary anxiety. Unfortunately, as I continue to grow my experience in the clinic and hospital setting, I have come to increasingly understand that my mother’s story is reflective of the wider issue that medical care has a long way to go toward cultural and racial competence.
Indeed, research bears this out: Studies have shown that minority populations receive poorer quality of care and have worse clinical outcomes. Asian populations specifically are disproportionately affected by hepatitis B infection, one of the leading causes of liver cancer and a possible cause for new onset jaundice. Though infection rates in the U.S. are less than 1%, Asian Americans, who only comprise about 6% of the entire U.S. population, make up 60% of the chronic hepatitis B burden. Despite federally funded community-based efforts to increase screenings and vaccinations, the vast majority of Asian Americans remain unscreened and undiagnosed. In addition to lack of knowledge of Asian Americans as a high-risk population for chronic hepatitis B, the lack of ability to recognize the manifestations of chronic hepatitis B, such as jaundice, remains a leading barrier to proper care. Though my mother’s physician mistook my mother’s naturally yellower skin to be jaundice, one might be able to see how the situation could be reversed. Given that most Asian Americans’ chronic hepatitis B infections go undiagnosed, perhaps it is more often the case that true jaundice in an Asian American person is mistakenly assumed to be their natural skin tone rather than evidence of disease.
As the racial disparities in health care continue to come to light not only for Asian Americans but for all minority populations, my hope is that doctors, both old and new, will increasingly see the need to build their cultural competency skills. One tool that I have come to particularly rely on as I build my own skills is VisualDx, a diagnostic support platform and peer-reviewed image database that allows users to search by chief complaint, diagnoses, drug reactions, and more. By showcasing side-by-side comparisons of skin pathologies across different skin complexions, VisualDx has allowed me to easily visualize the often overlooked variations in skin presentation that remain underrepresented in traditional medical resources.
In addition to diagnostic support resources such as VisualDx, educational platforms exist such as Think Cultural Health, which offers users the ability to earn CME credits through online case-scenario-based training. By utilizing such resources, physicians, in addition to medical students, can regularly train themselves to be able to recognize outward manifestations of diseases among different races.
While research on the efficacy of cultural competence training is still being performed, early studies have shown that cultural competence training improves the knowledge, attitudes, and skills of health professionals, while also improving patient satisfaction. Although patient health outcomes have yet to evince significant change, if we can collectively learn how to embrace our patients’ differences rather than misconstrue or ignore them, perhaps one day such a mistake as my mother’s physician’s could truly be seen as silly, and the disparities can slowly be bridged.
What tools do you find helpful for closing the competency gap? Share in the comments.
Sarah Kim is a second-year medical student at Cooper Medical School of Rowan University in Camden, NJ.
Illustration by Jennifer Bogartz
