Considerations of equity, diversity and inclusion in peer reviews conducted for Medical Education

Efforts by authors in this Medical Education issue to engage in cross-cultural dialogue and share diverse perspectives with our readership¹ make this an ideal time to consider how equity, diversity, and inclusion (EDI) issues are, or are not, reflected within our field.

The racial reckoning in North America in response to anti-Black racism and the awakening in colonial states including Canada and Australia regarding treatment of Indigenous peoples highlight how systems and structures oppress individuals from underrepresented groups. Such situations foreground the need for research to consider EDI in pursuit of social justice.

Medical education is no exception. Its research shapes understanding of how learning occurs, what curricular content and pedagogical strategies are needed, how outcomes are measured, and what outcomes are achieved. As with most scientific disciplines, however, the field has predominantly reflected the work and views of individuals with power and privilege.² Scientific publications disproportionately originate from the United Kingdom, United States, Australia, Canada, and the Netherlands. In these (and many other) nations, research is traditionally conducted by academic faculty who are disproportionately senior, White, and male compared to the population.^3-5 Emphasis on certain research topics, methods, approaches, and interpretations, therefore yields published literature primarily reflective of the perspectives and experiences of White, Eurocentric scholars.⁶ To disrupt these ingrained practices and assumptions, and broaden the published health professions, education literature, researchers, reviewers, and editors must prioritize social justice within scholarly work.

To share what we learned from reviewers through this prompt (i.e., to reflect on how reviewers consider aspects of EDI in manuscripts), three editors (KEH, RA, KE) and a journal editorial internship alumna (LA) undertook content analysis of responses to the above prompts. After receiving ethics approval from University of California, San Francisco (UCSF,#22-38235), we reviewed and coded all comments uploaded for manuscripts received during the first 18 months post-implementation (March 2022–August 2023), anonymized to reviewer and manuscript author identity. We read all comments to identify concepts and potential codes in the data and developed a codebook using definitions from the American Psychological Association Equity, Diversity, and Inclusion Inclusive Language Guide.⁹ All comments were independently coded by two investigators with discrepancies reconciled through discussion. All investigators reviewed the final findings.

Seven hundred twenty reviewers' comments were received from 43 countries distributed across six continents: North America (39.4%), Europe (32.6%), Oceania (16.7%), Asia (6.1%), Africa (3.8%), and South America (1.4%). There was more similarity than difference when comparing reviewer EDI comments from different parts of the world, without clear trends by reviewer region.

Comments were assigned 1403 codes, about one third (30.3%) of which were positive (praise, commendation); about one third (32.2%) were negative (critical, focused on something wrong or missing); and, about one third (37.5%) did not mention EDI or indicated EDI was not applicable to the manuscript.

Overall, 382 reviewers' comments were coded as specifically addressing equity, diversity or inclusion. Diversity-focused comments were most common (57%); of those, 65% addressed participant demographics, and 21% addressed geography (i.e., study location). Researcher identities or reflexivity, audience/readership, and language were also mentioned. Thirty-six percent of the 382 comments were equity-focused, addressing the influence of power/hierarchy (54%) or the value of critical analysis (46%). Inclusion was least commonly addressed, in only 7% of the comments.

The new reviewer field afforded comments to authors on about two thirds of manuscripts, suggesting the possibility that this effort meaningfully increased attention to EDI in submitted manuscripts. However, reviewer responses varied widely, implying that questions about EDI may be interpreted differently. Equity, diversity, and inclusion were sometimes conflated as if “EDI” is a single construct, whereas these are linked but distinct concepts serving different functions.⁹ Rewording the prompts may give better direction to reviewers, the particulars of which are currently being discussed by the journal's International Editorial Advisory Board. We have heard (and will heed) advice to encourage authors to think more about how EDI influences (but may be overlooked in) all aspects of comprising a research team, conducting a study, and preparing a manuscript for a wide audience. We will strive to encourage authors, reviewers, and editors to consider EDI as a set of values and beliefs rather than something that can be retrospectively fit to a paper. Where to position the EDI prompts will be debated as well: Being last on the reviewer form may have yielded shorter responses due to reviewer fatigue, but this positioning also enables reviewers to consider the whole manuscript before offering impressions of EDI implications.

We will continue to broaden efforts to reduce bias, power, racism, and oppression throughout the research process to strengthen the impact, inclusivity, and accessibility of medical education scholarship.¹⁰ Accordingly, the efforts documented above lead us to offer recommendations for authors, reviewers, and editorial teams:

In conclusion, creating an EDI field for reviewers, the first to our knowledge, and analyzing reviewers' responses are initial steps in a journey to strengthen the equitability, diversity, and inclusivity of medical education scholarship. EDI requires time, effort, vulnerability, and patience to reach understanding and improvement, collectively, within the medical education scholarship community. At Medical Education, we welcome feedback and ongoing dialogue from readers, authors, and reviewers as we continue to grow and improve.⁷