At UCSF’s Skin of Color Clinic, alumna Jenna Lester addresses disparities in patient care.
No one enjoys looking at photos of sexually transmitted infections. But they were particularly disturbing to Jenna Lester MD’14 when she was a medical student at Brown.
“I remember distinctly leaving a lecture,” she recalls, and turning to her friends and asking, “Was that just in my head or was that real, that they only showed dark skin with syphilis?”
She wasn’t imagining it. In a review of dermatology educational materials that Lester published in 2019, she found that roughly half of the images of STIs depicted skin of color. The bias was real.
Lester can’t point to any one moment that set her down the path to a career in dermatology, research on disparities in her field, and the establishment of the Skin of Color Program at the University of California, San Francisco, School of Medicine, where she did her residency and is now an assistant professor of dermatology.
“I wanted to be a doctor. I didn’t want to be a specific type of doctor,” says Lester, whose mother is a geriatrician and grandmother was one of the first Black nurse practitioners in New York. Then Lester helped Martin Weinstock, MD, PhD, professor of dermatology at Brown, pilot a teledermatology program at the VA. “I thought it was really cool to see how technology could improve care for people at these community-based outpatient clinics who otherwise would have to drive hours to go to a dermatologist, or just would go without,” she says.
The issue of access motivated Lester, who accepts all types of insurance—a rarity in the field. Dermatology is a “gateway specialty into the medical system,” she says. “You’re drawing them in based on something they can see, and they can’t see their high blood pressure.” That’s an opportunity to refer the patient to primary care. If they have a good experience, they’re more likely to listen.
Many patients of color tell Lester she’s the first dermatologist of color they’ve had. “They felt I implicitly could understand what they were saying and they didn’t have to spend so much time explaining themselves,” she says.
Susan Taylor, MD, a professor at the University of Pennsylvania and the founder of the Skin of Color Society, was Lester’s mentor when she rotated there during her residency. In an email, Taylor emphasizes the importance of “race concordant visits,” which studies show improve health outcomes. “Dr. Lester has an understanding of the skin and hair concerns and practices of people of African descent from her personal experiences. Her warm and caring personality creates a level of extraordinary trust and comfort,” Taylor says.
With patients and colleagues, Lester corrects myths and misconceptions. “Patients with darker skin are less likely to get skin cancer, but the chance is not zero,” she says. Melanomas on Black people tend to appear on the palms of their hands or soles of their feet. If a doctor thinks a patient’s risk of skin cancer is low, “you’re not doing a full skin check,” she says. “Then you might miss it.”
The biggest knowledge gap is in dermatology education itself. In the 2019 study of teaching materials, Lester and Taylor found the images disproportionately depicted white skin. Even written descriptions are biased. “Psoriasis is described in textbooks as it ‘classically’ appears as salmon pink patches with scale,” Lester says. “Are you saying that white skin is ‘classic’ and … everyone else is different?” Meanwhile, readers never learn how psoriasis presents on darker skin.
While Lester designed UCSF’s Skin of Color Program to better serve patients and trainees, she hopes someday it won’t be needed. “It really isn’t different dermatology. It’s just that in many settings and certainly
in our educational tools, the default is white skin,” she says.
She has her work cut out for her. Last year, Lester published a literature review of dozens of images of rashes associated with COVID-19—a disease that disproportionately sickens and kills people of color. Not one photo depicted Black skin.