Beginning in the fall of 2020, in response to reader comments and the historic heightened awareness of racism as a public health crisis,¹ American Family Physician (AFP) editors have taken steps to improve our approach to and the advancement of health equity. Like many other journals across the United States and the world, AFP has historically fallen short in presenting diverse perspectives, and by not recognizing or challenging implicit biases in editorial content we have been silently complicit in allowing racial health disparities to persist. This editorial discusses enhancements to our editorial processes, improvements in representation in articles on skin conditions, and the addition of author guidance on the critical appraisal of medical literature.

Regarding our editorial processes, we are increasing content on health disparities, racism, and social determinants of health; reevaluating the use of language regarding race, ethnicity, and gender; collecting anonymous demographic information from our authors after publication as we seek to improve representation and diversity; and encouraging mentorship of underrepresented minorities in medicine and medical writing. A dedicated editorial team meets regularly to discuss specific and general matters related to diversity, equity, and inclusion (DEI).

Much of the health disparities in the diagnosis and treatment of dermatologic conditions in people with skin of color is a result of gaps in research, education, and availability of images depicting diverse populations.² In this issue of AFP, Frazier and colleagues discuss common dermatologic diagnoses that disproportionately affect this population.³ The topic was previously reviewed in AFP in 2013, but for this update, our DEI editorial team reviewed the terminology used to describe the patient groups discussed in the article to ensure that it was appropriate and inclusive. The article also discusses controversies surrounding the Fitzpatrick skin type scale, which was originally developed to assess potential reaction to sun exposure and phototherapy but has often been misused as a proxy for race.^4,5

Addressing the gaps in our coverage of dermatologic disease has been challenging, and we are learning along the way. For example, we published an article on basal cell and cutaneous squamous cell carcinomas, and a reader commented that the article was lacking a discussion of how these diseases present in darker skin.⁶ The comment served as a reminder that we should strive to reflect the diversity of patients that family physicians care for in all our articles, not just in separate special articles. Another example is a Photo Quiz we published, “Growing Mass in an Adolescent.”⁷ A reader commented that the use of the descriptors “usually brown or flesh-colored” suggests that flesh is always a lighter color. The article has been corrected with more accurate descriptors that are applicable to the variety of patients we see: “hyperpigmented or the color of surrounding skin.” We share these examples not to admonish the authors, editors, or anyone else involved but to be transparent and humble about the need to be more appropriate in the terminology we use to describe our diverse patient populations, with the goal of addressing inequities and promoting antiracism in publishing.

In addition, we are supporting health equity by helping authors to critically appraise the medical literature with the diversity of our patients in mind. We began by updating the Authors' Guide section on “Literature Search and Data Sources” (https://www.aafp.org/pubs/afp/authors.html). Within the updated guidance, the DEI editorial team has made recommendations on how to critically appraise the use of individual patient characteristics, such as race and gender, as variables in analyses or models. Authors should seek to understand what these variables are truly measuring (e.g., is using self-identified race as a factor in the estimation of kidney function an indicator of the effects of systemic racism?) and how they affect clinical practice and treatment recommendations.⁸

Feedback on these initiatives has mostly been positive, but we have also received critical comments. Some have suggested that we are taking an overtly political stance or sacrificing our longtime emphasis on evidence-based medicine and CME. Others have stated that we are not doing enough or not acting fast enough.

At AFP, our aim has always been to provide the most up-to-date information for family physicians who care for an incredibly diverse population of patients. The AFP editors are committed to promoting a dialogue around why health inequities exist and how to address them, but we recognize that more work is needed to provide equitable care to all populations. Growth and change take time, but we will continue to learn and accept feedback as we go. It takes collaboration, respectful dialogue, and humility, and we are hoping we can do this together.

Editor's Note: The authors are AFP medical editors and members of the DEI editorial team.

The authors thank Amber Randel, Danielle Jones, Dr. Priscilla Auguste, and Dr. Jarrett Sell for their assistance in formulating AFP’s DEI initiatives.