Racism and peer review: When your “peers” are not your peers

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Following George Floyd’s murder and the ongoing racial justice movement, funders and journals in public health announced a slew of new opportunities specific to anti-racism, structural racism, and so on, suddenly feeling the urgency to acknowledge that racism has been killing Americans…since, well, the beginning.

These were important first steps in recognizing how scholars have been shut out of research and academia- but these opportunities were still built off the existing research enterprise infrastructure. Which- no surprise- is racist in its construction.

How so? Besides systematically denying funding and publication on racism and health, to scholars racialized as non-white, we also have:

  • Systematic underfunding/disinvestment in minority serving institutions, including Historically Black Colleges and Universities- thus less support services for scholars at those institutions and lower ratings on institutional environment (in grant review)
  • Ignorance (deliberate or intentional) of scholarship particularly those with a critical stance (eg devaluation of the work in ethnic studies, critical race theory and extensions)
  • Denigration of methods of those scholars, as well as other methods e.g. all of qualitative research, community-engaged work, etc
  • Lack of diversity and advancement within academia

To name a few.

These conditions have led us to the present conditions which we have new funding and publication mechanisms, reliant upon a traditional peer review system in which reviewers are poorly qualified- and at times oppositional- to any work on racism. Furthermore, editors are not necessarily equipped to identify or mitigate low quality peer review. This is just one pillar of the racism within research.

What happens when you just stack new objects on the same old foundation?

Check out the Health Affairs Forefront essay on the poor quality of peer review and consequences: Peer Review and Structural Racism.

 

 

Structured travel time and distance inequities in access to hospitals in the U.S. South

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White sign covers the existing sign of in front of a hospital and says "This hospital is CLOSED, if this is an emergency call 911." The sign is flanked by shrubs and lamps posts.

In 2019, a PhD student in medical geography at the University of Illinois posted on Twitter about her interest in studying rural hospital closures. An assistant professor from UC Davis DM’ed her to say, we should talk! They met up at a cafe near the AcademyHealth Annual Research Meeting in Washington, D.C. And a speedy 4 years, many datasets, analyses, a move, a new baby later…they finally published the first analysis.

Following up from her previous conceptualization on time as a social determinant of health, Arianna M. Planey uses the cases of access to acute care hospitals in the U.S. South to illustrate the construction of racialized inequities in healthcare.

In addition to grounding the motivation and analysis in the theoretical frameworks of structural racism and access to healthcare, Dr. Planey’s approach shows the benefits of drawing from geography methods to improve health services research, including:

Methodological improvements:

-Use of a validated hospital dataset that accounts for closures and mergers to determine actual losses of sites.

-Use of travel time/distance as an outcome. Most analyses of rural hospital closures, which use ‘container’ methods, e.g. documenting changes in hospital supply by county. In this manuscript, Dr. Planey examines travel time and travel distance. She shows that the impact on travel time and distance is relatively smaller than simply examining gains/losses by county.

-Estimates from the population-weighted centroids of Census tracts, i.e. not the geographic center (commonly used) but rather, based on where people live within the tract.

–Examination of both nearest and next-nearest hospital. This is a key consideration in rural hospital analyses, as community members have high rates of hospital bypass- for many reasons, including lack of specialty services and distrust of the nearest facility. For racially minoritized communities, the nearest hospital may not offer the services for linguistically, culturally appropriate care, which can include care that is respectful and trustworthy.

Findings: You can read more, TLDR Black and Latinx communities have longer travel times/distances to next nearest and nearest hospitals, despite being less remote than rural white communities.

And…what? you want to see what the impact is on access to care? Stay tuned….

Planey AM, Planey DA, Wong S, McLafferty SL, Ko MJ. Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018. Milbank Q. 2023 May 15. doi: 10.1111/1468-0009.12655. Epub ahead of print. PMID: 37190885

 

Medical school admissions and institutional racism

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Large boulder in desert sands with clear blue skies and sandy brush in the background

Grant Marek/SFGATE The purported largest freestanding boulder in the world, Giant Rock, in the California Mojave Desert.

Nearly 25 years ago, during my lit review for my med school research thesis on diversity and medical education programs, I found many prior articles had already been published about the lack of diversity in medicine. 1985. 1996. and so on. In 2013, a physician fellow contacted me for advice on her brief research letter documenting the lack of diversity in medicine.

So, when the news cycle had once again “discovered” the dearth of Black men in medicine in 2018 (or was it 2016?), it felt like time to get back into workforce research. And instead of yet another quantitative paper, it also felt like time to ask, what is going on?

Some failed grant applications, a modicum support from UCD Center for a Diverse Health Workforce (not the Center’s fault- there has been barely any money for workforce research until last year), and a *lot* of team effort, and we managed to conduct key informant interviews with 39 deans and directors of 37 MD-granting medical schools, asking them about admissions in general. Then zeroing in on diversity.

We plugged away through the onset of the pandemic to finish the interviews. Coding and analysis, reading, more analysis, more reading, and the final writing-as-analysis phase were a real bear, even more so than usual. But finally this came out:

US Medical School Admissions Leaders’ Experiences With Barriers to and Advancements in Diversity, Equity, and Inclusion

It’s hard to pick a favorite quote so please read the paper if you can. As a teaser, here’s one:

“After our white coat ceremony, [my dean] received a lot of questions [from alumni and faculty], ‘Whatever happened to the six-foot-two blonde, white boys we used to have in our medical school, where did they all go?'”

Key takeaways:

  • Racism has wormed its way into so many places, small and large, throughout the entire admissions cycle and school of medicine.
  • This means there are many opportunities, from small process changes to large institutional system-wide transformations, to conduct anti-racist change (see the Supplement!)
  • Med schools, get out of US News and World Report already. It doesn’t matter as much if the Harvards of the world do it- but you can make a difference if the mid-tier schools do.