Our current Author Spotlight features Natalia Neha Khosla MD MSc, who authored the article titled, “Socioeconomic Disparities in Gentle Skin Care Access for Atopic Dermatitis: Affordability and Pharmacy Deserts” published in JDD’s July issue. In addition to the article, JDD asked Dr. Khosla some questions related to dermatology in order to provide some deeper insight to our readership on the author behind the article.
In your experience, what is one commonly overlooked factor in diagnosing or managing a specific skin condition that you think deserves more attention?
I think the psychological, psycho emotional, and stress contributions to cutaneous disease is critically overlooked, particularly for the populations that experience it most – vulnerable groups including immigrant groups, women, patients with skin of color, and sexual and gender minorities. The reason is, consistent with the weathering hypothesis of chronic stress-induced inflammation, a lifetime of chronic stress exposure maintains high levels of cortisol over a lifetime, compromising immune response. Marginalized and minoritized groups experience even higher levels of this chronic stress due to the experience of being marginalized over a lifetime. This is now becoming known in the literature, more slowly in the medical literature, as race-based or gender-based stress, due to experiences of chronic discrimination over a lifetime. We know from social psychology studies of bias that minorities experience significantly higher stress due to being treated in undignified ways, being questioned in various formats, or having their sense of belonging or worth questioned multiple times per week or even per day. This creates a chronic state of hypervigilance and hypercortisol state that promotes inflammation and prevents appropriate healing. We know from telomerase studies that Black women, for example, have higher telomerase activity than White women in the USA, shortening DNA strands and promoting aging faster. We also see from studies in breast cancer that Black women in the US are the most likely to be diagnosed with triple-negative breast cancer, the most aggressive form, but this significantly less prominent among Black women in African countries, even when controlling for factors like diet. This indicates that the state of being a marginalized identity in the US and the daily experiences of othering are inflammatory risk factors.
Example conditions where there is growing evidence for this concern in dermatology include atopic dermatitis and discoid lupus. However, I believe there is a massive gap in the literature in this area, which is my prime focus. I am working on a study now with my mentors to assess whether there is a relationship between the self-reported race-based and gender-based stress that patients experience and their levels of inflammatory severity and frequency, comparing across races and genders in patients with chronic inflammatory diseases including discoid lupus, CCCA, HS, alopecia areata, vitiligo, psoriasis, and cutaneous sarcoidosis. This work draws on my background in social psychology in undergrad, which is when I first started studying carefully the phenomenon of chronic experiences of race-based and gender-based bias and discrimination in the Intergroup Relations Lab, and first-author published a study I designed on physician racial bias towards otherwise identical Black versus White patients and how this influences treatment recommendations made in a European country (France) versus the USA.
I developed an early interest in how chronic stress due to long term experiences of race-based and gender-based stress influence health because of my own experiences growing up in an Indian immigrant household in a largely homogenous white community. It was this experience early on that led to my path since, and was able to find my niche that feels ripe for discovery at the intersection of identity, chronic stress, and chronic inflammation in dermatology. So many of our patients experience overt mind-skin connection in their experience of disease because of its visibility, so I think it is crucial that dermatology as a field lead this area of discovery.
Of all your research findings, are there any surprising or unexpected results that changed your perspective on the topic?
In my study of food deserts, much of the inspiration for applying the same framework to pharmacies, I anticipated that we would similarly also find differences in store quality between richer and poorer neighborhoods, in addition to there being fewer in density. I did not necessarily expect that we would actually see lower stock at the stores in lower income neighborhoods, that was striking and an important finding that gave insight into the importance of dermatologists and physicians holding businesses and corporations to account who own these chain stores.
How do you see artificial intelligence and digital dermatology evolving in clinical practice over the next five years?
I think about this quite a lot! I actually built an AI tool during medical school to solve some of the problems of health disparities I was experiencing: it is an AI voice agent, human-like, that is able to call patients after visits in their own language to review their medications, dosages, and diagnosis names to improve patient education, confidence, psychological safety, and adherence. I think artificial intelligence can and should play a critical role in how the practice of medicine and dermatology evolve. I feel more strongly at this moment about the usefulness of workflow and care delivery tools like the one I built over diagnostic tools (e.g. visual diagnostics from images, clinical decision support). This may change over time, but my reasoning is that from the data what we know is that physicians are very good at their work. The quality compromise and inefficiencies in our healthcare system are not rooted primarily in physician diagnostics or medical decision making capacity. The much lower hanging fruit, I believe, is the component of the healthcare system we receive data over and over again is entirely dysfunctional: the actual system of care delivery, the workflows and processes, that envelope the care. It doesn’t matter if you choose the most perfect treatment regimen for a patient if they can’t get in touch with the office when insurance rejects the prior auth, if they can’t pick up their refill because they can’t get a ride, if they can’t understand their medication instructions so they just don’t take the medication at all. To me these system processes in healthcare delivery are where I am excited to see AI make major strides so that doctors can be allowed to spend their time doing what we’re actually trained to do instead of filling the gaps of our disjointed system – we can focus on patient care, counseling, and excellent medical decision making while AI takes care of the rest – communications, schedules, processes, data entry, documentation, and the likes.
If you could implement one immediate policy change to improve dermatologic care on a broader scale, what would it be and why?
I would create a rule mandating that private corporations that profit from existing in, or selling to, marginalized groups like those in poverty and those racially minoritized are held to account on various measures, including like one we found in this study: equally stocking stores in higher versus lower income neighborhoods with products that are critical to patients’ health and wellbeing. I think physicians should have a much stronger voice and role in advocating against tax breaks for these large corporations, and when public money goes towards building new infrastructure that corporations benefit from that sell to our patients, those corporations should be required to “pay back” in the form of upholding strict, egalitarian practices in lower income neighborhoods. They should be required to set up shop equally across lower and higher income neighborhoods, if they want to benefit from the city ecosystems enabled and built on the backs of low income folks who do all the lowest paying jobs that are critical to the city’s infrastructure. These companies free ride off of that work currently, and I think in the vein that healthcare is a systems issue beyond the 4 walls of the clinic, and we now talk openly about social determinants of health – I think it is physicians’ responsibility to advocate together outside of clinic specifically to ensure the private sector is held accountable to playing its role. I think this requires, critically, physicians to organize – another area I feel passionately about where I think we have a ways to go, and exciting opportunities ahead.
Are there any misconceptions among dermatologists or patients about a specific treatment or condition that you’d like to address?
I think that hair loss patients are among the most likely to not be taken seriously in dermatology. When I’ve seen them, they often have bounced across 3-5 providers already and had traumatizing experiences of being invalidated. I think this is a critical area of conditions to consider from an identity perspective, because it is wrapped up entirely in societal constructions of identity, most prominently, gender. The only real reason that hair loss conditions are considered conditions, or medical diagnoses, is not because they will kill someone physically, but they will chip away at someone nearly to death emotionally specifically because of the societal importance placed on hair for femininity. And being part of femininity, having inclusion to white western femininity to have dignity and respect in western society, is imposed extremely aggressively yet ambiently by this society especially on nonwhite women. I think constructions of race and gender, especially what a “real” or “feminine” woman looks like, acts like, what their hair looks like, are at the core of hair loss conditions, and they should be seen and taught that way so we don’t have patients being traumatized further by physicians when they are already weighed down by the rigid expectations of a highly stigmatizing society. A related and converse area is hair removal or having too much hair – again a highly socially constructed “condition” that results in thousands of dollars spent to “fix” oneself, not because of physical harm but because of the emotional burden of society’s narrow definition of a proper woman as hairless – a particular conundrum for nonwhite women who have more hair.
If you could collaborate with any other specialty or field to advance dermatologic research, which would it be and why?
Psychiatry because of the reasoning above!
Outside of clinical practice and research, what excites you most about the future of dermatology?
The opportunity for the health equity and technology communities to actually come together as one instead of being separated. My passion lies across the two together: I started my journey on a mission to understand how being socially marginalized and excluded has meaningful psychologically and physically harmful effects on people of color and women, and my desire to act on my findings led me to technology, which actually allowed me to build tools and interventions based on my research. I love research but think it is most powerful when we actually take action as a result of it – create something, incorporate a new workflow, change how something is done concretely. An unfortunate phenomenon is that the health equity and tech communities have always been so separated – even at AAD and other conferences their sessions are on the opposite sides of the venue! I think this is because we’ve historically been taught to associate technology with exploitative capitalistic business enterprise – and I think those enterprises have created the false impression that technology itself is exploitative. I wholeheartedly disagree and believe it is a critical tool that if we, those working for health equity, don’t embrace, we are doing our patients an immoral disservice by not opening up access to more powerful tools to combat health disparities.
For example, after this paper we published, we’ve started working on a tool that could “monitor” or enable real transparency on corporations with retail locations by allowing users to real time give reviews on the pricing and stock, so we could have an updated birdseye view constantly of which neighborhoods are being understocked or underserved.
