Unconscious bias can run so deep that patients and doctors alike can miss a potentially fatal diagnosis.
Jennifer Filip, PA-C
Jennifer Filip received her Bachelor of Arts degree from Penn State University and completed the Post-Baccalaureate Pre-Health Program at the University of Pennsylvania. She completed her Masters training in Physician Assistant Studies at Philadelphia University.
She is a Fellow of the American Academy of Physician Assistants and the Society of Dermatology Physician Assistants. She is board certified by the National Commission on Certification of Physician Assistants and is fully licensed by the Pennsylvania Department of State to practice Medical Physician Assistant duties. She is especially interested in acne, pigmented lesions, and hair loss in women. A mom of two children, Jennifer also enjoys yoga, gardening, and is an avid scrabble enthusiast.
DDx SEASON 2, EPISODE 3 TRANSCRIPT
The Source of the Bleed
Raj: The patient is an 82-year-old African-American male who presents with complaints of a spot on the bottom of his foot that’s been present for years. His wife made him finally go see a doctor because he was leaving blood on the floor when he walked.
Raj: This is DDx, a podcast from Figure 1 and Novartis about how doctors think. This season is all about dermatology. I’m Dr. Raj Bhardwaj. Today’s case comes from Jennifer Filip, a physician’s assistant.
Jennifer: I’m a physician assistant, and I work exclusively in a private dermatology practice.
Raj: The patient visited a podiatrist, who referred him to the dermatology practice where Filip works. When she saw the foot, she was struck by the size and colour of the plaque.
Jennifer: There was approximately a six centimeter black dark plaque on the bottom of his left foot and in the middle there was an ulcer that was about a centimeter in size and it wasn’t bleeding when I saw it. The way that the story had been presented to me, it almost sounded like there maybe was a bleeding wart on the bottom of his foot. So to see something of that size was very surprising. And the only reason that he had presented to our clinic was because his wife had become annoyed that he was bleeding on the floor when he was walking. That part of the story was very concerning.
Raj: The patient believed he had an explanation for what had happened.
Jennifer: He states that he had pigmentation on the bottom of his foot since high school.
Raj: He was a runner. He told her he’d been on the track team in high school.
Jennifer: Part of being on the track team, for some reason, the coaches had them put tar on onto the bottoms of their feet, which I assume was to make the feet tougher or something of that nature. But he was convinced that he had some tar on the bottom of his feet that had been somehow trapped in the skin and just never could be washed out.
Raj: Filip brought in the clinic’s surgeon to do a punch biopsy, which they then sent to the dermato-pathologist. They were worried that they were dealing with a large acral lentiginous melanoma. “Acral” refers to extremities, and the soles of the feet are one of the most common locations to find melanoma in people of colour.
Jennifer: So I think that it’s just been — it’s just known that that’s the kind of melanoma that we see in skin of color.
Jennifer: But the pathology report came back a little bit different. So it came back as a primary malignant melanoma, at least 0.8 millimeters in depth. It’s a sign of it being a pretty aggressive melanoma.
Raj: When Filip told the patient, he was shocked. He didn’t know it was possible for a black person to get melanoma.
Jennifer: Absolutely. Just in total disbelief. It was as if they hadn’t heard of it before. They hadn’t heard of anyone else in their family having melanoma or skin cancer. They weren’t aware that somebody with African-American skin could get melanoma.
Raj: She had to decide where to send him. There’s a well-known clinic nearby.
Jennifer: But they’re a little bit difficult to get patients in to be seen in a timely fashion.
Jennifer: So there’s a smaller hospital in the city that focuses primarily on cancer care and has a department of cutaneous oncology. And that’s where we sent this patient. And we thought to ourselves, is this going to result possibly in some amputation of the foot or will they actually be able to to do a surgery to try to get a very large melanoma out of this person’s foot without. You know, that would still allow him to be able to walk and to be comfortable and, you know, still have a quality of life.
Raj: The patient went through surgery with a podiatrist specializing in cutaneous oncology.
Jennifer: And he had the entire plaque excised and it was found to be 4.2 millimeters in depth, which is a pretty deep melanoma and the margins were negative. So it turns out that he had a full workup for metastatic melanoma and that included a chest X-ray and hold on..let me just make sure I have this right. So what ended up happening was after chest imaging, it was revealed that there was a very diffuse large B cell lymphoma. You know, that they saw on a chest X-ray and that actually became more of a prominent health issue.
Jennifer: So it’s likely that without the presentation of the melanoma on the bottom of his left foot, they would not have found the B cell lymphoma in the rest of his body.
Raj: Filip thinks that healthcare practitioners need to be more aware of skin cancer in people of colour, especially considering the bias that’s often built in to medical education. Textbook photographs routinely feature images of rashes and other skin conditions on white skin, making it harder for some healthcare practitioners to quickly identify the same conditions in people with darker skin.
Jennifer: African-americans are often overlooked as patients that could develop skin cancer and they don’t realize that they are also at risk. I remember just thinking at the time that there’s disparities in health care. It’s just very unfortunate that I think, you know, we’re not looking for skin cancer in this particular population. And it often gets overlooked. But by the time that it’s found the outcomes are often worse. It’s much more advanced. It wasn’t picked up. It doesn’t present the same way that it does in people with light skin.
Raj: According to the American Academy of Dermatology, skin cancer in patients with skin of color is typically diagnosed in later stages. Because of this, they are less likely to survive melanoma than Caucasian patients. Patients with darker skin are also more likely to develop skin cancer in areas that aren’t commonly exposed to the sun, like the palms of the hands, the soles of the feet, the groin and the inside of the mouth.
Although melanoma is more commonly found in people with lighter skin, survival rates for people of color are much lower. The Centers for Disease Control lists the 5-year survival rate for melanoma at 66.9% for Black people, and 89.2% for White.
Jennifer: So, it’s like, of course, like we’re talking about race and we’re trying to be as sensitive as possible, and that’s something that I struggle with really everyday when even when I’m talking to patients. But if you don’t think about it, you won’t see it and you won’t suspect it. And you have to be on alert. You know, just because most of the skin cancers that we see occur in white patients. It could have devastating, devastating outcomes in patients who are African-American or even Hispanic or Asian, because we don’t expect to see skin cancers in that population.
Jennifer: But yeah, just. I shouldn’t be saying this, but it’s like dermatology is like white men studying other white men. It’s kind of like, you know, a study of white skin. And so no one thinks to look to check for it, to even think about it.
Raj: After seeing this patient, Filip changed her approach to people of color who present with skin problems.
Jennifer: Ever since then, I have… I do a good number of skin exams on patients who are African-American. And I teach them that you have to look at the bottom of your feet, the palms of your hands, your fingernails, because this is where you’re more likely to get skin cancer. And just because you’re less likely to get skin cancer if your skin is darker, it doesn’t mean that you can’t get it.
Thanks to Jennifer Filip for speaking to us.
This is DDx, a podcast by Figure 1.
Figure 1 is an app that lets doctors share clinical images and knowledge about difficult-to-diagnose cases.
Novartis is a global healthcare company that provides solutions to the evolving needs of patients worldwide.
I’m Doctor Raj Bhardwaj, host and story editor of DDx. You can follow me on Twitter at RajBhardwajMD.
Ddx is produced by David Crosbie for Earshot Podcasts.
Sound design and mixing by Chandra Bulucon.
Our theme music is by Nathan Burley.
The executive producers of DDx are Jesse Brown and Kevin Sexton.
Head to Figure1.com/ddx, where you can find full show notes, photos, and speaker bios.
This episode was brought to you by Novartis Pharmaceuticals Corporation.
Thanks for listening.