Diversity and Inclusion in Medical Publishing

As the second decade of the 21st century begins, facial plastic surgery must face a glaring disparity: we are a field in which women comprise 70 to 90% of patients, yet senior leadership in education, organized medicine, and even publishing is still overwhelmingly male. It is clear that underrepresentation like this can lead to a narrow and myopic worldview. A recent article in the Journal of Vascular Surgery [1] attempted to assess unprofessional behavior among recent and soon-to-be graduates of U.S. vascular surgery training programs on social media. The prevalence of social media in modern society made this an exercise of potential benefit, as patients may draw inferences about a surgeon's competence and professionalism based on what they might see on public sites like Facebook, Twitter, and Instagram. However, implicit biases in the formulation of the study were propagated and compounded through the review, production, and editorial processes and allowed this flawed study to be published.

The authors of this publication, since withdrawn, used definitions from a 2014 study[2] of professionalism among surgical trainees as well as a later study[3] of U.S. urology trainees (determined by review of their social media posts). These studies classified “unprofessional content” as any posting of images or text of patients' protected health information, personally engaging in or advocating unlawful behavior, possession of drugs/drug paraphernalia or advocating illicit drug use, “appearing intoxicated,” referencing specific instances of unprofessional behavior at work or in a professional capacity, uncensored profanity, and “offensive comments” about colleagues or a specific patient. “Potentially objectionable content” was defined as holding or consuming alcohol, “inappropriate or offensive attire,” appearing in sexually suggestive attire or circumstances, engaging in discussions of politics, religion, or polarizing social topics and censored profanity, as well as links to posts related to sex or sexual behavior.

The authors of the recent study found 3.4% of trainees had “unprofessional content” and 25% had “potentially unprofessional” content on at least one social media site. While these authors noted no difference based on gender, 30% of female trainees were judged as having objectionable content in their social media postings. It is important to note that only one (who was not involved in categorizing the posts) of the seven authors of this paper was female; of the other two papers mentioned, only two of the eight listed authors were women. In the United States, a social media backlash ensued, the Journal of Vascular Surgery withdrew the paper and the senior author has apologized.

Why the backlash, and why is this important? The papers in question sought to determine the level of “unacceptable” behavior by physicians on social media. Some things like disparaging a patient or advocating unlawful activity are fairly straightforward and can be defined. However, short of “detrimental to a patient” or “criminal activity,” “unprofessional behavior” is difficult to pin down. The authors sought to establish a “societal” norm, but unfortunately relied on a previous publication as justification of their definition. In these studies, a woman on vacation wearing a bikini sitting poolside might be judged as “unprofessional” in terms of attire, even though this image was published on a personal social media site. The reader should ask, “Would a man be similarly judged?” Likewise, a woman who expressed belief in her reproductive autonomy (current law) would have been judged “potentially unprofessional” as the researchers would deem this “socially polarizing.” While a review of the authors' statistical methods may have found the study acceptable, evaluating this article from a wider perspective might have identified the inherent biases in the questions posed.

In response to this, we have answered the call from Melina R. Kibbe, MD and Julie Freischlag, MD (current and past Editors of JAMA Surgery) and the Surgery Journal Editors Group to join with the editors of 107 (and growing) other surgical journals worldwide to commit to work toward gender equity in the peer-review process and on editorial boards.[4] We will seek out contributions from those whose voices have been underrepresented in facial plastic surgery publications. We will broaden our reviewer panel and enhance our peer-review process, making it more responsive and more inclusive. We will seek to include new voices, as gender, racial, and nationality diversity will improve the breadth, depth, and quality of reviewers' comments and our journal. We will draw on the full spectrum of facial plastic and reconstructive surgery community as we seek to best serve our readers.

It is time for parents to teach young people early on that in diversity there is beauty and there is strength. -Maya Angelou

Publication History

Article published online:
17 September 2020

• References

• 1 Hardouin S, Cheng TW, Mitchell EL. et al. Prevalence of unprofessional social media content among young vascular surgeons. J Vasc Surg 2020; 72 (02) 667-671
• 2 Langenfeld SJ, Cook G, Sudbeck C, Luers T, Schenarts PJ. An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media. J Surg Educ 2014; 71 (06) e28-e32
• 3 Koo K, Ficko Z, Gormley EA. Unprofessional content on Facebook accounts of US urology residency graduates. BJU Int 2017; 119 (06) 955-960
• 4 Kibbe MR, Freischlag J. Call to action to all surgery journal editors for diversity in the editorial and peer review process. JAMA Surg 2020; (e-pub ahead of print) DOI: 10.1001/jamasurg.2020.4549.