When skin color makes a difference

Once upon a time in Barbados, there was a girl who dreamed of becoming a doctor. At age 19, she met a local physician who took her under his wing and encouraged her to follow her dream. Years later, that little girl grew up to become Dr Maria Goddard, a burn and wound care surgeon with her own practice in the state of Kansas. Maria agreed to share her experiences with our Medmastery learners and to shed light on the misconceptions about caring for patients of different races and ethnicities.

The history of wound care goes back centuries. We can find recipes of herbal concoctions used to heal wounds dating back to 2000 BCE. However, it wasn’t until the mid-1800s that the medical community started applying basic hygiene practices and a more holistic approach to treating wounds. The first person to understand the role that cleanliness, the environment, and a healthy diet can play in the wound-healing process was Florence Nightingale, who paved the way for the modern approach to wound care. The discipline has evolved relatively slowly until very recently, and Maria can testify about how it has changed dramatically over the past few years.

In the beginning, we would just do wet-to-dry dressing changes, which would mean just soaking gauze and placing it on the wound, and then removing it. Now we're in this age where there are several great technological advances for wound imaging and wound dressings.

Nowadays, clinicians have access to more diagnostic tools and treatment options, such as antimicrobial or antibiotic dressings, apps to measure the wounds, and new imaging modalities to check for deeper infections. The quality of care wound patients receive today is top-notch and will only improve going forward.

Maria loves her job, but wound care was not what she had originally planned for her future. While training to become an orthopedic surgeon, she spent some time in a burn unit. Her experience there ignited a spark, and that is when she accidentally fell in love with it. The burn unit is a unique environment because it allows physicians to work closely with patients, families, surgeons, and specialists in different areas of medicine. The opportunity to work in a multidisciplinary team and improve the lives of patients felt like the right fit for Maria. She completed two burn fellowships and became a burn and wound care specialist.

You're working closely with the surgeon. These patients would come in with very large burns or wounds, and we would get really close to the families because it involves head-to-toe care….You're taking care of the largest organ in the body, the skin. It can really be quality-of-life changing.

Patients with wounds on their legs or feet cannot walk. This means they have difficulty going back to work, spending quality time with their families, and doing other things that are important to them. Maria provides her patients with the care and connection they need to get back on their feet, both physically and psychologically. She is extremely proud to have a positive and meaningful impact on their lives. Unsurprisingly, her patients feel this connection, and they often keep her updated on their progress even after their wounds have healed.

Many different elements can influence wound healing. Factors like underlying conditions, stress, and diet can impact treatment outcomes. Having worked with colleagues in various disciplines, Maria has an excellent understanding of the bigger picture and really enjoys the multidisciplinary aspect of her job.

If we really want to do what's best for our patients, we need to get all of the specialties involved, and it gives our patients the best chance of having a good outcome. And it also builds a team within the system as well.

When patients don't respond to treatments the way they should, it is crucial to have the support of a multidisciplinary team to look at the issue from different perspectives. Today, Maria works with vascular and plastic surgeons, dieticians, physical therapists, mental health professionals, and other specialists to care for patients long term.

In deeply pigmented skin, some conditions have different characteristics. Maria explains that a first-degree burn, a superficial burn, or a sunburn may not show up as red on dark skin types. She points out that pressure injuries and pressure ulcers also look different depending on the skin tone. Maria noticed that most medical books still don't include this diversity and because of this lack of knowledge, it is not uncommon for patients of color to wait longer for a proper diagnosis of their skin conditions. Although things have changed over time and physicians are more aware of these differences, more must be done. It is essential for specialists in all disciplines to recognize potential conditions faster and start treatments sooner.

Many of the textbooks still don't describe skin conditions in a more deeply pigmented skin…There's been a delay in care, especially in things like pressure injuries and pressure ulcers, because they don't present in the same way [as those with lighter skin tones].

Skin color doesn’t make a difference only in the clinical aspect of wound healing. Unfortunately, Maria has experienced bias throughout her career because of her skin color, as well as her gender. Some patients have mistaken her for a nurse, acting surprised when she explained she was the doctor. Others have asked to be treated by a different physician. Having to deal with these situations is challenging. Yet, Maria remains professional, moves on, and thinks about what's best for patients.

Maria also points out that many patients of color distrust the healthcare system due to historical injustices committed against them. For this reason, patients might be labeled as non-compliant when they don’t adhere to recommendations. Clinicians should make an effort to understand the motivations behind this behavior and the legitimate fear and distrust patients are feeling. This lack of trust usually stems from negative experiences, a belief that their pain is not being taken seriously, or cultural differences. Clinicians must build trust over time and involve patients in decisions regarding their treatment plans. In recent years, Maria has witnessed a significant push toward diversity and inclusivity in healthcare. However, we need to ensure that this is not a temporary phase and keep working to improve the lives of patients and clinicians of all races and backgrounds.

Maria has a natural curiosity and love for learning and wears her detective hat even outside of medicine. She enjoys reading mysteries and solving puzzles or other challenges. Although she does this for fun, she sees a strong connection between her pastimes and her work.

That's sort of how I approach wound care as well. It's looking at the different clues that you're given and listening to the history, so you're getting evidence. And so I exercise that muscle when I'm doing recreation and also doing things like puzzles.

 

As mentioned earlier, Maria's career journey toward wound care wasn't straightforward, yet her previous experiences opened her mind and gave her an edge. Her holistic approach to the healing process allows her to look for clues that aren't necessarily obvious and pushes her to go deeper to find a solution to each case. Maria appreciates all the knowledge she gained working in different specialties and advises students to have similar experiences. There's much more to a medical specialty than the discipline itself, and medicine is constantly changing, even more so since the COVID-19 pandemic. For example, our parents and grandparents remember how clinicians would visit them in their homes, and we are now partially reverting to that service model. Maria says that, because of this, students should keep an open mind and consider their options from a broader perspective.

When Maria isn’t working, she tries to make time to connect with students at all education levels to discuss the different aspects of medicine with them. She believes that the best way to encourage people from minority or underprivileged backgrounds to pursue a career in medicine is to expose them to a clinical environment at an early age. Direct contact with clinicians and patients can spark student curiosity and passion for the medical profession.  

We thank Maria for this interview and for bringing up many important and sensitive topics. We are particularly grateful to her for highlighting the gaps in medical education relating to skin color and wound care. We echo her in encouraging a more understanding approach to patients of color, as well as fostering a more diverse clinician workforce. In other words, embracing diversity makes us better clinicians.