Equity and the JAMA Network

Racial and ethnic socioenvironmental inequity and neuroimaging in psychiatry: a brief review of the past and recommendations for the future

Neuroimaging is a major tool that holds immense translational potential for understanding psychiatric disorder phenomenology and treatment. However, although epidemiological and social research highlights the many ways inequity and representativeness influences mental health, there is a lack of consideration of how such issues may impact neuroimaging features in psychiatric research. More specifically, the potential extent to which racialized inequities may affect underlying neurobiology and impact the generalizability of neural models of disorders is unclear. The present review synthesizes research focused on understanding the potential consequences of racial/ethnic inequities relevant to neuroimaging in psychiatry. We first discuss historical and contemporary drivers of inequities that persist today. We then discuss the neurobiological consequences of these inequities as revealed through current research, and note emergent research demonstrating the impact such inequities have on our ability to use neuroimaging to understand psychiatric disease. We end with a set of recommendations and practices to move the field towards more equitable approaches that will advance our abilities to develop truly generalizable neurobiological models of psychiatric disorders.

Gender Representation on Editorial Boards of JAMA Network Journals

Objective: Underrepresentation of women on editorial boards of biomedical journals has occurred for decades. The JAMA Network Journals have substantial and broad impact on advances in the biomedical sciences. We sought to determine the current status of gender representation on editorial boards of the 12 JAMA Network Journals. Methods: The gender of each editorial board member of the 12 JAMA Network Journals was classified based on review of online sources. The percentage of women on each board (i.e., number of women relative to total members) was calculated and compared to gender equity and parity benchmarks. The gender equity benchmark for each journal was defined as the percentage of women physicians in the medical specialty reflecting the journal's content based on Association of American Medical Colleges data. The gender parity benchmark for all journals was defined as 50% women. Results: There was considerable variation in the representation of women on the editorial boards of the JAMA Network Journals relative to gender equity and parity benchmarks. Women were underrepresented on 50% (6 of 12) of boards relative to gender equity and 67% (8 of 12) of boards relative to gender parity. Conclusions: Women were found to be underrepresented on 50% or more of the editorial boards of the JAMA Network Journals. This finding reflects gender inequities in academic publishing and the broader biomedical enterprise, which limits advances in the biomedical sciences and health care. Those JAMA Network Journals that continue to underrepresent women on their editorial boards are urged to remediate this longstanding issue.

Health equity assessment of machine learning performance (HEAL): a framework and dermatology AI model case study

Background

Artificial intelligence (AI) has repeatedly been shown to encode historical inequities in healthcare. We aimed to develop a framework to quantitatively assess the performance equity of health AI technologies and to illustrate its utility via a case study.

Methods

Here, we propose a methodology to assess whether health AI technologies prioritise performance for patient populations experiencing worse outcomes, that is complementary to existing fairness metrics. We developed the Health Equity Assessment of machine Learning performance (HEAL) framework designed to quantitatively assess the performance equity of health AI technologies via a four-step interdisciplinary process to understand and quantify domain-specific criteria, and the resulting HEAL metric. As an illustrative case study (analysis conducted between October 2022 and January 2023), we applied the HEAL framework to a dermatology AI model. A set of 5420 teledermatology cases (store-and-forward cases from patients of 20 years or older, submitted from primary care providers in the USA and skin cancer clinics in Australia), enriched for diversity in age, sex and race/ethnicity, was used to retrospectively evaluate the AI model's HEAL metric, defined as the likelihood that the AI model performs better for subpopulations with worse average health outcomes as compared to others. The likelihood that AI performance was anticorrelated to pre-existing health outcomes was estimated using bootstrap methods as the probability that the negated Spearman's rank correlation coefficient (i.e., "R") was greater than zero. Positive values of R suggest that subpopulations with poorer health outcomes have better AI model performance. Thus, the HEAL metric, defined as p (R >0), measures how likely the AI technology is to prioritise performance for subpopulations with worse average health outcomes as compared to others (presented as a percentage below). Health outcomes were quantified as disability-adjusted life years (DALYs) when grouping by sex and age, and years of life lost (YLLs) when grouping by race/ethnicity. AI performance was measured as top-3 agreement with the reference diagnosis from a panel of 3 dermatologists per case.

Findings

Across all dermatologic conditions, the HEAL metric was 80.5% for prioritizing AI performance of racial/ethnic subpopulations based on YLLs, and 92.1% and 0.0% respectively for prioritizing AI performance of sex and age subpopulations based on DALYs. Certain dermatologic conditions were significantly associated with greater AI model performance compared to a reference category of less common conditions. For skin cancer conditions, the HEAL metric was 73.8% for prioritizing AI performance of age subpopulations based on DALYs.

Interpretation

Analysis using the proposed HEAL framework showed that the dermatology AI model prioritised performance for race/ethnicity, sex (all conditions) and age (cancer conditions) subpopulations with respect to pre-existing health disparities. More work is needed to investigate ways of promoting equitable AI performance across age for non-cancer conditions and to better understand how AI models can contribute towards improving equity in health outcomes.

Funding

Google LLC.

When the Boards Fail Us-Structural Bias in Certification Examinations

This essay shines a light on structural bias inherent to the board certification examination process, sharing the author's experience preparing and sitting for the examination while contending with co-occurring challenging life events.

Gender distribution in surgical pathology journal publications and editorial boards

AIMS

To investigate trends in representation of women among authors and editorial boards of surgical pathology journals over the last two decades.Secondary aims: to identify barriers and potential solutions.

METHODS

The names and gender of first, middle, last authors and editorial board members were obtained from original articles from seven pathology journals from various geopolitical regions in 2002, 2011 and 2021. The proportion of women first, middle, last authors and editorial board members were compared over time.

RESULTS

1097 publications and 8012 individual authors were extracted. In 2002, 2011 and 2021, respectively, the percentage of women first authors were 28.3% (257 of 907), 31.9% (566 of 1773) and 41.1% (1421 of 3457); women middle authorship rates were 30.0% (159 of 530), 32.8% (375 of 1145) and 40.9% (1067 of 2609) and women last authors were 18.0% (34 of 188), 26.0% (82 of 315) and 36.0% (152 of 422). Women representation on editorial boards has increased (11.3%, 15.8%, 26.5%), but of the chief editors, there was only one woman in 2021, while all were men in 2002 and 2011.

CONCLUSIONS

To our knowledge, this study is the first to document under-representation of women among authors and editorial boards of surgical pathology journals. While women representation has increased over time, predominance of men remains relative to workforce proportions. Our findings are comparable to those from other medical fields and prompt the need to investigate the underlying causes for this imbalance and implement strategies to promote diversity, equity and inclusion in academic surgical pathology.

The gender composition of the members of the editorial board of toxicology journals: Assessment of gender equality

In many areas of medicine, gender equality has not yet been fully adopted despite recent developments. The inequality of gender in various areas of medicine is still debated. In this study, we analysed the gender composition of the editorial boards of toxicology journals in the Science Citation Index-Expanded (SCI-E) databases and the factors affecting this composition. The genders of the participants were determined by the data obtained from the official websites of the journals in September 2023. We analysed the journal metrics and publisher properties using Mann-Whitney U, Fisher's exact, Chi-square tests and Spearman's correlation coefficient. We used logistic regression analysis to reveal the independent factors related to gender parity. The representation rates of women were 28.62% on all editorial boards and 23.33% in editor-in-chief positions. The 'Neuroscience' (OR, 2.46 95%CI, 1.68-3.60, p < 0.001), 'Reproductive Biology'(OR, 2.05 95%CI, 1.22-3.42, p = 0.006) and 'Public, Environmental & Occupational Health'(OR, 1.49 95%CI, 1.18-1.88, p = 0.001) as a coverage category, the United States as a journal country (OR, 1.21, 95%CI, 1.04-1.40, p = 0.001), 5-year-IF≥3.6(OR, 1.54, 95%CI, 1.27-1.86, p < 0.001), 5-year H index≥29 (OR, 1.23, 95%CI, 1.01-1.49, p = 0.037) were the independent factors for gender parity. However, 'Oncology' (OR, 0.08 95%CI, 0.01-0.55, p = 0.011), 'Biochemistry, Molecular Biology' (OR, 0.62 95%CI, 0.44-0.86, p = 0.005) and 'Pharmacology & Pharmacy' (OR, 0.69 95%CI, 0.59-0.82, p < 0.001) as a coverage category, Japan as a publisher country (OR, 0.52 95%CI, 0.35-0.77, p = 0.001), and Switzerland as a journal country (OR, 0.61, 95%CI, 0.46-0.81, p = 0.001) were related to gender disparity. Greater endeavours are needed to reduce gender discrimination in toxicology. Toxicology authorities should continuously improve existing policies by optimising the analysis of objective information to eliminate barriers for toxicologists in terms of gender equality.

Relationship between journal impact factor and the thoroughness and helpfulness of peer reviews

The Journal Impact Factor is often used as a proxy measure for journal quality, but the empirical evidence is scarce. In particular, it is unclear how peer review characteristics for a journal relate to its impact factor. We analysed 10,000 peer review reports submitted to 1,644 biomedical journals with impact factors ranging from 0.21 to 74.7. Two researchers hand-coded sentences using categories of content related to the thoroughness of the review (Materials and Methods, Presentation and Reporting, Results and Discussion, Importance and Relevance) and helpfulness (Suggestion and Solution, Examples, Praise, Criticism). We fine-tuned and validated transformer machine learning language models to classify sentences. We then examined the association between the number and percentage of sentences addressing different content categories and 10 groups defined by the Journal Impact Factor. The median length of reviews increased with higher impact factor, from 185 words (group 1) to 387 words (group 10). The percentage of sentences addressing Materials and Methods was greater in the highest Journal Impact Factor journals than in the lowest Journal Impact Factor group. The results for Presentation and Reporting went in the opposite direction, with the highest Journal Impact Factor journals giving less emphasis to such content. For helpfulness, reviews for higher impact factor journals devoted relatively less attention to Suggestion and Solution than lower impact factor journals. In conclusion, peer review in journals with higher impact factors tends to be more thorough, particularly in addressing study methods while giving relatively less emphasis to presentation or suggesting solutions. Differences were modest and variability high, indicating that the Journal Impact Factor is a bad predictor of the quality of peer review of an individual manuscript.

Variations in how medical researchers report patient demographics: a retrospective analysis of published articles

Background

The use of demographic variables in the medical literature has been a topic of much recent debate. Recent studies found that race and socioeconomic status (SES) are inconsistently reported. Best-practice use of sex and gender has been contentious. We aimed to characterise the state of medical demographic reporting in greater detail, especially regarding geography and specific terms used in articles.

Methods

Original articles were included from issues of the New England Journal of Medicine (NEJM), JAMA, The Lancet, and the American Journal of Epidemiology (AJE) published from 1 January to 31 December 2020 (n = 640). Articles without human participants, case reports, or with only aggregate data were excluded, leaving 594 articles. Use of age, sex, gender, race, ethnicity, and SES were coded, as well as corresponding author and participant geography.

Findings

99.0% of articles reported age. While 92.9% reported sex alone, only 4.7% used the term gender and 1.0% transgender. 47.8% of articles reported race and 29.6% reported ethnicity. Studies with U.S. corresponding authors or participants were significantly more likely to report race (72.9% and 73.7% respectively) or ethnicity (47.3% and 45.3% respectively) than those without (25.9% and 25.6% for race, 14.2% and 16.3% for ethnicity), p < 0.01 for all. Of articles reporting race, 40.9% used only a Black-white binary; of those reporting ethnicity, 85.2% included two or fewer terms. Under 5.0% of all articles used Office of Management and Budget (OMB) categories. Across all articles, 33.0% reported SES, from 15.2% in NEJM to 80.2% in AJE.

Interpretation

We found that while some factors (age, sex) are reported consistently, others (gender, race, ethnicity, SES) are not, despite recent attention. Authors often rely on binary or limited categories that inadequately capture human diversity. The presence of U.S. researchers or participants increased the reporting of race and/or ethnicity, highlighting wide variations that persist even as multinational collaborations become widespread. Researchers should reflect on their use of these terms, justify their decisions, and report results with care.

Funding

None.

Can Peer Review Be Kinder? Supportive Peer Review: A Re-Commitment to Kindness and a Call to Action

Peer review aims to select articles for publication and to improve articles before publication. We believe that this process can be infused by kindness without losing rigor. In 2014, the founding editorial team of the Canadian Journal of Kidney Health and Disease (CJKHD) made an explicit commitment to treat authors as we would wish to be treated ourselves. This broader group of authors reaffirms this principle, for which we suggest the terminology “supportive review.”

A Framework for Anti-Racist Publication in Palliative Care: Structures, Processes, and Outcomes

Systemic or structural racism describes an embedded pattern of explicit and implicit racial biases that, through policy and action, systematically confer advantage to white people and disadvantage Black, indigenous, and other people of color. Hospice and palliative care journals participate in this broader system of racial discrimination. Building on palliative care's explicit focus on patients' goals and values, which may in and of itself comprise a form of social justice in healthcare, palliative care journals and their publishers have an opportunity to lead others in cultivating anti-racist practices and explicitly promoting equity. The publication life cycle of submission and solicitation, manuscript peer-review, and publication provide a framework for examining the structures, processes, and outcomes by which palliative care and other journals might address systemic racism. We describe the current academic publishing landscape, which diminishes the voices and experiences of racial and ethnic minority patients and undermines the careers of under-represented scholars. We then propose reforms that we believe will improve publication equity and quality as well as healthcare outcomes. These include an Equity in Publication checklist, solicitation of manuscripts on equity-relevant topics, promotion of scholars through editorial structures and peer review processes, and a standard Equity Rating for publications. Greater efforts to include non-dominant voices in every aspect of publication, through appropriate recognition of their scholarship and remuneration for their efforts, will drive equity in health outcomes. By pursuing an anti-racist and equity-focused publishing agenda, hospice and palliative medicine journals and their publishers have an opportunity to transform healthcare.

Achieving Greater Health Equity: An Opportunity for Anesthesiology

Anesthesiology and anesthesiologists have a tremendous opportunity and responsibility to eliminate health disparities and to achieve health equity. We thus examine health disparity and health equity through the lens of anesthesiology and the perspective of anesthesiologists. In this paper, we define health disparity and health care disparities and provide tangible, representative examples of the latter in the practice of anesthesiology. We define health equity, primarily as the desired antithesis of health disparity. Finally, we propose a framework for anesthesiologists, working toward mitigating health disparity and health care disparities, advancing health equity, and documenting improvements in health care access and health outcomes. This multilevel and interdependent framework includes the perspectives of the patient, clinician, group or department, health care system, and professional societies, including medical journals. We specifically focus on the interrelated roles of social identity and social determinants of health in health outcomes. We explore the foundational role that clinical informatics and valid data collection on race and ethnicity have in achieving health equity. Our ability to ensure patient safety by considering these additional patient-specific factors that affect clinical outcomes throughout the perioperative period could substantially reduce health disparities. Finally, we explore the role of medical journals and their editorial boards in ameliorating health disparities and advancing health equity.