From Stone Tablets to Counternarratives: There is Another Way to Approach Decision Letters in Health Professions Education Publishing

Keywords:

• Diversity
• equity
• inclusion
• peer review

The intersection of being a Black Woman in Medicine is a unique experience that exacerbates racial trauma and can lead to the hypervigilance, withdrawal, and emotional exhaustion that many minority students experience.

-Monnique Johnson, “Research as a Coping Mechanism for Racial Trauma: The Story of One Medical Student”¹

On my journey as a novice researcher, I (MJ) wrote and submitted a perspective piece based on my unique experience as a Black Woman in Medicine and the intersectionality of that identity. This writing process for me was vulnerable and emotional. I submitted my piece to multiple academic medical journals throughout the peer review process and ultimately received a revise and resubmit. Throughout, I received comments from reviewers and editors, which in itself was a further experience of vulnerability for me.

-Monnique Johnson, “Maintaining Your Voice as an Underrepresented Minority During the Peer Review Process: A Dialogue Between Author and Mentor”²

The quotes above are from two pieces I (MJ) published, the first one in Teaching and Learning in Medicine (TLM) sharing my intersectional trauma of being a Black Woman in medical school, and the second one in Perspectives on Medical Education (PME) voicing the subsequent trauma of publishing about it. I am now experiencing the duality of coping with this trauma while engaging with one entity—TLM—that contributed to it, but is committed and positioned to prevent/minimize future harm for marginalized authors. This editorial, however, is not about my traumas, which have been described elsewhere.^1–2 I am writing this editorial with AC, TLM’s Editor-in-Chief, and AK, a TLM Deputy Editor and one of my mentors, to surface the behind-the-scenes work we are doing together to move forward. As such, this piece is not just about what TLM can do better for marginalized authors, but about how health professions education (HPE) publishing as a community can improve. Through our conversation below, we demonstrate active equity amidst a performative culture that creates excuses and shows by lack of action that somehow equity is impractical. I am acknowledging my experienced harm by partnering and DOING equity.

Background: stone tablets

We–AC and AK–are committed to forwarding MJ’s voice while remaining accountable for her harm. To this end, we introduce the context of this editorial so that MJ does not have to relive past trauma by doing so.

Throughout the experience of writing and revising her personal narrative article, “Research as a Coping Mechanism for Racial Trauma: The Story of One Medical Student,”¹ MJ shared with AK how the process felt traumatizing. This was her first experience publishing about her own experiences, and she felt distanced throughout the process. AK encouraged MJ to write about this, resulting in a joint commentary, “Maintaining Your Voice as an Underrepresented Minority During the Peer Review Process: A Dialogue Between Author and Mentor.”² This second publication prompted AC to reach out, which began a crucial conversation between a Black author (MJ), a white mentor and new deputy editor (AK), and a white editor-in-chief (AC) that catalyzed change in the editorial decision making process at one HPE journal (TLM).

We organize this editorial around the metaphor of editors’ decision letters as “stone tablets” from the Judeo-Christian tradition: unchanging, nonnegotiable commandments issued from God to govern behavior and ways of interacting with others. We argue here that, rather than serving as stone tablets commanding authors to adapt their voice to communicate with readers, decision letters can begin conversations that cultivate authors’ voices. We offer our story as a counternarrative (i.e., a perspective that runs “opposite or counter to the presumed order or control,”³ about the role of decision letters in oppressing would-be authors. With this counternarrative, we seek to disrupt oppression in HPE publishing by encouraging conversations between marginalized authors and journals to create an equitable publication space and ultimately increase publications while decreasing trauma. Further, we assert that maintaining authors’ voices in HPE publishing requires editors to use their relative position and power to support authors by engaging in radical honesty in decision letters: truth telling, valuing the narrative and the personal, and acting for social change.⁴ We are committed to listening to counternarratives and applying this radical honesty approach at TLM, and we hope this piece encourages other HPE journal editors and peer reviewers to join us in this important equity work.

Below we use a dialectical form to narrate what happened after “Maintaining Your Voice” was published in PME, demonstrating that structural change can result from engaging vulnerably and meaningfully with voice. AC begins with her story as TLM’s Editor-in-Chief, describing how “Maintaining Your Voice” caused her to revisit her decision letter on MJ’s “Research as a Coping Mechanism” manuscript, discover her blind spots, and initiate effort to transform TLM’s editorial process away from the stone tablet mentality. AK then tells her story as MJ’s mentor and new TLM Deputy Editor, applying her linguistic lens to analyzing MJ’s decision letter and offering radically honest alternatives to the stone tablets typically issued. We purposefully end our piece with MJ’s involvement in this conversation, giving her the last word. Through this exchange, we seek to problematize and change the editorial process–particularly decision letters–to reduce trauma and other harm suffered by Black women authors and other individuals from marginalized groups.⁵

Editor-in-Chief (AC): am I in the business of issuing stone tablets?

I first learned of “Maintaining Your Voice” from a mass email announcing the new issue of PME. The title caught my attention because, as Editor-in-Chief of TLM, I had been thinking a lot about the topic. In 2020, I had gone so far as to lead my editorial board on a long-overdue journey to make TLM an antiracist journal, declaring publicly our intention to amplify oppressed voices.⁶

I noticed with even greater enthusiasm that the commentary’s authors included both a Black medical student who had recently published in TLM (“Research as a Coping Mechanism”¹) (MJ) and a new TLM Deputy Editor (AK). Until recently, most of the work we have done at TLM to improve access to HPE publishing has flown under the radar as we have embarked on the long and challenging path toward a destination we cannot readily envision: trying new things, discovering our blind spots, and wrestling to understand what antiracism really means.⁷ I counted MJ’s article among the signs that we were making progress, proudly sharing it as an example of welcoming new voices to our pages and encouraging others to submit in kind.

In short, as I began reading “Maintaining Your Voice,” I anticipated a success story. Instead, it was a precious opportunity to discover the negative, even retraumatizing impact our review process had, even though the outcome–publication–could be considered “successful.”

Revisiting the decision letter I sent you (MJ) on your initial manuscript, I could see clearly what you observed in your PME commentary “…the reviewers were unsatisfied with how I explained my experience.”² There was no mistaking how the reviews—including mine—suggested that you had to “…frame my experience through previous literature to be ‘acceptable’ for academia; I needed more published experiences to cosign my own in order for it to be validated.”² You graciously noted that our intent was not malicious, and that I had tried to be “sensitive and intentional.”² Indeed, I had set aside your manuscript for special consideration given that it was somewhat outside our publication categories (TLM historically has not published personal narratives), and I purposefully recruited peer reviewers who were themselves Black medical trainees or graduates. Nevertheless, I had created a space where you felt unsafe to raise your voice—twice—both in your original manuscript and in your response to the reviews. Until “Maintaining Your Voice” came out in PME, I was ignorant of our impact and, by extension, dangerously unaware of our potential impact on other racially marginalized authors and mentees. Failure to still not hear you would amount to malicious intent.

I reached out to apologize for the harm I had caused, hopeful we could continue the dialogue you and AK had started, this time including a senior editor. Your PME commentary helped me recognize that as TLM’s Editor-in-Chief, I have the capacity to foster radical honesty between peer reviewers, authors, and editors by writing decision letters that are more explicit about positionality and that invite dialogue about how the developing manuscript could take shape. This is important not only to encourage and amplify the voices of junior authors and authors from minoritized racial or ethnic groups in the U.S., but also to build more constructive exchanges with authors in the Global South, who regularly receive decision letters with dismissive and patronizing language and who struggle to get their work published in Global North HPE journals.^5,8 As a partner in this process, we now have a Global Diversity, Equity, and Inclusion Editor, who carefully reviews our decision letters for openness and fairness in the language and helps us identify our blind spots. Hopefully, in this way, we can better “value the author’s experience and be intentional about what role other voices from the literature would play in the piece and whether they are needed.”² Anecdotally, we have been receiving very positive remarks on our decision letters and editorial process since we started making these changes, and our rate of publication among Global South authors has increased nearly tenfold in the past year.

In addition, at TLM, we are overhauling our instructions to peer reviewers, deputy editors, and authors based on what we are learning from our antiracism effort, to which the dialogue here is especially timely and pertinent. A larger lesson we are trying to learn is how to cultivate personal narratives, particularly counternarratives, within a field dominated by epistemologies that devalue, even delegitimize introspection as a mode of knowledge construction.⁹ I cannot overstate how grateful I am for this opportunity to rethink the very foundations of our approach. Moreover, I deeply appreciate the courage both you (MJ) and AK demonstrated to raise your concerns and the constructive spirit in which you shared them. I hope our public conversation and the changes it catalyzed encourage other editors, and the peer reviewers who support them, to follow suit. Other HPE journals, including Medical Education and Medical Teacher, have made inspiring movements toward equity in publishing, to include appointing equity editors and adopting formal diversity, equity, and inclusion policies. I think reimagining decision letters as radically honest dialogues offers a way to put such policies in practice at the individual level.

Mentor (AK): deconstructing the stone tablet

AC, when you first reached out to MJ and I as the Editor-in-Chief of TLM, you asked for our insights on your decision, given the concerns raised in our commentary. This made my stomach simultaneously experience butterflies about the opportunity for institutional change and lurch about you seeing a potentially personal critique in our piece. It gave greater clarity to my feelings of inadequacy and discomfort around mentoring, writing, and researching in the racial equity space as a white woman. After you reached out to mitigate the traumatizing effects of your decision letter, I applied the linguistic tools I use in my research to “denaturalize” (i.e., to make strange and, therefore, more visible) the normative structures in that letter.¹⁰ First, I noticed that the structure was familiar–a structure that most decision letters follow without explicit rules to do so (quotes below are from the decision letter MJ received for “Research as a Coping Mechanism”):

1. An introductory paragraph noting the decision, written in first-person plural (“we are not able to accept the manuscript, but we would like to offer to consider a revision”);

2. A 2-sentence summary of the major feedback, focused mostly on inanimate constructs (“Constructive criticism centers on…”);

3. A note about (modest) expectations (“it is not assumed that your revision will meet TLM’s publication standard”) along with a due date, a link, and some tips for navigating the website, signed by “Dr. Anna Cianciolo, Editor-in-Chief.”

4. Following this, “Editor’s Notes,” written in first person, summarized the piece and offered feedback as a reader, sometimes sharing experiences and views (e.g., “I believe that more courageous conversations of this nature need to happen in the medical education literature”). Then followed both reviewers’ (anonymous) responses.

I started to wonder why we structure these letters in this way. Are there other ways to approach it? Diving in further, I saw three distinct features we (I speak, AC, as a TLM Deputy Editor committed to this work with you) might address as we deconstruct the stone tablet of a decision letter.

First, MJ, while there were places in the letter that gave you agency over your piece (“consider including X”), there were other, constraining places (e.g., noting that a part of your narrative was “extraneous”). You expressed to me that, as a Black woman new to publishing, the final impression was of “having” to do what the editor and reviewers recommended. To make these letters feel less like stone tablets, we at TLM, editors and peer reviewers, should do more hedging (mitigating a stance with words like “maybe”) throughout to maintain authors’ agency and help them save face.¹¹ We could, for example, urge reviewers to use “I” to signal responses as individual versus universalizing, for example saying “I found the narrative confusing” versus “The narrative is confusing.”¹¹ We might also consider a positionality statement, e.g., “The feedback below is not meant to be set in stone, but is simply our experience of your work; ultimately, this is your experience, and we want to support you in sharing it.”

Second, the letter followed a generic form and structure, even though it was not a response to original research or even policy recommendations, but to a Black woman’s particular story of trauma. The calls to support the argument with literature or statistics and one reviewer’s suggestions for making the story “more generalizable” framed this particular story as inadequate to stand on its own. To allow counternarratives to be heard, maybe we could think about different types of decision letters for different types of writing. When authors from historically oppressed groups–authors of color, queer authors, disabled authors–write about their experiences, maybe we offer our feedback personally via Zoom or through unstructured reflections rather than–or in addition to–decision letters.

Finally, while there were moments of connection in the “Research as a Coping Mechanism” decision letter (e.g., AC, you shared some of your experiences mentoring Black women trainees), there are also places where legal and formulaic aspects create distance (e.g., using the passive voice and third person: “it is not assumed that your revision will meet TLM’s publication standard”). I wonder if there is more genre-bending opportunity here, pushing against legal language or putting it in a separate space where it is not directly from us, the editors. We can also try to eliminate some of the distance the stone tablet creates by sharing our experience with the piece as reviewers and encouraging conversation with the author about their message. In this way, we could join together with authors to strategize about how to effectively portray their voice.

I am thankful to you, MJ, for allowing me to accompany you on your journey despite my inadequacy and to both you and AC for co-creating this writing space with me where the work of resisting oppressive practices takes precedence over discomfort.

Author (MJ): realizing the tablet was not a tablet

AC, when you approached us in response to reading “Maintaining Your Voice,” I felt scared. I was worried you saw “Maintaining Your Voice”–my radical honesty–as a personal offense; I was worried that I had shared my perspective and now cost myself a chance at publishing again. I was relieved and shocked when you first offered your apology, reflections, and accountability, and then extended an opportunity that would ultimately put you and your journal in the hot seat (this collaborative piece). I realized decision letters could prompt a dialogic relationship: a conversation with the reviewers, editors, and journal. Earlier, I would never have dreamed of reaching out to an editor directly at any point in the process; I perceived an invisible wall between journals and me as the author. These mystical journals and their staff seemed unreachable outside of the channels for submitting a manuscript, with the decision letter being the final word. Although this particular decision letter had the words “major revisions were requested,” it did not look like a request, or something I could deviate from. I read it as, “in order to publish you need to make these ‘requested’ changes,” i.e., this is nonnegotiable, like a stone tablet. As Black woman and a student, I have experienced spaces where rebuttal, dialogue, or conversation with a higher power about their decision or “suggestions” in any form would be viewed as combative, so I assumed that to be true in this unfamiliar space. Our dialogic relationship did not erase the trauma of the publishing experience. It restored a sense of safety and built trust for me as a marginalized author. It was not until several conversations with you that I felt safe, and trusted that this exchange was a dialogue where I could use my voice outside of a manuscript and trusted that I would be heard.

The other takeaway from my exchange with you was the opportunity to reflect on what I would like to see in publishing more generally. All too often the recommendations and suggestions of marginalized people are made reactively. Consequently, they are vague and generic so as to not be offensive and too direct. These recommendations seem to come from negative experiences we do not want to repeat as opposed to positive experiences we want to emulate.¹² Often we have never seen but can only imagine what we want. The only thing we know for certain is what we do not want. This conversation with you is an opportunity to work with an entity who has the power to make tangible change. It is an opportunity to think deeply about what it tangibly means to be “sensitive and intentional” with someone’s narrative, and what I would want to see happen from a place of positive experiences. It has felt empowering to experience, participate, and model firsthand the fluid and dialogic nature of publishing to help create a template for other interested editors, reviewers, and authors so they can have a positive experience; unlike some of the negative encounters many marginalized authors face with that rigid stone tablet, there is another way.

Monnique Johnson
Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA

http://orcid.org/0000-0001-6746-4270 Abigail Konopasky
Medical Education at Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA

http://orcid.org/0000-0002-3033-5552 Anna T. Cianciolo
Medical Education at Southern Illinois University School of Medicine, Springfield, Illinois, USA
[email protected]
http://orcid.org/0000-0001-5948-9304

Acknowledgements

We would like to thank the TLM interns and board member who reviewed this piece and helped us to expand our thinking.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.