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Sanziana A. Roman, MD, FACS Ombuds, Diversity, Equity and Inclusion

Unconscious bias, professionalism and peer review recently have been in the spotlight after #MedBikini went viral on social media. It is probably long overdue and delivers us to a pivotal moment and call to action.


For those unfamiliar with the controversy, here is a brief recap. The Journal of Vascular Surgery published the study, ‘Prevalence of unprofessional social media content among young vascular surgeons,’ which stemmed from an abstract presented at the 2019 annual meeting of the Society for Clinical Vascular Surgery and that went online in December 2019; it was accompanied by an invited commentary, lending gravity to the work. The purpose of the study was to evaluate the extent of ‘unprofessional’ social media content on vascular surgery trainees’ public accounts, including Facebook, Twitter and Instagram. Three male coauthors created social media accounts and levied judgments based on what they observed on these public social media accounts. While the study was approved by an Institutional Review Board, the authors did not obtain approval of the Association of Program Directors in Vascular Surgery to use its database in identifying the vascular surgeons in training who were evaluated for their participation on social media.


Medical professionalism is one of the six core competencies identified by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties in 1999, and it has continued to be emphasized and extends beyond just direct patient encounters. How such professionalism should be defined in 2020, however, is now (appropriately) being debated. In the JVS study, potentially unprofessional behavior included ‘inappropriate attire [such as] pictures in underwear, provocative Halloween costumes, and provocative posing in bikinis/swimwear.’ The subjectivity of these definitions was called out, along with the observation that they applied more to women than men, given that ‘bikinis’ specifically were called out as ‘provocative’ and ‘unprofessional.’ This led to the viral hashtag #MedBikini on Twitter and an explosion of Twitterati posting photographs of themselves in swimsuits and bikinis. Within hours of publication, the study, its authors, and then the overwhelmingly male editorial leadership of JVS were the objects of criticism and outrage. Ultimately, the paper was retracted, and robust discussion has ensued about a litany of significant concerns, including the methods of data collection employed, lack of diversity of the authors performing the study, overtones of sexism and misogyny tied to an outdated definition of professionalism based on White, elitist, heterocentric, patriarchal norms, errors in the design of the study reflecting conscious and unconscious bias, and ultimately a peer review system that did not pick up these flaws.


There are many issues that must be discussed and addressed, but as an Editor-in-Chief of WJS, I believe that there are several that rise to the top. It is absolutely essential that we call out the lack of diversity that currently exists among peer reviewers and also among the editorial leadership of surgical journals. Dr Melina Kibbe, Editor-in-Chief of JAMA-Surgery and incoming Chair of the Surgery Journal Editors Group (SJEG), took a compendium of 210 journals listed in the surgery category from the Journal Citation Reports Web site for impact factor and added a few other journals that are in existence but which do not have an impact factor yet. Looking up names and email addresses, she determined that there are 215 surgery journals in total, with 252 editors, of which just 17 are women (6.7%)!


We are proud that WJS has had a woman Editor-in-Chief (EIC) since 2018, but it is also essential that our editorial leadership be diversified to better reflect our authors and readers. Again, WJS is striving to do such; in the last two years, we have added Drs Sandra Wong, Nancy Baxter, Cheng-Har Yip, Sanziana Roman, and Ann Lazar to our associate editors group; women now represent 47% of the editorial leadership, with Janice Pasieka also a member of the group. We have excellent international representation, with seven countries represented. Going forward, we still can do better. We are committed to broadening our racial and ethnic diversity and also including more editorial board members from low- and middle-income countries. We also want to assure that our peer reviewers and editorial board members are diverse; care will need to be taken to avoid a gender or minority ‘tax.’ Since so many surgical specialties have a relative scarcity of diversity, we must avoid calling on a small number of under-represented minorities and women to carry more than their share of the review burden. This speaks to the absolute and urgent need to press for greater diversity, equity, inclusion (DEI), and empowerment within surgery internationally. These principles require fastidious surveillance and accountability. To that end, we are proud to announce that Dr Sanziana Roman, who is our Associate Editor for Innovation and Special Features, will also take on the role of Ombudsperson for DEI, reviewing all accepted manuscripts to help assure scientific rigor, specifically around unconscious/implicit bias.


The World Journal of Surgery is determined to lead the way around issues like these. As EIC, I am committed to speaking up and out around the importance of diversity, equity and inclusion in science, scholarship and peer review. We must work together as members of SJEG to promote diversity among our peer reviewers and our colleagues in editorial leadership; we should share best practices among our community. We must hold ourselves accountable, working together to collect metrics that demonstrate where there are opportunities for progress to be made. In the end, some specialties within surgery and some countries around the world face greater barriers to get to diversity, inclusion and equity, given their starting points (around a relative lack of diversity); they should not be deterred, as it will only make progress sweeter. All of us can do better, and commitment to improvement is essential. The issues raised via #MedBikini are not unique to the USA or vascular surgery. Rather, they are ubiquitous. The International Surgical Society and the International Surgical Community must pledge to diversify, support, include and empower all of its members, especially those who are underrepresented.


We cannot—and should not—shy away from social media. It is here to stay and is an important vehicle for professional development and scientific dissemination. Harnessing it responsibly, however, is critical. WJS is committed to doing such, with visual abstracts for the best science and for the distribution of other initiatives, like ‘My First Paper.’


Finally, I will finish with a plea to young academic surgeons around the world. Reading and reviewing the work of colleagues is a privilege and a responsibility of being part of our larger surgical community and helping drive science forward. So when invited to review, say ‘yes’! You will learn from others, get inspired, enhance your critical thinking and engage in an essential form of service. We thank you in advance.


Onward!