A Call to Humility

The article “Confronting Bias in Journals” addresses the critically important topic of how we address equity in our approach to medical research and knowledge generation. The cited examples, while current, echo a history of troubling and discriminatory practices that have stymied equity research or failed to consider bias in research. I am reminded, for example, of the Baltimore Lead Abatement Study conducted in the 1990s, which was ultimately unfavorably compared to the Tuskegee Study and yet managed to be published in the medical literature. This article raises two core issues in its examples. First is that some medical leadership, at journals and in healthcare broadly, may not recognize the value of representation. Personal reflection and the extensive literature on disparities and our collective shortcoming in achieving health equity – examples of which are provided in this and many other articles – should be enough to demonstrate the fallacy of this view. We cannot be fully aware of our shortcomings until we engage the individuals and populations who experience our failings. Second, and more insidious, is a lack of humility – the belief that we collectively have total understanding of the relevant issues. Again, the data does not support this, but such thinking is particularly erosive for medical journals since it suggests that further research and interrogation are not required.

We would ideally be able to engage issues of equity, discrimination, and bias from a shared understanding. Structural racism is real and deeply rooted in American institutions, including healthcare. Healthcare leaders are not immune to prejudice, bias, even racism since these issues are pervasive in our society. Patients endure safety, quality, and financial consequences when we fail to act equitably. I take these as statements of fact – but if there is any disagreement, it is precisely the role of journals and their leadership to settle these questions through thoughtful policies that publish and promote relevant research. The article points out a number of actions some journals are taking, and which should be widely adopted. Arriving at the right policies can begin with relatively easy actions: embrace humility and empower representative diversity in every board, committee, panel, and organization. Structural changes and real inclusivity will drive necessary reforms.

Shantanu Agrawal, MD, MPhil  // Chief Health Officer, Anthem, Inc.

The Cost of Bias in Medicine

I was recently reminded of the question “What is the cost of NOT addressing bias in medicine now?” The cost is clear. Not addressing bias and racism will allow health inequities to persist and overwhelm those who diligently fight to eliminate them daily. While the current medical community did not create the problem, it is now our time to fix the problem and to uphold the standards we aspire to achieve. One step towards addressing health inequities is changing the medical journal system which we use.

While many may believe that medical journals are race and bias neutral, history tells us  otherwise. Western medicine has its roots in the experimentation and exploitation of Black and brown bodies. And medical journals were used to immortalize and exhibit this exploitation in the name of “scientific discovery.”  While current standards of medical practice currently have checks and balances against the experimentation of people, the ‘systems” we have in place now for medical journals merit scrutiny to ensure they are not upholding historical norms of bias and racism in its reporting. To move the needle towards health equity, medical journal review boards need to be transformed to reflect the diversity of our country and our medical community.

Alana Biggers, MD, MPH, FACP // Co-Chair Department of Medicine Inclusion Council, University of Illinois at Chicago

Bias a Blind Spot

The JAMA podcast at the heart of “Confronting bias in journals” (Fall 2021) should remind us of the importance of managing our blindspots. Beginning drivers are taught about space that is unobservable in mirrors and requires craning one’s neck to check for other vehicles. Ignoring this blindspot can prove disastrous.

Similarly, failing to detect our biases when we look in the mirror is less about their absence than it is of our failure to recognize and check our blindspots. Awareness of biases is often a precursor to curbing their impact. Just as a patient who denies being obese is unlikely to increase activity or alter their diet, reviewers, editors, or physicians who deem themselves unbiased often contribute to the continuance of racial (and other forms of) injustice. Society seems to have conflated being unbiased with being a good person, stemming widespread denial that bias exists or we harbor any.

Let’s be clear: Being biased doesn’t make you a bad person, it makes you human. Our morality comes into question when we elect to ignore, accept, or double down on our biases. Simply, you cannot fix a problem by pretending it doesn’t exist.

Derek R. Avery, Ph.D.  // C.T. Bauer Chair of Inclusive Leadership, Bauer College of Business, University of Houston