Eleanor Shaw analyses the role of privilege, gender, racism, and sexism in the making of academic journals in the medical humanities.
In the past few years, the critical turn in the medical humanities has prompted calls for an expansion of the spaces and places considered by those working in the field beyond the clinical encounter and medical education. Whitehead and colleagues (2016) have called for more critical attention to be paid to spaces of knowledge production and increased engagement with critical theory and social justice. One of the spaces that has been little examined is the medical journal. Recent historical work has begun to conceive of medical journals and academic publishing more generally beyond simple amplifiers and publishers of research, and to consider them as social groups and institutions in their own right (e.g. Baldwin 2018; Csiszar 2018; Fyfe et al. 2022). This work offers a foundation from which to apply medical humanities methods and concerns.
It is an accepted truism that medical journals are elite and exclusionary spaces, but work exploring the functioning of these spaces and the experiences of insiders is limited. By undertaking oral history interviews with journal insiders and centring the experiences of minority voices in these spaces, my work considers how elite spaces like medical journals function. Further, I explore and argue for a more intersectional approach to identity that is not always prioritised in oral history research. By listening to the experiences of women and people of colour inside an elite anaesthesia journal, for instance, I suggest that we can begin to understand the concentration of power at these institutions into an old boy’s network and the consequences for journal insiders and the research they publish.
An elite oral history?
While Thompson (1998) identifies that oral history can allow us significant insight into the functioning of all social networks, in general oral history interviews are used to seek out the voices of vulnerable, disadvantaged or otherwise silenced groups (Perks 2010a, 36). Rob Perks notes that ‘oral historians continue to regard elite oral history with deep suspicion’ (Perks 2010, 215) and that the pursuit of oral histories of particularly corporate elite groups has been openly criticised by those in the oral history community who have been concerned with foregrounding hidden voices and marginalised communities (2010b, 219). Perks argues that the omission of oral histories engaging with elite groups is a dereliction of duty, and that the reluctance to engage with topics that challenge ‘our notions of control within the interview power dynamic’ results in a limited ability to understand the world in which we find ourselves (2010b, 220).
This reluctance to engage with more elite groups has stunted theoretical and methodological engagement with the unique challenges and opportunities such groups present. Julian Simpson’s work on the experiences of Asian GPs in the NHS identifies that much of the work on interviewing elites ‘retains a dichotomy between elite and marginalised histories which can at times be problematic’ (Simpson 2018, 12). As Simpson identifies, all identities are intersectional, and while some elite figures may be read as privileged when compared to society at large, within certain groups, for example South Asian GPs within the field of UK doctors, they may hold marginalised identities at the same time. When combined with the binary doctor / patient approach common in the medical humanities (Whitehead et al. 2016, 4), there is still much work to be done across these fields to expand understanding of marginalised identities within elite groups.
In my own work, women and Black and Asian doctors represent marginalised groups within the elite world of medical journals. I categorise the journal I work on as an old boys’ network, both because that is the phrasing that most of the female board members I interviewed used, and also because until the 21st century, recruitment to the board was based on entirely informal shoulder tap arrangements and depended on personal and professional connections to the existing board members. Despite the journal having existed continuously since 1923, the first woman was only invited to the board in 1989 – and the second in 2001. The first board member of colour joined in the mid-2000s and became Editor in Chief in 2012. Recent high-profile incidents, such as the Journal of the American Medical Association’s withdrawal of a podcast that denied the existence of structural racism, and research on racism in UK medical specialties, has seen commentators draw a connection between old boys’ networks in medicine and racist and sexist medical practice and research (see e.g. Booth 2021; Lee 2021). More research is needed into the ways in which mechanisms such as recruitment practices and invitations to review for academic journals perpetuate and construct elite exclusionary networks.
Experiencing the old boys network
As part of my PhD research, I conducted a series of oral history interviews with 20 journal insiders between November 2020 and February 2022, followed by a small number of interviews with anaesthetists outside the journal. These interviews illuminated the workings of power within the journal in ways unachievable by historical document research alone. By analysing the ways that journal members spoke about the processes of journal recruitment, how they framed suitability for the journal board, their discussions of the review process, and their own experiences at the journal, we can gain new insight into how the old boys network of the journal functions on a day to day level and begin to think about what impact this may have.
Across my interviews, suitability for the journal board was codified through several repeated phrases that emphasised sameness and intelligence, such as ‘on the same level’, ‘able to get on with people’, and ‘have a sense of humour’. These ideas of sameness and intelligence are important, as they guided individual members of the board who had total control over who would be offered a seat on the board. With no recourse to official processes, the perception of whether someone would ‘fit’ on the board governed access to this elite space. There are no gender or racial profiles attached to these descriptors, and yet until 1989, they were apparently only fulfilled by white men. So by codifying suitability for the board in those terms, the board verbally signals a meritocratic nature while also retaining complete control over who is deemed to fit those criteria. By 2007 28% of anaesthetic consultants, and 35% of all anaesthetists were women, so the journal in the 1990s and early 2000s did not reflect the composition of the wider anaesthesia workforce (‘Medical Workforce Census Report 2020’ 2020). The result of this construction of an elite environment based on sameness and reliant on personal connection was a set of negative experiences for the first women to join the board:
One thing I’ll never forget in my life is the day I walked into my first board meeting in December ‘89. And this crowd of about 25 men, who were having coffee waiting to start, just all stared at me and went silent and just gaped at the sight. And then two men who had examined my thesis stepped forward and welcomed me but there was this terrible silence which was probably only seconds but seemed like minutes. (Oral history interview with female board member 30.11.20)
They used to call them retreats, we’d go away somewhere every September, the whole of the board. There was one that was held in Aberdeen that I helped to arrange and I think that was probably 2002, something like that. And we had a photograph, it was late summer sun in the evening and we had a photograph taken on the steps, and one of the board members stood next to me, I was there in my posh frock and we were just about to go in for dinner, and sort of sniffed me and said, “Ooh, I’d like to have that smell on my pyjamas.” And I was just… so I just bent down and said, “In your dreams, mate”, and left it at that, but I was horrified, absolutely horrified that anybody would dare say that to me. (Oral history interview with female board member, 12.11.21)
Everybody had been drinking so there was a lot of banter and what have you. And there was a long table and it was like bench seats, so you were kind of stuck in the middle, there was one either side, these two blokes. And they were talking across me, and I just said, “Come on, chaps, I’m feeling a bit left out here”, and one of them turned to me and said, “Oh, are we not looking at your tits enough, [name]?” And again, you don’t…and I just got up and walked out and I didn’t say anything else. Now, I wouldn’t let that go, but at the time I was sufficiently junior that I didn’t feel I could.” (Oral history interview with female board member, 12.11.21)
These experiences of exclusion and harassment show clearly the consequences of constructing suitability for the board in ways that emphasise sameness, in this case taken to mean maleness. Despite clearly being accepted by some male members of the journal, hence their invitations to join, they still entered an environment that was actively hostile towards them. They had little recourse in this environment, with their perceptions of their junior status and lack of a guarantee of support preventing them from protesting this behaviour.
A letter from the journal’s organisational archive from 24th April 1972 indicates that the characteristics that were deemed to indicate suitability for acceptance to the board were also perceived as excluding anaesthetists of colour:
Does the British Journal of Anaesthesia have a sense of humour? No doubt the question will surprise you. The reason for it will become apparent if you read the enclosed circular which was sent round our hospital by one of the brighter sparks of the Residency on 1st April 1972. Dare we publish it? Or would too many of our Indians and what have you, take it literally? I think if we do publish it, it should have an initial paragraph indicating that it is a spoof.
Unfortunately the enclosed circular is long gone, but it’s clear from this covering letter that Asian people are outside the bounds of the journal and are a barrier to the enjoyment of an exclusionary joke. These incidents show that the old boys network of shoulder taps and personal connections have an impact on the kind of environment constructed as a result of those processes. While impossible to quantify from the available sources, it is likely that many potential board members were also not able to gain a position on the board due to the codification of suitability of the role as white and male. The systems outlined here have recently been expanded at this journal, to include a more explicit and open application process, in part due to recognition of the impact that such processes have on the environment of the journal.
The research impact of exclusion
The construction of the space of the journal as a white, male, elite exclusionary space also has an impact on the kinds of research that the journal reviews, publishes, supports, and funds. Other women editors I interviewed highlighted the system for deciding who reviews papers as an ongoing source of exclusion:
I only ever seem to get asked to review papers by two of the ten handling editors [at another journal] and there is favouritism and they may not rate me as an Australian or as a woman or as a clinical trialist. It’s very unclear and not very transparent and you can curry favour with the handling editors and become essential to them, if you want to be strategic. It’s frustrating for some people who want to do more reviews, who don’t get them and I’m sure there’s bias. The whole system is a bit of a perpetuation of the old boys club, it can be a closed shop and it can be very hard for outsiders to get in and to make themselves a name in that situation, I think. Even if you have a diverse group of people from which to choose, if you give the handling editors carte blanche about who to choose, they’re going to make bias selections and it may be that they don’t simply take us because they don’t think I’m smart enough, they only send me shit. (Oral history interview with female board member, 24.11.21)
Reviewing articles for journals is not just a crucial part of the academic labour system, but at this journal, it is also still the primary way to demonstrate suitability for a position on the board. The centrality of membership of journal editorial boards to academic success, to receiving research grants, and to publishing your own research mean that the mechanisms by which reviewers are chosen for papers submitted to the journal have a material impact on the kinds of researchers that are able to succeed in academia, and the kinds of research that are promoted, indirectly and directly, through the journal.
Other interviewees also highlighted the tendency for many editors at the journal to choose reviewers most like themselves, and to concentrate access to the opportunity to review papers into the hands of a few white male reviewers. This ongoing approach perpetuates the space as a white male one, which my interviewees saw as clearly restricting the kinds of research that the journal was willing to publish:
Probably I’m the most proud of our editorial on the hidden curriculum, which was a controversial subject and more opinionated. And it took me a lot of review rounds to get it accepted, because it’s more an opinion or a view on how women are treated in medical education. The societal impacts of [the journal] is less than of [another anaesthesia journal]. And that’s a pity, because I think [the journal] should enhance its societal accountability, since our future physicians are more interested in the whole package, not only in high quality research. And there I still see limitations in the board. The board is very UK-ish and pretty old-fashioned in that respect, and this requires a real change. So we look at the Lancet, or Nature, they already have a lot of impact, also on political or strategic challenges in countries. And I think [the journal] can enhance its position in this. And that’s probably not so easy if you look at the type of people that are now involved. (Oral history interview with female board member, 09.11.21)
In this quote the speaker draws a division between social accountability and high-quality research. However, the two cannot be so neatly divided as the circumstances of knowledge production, such as with so-called high quality research, are inextricably tied to the societal context of its production (e.g. Jasanoff 2004; Knorr-Cetina 1999). If topics such as women in medicine, or the impact of race on medicine, are viewed by the journal as separate to, or not fulfilling the requirements of, high-quality research, this significantly limits the ability of the journal to publish research that addresses the complicity of medical institutions in the oppression of women and people of colour that lead to the perpetuation of health injustice (Adams and Reisman 2019, 1404). The direct connection the board member draws between the publication of research that aims to address social injustices and the composition of the journal board demonstrates that we need to pay more attention to the functioning of mechanisms of inclusion and exclusion within spaces that impact the production of knowledge.
Journals take part in complex work, a crucial part of what Menchik (2021) calls the “occupational project”, that identifies the kinds of research and knowledge production that specialisms should focus their attention on. In the case of the journal described above, they directly fund and choose the recipients of funding for anaesthesia research. When these spaces are constructed as ones that exclude women and people of colour, either explicitly or implicitly, through codified signifiers such as intelligence and sameness, these spaces become harmful to those who rely on them for progress in their careers, and the kinds of research they deem suitable for review, publication, support and funding are restricted. The concern of the medical humanities for individual experiences, for methods such as oral history that give voice to unheard experiences, and attention to authority and expertise, can shed rich and productive light on these connections and spaces.
The oral history interviews included in this article were collected as part of Eleanor Shaw’s PhD Thesis on a specialist academic medical journal in the 20th century. Her research was approved by the University of Manchester University Research Ethics Committee and permission to use these quotes has been given by all participants. You can find out more about Eleanor’s project here.
Eleanor Shaw is a PhD student at CHSTM at the University of Manchester. She has previously worked in health and development, running projects to educate and support health professionals both in the UK and around the globe. Eleanor’s PhD is on a specialist British anaesthesia journal during the 20th century. She is particularly interested in understanding the relationship of specialist journals to the community they represent, making clear the impact of elite institutions on the research they produce, and the changing face of acceptable medical knowledge in the late twentieth century. You can see more of her work here.
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