The leading U.S. medical journal, read regularly by doctors of all specialties, systematically ignores an equally reputable and rigorous body of medical research that focuses on Black Americans’ health.
The American Medical Association created a segregated “whites only” environment more than 100 years ago to prohibit Black physicians from joining their ranks. This exclusionary and racist policy prompted the creation in 1895 of the National Medical Association, a professional membership group that supported African American physicians and the patients they served. Today, the NMA represents more than 30,000 medical professionals.
In 2008, the AMA publicly apologized and pledged to right the wrongs that were done through decades of racism within its organization. Yet our research shows that despite that public reckoning 15 years ago, the opinion column of the AMA’s leading medical journal does not reflect the research and editorial contributions by NMA members.
Invisibility in the opinion column of one of the most prominent medical journals in the U.S. is another form of subtle racism that continues to lessen the importance of equitable medical care and health issues for Black and underserved communities.
As rhetoricians and researchers who study scientific communication, we look at the ways scientific writing perpetuates or addresses racial inequity. Our recent study traced how research is referenced by medical professionals and colleagues, known as citations, of flagship journals of the NMA and AMA: the Journal of the National American Association and the Journal of the American Medical Association.
Invisible research
Our research began with a question: Has the AMA’s 2008 apology had any effect on the frequency with which JAMA opinion writers draw on insights and research of JNMA scholars and authors?
We studied opinion columns, also referred to as editorials, precisely because they are useful indicators of current and future research as well as priorities and agendas. The purpose of editorials is to critically analyze and sift through various opinions and evidence. Effective editorials in scientific journals are especially rich forums for debate within the medical community.
Medical publications like JNMA and JAMA do not simply convey knowledge. They also establish professional community values through the topics that are studied and who is credited for ideas related to research. When writers choose to reference or cite another scholar, they are acknowledging and highlighting that expertise.
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As such, citations play an important role in the visibility of research. Articles and authors with more citations are more likely to have a greater effect on the scientific community and patient care. Opinion pieces can shape the broader conversation among medical professionals, and citations can widen that circle of communication.
Invisible racism
We traced how frequently JAMA and JNMA opinion writers referenced one another from 2008 to 2021 by reviewing the 117 opinion pieces published in JNMA and 1,425 published in JAMA during this 13-year period. We found that JAMA opinion columns have continued to, in effect, uphold racial bias and segregation by ignoring JNMA findings.
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Even when focusing on race, racism and health disparities, topics that JNMA has explored in great detail, JAMA opinion columns did not reference JNMA colleagues or research. Only two JNMA articles were credited and referenced in the 1,425 JAMA opinion pieces that we reviewed.
Editors at JAMA did not respond to our requests for their comments on our analysis.
Racial equity in medicine
The story of the AMA and NMA is not only a reminder of the racist history of medicine. It demonstrates how the expertise of Black professionals and researchers continues to be ignored today. The lack of JNMA citations in JAMA research undercuts the AMA’s own work on racial equity and potentially compromises the quality of medical knowledge published in its journals.
For example, a recent study in the Proceedings of the National Academy of Sciences found that scientists from underrepresented groups innovate, or contribute novel scientific findings, at a higher rate than those from majority groups.
An article published in the weekly medical journal of the Public Library of Science noted that diverse research teams are often more successful in developing new knowledge to help treat women and underrepresented patients with greater precision.
Dissolving systemic bias
One way to intentionally tackle racial bias and segregation in medical knowledge is by deliberately referencing Black researchers and their work. To change this dynamic of racial bias, medical journals must pay attention to how much and how often the Black medical establishment is referenced. Health issues in underserved communities would likely become more visible and achieve greater quality of care in keeping with the AMA’s commitment to social justice.
Journal editors could tell writers and editorial staff to prioritize citation practices. Individual authors might conduct research and evaluate their reading habits to intentionally include research from the Black medical community.
However, this work must go beyond individuals. Undoing decades of collective habits and embedded racism requires collaborations that work across systems, institutions and disciplines.
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For example, libraries, databases, and search engines that help researchers find and evaluate medical publications might review today’s research tools. It is hard to contribute to a research conversation if your work is invisible or can’t be found.
Many tools, like impact factors, rank research according to how influential it is. If research begins in a category of less importance, it can be harder for the technology to rank it equitably. JNMA’s work was already marginalized when the tools that rank research were developed.
Thus, search results can hinder efforts of individual authors to work toward equitable citation practices. Black researchers and their research of Black health were excluded from the beginning, and existing systems of sharing knowledge and drawing attention to important studies incorporate that structural racism.
The AMA apology in 2008 and its recent progress on addressing racism in its publication process are promising steps. Influential medical journals serve to inform and shape health care. Who is referenced in these journals matters to the medical establishment, research funders and, ultimately, to the patients that are served by innovations in medicine.
Attention to citation can help reduce systemic bias in medical knowledge to achieve greater fairness in health care and, in the long run, help increase attention and resources that will help solve health issues in underserved communities.
