Bias and Dermatology: Critically Evaluating and Actively Addressing Our Biases

By Dr. Morgan Murphrey

Earlier this year, Dr. Susan Taylor and Dr. Jenna Lester published a call for action in JAMA Dermatology, charging dermatologists to reflect on structural racism and how it manifests within our field.1 Bias plays an important role in patient interactions and encounters, as well as structural racism and inequities. Within dermatology, there are important opportunities to identify, address, and combat biases.

When people make decisions, they rely on their quick, intuitive reasoning, as well as their slow, deliberate cognitive thinking. Psychologists call this Type 1 and Type 2 processing, respectively. Type 1 thinking can be riddled with bias, often unknowingly. Implicit biases are biases that we are not consciously aware of, which affect our interactions with the world around us. A recent pilot study suggests that dermatologists are susceptible to these biases, and prescribing practices may be influenced by extraneous factors such as skin tone and sex.⁴

Thinking about type 2 processes and cognitive biases, Drs. Cohen and Burgin have identified common cognitive biases seen in dermatology, including: affective bias (where our emotions about our patients affect our type 2 processing), anchoring bias (where an initial thought or feeling anchors our perspective and prevents us from changing our mind), availability bias (where we make a diagnosis based on common diagnoses or recent patients), confirmation bias (where we seek information that confirms our own beliefs), and overconfidence bias (where we believe we know more than we actually do).⁵

Thinking back to the call to action from Drs. Taylor and Lester, we also encounter structural bias in the field of dermatology. For our patients, the authors point to the example of residential segregation and pediatric atopic dermatitis.

Within the field, dermatology is one of least diverse specialities⁶ and medical text books underrepresent dark skin tones.⁷ There is more research to be done to further identify structural issues that lead to inequities in our field and for our patients.

As we continue to define the problem, we can also think about solutions. Botto et al recently published a fantastic Bias Awareness Toolkit in our very own IJWD.⁸ They offer effective ways to deal with cognitive and implicit biases. The first and arguably most important step is reflecting and identifying our own biases. A great resource and self-evaluation tool, Implicit Association Tests, reveal our biases and can be accessed for free here. As we identify our own biases, we should work to maintain awareness and actively address them. One way to better understand other cultures or communities is to increase exposure, such as through books, podcasts, or relationships. This can help us build rapport with our patients, better understanding one another and communicating in ways they understand.

And finally, we can consider structural changes suggested by Botto et al to combat structural bias within our field.⁸ We should make every effort to aim for diverse representation in our clinical providers and cultivate a culture that honors diversity. This includes making time and safe spaces to discuss and actively address workplace diversity. In addition, considering the previously mentioned lack of representation in medical literature, we should also seek to expose ourselves to and increase representation in textbooks and learning materials. In fact, VisualDx recently launched Project IMPACT, which focuses on reducing health care bias in skin of color, and improving representation in the medical literature.

The past few years have been a dynamic time of social activism and change. As we reflect on the events in our communities, we must also reflect on our own thoughts and perspectives. The first step toward creating social change is creating change within ourselves. Armed with a better understanding of our own cognitive and implicit biases, we can actively address them, contributing to a more equitable field and discipline.


Dr. Murphrey has no conflicts of interests pertaining to this article.

1. Lester JC, Taylor SC. Resisting Racism in Dermatology: A Call to Action. JAMA Dermatol. 2021;157(3):267-268.
2. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58-ii64. 
3. Varga AL, Hamburger K. Beyond type 1 vs. type 2 processing: the tri-dimensional way. Front Psychol. 2014;5:993. 
4. Schoenberg E, Wang JV, Duffy R, Keller M. Uncovering Unconscious Bias and Health Disparities in the Practice of Dermatology. Skinmed. 2019;17(6):367-368. 
5. Cohen JM, Burgin S. Cognitive Biases in Clinical Decision Making: A Primer for the Practicing Dermatologist. JAMA Dermatol. 2016;152(3):253-254. 
6. Pandya AG, Alexis AF, Berger TG, Wintroub BU. Increasing racial and ethnic diversity in dermatology: A call to action. J Am Acad Dermatol. 2016;74(3):584-587. 
7. Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018;202:38-42. 
8. Wilson BN, Murase JE, Sliwka D, Botto N. Bridging racial differences in the clinical encounter: How implicit bias and stereotype threat contribute to health care disparities in the dermatology clinic. Int J Womens Dermatol. 2021;7(2):139-144. 

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