Published On November 20, 2021
Last February, the Journal of the American Medical Association aired a podcast episode that would spark a heated conversation throughout the medical community. It featured two editors—both white male physicians—from its network of publications discussing the hot-button topic of structural racism. To promote the podcast, the journal posted the tweet: “No physician is racist, so how can there be structural racism in health care?”
The podcast was offered for continuing medical education credit, meaning that it was a nationally approved resource for physician learning. But neither physician is considered an expert on racism, and it didn’t take long for one of the men—host Edward Livingston, then deputy editor of JAMA—to voice skepticism about whether it was possible now for racism to be embedded in society. After all, he said, it has been illegal under civil rights legislation since the 1960s. “Structural racism is an unfortunate term …” Livingston said in the podcast. “Personally, I think taking ‘racism’ out of the conversation would help. Many people like myself are offended by the implication that we are somehow racist …”
Although Livingston’s guest, Mitchell Katz, president and CEO of the largest municipal health system in the United States and deputy editor of JAMA Internal Medicine, attempted to provide a more nuanced take, the podcast failed to address the considerable evidence that structural racism and health inequalities are indeed embedded in medicine. The podcast, unsurprisingly, was not received quietly.
“It was difficult for me to even get through it,” says Ron Wyatt, a Black physician who co-chairs the Institute for Healthcare Improvement’s equity advisory group. “It was a case study of bias and racism stereotypes in health care and a perfect example of the audacity of whiteness.”
Wyatt and many others view the JAMA podcast as symptomatic of a much wider problem: Medical journals, in their role as gatekeepers of scientific knowledge, are overdue for a reckoning. While Livingston may question the idea of structural racism, the evidence for it has been extensively documented through decades of research into racial bias in housing segregation, job discrimination, substandard public education, exposure to environmental hazards, psychological stress and inadequate health care. While journals might be expected to lead the charge rooting out this bias, mounting research shows how many of them may be party to it, ignoring, minimizing and mismanaging issues of race, ethnicity, gender and other disparities.
“This isn’t just an example of one time when someone misspoke,” says Julie Silver, associate chair in the Department of Physical Medicine and Rehabilitation at Massachusetts General Hospital and a longtime advocate for addressing racial and other disparities in the medical workforce. “It’s the result of decades in which leading medical journals haven’t addressed equity on their editorial boards or published studies on racism or the social determinants of health.”
That lack of diversity, in turn, ultimately hurts patients, too. Journal editors influence what medical topics are priorities, and that helps shape the nature and direction of scientific research. Moreover, persistent systemic bias can lead to flaws in understanding about physiology and treatment.
For example, a 2013 study in the American Medical Association Journal of Ethics found that because of myths perpetuated in the scientific literature—in this case, that people of color have a higher tolerance for pain—Black and Hispanic people received inadequate pain management compared with white patients. A 2016 survey of white medical students and residents published in the Proceedings of the National Academy of Sciences of the United States of America showed that half endorsed at least one false belief about physiological differences between Black and white people, including that Black people’s nerve endings are less sensitive than whites’. Demonstrating the impact of such beliefs, a study published last July in The New England Journal of Medicine that reviewed 2016 and 2017 Medicare claims data discovered that annual pain medication doses for Black patients were more than a third lower than prescriptions for white patients.
Now, finally, many top journals and less well-known publications are attempting to change, with broad efforts to investigate and address forms of bias. Yet even—and perhaps predictably—in the face of these initiatives, some voices are pushing back, arguing that the proposed remedies could undercut journals’ quality and scientific integrity. While the proponents for change see these objections as symbolic, rearguard actions, many worry that the pushback could have a more lasting effect, dampening the momentum for real change.
In an 1884 address to the American Association of Medical Editors, president Leartus Connor described medical journals as “the greatest factor of modern medical progress” and an ambitious convergence of “a medical school, a residency program, a clinical preceptor, a set of textbooks and a medical society unto itself … the great unifier of the past and present, the diffuser of all new facts …” Medical journals continue to be the primary conduit through which medical knowledge is created and, to some extent, how medical culture takes shape.
Historically, white men have held the majority of editorial positions at U.S. medical journals, and an audit in 2020 by Raymond Givens, a physician at Emory University Medical Center in Atlanta, found a continuation of the status quo. At the time, only one of 51 editorial board members of The New England Journal of Medicine was Black, one was Hispanic and six were Asian. That same year in the JAMA Network of 12 journals, approximately 90% of top editorial positions were occupied by whites. Currently, only four of the JAMA Network journals are being led by women.
“That lack of diversity continues to contribute to inequities in how research is conducted and published today,” says Melissa Simon, vice chair for clinical research at the department of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine and founding director of the Center for Health Equity Transformation. Journals are complicit in perpetuating inequalities, says Simon, who is Latina. “It’s deep and baked into the system,” she says. “And who gets to sit at the table and who has a voice at every step of the way is critical.” What top-tier journals decide to publish also influences whose careers move forward. “To be highly regarded in your field, you need to have publications in high-impact journals,” she says.
Increasing numbers of studies have documented how this lack of editorial diversity has undercut interest in research about minority groups and supported prevalent and persistent disparities in peer review and authorship. Consider that in more than 200,000 articles that the top four medical journals have published in the past 30 years, fewer than 1% even had the word “racism” anywhere in the text, according to a study published last April in Health Affairs. “Science begets science,” says Simon. “So when you have science that filters out nondiverse eyes and opinions, you get science that benefits one group and can disadvantage another.”
Excluding marginalized voices is one issue. The other is what to do about problematic research and opinions that do make their way into the journals—something that is increasingly litigated on social media and other public forums. Recently, Twitter critics took aim at a paper published in JAMA in September 2020 that tied higher rates of COVID-19 infection in Blacks, compared with rates in white people, to differences in the expression of a gene in the nasal epithelium. None of the three authors of the JAMA paper were white. Yet many commenters criticized the paper as “racist medicine,” citing increased concerns in the research community about using social constructs of race as a proxy for genetic makeup. Others noted medicine’s long history of blaming the health woes of Black people on supposed genetic differences instead of larger, structural factors. The clinical relevance of the gene’s expression is still unknown.
While journals might be expected to lead the charge rooting out this bias, mounting research shows how many of them may be party to it.
Another study that drew fire examined racial bias as a design flaw in pulse oximeters, oxygen sensors crucial in monitoring the status of COVID-19 patients. The devices were developed and tested largely on people with white skin, and the study’s authors later referenced three decades of evidence that pulse oximeters perform differently in patients with different skin tones. Here, the outrage was directed toward a subsequent letter published in NEJM that challenged the original study’s use of the phrase “racial bias.” “Medical devices such as pulse oximeters are blind to color and cannot exhibit such a bias,” the author of the NEJM letter wrote. Critics questioned why NEJM published the letter.
A March 2020 article in the Journal of the American Heart Association has been a particular focus of controversy. The paper criticized diversity initiatives in cardiology, arguing that data from the past 50 years show that affirmative action and other mandated diversity initiatives have failed to contribute significantly to rising numbers of Black and Hispanic clinicians or to improve patient outcomes. Its author, cardiologist Norman Wang at the University of Pittsburgh Medical Center, proposed that medicine adopt race-neutral policies in hiring. “Ultimately, all who aspire to a profession in medicine and cardiology must be assessed as individuals on the basis of their personal merits, not their racial and ethnic identities,” he wrote.
Critics on Twitter called the article “shocking.” But after the JAHA retracted Wang’s article and apologized, Wang asserted that he stood by his findings, and he has filed lawsuits against the University of Pittsburgh Medical Center and the American Heart Association, which owns the journal, alleging that he was demoted and defamed because his views were unpopular. Proponents have lined up on both sides of the debate.
Emory’s Givens questions the processes that were in place among JAHA reviewers. “Where was the voice in the room that said ‘this is going to cause a tremendous firestorm,” he asks. Givens believes the same could be said of the JAMA paper about gene expression in the epithelium, a view he expressed in a letter to that journal last fall. “These are elite journals and the journal editors are very bright people,” he says. “But when it comes to issues of race and science, something goes haywire and their ability for nuanced thinking is blunted.”
In recent years, medical journals have made efforts to improve inclusion and diversity, and the uproar about the JAMA podcast has brought renewed urgency to those efforts. “There’s simply no excuse at this point for inequities to exist on journal editorial boards for women or minorities,” says Julie Silver.
Many leading journals have published plans that prioritize equity across leadership, authorship and content, and in May, the AMA released a blueprint for dismantling structural racism within the organization and medicine at large. Weeks later, a JAMA editorial detailed new strategies to address “inclusion and antiracism in all journal-related activities.”
Other top-tier journals are taking similar steps. Since Eric Rubin became editor of NEJM in September 2019, the journal has added four editors and four editorial board members. Among this new group, four are people of color. In June 2020, the journal created a Race and Medicine page on its website, which has since published more than 100 articles probing the issues of race and diversity. And late last year, Winfred Williams, associate chief of the MGH Division of Nephrology and founding director of the MGH Center for Diversity and Inclusion, became the journal’s first Black deputy editor.
Williams says that during his first year, he has reviewed manuscripts related to his clinical expertise in nephrology and other diseases but also a flood of submissions covering diversity in medicine. “Part of my role is to bring a new perspective on these issues,” Williams says. “Leading journals have long published studies that simply don’t include enough participants from racial and ethnic groups that are disproportionately affected by certain illnesses.”
A new NEJM protocol for submissions will require a table that breaks out whether the disease or condition being considered has a greater burden for specific groups, and the participation rates of those groups in the research. That information will then be posted with published articles. “We can take steps to ensure that research papers really reflect gender, race and ethnicity appropriately in the study’s sample,” Williams says.
The IHI’s Ron Wyatt considers such changes to be largely positive, but he also notes that past flurries of self-scrutiny and promises to improve were quickly replaced by business as usual. “I’m optimistic, but with a lot of caution,” he says, noting that journals need to dedicate financial resources to support new equity initiatives and staff development.
Better compensation for editors and reviewers could help, says Julie Silver at MGH. Most leading journals pay their top editors handsomely yet ask peer reviewers to serve gratis. “Inviting diverse people to work for free is ethically and financially problematic, particularly when there are few opportunities at the top for women and minority groups,” says Silver.
In a paper last year in Health Affairs, Rhea Boyd, a pediatrician and public health advocate who teaches about structural inequality and health, and her colleagues laid out other proposed remedies, including setting rigorous standards for publishing on racial health inequities—for example, by defining race in the experimental design of the study and specifying, within a sociopolitical rather than a biological framework, why race is being used. But she also proposes that journals make public the histories of article submissions—draft revisions, reviewer comments, rejections and where rejected articles ultimately get published—and use that information to help understand how the medical canon excludes certain types of studies and what can be done to address that.
Within a week of the February airing of the JAMA network podcast on racism in medicine, the American Medical Association issued a statement. The organization affirmed the existence of structural racism while saying that both the tweet and podcast were “inconsistent” with the AMA’s views and policies. It announced an independent investigation into the incident and the resignation of Edward Livingston, who hosted the podcast. Harold Bauchner, JAMA’s editor in chief, was put on administrative leave and resigned in June.
While perhaps justified, the staff changes seem like a small step on the long road to transforming the way race, gender and other biases are addressed. Bigger changes are needed. “The science is really just developing, and the stakes are high,” Wyatt says.
Those who investigate structural racism believe bigger changes are needed.
While there is broad agreement within the AMA on the need to address inequities in health care, many delegates felt the AMA’s strategeic plan to address health inequities and embed racial justice should have been presented to the House of Delegates for debate. This year, a group of AMA delegates wrote to the association’s leaders in a letter that was leaked online. The letter called out portions of the AMA’s new plan for health equity as, at times, “divisive, accusatory and insulting” and asked how one could question the plan without being labeled racist. One complaint was that “white males are repeatedly characterized as repressive and to some degree responsible for the inequities.” Suggesting that firing the JAMA editors over the podcast was “perhaps precipitous, possibly a blot on free speech and also possibly an example of reverse discrimination,” the letter requested an independent group be charged with reviewing the podcast and preparing a report.
Although the dissenters’ letter didn’t dissuade AMA delegates from pushing ahead with the new policies, it is an example of the kind of pushback being seen, particularly on social media, from those who have voiced worries that the growing focus on racism and other biases has the potential to constrain medical discovery if it suppresses work by those with other priorities.
But Samir S. Shah, a pediatric hospitalist at Cincinnati Children’s Hospital Medical Center and editor of the Journal of Hospital Medicine, continues to champion reform. A first and important step is to make sure that all voices are heard, Shah says. “Diversity isn’t the goal in and of itself, but for our journal, it’s one important step,” he says. “We were one of the first journals to develop a systematic process for gathering information from authors on race, ethnicity and gender”—information that the editorial team then used to compose lists of scholars from whom to solicit review articles and editorials and “determine whether there are biases.”
“In the end, discussions about diversity and structural racism are for the greater good,” Shah says. “This is something we have to really lean into with intention. Change is never easy.”
“Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism and Health,” by Nancy Krieger et al., Health Affairs Blog, April 2021. This in-depth analysis of the 50 highest-impact health journals documents a persistent absence of articles relating to race and health.
“Gender, Race, Ethnicity, and Sexual Orientation of Editors at Leading Medical and Scientific Journals: A Cross-Sectional Survey,” by James W. Salazar et al., JAMA Internal Medicine, June 2021. In the first study to assess the diversity of editors at 25 leading medical and scientific journals, researchers found that about 77% of the 368 editors identified as white (compared to 1.1% Black) and more than 88% identified as heterosexual.
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