Letters to the Editor

Medical Content Should Be Equitable and Inclusive of Diverse Populations


Am Fam Physician. 2019 Jun 1;99(11):664-665.

To the Editor: I am writing to bring your attention to the need for more racially inclusive language and equity-driven content in American Family Physician (AFP). For example, I was struck by the noninclusivity of one sentence in the article on vitamin D screening and supplementation in the February 15, 2018, issue.1 In the context of describing recommended dietary allowances of vitamin D, the authors wrote, “Sufficient sun exposure to produce a light-pink skin hue (one minimal erythema dose) is equivalent to 20,000 IU of oral vitamin D.”1 By writing about light-pink skin hue without qualifying the sentence, the authors implied that light pink is the only skin hue relevant to the reader. I suggest that sentences that apply only to a portion of the population be preceded by qualifiers, such as, “For those with light skin color, […].” The sentence should then be followed by a statement relating the effects of sun exposure on vitamin D levels of people with darker skin colors.2

The American Academy of Family Physicians has made efforts to reduce health disparities by launching the EveryONE project, which seeks to address the social determinants of health at the home and neighborhood levels (https://www.aafp.org/family-physician/patient-care/the-everyone-project.html). Eliminating health disparities requires a multipronged and multilevel approach involving every institution and sector of society. As one component, AFP is well positioned to help readers address inequities in our one-on-one patient encounters through improving the quality of care that we provide to marginalized groups. I have three suggestions:

  1. Provide Continuing Medical Education (CME) content that uses inclusive language to guide care for all of our diverse patients. Language used in the journal should be inclusive of all skin colors, genders, ranges of able-bodiedness, and socioeconomic backgrounds that our patients represent.

  2. Highlight the gaps in literature when research studies underrepresent marginalized groups. Consider making it a criterion for authors of AFP to critically apply a health equity lens and to make it transparent when a content area is lacking in generalizability.3

  3. Acknowledge and address the impact of implicit bias. One factor that contributes to health care disparities in the United States is implicit racial biases that affect physician-patient interactions and influence medical decision-making.4 One step toward reducing implicit biases is to make physicians aware of their susceptibility to biases so that engrained habits can be actively and intentionally dismantled.5 Wherever evidence for implicit biases negatively affecting care is available, AFP review articles can draw upon existing work and propose specific strategies to disrupt the perpetuation of biases from one generation of physicians to the next.6

Author disclosure: No relevant financial affiliations.


show all references

1. LeFevre ML, LeFevre NM. Vitamin D screening and supplementation in community-dwelling adults: common questions and answers. Am Fam Physician. 2018;97(4):254–260....

2. Khalid AT, Moore CG, Hall C, et al. Utility of sun-reactive skin typing and melanin index for discerning vitamin D deficiency. Pediatr Res. 2017;82(3):444–451.

3. Geller SE, Koch A, Pellettieri B, Carnes M. Inclusion, analysis, and reporting of sex and race/ethnicity in clinical trials: have we made progress? J Womens Health. 2011;20(3):315–320.

4. Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J Public Health. 2012;102(5):945–952.

5. Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv Health Sci Educ Theory Pract. 2015;20(5):1255–1262.

6. Brooks KC. A piece of my mind. A silent curriculum. JAMA. 2015;313(19):1909–1910.

In Reply: Thank you for your insightful comments. We agree that it is essential that topics covered in AFP be inclusive of diverse populations. Given the concise nature of our articles, the emphasis is often on practical evidence-based points that are supported in the existing literature rather than highlighting knowledge gaps and making recommendations for further research. We can certainly be more mindful of noninclusive language, but here are the ways we've already been addressing diversity and health equity in the journal:

  1. A recent editorial on social determinants of health highlighted the EveryONE Project resources (https://www.aafp.org/afp/2019/0415/p476.html).1

  2. We've published articles on dermatologic conditions in skin of color (https://www.aafp.org/afp/2013/0615/p850.html and https://www.aafp.org/afp/2013/0615/p859.html)2,3 and also a recent article on transgender care (https://www.aafp.org/afp/2018/1201/p645.html)4 that has been acknowledged as an important resource in other articles (https://www.medscape.com/view-article/909885 [login required]).5

  3. We have an AFP By Topic collection of content on Care of Special Populations, including historically marginalized groups (https://www.aafp.org/afp/populations).

  4. We constantly reevaluate medical terminology to make sure that it's inclusive and does not promote implicit bias (e.g., “patient with opioid use disorder” instead of “opioid-dependent” or “opioid addict”).

As always, we appreciate reader feedback and your interest in making AFP applicable to all of the patients family physicians care for.


show all references

1. Sherin K, Adebanjo T, Jani A. Social determinants of health: family physicians' leadership role. Am Fam Physician. 2019;99(8):476–477....

2. Kundu RV, Patterson S. Dermatologic conditions in skin of color: part I. Special considerations for common skin disorders. Am Fam Physician. 2013;87(12):850–856.

3. Kundu RV, Patterson S. Dermatologic conditions in skin of color: part II. Disorders occurring predominantly in skin of color. Am Fam Physician. 2013;87(12):859–865.

4. Klein DA, Paradise SL, Goodwin ET. Caring for transgender-diverse persons: what clinicians should know. Am Fam Physician. 2018;98(11):645–653.

5. Citroner GW. Confronting transphobia in healthcare. Medscape. March 8, 2019. https://www.medscape.com/view-article/909885 [login required]. Accessed April 24, 2019.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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