Dear Editor:
Social constructs of race and ethnicity are designed to assign value to different groups of people. Despite the current and historical practice of considering race and ethnicity to be biological extensions, these categories have no real genetic basis. The improper use and interpretation of race and ethnicity in medicine and health care research remains relevant, however, given differential treatment experienced by traditionally minoritized groups.
A 2021 article in the Journal of the American Medical Association (JAMA) gives a contextual framework for using race and ethnicity in medicine and health care research, 2 including defining those terms and the commonly misunderstood terms of systemic, individual, and internalized racism. The authors of that article also suggest best practice methods of designing and reporting results of future clinical studies going forward.
With the above in mind, we have concerns about the methodology behind the 2021 Orthopaedic Journal of Sports Medicine (OJSM) article titled “Current Perceptions of Diversity Among Head Team Physicians and Head Athletic Trainers.” 3 The study attempts to examine the current racial and gender diversity of the medical teams of professional sports leagues based in the United States. We acknowledge the importance of understanding the diversity of the medical providers who care for a diverse group of athletes and recognize that more research is needed in this area, but our concern is with the design and methods utilized in this study. Two independent reviewers, neither of whom was identified by race, ethnicity, or gender, evaluated public images of the head team physicians and head athletic trainers (ATs) and assigned them a single racial classification. Although the JAMA article does mention using visual assessment as one methodology, 2 this sight-based approach seems to reinforce the current societal practice of labeling by sight alone, which is problematic and likely introduces bias. It does not accurately account for the individuals’ self-identified race, instead labeling people according to their perceived race, which may categorize people incorrectly. This methodology creates the presumption that it is acceptable to make assumptions based on visual perception in other spaces medically, which may lead to inferior care.
We are also concerned with the terminology utilized, specifically with the variations on the word “minority” or “minorities” as well as with the limited number of race choices and the solitary nature of the choice (ie, each person was assigned to only 1 race). JAMA recommends against the use of “minority” as a standalone noun and suggests either “racial and ethnic minority groups” or “underrepresented populations” as alternatives. In addition, assigning each person to a single race ignores the unique experience of biracial or multiracial providers. These research methods were not recommended in the JAMA article. Although there is a brief discussion as to the lack of diversity in head team physicians and ATs in the OJSM article, there is little-to-no discussion of the historical nature of the disparity, ways one might mitigate the disparity, or directions for future research. Furthermore, the study fails to evaluate the effect of implicit bias in research and how visual summations of individuals or groups can disproportionately affect behaviors, decisions, policies, and practices.
As sports medicine physicians, we can do better than this as we work to create diverse, equitable, and inclusive spaces in which to live and work.
We suggest reviewing and utilizing the JAMA recommendations and other best practices, including those noted in “Advancing Health Equity: Guide on Language, Narrative and Concepts,” 1 to ensure accurate data on racial and gender diversity are obtained and shared. We also recommend researchers consult an experienced social science researcher, or other related specialist, with the knowledge and understanding of diversity, equity, and inclusion, in advance of the study initiation and before journal submission. We call on journals to diversify their editorial boards and adopt best practices by providing appropriate article guidelines and by ensuring an experienced review of manuscripts with regard to racial and gender diversity.
Monique S. Burton, MD
Seattle, Washington, USA
Shelley Street Callender, MD
Macon, Georgia, USA
Nailah Coleman, MD
Washington DC, USA
Carly Day, MD
West Lafayette, Indiana, USA
Bianca R. Edison, MD, MS
Los Angeles, California, USA
Katherine H. Rizzone, MD, MPH
Rochester, New York, USA
Nicole Stern, MD, MPH, FACP
Colton, California, USA
Footnotes
The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Contributor Information
Monique S. Burton, Seattle, Washington, USA.
Shelley Street Callender, Macon, Georgia, USA.
Nailah Coleman, Washington DC, USA.
Carly Day, West Lafayette, Indiana, USA.
Bianca R. Edison, Los Angeles, California, USA.
Katherine H. Rizzone, Rochester, New York, USA.
Nicole Stern, Colton, California, USA.
References
- 1. American Medical Association and Association of American Medical Colleges. Advancing health equity: guide on language, narrative and concepts. Published 2021. http://www.ama-assn.org/system/files/ama-aamc-equity-guide.pdf
- 2. Flanagin A, Frey T, Christiansen SL; AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA. 2021;326(7):621–627. [DOI] [PubMed] [Google Scholar]
- 3. Wiggins AJ, Agha O, Diaz A, Jones KJ, Feeley BT, Pandya NK. Current perceptions of diversity among head team physicians and head athletic trainers: results across US professional sports leagues. Orthop J Sports Med. 2021;9(10):23259671211047271. [DOI] [PMC free article] [PubMed] [Google Scholar]