JAMA Editor Resigns, Here Is The Latest Fallout From Podcast Questioning Structural Racism
A JAMA Network podcast on structural racism and a tweet that began with, “no physician is racist, so how can there be structural racism in health care,” may end up having quite an impact. Although, perhaps not in the way that the JAMA Network had originally intended.
Last Tuesday, JAMA announced the latest fallout from this “what the heck were they thinking” podcast and tweet. Effective June 30, 2021, Howard Bauchner, MD, will be stepping down as the Editor-in-Chief of JAMA and JAMA Network, after a decade at the helm. In case you didn’t know, JAMA, which rhymes with “pajama,” is short for the Journal of the American Medical Association, one of the longtime leading medical journals. Apparently, Bauchner wasn’t involved directly with the tweet and podcast of concern but did say in a statement: “I remain profoundly disappointed in myself for the lapses that led to the publishing of the tweet and podcast. Although I did not write or even see the tweet, or create the podcast, as editor-in-chief, I am ultimately responsible for them.”
Bauchner, who has been Editor-in-Chief since July 1, 2011, had already been on administrative leave since March 25, due to the uproar generated by the since deleted and ill-conceived podcast and tweet that were originally posted during the last week of February.
Back on March 7, I covered for Forbes this JAMA Network podcast entitled “Structural Racism for Doctors: What Is It?” and the podcast’s promotion, which was soon received about as well as cinder block soup. This was not surprising. After all, what would you expect when a podcast about structural racism featured two White men and no persons of color and had a host, Ed Livingston, MD, saying things like: “what you’re talking about isn’t so much racism…it isn’t their race, it isn’t their color, it’s their socioeconomic status.” Oh, and to top it off, the website hosting the podcast begin with the words “many physicians are skeptical of structural racism.” Is that a bit like having two people who have never played golf in their lives hosting a podcast called “Golf: What Is It?” on a web site that says “many people are skeptical about this golf thing?” To many persons of color and their allies, all of this seemed to be quite tone deaf, that is, skin tone deaf.
The resulting uproar has now led to the resignation of two JAMA editors: first Livingston, who was at the time Deputy Editor for clinical reviews and education at JAMA, and now Bauchner. But will the resignation of just two editors be enough? After all, a podcast isn’t simply like a fart. It doesn’t just come out involuntarily. Presumably, a series of people had to greenlight the idea and its promotion. Were the podcast and tweet instead just the tip of the iceberg, signs of much deeper issues? For example, Uché Blackstock, MD, Founder and CEO of Advancing Health Equity, tweeted the following:
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In fact, Raymond Givens, MD, PhD, an Assistant Professor of Medicine at the Columbia University Medical Center, told me that he had warned JAMA last fall that something like the podcast fail would eventually happen. He didn’t specifically tell the journal, “soon you will produce a podcast that will go about as well as sandpaper toilet paper.”
Instead, here’s what happened, according to Givens. Last September, he submitted a letter to JAMA in response to a research letter published in the journal that reported results from a Covid-19-related study. Givens felt that the study “conflated race with biology” by suggesting that Black Americans may have higher Covid-19 coronavirus infection rates and death due to biological reasons. Givens’ letter questioned the design of the study and why the research letter got published in JAMA. As you can see in the following tweet, Givens’ letter also raised concerns that the editorial board did not include enough diversity to recognize the role that racism may play in Covid-19 infection risk:
However, per Givens’ tweet, JAMA rejected his letter. Undaunted, Givens took a closer look at the racial/ethnic compositions of the editorial boards for the various JAMA journals. He identified whom on the boards could be categorized as Black (B), East Asian-descent (EA), Latino (L), Middle Eastern-descent (ME), South Asian-descent (SA), and White (W) and constructed the chart shown in the tweet thread below:
As you can see, the numbers under the persons of color columns looked a bit like baseball scores: lots of zeros, ones, and twos. Meanwhile, the numbers under the W column looked more like football and perhaps even basketball scores, double-digits for nearly every line except for the Journal Oversight Committee. And that committee featured six Whites and one Black.
What’s even more striking is that even fewer persons of color occupy the higher positions of power in in each journal’s hierarchy. For example, all but one of the 14 Editors-in-Chief or Executive Editors are White, according to Givens’ chart. Editor-in-Chiefs can play major roles in setting the overall direction of the journal and choosing other editors.
Givens took a closer look at the composition of the New England Journal of Medicine editorial board as well, as seen in tweet below:
Compare the breakdowns compiled by Givens with the racial/ethnic breakdowns of U.S. medical school graduates. For example, according to the Association of American Medical Colleges (AAMC), the 2018-2019 breakdown of U.S. medical school graduates by race and ethnicity was as follows: 54.6% White, 21.6% Asian, 6.2% Black, and 5.3% Hispanic, Latino, or of Spanish origin. The following tweet response to Givens’ thread above questioned why there such a discrepancy between who have been graduating from medical school and who is serving on these editorial boards:
“I reached out in October 2020 to the Editors-in-Chief of the NEJM and JAMA and presented the data,” Givens recalled. “I made the case that it wasn’t representative of not only the medical profession but the patient populations served.” Note: I have reached out to JAMA and the NEJM and will update this article accordingly.
Givens felt that the lack of racial diversity would result in a “Swiss cheese model with holes that alllow many things to fall through, like publications with flawed logic that miss the boat.” And while Swiss cheese may be delicious on sandwiches, it may not be what you want among those determining what studies and information should be disseminated to the broader medical community and beyond. Givens added. “Without diversity in editorial board, you don’t know what you don’t know. Journals like JAMA will have blind spots to the point that something’s going to happen.” So when the JAMA podcast landed with a thud, Givens essentially said, “I warned you about this, yet you ignored the warnings.”
In a statement, Bauchner said, “I share and have always supported the AMA’s commitment to dismantling structural racism in the institutions of American medicine, as evident by numerous publications in JAMA on this issue and related subjects, and look forward to personally contributing to that work going forward.” However, Givens felt that many of these published articles “missed the boat. The logic was flawed.”
A medical journal’s editorial board ultimately has substantial influence over what gets published in that journal. By setting the editorial direction of the journal, the board in effect determines the types of articles that the journal will even consider. Therefore, you may be out of luck when your work isn’t aligned with the editorial board’s “priorities.” Plus, editors can “desk reject” a submitted manuscript, which doesn’t mean throw a desk at the manuscript but rather means reject the manuscript without even the opportunity for peer review. Moreover, the editors choose whom to invite to review the manuscript, which in turn can affect how the manuscript is judged.
All of this can have a cascade of effects. Leading medical journals such as JAMA can influence what health and health care topics are prioritized among the medical profession, the research community, and policy makers. It can affect what types of work receive funding. It can greatly influence the trajectory of many doctors and researchers’ careers, especially early on when they are still struggling to establish themselves.
At the same time, it’s not always clear how editorial board members for high-profile medical journals are selected. It doesn’t seem to be like college or medical school applications where there are listed criteria, an application form, and a chance to write an essay like “Why I Want to Be Your Editor.” It doesn’t seem to be like the TV show America’s Got Talent either with a televised talent competition and audience voting. “These processes are shrouded in secrecy,” said Givens. He indicated how there doesn’t seem to be boards or committees completely external to the journal or the American Medical Association that check the editor selection process. Given said: “The stated duty of the oversight committee is to serve as buffer between the American Medical Association and the journals. The journals may not be choosing from the whole range of available talent. There needs to a full overhaul of the process.”
For now, JAMA Executive Editor Phil Fontanarosa, MD, will serve as interim editor-in-chief until a search committee identifies a new editor-in-chief. The committee is being chaired by Otis Brawley, MD, a Bloomberg Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, who is Black. On June 3, JAMA published an editorial that called the podcast and tweet “wrong, misguided, and uninformed. An extensive evidence base strongly supports the presence of structural racism in medicine and its adverse influence on health.” Editors from the various JAMA journals authored this editorial, which included a list of “Ongoing and New Editorial Priorities and Key Approaches of JAMA and the JAMA Network Journals to Strive for and Promote Diversity, Equity, and Inclusion (DEI),” a very long name for a list. One of the items on this list was, “continue to increase the diversity of editors, editorial boards, advisory committees, and editorial staff.”
“Just appointing non-White faces is not the solution,” said Givens. “The concern is that they may simply find diverse faces who think think like they do. They may not be selecting those who are willing to speak out boldly, people who are willing to hold the system accountable.”
Givens said that he worried about “erasure” as well. In this case, he’s not talking about the musical group that sang the song “A Little Respect” but instead attempts to remove what happened from the history books. He gave the example of the Tulsa Race Massacre of 1921, when a white mob attacked those in a predominantly Black neighborhood of Tulsa, Oklahoma, and how nowadays many people don’t even realize that such an atrocious event occurred. He is concerned that whenever someone or some group is perpetuating racial inequity “someone had to confront them about the problems.” Givens warned that “when they realize that they are caught, they may not include you in the discussion. In fact, they may pretend that you never existed.”
Medicine has long been known as a noble profession. After all, saving and improving lives isn’t a bad thing unless you happen to be a virus covered with spike proteins. The question though is how many people and systems in medicine are actually following all of the noble stated principles of medicine? Obviously, statements such as “no physician is racist” are absurd. Just because you went to medical school doesn’t mean that you have a “get out of racism for free” card or maybe a “get out of racism for over $200,000” card. “Medicine is not different from the rest of society,” Givens lamented. “There is a need to have medical civil rights movement.”