By Christine P. Lin*

*Keywords: Free clinic, Health disparities, People of color, Skin cancer

*The author has no conflicts of interest to report  

Nestled at the intersection of 34^th Street and Boston Avenue, The Free Clinic at Lubbock Impact has diligently served over 5,300 uninsured patients in the past 10 years. Every Wednesday evening from 6 to 9 PM, our clinic offers free primary care services to the uninsured Lubbock and West Texas population ages 19 to 64 years old. Specialty nights such as Dermatology, Ophthalmology, and Physical Therapy are also held every month. Texas Tech University Health Sciences Center (TTUHSC)-affiliated volunteer physicians, residents, medical students, nurses, pharmacists, social workers, and mental health counselors collaborate to see an average of 25 patients nightly.

There is a great need for accessible quality primary and specialty care services for the uninsured across the nation. The mission of The Free Clinic is to address this need. In 2018, it was estimated that 16.1% of the Lubbock population 19 to 64 years old was uninsured,¹ sitting above the national percentage of 12.5% uninsured for this population.² Known factors that contribute to health care disparities include, but are not limited to, race and ethnicity, gender, insurance status, education status, poverty, geography, employment status, and age.³ Approximately 44% of our clinic’s patients is Hispanic, 55% is unemployed, and 45% is homeless.

Every week, patients at The Free Clinic are able to receive basic in-house laboratory services, diagnostic tests such as ultrasound and electrocardiograms, prescription medications from the in-house pharmacy or through Patient Assistance Programs, mental health counseling, vaccinations, and social services. During our monthly Dermatology Nights, patients with skin complaints are seen by volunteer TTUHSC dermatologists. Patients receive comprehensive on-site dermatologic care including procedures such as biopsies, excisions, and electrodessication and curettage. These services are essential in assessing and treating non-melanoma skin cancers (NMSCs) in our uninsured patient population since they may be at a higher risk of NMSC due to lack of access to care and increased sun exposure from insecure housing.⁴ Topical medications such as topical steroids, antifungals, and antibiotics are also carried by the in-house pharmacy, and patients who may need targeted immune modulators such as Otezla (apremilast) may receive them through Patient Assistance Programs.  

Although there is limited data highlighting the extent of dermatologic health disparities, it is known that skin cancer morbidity and mortality outcomes are worse in people of color, the uninsured, and those of low socioeconomic status.³ These poorer outcomes may be due to lack of access to outpatient dermatologic care, lack of awareness of skin health, and diagnoses at a more advanced stage.^5,6 A 2018 study revealed that patients of minority background, lower education status, lower income, and uninsured status were less likely to have access to outpatient dermatologic care.⁵ In 2019, the incidence of non-melanoma skin cancers (NMSCs) at The Free Clinic was 1.5%; the incidence of NMSCs within the general U.S. population in 2006 and 2012 was 1.17% and 1.27% respectively.⁷ This emphasizes the need for accessible quality dermatologic care and patient education in the Lubbock uninsured community and other communities across the nation that experience inequities in health care based on geography, demographics, race/ethnicity composition, and socioeconomic factors.

Dermatology Nights at The Free Clinic represent only one of many solutions and steps we can take to reduce dermatologic health disparities. Below are some steps we can actively take to create a more equitable health care system for our underserved patients:

• Raise awareness and directly educate the medical and non-medical community that people of color are at risk of developing skin cancer, thus should regularly practice sun-protective behaviors, perform monthly self-skin exams (in those with multiple nevi or history of skin cancers), avoid tanning beds, obtain a regular skin exam by a dermatologist, and monitor for any changes in pigmented lesions.⁶ This can be in the form of skin cancer awareness events (e.g. melanoma walks, health fairs) and free skin cancer screenings in the community. There is also a need to integrate skin of color in lectures, textbooks, curricula, conferences, and other educational resources for medical professionals.  
• Provide comprehensive dermatology-specific services and care at an established free clinic (e.g. Dermatology Nights at The Free Clinic). This requires a strong network of local volunteer dermatologists, residents, and students able to dedicate their time regularly; grants, funding, and/or donation of dermatologic supplies; and an infrastructure that is able to support these services.
• Offer weekend or evening clinic hours for employed patients so that they can attend their appointments without the need of missing work.⁸
• Utilize certified medical/healthcare interpreters (instead of ad hoc interpreters) to reduce language barriers. Over the phone interpretation services are also an alternative.⁸
• Teach health professionals and community health workers (not trained in dermatology) about primary skin cancer prevention strategies so that they can educate the communities they care for.
• Integrate cultural competency and implicit bias training into professional curricula. This is important for providers to understand their own attitudes and biases that may be affecting the care and management of their patients and to gain the skills needed to effectively communicate across cultures, languages, and literacy levels.⁸
• Increase students of color and underrepresented minorities in dermatology through longitudinal mentorship by dermatologists and partnership with minority-serving medical student organizations such as Latino Medical Student Association and Student National Medical Association. The American Academy of Dermatology (AAD) also has a Diversity Mentorship Program for underrepresented minorities interested in one-on-one mentorship and learning more about dermatology.

As a dermatology community, we should continually work towards increasing access to quality care, addressing socioeconomic barriers in health, and including people of color in medical research and dermatology careers. Through awareness and proactivity, we can overcome these health disparities and transform the field of dermatology both in the clinic and in the community.

*Author Bio: Christine P. Lin is a 4^th year medical student at Texas Tech University Health Sciences Center (TTUHSC) in Lubbock, Texas. She is pursuing a career in dermatology and is passionate about reducing health disparities.

References:

1. US Census Bureau. data.census.gov. Lubbock County, Selected Characteristics of Health Insurance Coverage in the United States, 2018 American Community Survey 1-year Estimates. Available at: https://data.census.gov/cedsci/table?q=lubbock%20county
   %20uninsured&g=0500000US48303&tid=ACSST1Y2018.S2701&layer
   =VT_2018_050_00_PY_D1&vintage=2018. Accessed September 15, 2020.
2. US Census Bureau. data.census.gov. United States, Selected Characteristics of Health Insurance Coverage in the United States, 2018 American Community Survey 1-year Estimates. Available at: https://data.census.gov/cedsci/table?q=lubbock%20county
   %20uninsured&g=0500000US48303&tid=ACSST1Y2018.S2701&layer
   =VT_2018_050_00_PY_D1&vintage=2018. Accessed September 15, 2020.
3. Buster KJ, Stevens EI, Elmets CA. Dermatologic health disparities. Dermatol Clin. 2012;30(1):53-viii. doi:10.1016/j.det.2011.08.002
4. Sturgeon A, Pate DA, Patel R, Snodgrass K, Tarbox M, Prabhu F, Watkins P. Incidence of Non-Melanoma Skin Cancer in the Uninsured. Journal of Health Care for the Poor and Underserved, 2017;28(4):1327-1332. doi: 10.1353/hpu.2017.0117
5. Tripathi R, Knusel KD, Ezaldein HH, Scott JF, Bordeaux JS. Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States. JAMA Dermatol. 2018;154(11):1286-1291. doi:10.1001/jamadermatol.2018.3114
6. Agbai ON, Buster K, Sanchez M, et al. Skin cancer and photoprotection in people of color: a review and recommendations for physicians and the public. J Am Acad Dermatol. 2014;70(4):748-762. doi:10.1016/j.jaad.2013.11.038
7. Rogers HW, Weinstock MA, Feldman SR, Coldiron BM. Incidence Estimate of Nonmelanoma Skin Cancer (Keratinocyte Carcinomas) in the US Population, 2012. JAMA Dermatol. 2015;151(10):1081–1086. doi:10.1001/jamadermatol.2015.1187
8. Sauaia A, Dellavalle RP. Health care inequities: an introduction for dermatology providers. Dermatol Clin. 2009;27(2):103-v. doi:10.1016/j.det.2008.12.001