Reply to the Letter to the Editor: Editorial: Beware of Studies Claiming that Social Factors are “Independently Associated” with Biological Complications of Surgery

Dear Dr. Simkin and Colleagues,

Thank you for your thoughtful letter about my recent editorial in Clinical Orthopaedics and Related Research® [3].

I don’t believe our viewpoints are as far apart as you may think.

First and most importantly, I agree with your concluding comment: “Race-associated health outcomes disparities represent a national healthcare crisis, and our healthcare journals should put a spotlight on this crisis instead of hiding it.”

I don’t just agree; I’ve taken pains to keep these issues front-of-mind for CORR’s readers over a sustained period of time. In the 7 years since I’ve been the Editor-in-Chief here, we have placed race, gender, social deprivation, and healthcare disparities at the forefront, with numerous special issues and symposia, as well as many editorials [4, 6, 10], Editor’s Spotlight features [8, 9], and regular columns and commentaries [1, 2, 12-15] spanning from my first days in this role [5, 7, 11] to the present [3, 4].

I also agree with you that where race can plausibly be linked to physiology, and when it is recorded by researchers in a reliable and sensible way, it can and should be studied as a covariate in research about biomedical endpoints. The problem is, race often is used when there is no such link, and when the recording of those endpoint is not sufficiently robust to give the reader confidence. Same goes, as I mentioned, for other factors that lack a biological component (like insurance status). Using race (and those other factors) thoughtlessly can potentiate the kinds of prejudice that you and I both would like to see disappear, as pointed out in my editorial. But when used rigorously, to test premises that have a biologically sensible link to the outcomes of interest, I certainly agree with you.

At no point do I suggest that we should “abandon health disparities research”. Indeed, I hope that my record here makes it clear enough that both CORR’s team and its Editor-in-Chief believe that the opposite is true. More research—thoughtful, high-quality research—desperately is needed. You provided a long list of what I would call confounding variables, including economic stability, health literacy, nutrition, healthcare access, mental health (including but not limited to depression), hypertension, coronary heart disease, diabetes, cancers, and end-stage renal disease. The fact that these variables have been linked to race does not make race a suitable surrogate in all or most cases for the complications those factors might cause. That is the essence of my point in the editorial: Find the covariate(s) that connect in a plausible way to the biological endpoints of interest, rather than using race as a sloppy surrogate. I know that you understand this. Unfortunately, though, my experience evaluating many thousands of manuscripts over a span of years suggests that not everyone does.

Please know that I am an admirer of the work that your programs produce, I hope to see some of that work published in CORR sometime soon, and I’m deeply grateful that you took the time to write.