American Council of Academic Plastic Surgeons
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Representation Matters: Disparities in Imaging in Plastic and Reconstructive Surgery Education Materials
Rachel M. Smith, MS Emily S. Andersen, MD Lauren E. Powell, BA Olga Schuth, MD Paschalia Mountziaris, MD, PhD Michael Feldman, MD

Background: Racial disparities permeate our healthcare system. One known contributor is implicit bias among healthcare professionals. Lack of representation among images used in medical education materials, a well documented phenomenon, contributes to such bias. Because plastic surgery relies heavily on patient images it is highly susceptible to incorporating and perpetuating racial implicit bias. This study aims to assess visual representation of patient diversity in the American Society of Plastic Surgery (ASPS) Resident Education Curriculum (REC).
Methods: Color photos, graphics, and videos featured in the “Course Materials” (excluding articles) for each module in the REC curriculum were categorized using the Fitzpatrick scale (I-II, III-IV, or V-VI) by a team of six reviewers. Proportional data and average number± standard deviation of photos and graphics for each category were reported. Significant difference between Fitzpatrick I-II and V-VI was investigated via a one-way ANOVA with Tukey’s post-test to adjust for multiple comparisons.
Results: An average of 1861 photographs and 237 graphics were assessed with 82% (1518± 25.11) of photos and 97% (231± 24.45) of graphics categorized as Fitzpatrick I-II, 12% of photos (220±9.57) and 2% (5± 2) as Fitzpatrick III-IV, and 7% (124± 2.64) of photos and 1% (2± 0.31) of graphics as Fitzpatrick V-VI. A one-way ANOVA with a Tukey’s post-test demonstrates a statistical difference between images and graphics categorized as Fitzpatrick I-II and Fitzpatrick V-VI (P<0.001). Significance was maintained despite excluding benign and malignant skin chapters (P<0.001).
Conclusion: Our data reveals an opportunity to improve racial representation in resident education. When 76% of patients in the US are white and 13% are Black, our findings demonstrate both an unequal and unrepresentative distribution of photos of non-white patients. This is furthered by the vast overrepresentation of fairer skin tones in included graphics, which are not limited by patient presentation. The discussion of implicit bias is incomplete if it does not also consider ways such biases are perpetuated (e.g. images). Residency is a formative time in a surgeon’s career and exposure to an accurate reflection of our diverse patient population is imperative.

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