In April, the Journal of Hospital Medicine retracted an article entitled “Tribalism: The Good, The Bad, and The Future” (by Zahir Kanjee and Leslie Bilello of Harvard Medical School). The article, which had been promoted on social media, was met with sharp criticism stating that the term “tribalism” was disrespectful to indigenous people.

On May 21, Samir S. Shah, MD, MSCE, editor-in-chief of JHM, issued an editorial entitled “Microaggressions, Accountability, and Our Commitment to Doing Better,” together with four other editors. The statement apologized for use of the terms “tribe” and “tribalism” and expressed gratitude to readers for bringing the issue to their attention.

On the same day, the journal published a replacement for the original article, now entitled “Leadership and Professional Development: Specialty Silos in Medicine.”

The revised article contained the same content and message, but used the terms “groups” and “medical specialties” instead of “tribes,” and “siloed” and “factional” instead of tribalism.

To gain deeper insight into the decision to retract and reissue the article and the lessons learned about the use of language in medical journals going forward, Medscape spoke to Shah, who is also the director of the Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, and a professor of pediatrics at the University of Cincinnati. Shah, who practices both pediatric hospital medicine and pediatric infectious diseases, also holds the James M. Ewell endowed chair.

What was the context of the use of the term “tribalism” in the original article that was subsequently retracted?

The original article used the term “tribalism” as defined by Rosabeth Moss Kanter, a professor at Harvard Business School. Kanter said that tribalism “reflects strong ethnic or cultural identities that separate members of one group from another, making them loyal to people like them and suspicious of outsiders, which undermines efforts to forge common cause across groups.”

In that context, the authors used the term to describe the tendency of medical specialists to interact primarily with members of their own group in ways that hinder communication and cooperation with members of other specialties and negatively impact interpersonal relationships and patient care.

I should add that the authors did not apply this term in a brand new way to the world of healthcare practice. Two of the references cited used the term in exploring barriers to effective teamwork in healthcare settings.

The fact that a term is commonly or colloquially used is not necessarily a justification or an excuse for its ongoing use, but it is important to note that the expression was not original to this particular article.

What was the social media response to the term “tribalism” in the original article?

People pointed out some legitimate concerns. On the whole, the professional community’s tweets tended to be respectful and invited dialogue, but some of the other tweets were more hostile in nature. Here are examples of two tweets we found constructive:

“Love to see this very worthwhile topic getting attention! However, would also love to see y’all change the word “tribalism” to something not racially charged – thank you!!”

“Can you replace tribe as a concept for different areas? Why not just talk about bridging the divide?”

One person made a similar point, but with a very hostile tone:

“Hey Pundit Class, when you use ‘tribal’ to mean something other than a tribe:

1.    You’re being anti-Native.

2.    You’re being ahistorical.

3.    You’re imagining an audience that doesn’t include indigenous people.

4.    You’re being VAGUE! Did you mean ‘partisan,’ ‘sectarian,’ etc?”

How did you react to the criticism?

We were understandably distressed, but we were also appreciative that this was brought to our attention. In fact, one of the exciting things that this episode highlights is that we have a dedicated, passionate, engaged readership willing to offer constructive comments. We had promoted our article on social media using the hashtag “tribalism” and within hours of receiving the readers’ feedback, our editorial team and the authors met to discuss the feedback and understand our error.

We then deleted the original tweet and issued an apology for using “insensitive language that may be hurtful to Indigenous Americans and others.”

We said that we are “learning” and “committed to doing better” and we announced our intent to retract the article and republish it with appropriate language, and issue an editorial with our reflections and lessons learned.

On May 21, we issued our editorial and the revised article was published.

What did you learn about the words “tribe” and “tribalism”?

The original article used the word “tribalism” to describe factionalism and partisanship between two different medical specialties. But, in retrospect, I have to say that it was a woefully inappropriate use of the word. Simply referring to a dictionary or colloquial definition of a word such as “tribalism” is not sufficient, especially when we delve into how those definitions were created. Fundamentally, they were based on misperceptions about how indigenous tribes interacted with one another.

We learned from an article that appeared in Learning for Justice that these words actually have no consistent meaning, that they are associated with negative historical and cultural assumptions, and that they can perpetuate and even promote misleading stereotypes.

We also learned from another article that appeared in the Washington Post that the current use of the word “tribe” is based on racist stereotypes of how groups of such peoples supposedly interacted historically.

As we wrote in our editorial, “The term ‘tribe’ became popular as a colonial construct to describe forms of social organization considered ‘uncivilized’ or ‘primitive.’ In using the term ‘tribe’ to describe members of medical communities, we ignored the complex and dynamic identities of Native American, African, and other Indigenous Peoples and the history of oppression.”

How have your retraction and editorial been received on social media?

What really struck me about the response is that 90% were from the general public and only about 10% were from medical professionals or medical or scientific journalists. We got some very positive feedback, both via email and on social media, especially from the medical and scientific community. One physician reader tweeted, “This is incredible role modeling of how to respond when you realize what you published contains language that can be negatively construed, even though that was not the intention at all.”

On the other hand, we got some negative responses, mostly from folks outside the medical and scientific community. Someone associated with Quillette [editor-in-chief Claire Lehmann] wrote, “Twitter now decides what gets published in medical journals. I know that peer review isn’t perfect, but it’s at least one level above Twitter mob review, right?”

Someone else wrote, “To present this craven nonsense as an act of conscience and anti-racism speaks volumes. What it really demonstrates is we now live in a culture where people are looking for pretexts to take offense, and in such a culture, they will always find one or, as in this case, manufacture one.”

One reader called us “spineless” and another said we were “cowering to the woke cultists.”

How did you respond to this?

In jest — and based on the fact that many critics ignored the nuance of the rationale for our decision — I tweeted, “One of my favorite things about Twitter is that so many people who I don’t know are willing to engage in good faith and have nuanced and respectful discussions about complex issues.”

I am always delighted to engage in constructive dialogue. However, my feeling is that when you have people tweeting nonconstructively, why put yourself in the middle of that? If there are folks who are not interacting with us in good faith, there’s no reason to inject ourselves into that, only to be at the receiving end of such ire.

Some people who tweeted comments brought up points I didn’t agree with, which was fine. Retraction Watch published a piece on the retraction and republication. One reader wrote a comment, “Yes, ‘tribe’ was brutally imposed on indigenous people. But its history runs deeper. There’s no other word that I know that captures humans’ prewired tendency to form defensive, tightly-bonded, identity-based groups. The word ‘group’ just doesn’t cut it.”

I happen to disagree with this person. I think that the word “silo,” which was used in the replacement article, was equally effective as “tribe” in conveying the message that the article sought to communicate without causing offense. But I have no issue with someone who disagrees because reasonable people can disagree. What’s key is the tone and respect and willingness to engage in nuanced discussion, which was present in some of the tweets but notably missing from many others.

It is reasonable and appropriate for us to change how we use language in response to our evolving culture and values, and being respectful to others is a sign of a good and healthy society. It’s not “bowing down” to a “mob” of any sort.

There are many words in the English vocabulary that are used innocently without awareness of their origin, which might have roots in some type of racist ideology but have become part of common parlance. What have you learned from this incident to guide use of language going forward?

I think it is our responsibility not just to recognize when there are issues in how we use language but also our obligation to raise awareness when we have an opportunity to do things differently. We all felt it necessary to take decisive action here.

But I don’t think there is a “one-size-fits-all” approach. For this particular situation, because it was the first of its kind, we made an important point by immediately retracting and republishing the article, together with an editorial. In the future, it may be possible to include an erratum explaining that a particular word or expression was poorly chosen and what other type of language might be more appropriate.

I say “in the future” because we are all fallible and language is evolving. So it is likely that this type of situation will indeed arise at some point down the road and some word that might have offensive connotations will unintentionally be used.

Our use of language evolves and words either fall out of favor or take on different meanings. For example, the word “Negro” was once considered acceptable, but now it is not. The word “gay” once meant “happy,” but today, we commonly associate the word with the “LGBTQ+” community — terminology that only became widespread over the past several decades. Medical journals need to be cognizant of such changes in language.

As an editorial team, we are developing a more systematic approach to understanding, as much as is humanly possible, how to identify these words in advance. We are seeking to flag potentially problematic language in accepted manuscripts — words that may be racist, sexist, ableist, homophobic, or otherwise harmful. We have not yet finalized the process, but we are exploring the possibility of having an individual who specializes in language to review our articles and provide some guidance. We do not know at the moment what particular qualifications that individual will need.

In the meantime, we are identifying terms we didn’t perhaps appreciate that could be construed as offensive, and are conducting an intentional review of manuscripts to make sure the wording is appropriate for the scenario.

How did the authors feel about needing to revise their article?

In an interview with Retraction Watch, Zahir Kanjee, the first author of the paper, said, “In terms of the retraction and republication, once we learned of the harm and hurt caused, we were in favor of retraction/republication as well…I was on that initial Zoom call with the editorial leadership mentioned in the editorial to think about the right thing to do and agreed 100% with this plan of retraction and republication. Still do.”

I would like to emphasize that the decision to retract and republish was not a “top-down” approach. The article published in Retraction Watch stated that we will “try to more rigorously police the language” in the articles we publish. I take issue with the use of the word “police.” It implies that we are censoring authors. When we identify problematic language, we will do what we did in this situation: We will engage in dialogue with the authors about how to proceed. Changes will be the product of a respectful, collaborative, and mutual learning process for the editors as well as the authors.

I think the key word is “respect.” The issue of how we treat others is really important. We ultimately have to decide what type of world we want to live in. As a medical journal, we have the opportunity to shape those discussions and also articulate those values.

What other “values” are you referring to?

If we look at what JHM has published over the last 2 years, we think that it offers a great window into our values as a journal. Aside from original research and brief reports, our journal publishes 11 other article types focusing on health policy, quality improvement, implementation science, issues that arise in the emergency department prior to hospitalization, issues that arise in the ICU, and issues that arise after discharge, during the transition home or to another facility. So we have a broad purview.

For example, we recently published a perspective piece about ending the routine shackling of incarcerated patients during hospitalization. This topic is very relevant to all of those who care for hospitalized patients but also to those involved in prehospital care or law enforcement as well as patients and their families.

Another very recent article, “Trauma-Informed Transformation of Evaluation and Licensure for Physicians With Mental Illness” addresses a sensitive subject not sufficiently discussed in the medical community. The potential for adverse effects on medical licensure is an important barrier to physicians seeking care for mental health issues.

We issued new guidelines for authors on addressing race and racism in the articles they submit. These new guidelines will help authors better address root causes of disparities in patient outcomes.

We are committed to providing opportunities for women and racial/ethnic minorities, who are often underrepresented in academic environments, to be more included as authors and leaders in our journal. And we have made this a priority, as we discussed in a 2019 editorial, “Leading By Example: How Medical Journals Can Improve Representation in Academic Medicine.” And we are pleased to report that we increased the percentage of female journal leaders from 30% in 2018 to 49% in 2021.

So, our key values are transparency, diversity, inclusion, and respect. We communicate these not only in the content of our articles but also in the way we interact with one another, and with our authors.

For example, we have a no-hassle submission policy: we do not require a particular type of formatting of a submission in order to be willing to read it. A 2019 survey of 372 scientists found that the median formatting time that participants spent getting manuscripts ready for submission was 14 hours per manuscript, or 52 hours per person per year. The loss of time translated into a staggering loss of over $1900 per researcher per year. The authors call this a “scientific sinkhole” and I quite agree with them, which is why we will require journal-specific formatting only after a manuscript revision is requested.

Our goal as a journal is to thoughtfully explore issues and be transparent about how we are thinking about things. We welcome feedback and look forward to advancing the dialogue to help language evolve and grow within the medical community and beyond.

Batya Swift Yasgur MA, LSW, is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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