When a cardiologist flagged the lack of diversity at premier medical journals, the silence was telling

When cardiologist Raymond Givens read the article in the Journal of the American Heart Association last year, it stopped him in his tracks. Written by a fellow cardiologist, it claimed educational affirmative action programs were promoting underprepared Black and Hispanic trainees who would not gain admission to top medical schools or become the best doctors. While the article was widely condemned as racist and error-filled and was swiftly retracted by the journal, its publication left Givens with a host of questions.

“I thought, ‘How did this get published? Who gets this kind of space — 8,000 words — in a medical journal?’ That’s unheard of,” he said. “That started the wheels turning. Who’s on the masthead?”

So began a deep dive by Givens into the race and ethnicity of the editors and decision-makers at top-tier medical journals. His findings were stark, and stretched beyond the heart association publication, to the nation’s two premier medical journals.

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At the time of his analysis in late October, Givens found that of 51 editors at the New England Journal of Medicine, just one was Black and one was Hispanic. Of 49 editors at JAMA, two were Black and two were Hispanic.

“Maybe it’s not a surprise, but it’s the first time someone’s documented this on this scale,” said Givens, an assistant professor of medicine at Columbia University Irving Medical Center and a self-professed data nerd. “It’s the receipts.”

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What happened next was more upsetting, he said. He sent his findings to the journals’ top editors, hoping to start a conversation about how they could diversify their editing staffs. His email to JAMA editor-in-chief Howard Bauchner was ignored. “Crickets,” Givens said. NEJM editor-in-chief Eric Rubin acknowledged his email last fall and offered to talk, and Givens sent Rubin his cellphone number, but the two never connected at the time.

The entire experience has left Givens angry, frustrated, and tired. That he could not get the attention of his fellow physicians even as medical associations and journals were vowing commitment to racial equality after the killing of George Floyd and the summer’s racial unrest was a bitter disappointment. “There was a feeling on my part that this was the time, that if ever there was going to be a time to change medicine, this was it,” he said, “And to run into entrenched resistance then, that was difficult.”

Both NEJM and JAMA said they have increased the number of editors of color on their boards since October — NEJM has hired a Black deputy editor among others, and JAMA now has three Black and three Hispanic editors on its masthead. But Givens and other critics say the troubling overall lack of diversity on editorial boards may be one reason the issue of health inequities that shorten the lives of people of color has received less clinical and research attention than it should.

“You can see that far and wide these boards lack diversity of all kinds — age, racial and ethnic, gender, and sexual orientation,” said Melissa Simon, vice chair of research and professor of clinical gynecology at Northwestern University Feinberg School of Medicine. “The biggest problem is that journal editors are gatekeepers. Those are critical roles because they decide who gets reviewed and who gets rejected off the bat.”

The lack of diversity has come to the forefront in recent weeks after JAMA aired, then took down, a podcast in which one of its editors questioned whether racism exists in medicine, and the journal tweeted that “physicians can’t be racist.” The episode stunned many in the medical community because it revealed a lack of understanding by some JAMA editors about the extent of structural racism in their field. But it came as no surprise to Givens.

“When someone tells you your house is on fire, and you ignore them, it’s not a surprise when their house burns down,” he said.

“This deficit in diversity means there are tremendous blind spots. They don’t even know what they don’t know.”

Editorial staff diversity chart

Givens wrote to JAMA and American Medical Association leaders in a March 5 email, the day after Bauchner and AMA CEO James Madara made public apologies for the content of the podcast. (The AMA owns JAMA, though the journal is editorially independent.)

“You ignored that email,” he wrote, referring to his initial attempt to raise the diversity issue last fall. “Apologizing now for ‘lapses’ that are the foreseeable consequence of your deliberate indifference is an insult. We say to you, again, that your editorial board is embarrassingly and dangerously unrepresentative.”

Bauchner responded this time, acknowledging receipt of the email and saying he would review it carefully. After Givens thanked him for the reply, Bauchner wrote back: “Please call me Howard — these are difficult times — but regardless, I try to maintain a collegial relationship with individuals.”

Givens never heard from Bauchner again. He was placed on administrative leave March 25. Bauchner, JAMA, and the AMA have all declined to comment on specific matters relating to Bauchner or the podcast.

Rubin said he had received Givens’ October email just as he was leaving on vacation and regretted losing track of the conversation, but told STAT he had spoken with Givens at length recently. “I agree with him,” Rubin said in an emailed statement. “I’m dedicated to changing things.” Rubin said that in addition to hiring more people of color, the journal was publishing and highlighting more work on systemic racism (including a recent piece by Givens) and had joined a coalition of scientific publications working to make scholarly publishing more diverse.

RAY GIVENS - JAMA
Like many Black physicians, Givens said he had remained quiet about the racism he has seen in medicine, for fear of reprisals and worry he might jeopardize his career. That all changed in 2020. Biz Herman for STAT

While Givens is now becoming a leading voice among those calling for change in medicine, he never sought to speak loudly, or even publicly, about the lack of diversity at medical journals he carefully documented. “It wasn’t presented as a ‘gotcha’ or ‘I’m going to tell everyone about you.’ It was more like, ‘Guys, hey, I think we have a problem, and you’ll want to know about this,’” Givens said. “I was trying to be collegial.”

Like many Black physicians, Givens said he had remained quiet about the racism he has seen in medicine, for fear of reprisals and worry he might jeopardize the career he had worked so hard to build.

Raised by a single mother in Florida and Georgia, Givens, 45, is the first physician in his immediate family. He earned an M.D. from Duke and a Ph.D. in public health from the University of North Carolina, did his residency at Johns Hopkins, and completed two fellowships at Columbia University Irving Medical Center. In 2019, his hospital named him physician of the year.

“The culture of medicine is very much about conforming and I’ve done that,” said Givens, who has two young sons. “I didn’t feel I could risk my career, or not be able to support my family.”

That all changed in 2020.

Givens is associate director of the cardiac intensive care units at Columbia University Irving Medical Center in New York’s Washington Heights. His hospital treated one of New York’s first Covid-19 patients, and then faced a deluge. The hospital had to place two patients in each coronary care unit room instead of just one, and had IV poles and machinery filling the hallways to minimize the risk of contamination. “It looked like a war zone,” he said.

The emotional fallout was intense. “We’d never been in a situation where you couldn’t help someone,” he said. “Patients would die right in front of you.” Many of those patients, he said, were Black and Dominican. “We felt very helpless.”

He worried after every shift, especially in the early months, that he would infect his family. “Was I bringing home something deadly? We didn’t know. We didn’t know if we’d have enough PPE,” he said. “But we still showed up.”

Then came George Floyd’s death.

One of Givens’ sons had been born just a few weeks after Eric Garner, an unarmed Black man, was killed in a police chokehold in New York. George Floyd dying in much the same way, struggling for air and begging for his life, is what finally pushed Givens to speak out about the racism he saw all around him. Because he was so busy treating Covid patients, it took Givens months to realize just how upset he was about Floyd’s death. “The pain of walking this tightrope was too much. I decided I didn’t care if I lost my career if I couldn’t be myself.” His first target was not the medical establishment, but his own university, where he has been on the faculty since 2016.

“There was a feeling on my part that this was the time, that if ever there was going to be a time to change medicine, this was it. And to run into entrenched resistance then, that was difficult.”

Cardiologist Raymond Givens

For two years, Givens had taken his son to the medical school preschool, on the third floor of Bard Hall, a dormitory named after Samuel Bard, who was George Washington’s physician, the founder of Columbia University’s medical school — and a slave owner. Givens said he recalled his mother telling him she had worked hard to make sure he never had to live in a place named after a plantation, and he felt he was letting her down every time he walked his son into the building. But at the time, he didn’t feel comfortable speaking out. (Givens also received the university’s Samuel Bard Young Investigator Award in 2011 when he was a cardiology fellow.)

Despite a university project to research Columbia’s connection to slavery that started in 2015, Givens was upset that the university had not chosen to remove Bard’s name from the building. The name was finally removed in August in response to a petition Givens started. The Bard name was also removed from the professorship held by the school’s chair of the department of medicine.

The NewYork-Presbyterian Columbia University Irving Medical Center
The Columbia University Irving Medical Center complex in New York’s Washington Heights. Biz Herman for STAT

When the article questioning affirmative action appeared in March 2020, it gave Givens a new target: the prestigious journals of his own profession.

The article was retracted by the journal in August, with a statement that said it “contains many misconceptions and misquotes and that together those inaccuracies, misstatements, and selective misreading of source materials void the paper of its scientific validity.” The AHA said it would investigate just what Givens had wondered: “how a paper that is completely incompatible with the Association’s core values was published.” Last week, a Heart Association spokeswoman told STAT it has been working to diversify its editorial ranks and prioritizing the publication of research on health inequities, and in January announced it would spend $230 million on efforts to increase health equity.

The paper‘s author, Norman Wang, did not agree to the retraction and has sued both the AHA and his employer, the University of Pittsburgh Medical Center, for violating his right to free speech by removing him from his position as program director for the clinical cardiac electrophysiology fellowship. Neither Wang nor his lawyer returned a request for comment, but when filing the lawsuit last December, lawyer Terence Pell, president of the Washington, D.C.-based Center for Individual Rights, said: “What’s remarkable about this is that he was not punished for an inappropriate joke or an intemperate remark in the classroom, but for publishing a thoroughly researched article in a peer-reviewed journal.”

Spurred by his outrage, Givens combed the mastheads of more than 100 journals, including JAMA, the journals of the JAMA Network, NEJM, and dozens of cardiology journals. He compiled a list of the names of more than 7,500 editors. Then came the hard part. Race is not listed on mastheads, so to establish the gender and race of editors, Givens spent months searching the internet and social media for pictures and references to people. Many of the cardiologists he knew personally.

His analysis showed that as of October 2020, of 51 editorial board members at the New England Journal of Medicine, just one was Black and one was Hispanic, four were East Asian, and two were South Asian. Of the 49 editorial board members at JAMA, two were Black, two were Hispanic, three were East Asian, and one was South Asian. Not a single board member at either publication was Native American. In one particularly absurd detail, his analysis showed the editorial boards included more people named David than Black and Hispanic editors combined.

Givens said his analysis of JAMA and the 12 journals in its network showed that as of October, of 532 editorial positions, 25, or less than 5%, were Black, and 26, or less than 5%, were Latinx, nearly 19% were Asian, and nearly 70% were white.

Editorial staff diversity chart

A JAMA spokesperson said Givens’ data were out of date and that of the 341 editors and editorial board members across JAMA and the other 12 JAMA Network journals, 72% are white, 18% are Asian, 6% are Black, 4% are Hispanic, and 38% are women. JAMA did not provide a breakdown of its data, so it is unclear which positions they chose to include and why the numbers differ.

“We can quibble about a couple of people here and there, but it doesn’t change the big picture,” Givens said.

Givens acknowledged that his data are imperfect since race is not self-reported and that additional editors of color have been hired since he compiled his data. He said there could be some uncertainty about the race of some editors, including those who may be biracial. Givens included only editors who had an M.D. or Ph.D., he said, in part because these people had more information online, and also did not include statistical review editors, out of what he said was fairness to the journals, because so few medical statisticians are African American.

He plans to present his findings on the racial makeup of cardiology journals, which showed that of more than 7,000 editorial positions at dozens of journals, fewer than 2% are held by Black editors, at an upcoming American College of Cardiology meeting, he said.

NEJM did not refute Givens findings. “I’m afraid that they weren’t surprising to us,” Rubin said. Rubin said he had been working to address structural racism and the lack of diversity at the journal since taking the helm 18 months ago. He said that of eight additional editors and editorial board members hired since September 2019, four are people of color. “We readily acknowledge that we aren’t diverse enough, but we’re improving,” Rubin said.

In November, NEJM hired the first Black deputy editor in its 200-year history, Winfred W. Williams, who is associate chief of the division of nephrology at Massachusetts General Hospital. (No person of color has ever helmed either of the two journals; in the JAMA network of 13 journals, some of which are 150 years old, there has only been one non-white top editor, Givens said.)

Williams said he has spent his career focused on ameliorating medical inequities and he took the editing position to further that work. “I believe I am well-suited to breathe new energy and life into this critical area for NEJM,” he told STAT by email. He said he agreed that the lack of diversity Givens has highlighted is a major problem. “Having editorial representation by clinicians, physician-scientists, and other professionals-of-color is critically important,” Williams said. “It’s a matter of who has a seat at the table. … Who sets the priorities? It’s those who occupy those seats.”

JAMA officials said they were not responding to media questions while the AMA is undertaking a thorough review of their journals in response to the furor over the recent podcast, which raised numerous issues about how the journals handle issues of racism in medicine, including how few editors of color contribute to publication decisions.

Despite his focus on data, Givens said his fight is about more than numbers. While he wants to see more physicians of color (and women, and LGBTQ+ people, and people from outside of the Northeast) on editorial boards, he said the boards also need to include people who are willing to speak out and challenge the establishment.

“People who have a history of speaking bluntly and assertively are not asked to be on these panels,” he said. “It’s not team of rivals. People who are picked are your buddies, people who won’t challenge you. They need to make sure they have some bold voices in there.”

He’s also frustrated that his fellow physicians, able as they may be to handle a heart vascularization or craniectomy, seem paralyzed when it comes to dealing with, or even discussing, racism and the way it may be harming patients. “As physicians, either by instinct or training, we run to problems. If people are bleeding, we put our hands on them,” he said. “But when it comes to racism, people just run away.”

“As physicians, either by instinct or training, we run to problems. If people are bleeding, we put our hands on them. But when it comes to racism, people just run away.”

Cardiologist Raymond Givens

Givens is not running away. He has joined a group of Black physicians called the Black Healers Network who are calling for medicine to confront and dismantle the systemic racism within their field. And now they are finally getting the meetings they wanted. Givens said he appreciated the chance to speak with Rubin about the lack of diversity on the New England Journal’s editorial board. He said a group of seven Black physicians met with the American Medical Association’s top leadership last week. “It was NWA meets AMA — straight outta Covid,” said Givens.

“It was terrifying,” Brittani James, an assistant professor of clinical family medicine at the University of Illinois College of Medicine and co-founder of the Institute for Antiracism in Medicine, said of the meeting. “It was definitely a David and Goliath moment.”

James, one of the physicians who started a petition against JAMA and the AMA after the podcast, said the meeting was productive and association officials listened and “said all the right things.” But she said her group told the AMA it wants to see change, and quickly. The participants asked the association’s leaders for a progress report within a month.

“This is not the time for the AMA to continue to be cautious and conservative,” Givens said. He said AMA officials acknowledged the data he presented. “They said it was compelling and showed the scope of what was going on,” he said.

In a statement, the AMA said its leaders were grateful to physicians, including long-standing AMA members, for expressing concern about the podcast. “AMA leaders are listening and learning and we are committed to dismantling structural racism across the AMA and in health care,” the statement said.

Among other changes, Givens and James are asking the AMA, which excluded Black physicians until the 1960s, to diversify the editorial boards of JAMA and the other journals in its network. “The AMA has a history of brutal racism,” said James. “And when you look at the makeup of the editorial boards, it’s the same thing. We’re still being excluded.”

Source: STAT