Reporting Race in Orthopaedic Journal Articles: Commentary on an article by Cody Crnkovic, BS, et al.: "Low Rates of Reporting Race, Ethnicity, and Socioeconomic Status in Studies Published in Top Orthopaedic Journals".

Abstract

Commentary Whether or not it is proper to include race as a variable in clinical research studies has been a subject of debate for decades1. Crnkovic et al. lament the “underreporting” of race in articles published in Clinical Orthopaedics and Related Research and The Journal of Bone & Joint Surgery and call on the editors to remedy this perceived deficiency by requiring that race be recorded for all human research subjects. The authors quote from recent guidelines published in the Journal of the American Medical Association (JAMA) and from the recommendations of the International Committee of Medical Journal Editors (ICMJE) to support their view. In doing so, the authors greatly simplify a complex issue and mischaracterize the published guidelines. Thoughtful journal editors have long acknowledged that although race is a social construct without biological basis and that racialized medicine has been utilized repeatedly throughout history to mark a particular group as different, inferior, and defective, it is still sometimes necessary and helpful to collect meaningful data on race in order to identify, understand, and improve inequitable health outcomes2. The question is how best to do this. There is widespread agreement that when racial data are utilized in a study, there should be a valid reason. The JAMA guidelines state that “if race and ethnicity categories were collected for a study, the reasons that these were assessed also should be described.” The ICMJE guidelines state only that authors “should define how they determined race or ethnicity and justify their relevance.” Ioannidis et al. presented arguments for and against the inclusion of race in research and stated that “a large amount of research involving race variables has been, in hindsight, pedestrian and arguably lies among the greater waste of spurious, nonusable biomedical evidence.”3 He adds that “it is important to think carefully about the fundamental question. Why should race variables be used, if at all?” Some researchers, including Crnkovic et al., suggest that there is a universally applicable justification for including, even requiring, race data to be collected and reported. Knowledge of patient race is thought to be important for establishing the generalizability of the study results and for supporting research into inequities in health outcomes and processes. Although there are valid reasons to support the recruitment of diverse populations into research studies, the claim that it is important to know the racial makeup of a study population in order to assess the applicability to a reader’s own patients is questionable. The harm caused by the use of race as a cognitive framing device for clinical decision-making may be substantial4. The limitations of race as an explanatory variable are due both to its indistinct social construction and to its connection with other social determinants of health. The mutability of race is reflected in the JAMA guidelines, which recommend that authors include “an explanation of who identified participant race and ethnicity and the source of the classifications used (e.g., self-report or selection, investigator observed, database, electronic health record, survey instrument).” Cerdeña et al. stated that hypotheses that utilize racial labels “should make the definition and operationalisation of race explicit,” adding that “structural barriers to health that overlap with race should be considered, including socioeconomic status, discrimination, transportation, environmental exposures, criminal history, documentation status, English proficiency, and neighbourhood violence.”5 Winker noted that although the National Institutes of Health (NIH) requires race and ethnicity to be assessed, “the NIH does not require that authors consider thoroughly the implications of race in their study and measure other factors that might confound apparent associations of outcomes with race, such as socioeconomic status.”2 When considering race, Cooper et al. stated that to “resist racialized thinking, clinicians and researchers need to become better at appreciating social context and the potential personal and economic challenges that mediate susceptibility or lead to poor quality of care, and consider what all of that means for the analysis that contributes to a scientific report.”6 Simply reporting standard measures of socioeconomic status along with race does not accomplish this. There is a need for high-quality studies of what Ioannidis et al. called “the multifarious consequences of long-entrenched and continuously transformed racism” in medicine. Not every article published in The Journal of Bone & Joint Surgery will meet the high bar required, nor should they be expected to. Studies that seek to comment meaningfully on the effects of race should state a hypothesis, explain in detail how the race of subjects was determined, report relevant measures of socioeconomic status, consider alternative explanations for the findings, and place the results in the context of the health-care system. To do less adds to the cloud of unknowing that good journals try to dispel.