I can tell you, without diversity, creativity remains stagnant.
—Edward Enninful, OBE
The Journal of Neurosurgical Anesthesiology (JNA) has been, and continues to be, committed to publishing the most creative, innovative and highest quality perioperative neuroscience research.1 Commensurate with this mission is a dedication to support the growth and development of all editorial aspects of the Journal: authors who submit their work, reviewers who provide timely and expert commentary, Editorial Board members, and the Editor-in-Chief who is responsible for journal policy and governance. To date, ample evidence supports diversity, inclusion, and equity as advantageous to the organizational structure of a number of different societal establishments, and medical journals are no exception.
From financial performance in business to reducing health disparities, a diverse workforce is increasingly identified as essential for success. While diversity refers to the differences in experiences and perspectives within a group, inclusion ensures that all members have equal access to opportunities, and equity is defined by parity in processes and policies. In an analysis of over 2 million published articles, those published in higher impact journals had a more diverse authorship and were cited more often.2 In addition, diversity within the healthcare workforce has been demonstrated to increase communication, patient satisfaction, patient compliance and overall health outcomes.3 Heterogeneous groups with a variety of ethnicities, perspectives and experiences have also been shown to increase accuracy and innovation in finance.4,5 Despite these proven benefits, a lack of gender and racial diversity in academic anesthesiology has been highlighted as a persistent issue,6,7 perpetuated by entrenched societal biases and institutionalized racism.
The Journal of Neurosurgical Anesthesiology is an international journal which serves as the official journal of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC), itself an organization with a diverse international member base. In 2019, JNA received submissions from authors in 35 countries and all continents, with a readership extending to 72 countries. The Editor-in-Chief supported by the Editorial Board has an obligation to ensure that JNA content reflects a full range of ideas, perspectives, and approaches to scientific inquiry. Peer review, in particular, serves as a critical gatekeeper tasked with upholding the highest level of scientific rigor and quality of research published in JNA.8
The Editor-in-Chief recently reviewed the demographics of the JNA Editorial Board and Board of Reviewers over three time-points during the last two decades (2006, 2012 and 2019; Fig. 1). In 2006, 93% of Editorial Board members were based in the United States; this fell to 63% in 2019 with the other 37% of members representing 11 countries from all continents. Moreover, 40% of manuscript reviews are now provided by colleagues outside the United States compared with only 16% in 2006. Over the time period examined, women were underrepresented on the Editorial Board, making up only 20% of its members, similar to other journals in Anesthesiology.9,10 Encouragingly, there has been a small but steady increase in the proportion of women providing peer review for JNA over time, increasing from 17% in 2006 to 29% in 2019.
The diversity of the neuroanesthesia and perioperative neuroscience community as a whole is not well-defined. A glimpse into the demographics of SNACC’s international membership, however, reveals a group that is more reflective of today’s majority white, male medical establishment in the United States. A 2018 survey conducted to better understand the demographics and experiences of SNACC members revealed that the majority of respondents were from the United States (76% vs. 24% non-US) and were male (63%).11 Regarding race/ethnicity, most of the men and women respondents self-identified as white (67% and 63%, respectively). These findings are consistent with a previous analysis demonstrating a relative lack of racial and gender diversity in Anesthesiology as a specialty in the United States.6 These findings compel serious consideration of the systemic barriers to more equitable representation in physician workforce, medical education, medical societies, medical research, and medical journals. Targeted initiatives such as highlighting the work of minority groups and mentorship may be beneficial in improving diversity. Several of these initiatives have been employed by SNACC,12 similar to many medical societies around the world.
Overall, while JNA has made progress towards increasing geographic diversity and gender representation amongst peer reviewers, there is room for improvement going forward, particularly with regard to Editorial Board membership. Furthermore, the evolution over the past two decades occurred in the absence of a formal diversity and inclusion policy, an absence which we intend to address. Increasing diversity and inclusion is complex and requires a sustained and intentional approach to addressing many disparities. The first step is to systematically collect and analyze data, both to inform strategy and inform progress going forward. Next, we need to understand the obstacles to participation in neuroscience research, publishing and peer review. Finally, this information should be used to develop strategies to minimize systematic barriers and increase the inclusion of members of underrepresented groups. We look forward to a bright future for JNA as we strive to achieve a broader more diverse platform for the publication of perioperative neuroscience research.
Marie Angèle Thèard, MD
Vice-chair, SNACC Diversity and Inclusion Committee
Alana M. Flexman, MD, FRCPC
SNACC Representative to the JNA Editorial Board and SNACC Secretary/Treasurer
Martin Smith, MBBS, FRCA, FFICM
Editor-in-Chief, Journal of Neurosurgical Anesthesiology
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6. Nafiu OO, Leis AM, Wang W, et al. Racial, Ethnic, and Gender Diversity in Pediatric Anesthesiology Fellowship and Anesthesiology Residency Programs in the United States: Small Reservoir, Leaky Pipeline. Anesth Analg. 2020. [Epub ahead of print].
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10. Lorello GR, Parmar A, Flexman AM. Representation of women on the editorial board of the Canadian Journal of Anesthesia: a retrospective analysis from 1954 to 2018. Can J Anaesth. 2019;66:989–990.
11. Theard M, Flexman A, Aglio L. Diversity and Perspectives of the Society for Neuroscience in Anesthesiology and Critical Care Membership: A Survey. J Neurosurg Anesth. 2019;31:491–492.
12. Théard MA, Aglio LS. Diversity and Inclusion, Here and Now – SNACC Reaches Out to All Its Members. ASA Monitor. 2018;82:52–54. Available at: https://monitor.pubs.asahq.org/article.aspx?articleid=2695441
. Accessed June 12, 2020.