Emergency medicine research and gender: Sensitivity and censorship
American Journal of Emergency Medicine 38 (2020) 149-150
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Emergency medicine research and gender: Sensitivity and censorship
AJEM readers are encouraged to read the manuscript in this issue with the unpretentious and seemingly innocuous subject of assessing operator factors associated with successful first pass intubation. [1] Its publication represents the culmination of a months’ long internet brouhaha that embroiled AJEM in a social- political controversy.
Our editorial office received an unprecedented number of mis- sives about this manuscript, many in support, but most in opposi- tion, after a preprint version appeared on-line. This was on the heels of a good deal of ”cyber-bullying”, documented and analyzed adroitly by Ogle et al. in this issue’s Correspondence section [2]. A wide range of unprofessional and personal threats were made, often anonymously. The author initially wanted to withdraw his manuscript under these calumnies and fulminations. However, he recanted when the journal, after a second review by all its edi- tors and several additional reviewers (including three women), unintimidated and confident of its review process, reaffirmed its decision to publish. The author did request – and was thus granted- an opportunity to revise his manuscript a second time to clarify, uncontroversially, several scientific and methodological questions raised, as well as the presentation, emphasis and title. The data, results and conclusions remained the same.
Peer review is not without its flaws, and each reviewer brings their own specific experiences and even unconscious biases. Reviewers and editors make every effort to release the best possi- ble version of a given manuscript, and post-publication peer review is an equally important component of this process. Nonetheless, post-publication review (like pre-publication review) should focus on collaborative discussion and constructive feedback and not engage in defamation, intimidation or censorship.
Like almost any published observational study, the methodol- ogy in this particular was imperfect, but it should not be over- looked that scant critics advocated rejection (and post hoc censorship) on the basic merits of the publication in either version. This is unsurprising as it passed, with revision, our customary sci- entific standard of review. Rather it was the premise/hypothesis that purportedly needed to be banned, because it was ”manifestly illegitimate” (as one critic wrote), and any data that related to gen- der should not only be caveated, carefully framed and subject to additional scrutiny, but in some critics’ minds, simply suppressed. The first iteration of this manuscript highlighted the research’s findings broken down by gender. As it was conducted in a country where sexism is prevalent, the author felt this was a legitimate area of inquiry, and was pleased to demonstrate there were no gender differences. Of note, several female Korean physicians wrote to express their appreciation to AJEM for publishing an arti-
cle that would have raised considerable controversy domestically by suggesting women physicians were as competent as men!
All critics were invited to express themselves on the pages of AJEM, and this dialogue appears in this issue’s Correspondence sec- tion. The readers’ letters that were formally submitted are not only appreciated but raise, to a greater of lesser degree, in an appropri- ate, civil, constructive, and even erudite manner, issues that merit our editors’, reviewers’ and readers’ attention. (Many others chose not to submit comments for publication and attribution, including the authors of comments that were embarrassing, inaccurate, vul- gar and threatening.) This incident underscores a number of important, and also several troubling, issues impacting research that deals with gender in any sense (physician, patient, epidemiol- ogy, etc.). It should come as no surprise, given where we are today as a society, that these studies can be controversial. What should come as a surprise, however, is the perfunctory alacrity with which numerous readers (especially physicians) jumped to conclusions, apparently reliant upon abstracted, unvetted, and often anony- mous viral social media comments. This has significant and impor- tant implications well beyond the scope of this editorial. (i.e., physicians relying upon headlines and RRS feeds to make patient Care decisions without actually reading studies).
What is the appropriate format for expressing criticism of a published manuscript in a scientific journal? Surely it is through correspondence directly to, and hopefully published by, the very same journal. AJEM does not countenance author ”pocket vetoes” when readers write critical letters. The Journal has an explicit pol- icy to publish all letters to the editor commenting on published manuscripts, even when an author does not respond, provided they are not anonymous, scatological, libelous or incoherent.
Should any study that involves gender differences in providers be suppressed, regardless of the authors intentions, null hypothe- sis, methodology or results, as suggested by many? This is perhaps fine in the political and ”twitter” sphere, but can dismissed out of hand for any scientific medical journal. One is also left to ask, if the null hypothesis were reversed by gender, would it have been meaningful or controversial? While many insisted the premise of comparing specific skills has been settled, manifestly this is not the case in many countries, and perhaps not even in any country, given the international attention this paper received. This was a highly relevant and topical subject as evidenced by the unprece- dented amount of interest, pro and con, this manuscript elicited. Res ipsa loquitur.
Who is ”qualified” to review a study that makes gender distinc- tions or studies gender as a component, even incidentally? To be sure, a journal can commit to have at least one reviewer of each
https://doi.org/10.1016/j.diabres.2019.107932 0735-6757/(C) 2019
150 J. Douglas / American Journal of Emergency Medicine 38 (2020) 149-150
gender involved with such manuscripts, and reach out to other rel- evant disciplines in a good faith effort to achieve the broadest per- spective and Methodological soundness. Where this initiative ends, however, is uncertain. AJEM does not, understandably, develop or retain demographic data, for example, on its reviewers’ race or eth- nicity. Moreover, racial, ethnic or gender quotas should never be an explicit criterion for participation in the editorial review process.
In conclusion, moving forward AJEM will be more structured and proactive in identifying and mitigating the special method- ological risks posed by observational studies that invoke gender, however it has no intention to capitulate to clumsy imprecations of ”followers” with a sociopolitical agenda or solicit ”hits” from cursory voyeurs of our specialty. We seek readers focused on advancing the science and practice of Emergency Medicine.
Should the procedural competence of female physicians be called into doubt in this day and age? Hopefully not, but unfortu-
nately it ostensibly is; not only in Korea but also in the US, as evi- denced by the appropriate concern expressed in the published (and the inappropriate outrage expressed in many unpublished) com- munications we received. Our responsibility should, and our response will, be to publish more and better research in this arena, not less.
Editor
J. Douglas White, MD, MPH, MBA
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