INTRODUCTION
The population of the United States continues to diversify and the number of individuals with skin of color (SOC) seeking dermatologic care is increasing.1 Yet there are accumulating data that patients with SOC (defined for working purposes here as Fitzpatrick skin phototypes IV-VI) tend to have less favorable outcomes in dermatologic diseases compared with patients with lighter skin.2-7 A number of factors contribute to disparities in dermatologic care. Dermatology is the second least diverse medical specialty, with only 9% of US dermatologists being Black, Indigenous, or Latino.8,9 In addition, skin conditions often manifest differently on dark skin.10 Medical literature and textbooks have historically under-represented images of diseases in patients with skin of color. This drastically hinders dermatologists' diagnostic accuracy, given how critical pattern recognition is in the field.1,11-13 Further, there is a lack of research in diseases in darker skin and clinical features of skin disease are often influenced by skin tone.11 In addition, the management approach that providers select may vary between ethnic groups, in many cases despite a lack of evidence-base to support such a variance.3,14 There is little research on the adequacy of current dermatologic training to produce dermatologists with cross-cultural competence, confidence, and skill in treating patients from diverse backgrounds.3 It is unclear as to whether dermatologists have implicit biases (beliefs that may subconsciously influence thinking and reactions to information), whether these biases affect medical or aesthetic dermatology patients to a greater or lesser degree, and whether bias may affect patient care and outcomes. The purpose of this survey-based study was to assess biases and perceptions that could impact patient care based on a representative sample of dermatologists, and to determine which patient factors affect providers' clinical decisions in medical dermatology compared with aesthetic dermatology. We also sought to understand providers' perceptions toward the adequacy of cultural and implicit bias training received during and after residency. This was done in order to identify possible gaps in training and education as well as which factors may decrease bias and improve care.
