JAMA’s Editor: Rebuilding Trust & Reaching More Readers

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Margaret Flinter ( 00:01 ):
Recorded on location at Aspen Ideas: Health in Aspen, Colorado.
Mark Masselli ( 00:12 ):
If you've learned anything about the most recent research on obesity, diabetes, or cardiovascular
disease, you've probably read it in the Journal of American Medical Association. They're celebrating
their 141st anniversary.
Dr.Kirsten Bibbins-Domingo ( 00:27 ):
I think about what JAMA and the JAMA network has to do right now is do the core functions the same
way we've always done it. Vetting the science, making sure this is science you can trust, putting the
stamp of approval in that way on it and then publishing it. And then we have to do something that I
think all journals need to do better and certainly we do. And that is being a modern communication
vehicle.
Margaret Flinter ( 00:53 ):
Our guest today is Dr. Kirsten Bibbins-Domingo, the editor-in-chief of JAMA and the JAMA Network.
She's also a renowned physician scientist at the University of California at San Francisco, and she's the
first person of color and only the second woman to lead the Journal.
Dr.Kirsten Bibbins-Domingo ( 01:09 ):
I am not the keeper of trust for the Journal. I'm not the keeper of our focus on equity. In fact, the journal
and our sets of journals have always put equity at the forefront of how we have thought about this. But
my goal was to put more processes in place so that we could collectively have those conversations be
more transparent about them.
Margaret Flinter ( 01:32 ):
This is conversations on Health Care.
Mark Masselli ( 01:43 ):
Dr. Kirsten Bibbins Domingo, welcome to Conversations on Healthcare.
Dr.Kirsten Bibbins-Domingo ( 01:46 ):
Thank you for having me and please call me Kirsten
Mark Masselli ( 01:48 ):
Kirsten, Oh, that's great. And we find ourselves in this beautiful space here and Aspen Ideas:Health. And
I know you have a session coming up and I'm kind of interested about trust. And I'm wondering if people
are stopping to believe in science and that's maybe a driver of why this conversation is happening. Tell
us more about the session today and some of the thoughts that you are bringing.
Dr.Kirsten Bibbins-Domingo ( 02:14 ):
Yeah, I think it's a big issue for us. If you think about as physicians, as clinicians, we know that your
healthcare professional is the person that is the most trusted as the source of healthcare information.

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But we also know that when you survey the public, people are wildly mistrustful of institutions. Some of
that is within a political context, but also it's like just because it was published, do we really believe it?
And there's a lot of that type of questioning going on. It's an issue for us who are in healthcare. It's an
issue for us as scientists. It's an issue for us as a Journal because we are only as good as people trust
both our authors and our readers in what we publish. And so I think we have to actively engage in this
issue of the growing rise of mistrust.

Mark Masselli ( 03:08 ):
Yeah, absolutely.

Margaret Flinter ( 03:09 ):
Well, I have to say that I was surprised, I don't know why in a recent poll that this is true kind of across
the political divide. It's true among Democrats and it's true among Republicans. And it's my sense... You
can tell me if I'm accurate or not, that your journal is quite accessible and probably a wide range of
people, clinicians, non-clinicians interested, people are reading it. Is there a specific role that the Journal
can play in helping to elevate this belief both in scientists and science, I guess?

Dr.Kirsten Bibbins-Domingo ( 03:42 ):
Yeah, thanks for saying it that way because I think that we tend to think of this as the people on the
other side of the political divide from us. And that's not really the case. I think there is a bit of an erosion
of trust in professionals, in experts. And so I think what a journal has to do, a Journal is really... We are
publishing for scientists, we're publishing for clinicians, for health policy leaders for the lay public. We're
a global Journal. So we're always publishing to multiple people who might have different perspectives.
( 04:17 ):
My personal view on this is our goal is to broaden the conversation to bring more people in, not to say...
To be finger wagging and say this is the right answer and now you've got to believe it. But obviously we
believe very strongly that science is the foundation of providing the evidence for what we know works in
healthcare that we believe strongly in. But the conversations of how to draw people in to that, that is
where we can use a variety of techniques. We can use a variety of ways of communicating about the
science, a variety of ways of talking about the nuance using a variety of modes of communication. And
we have to do that to bring more people in.

Mark Masselli ( 05:00 ):
Speaking of bringing more people in, you say journal, I say JAMA.

Dr.Kirsten Bibbins-Domingo ( 05:08 ):
Thank you. I love that.

Mark Masselli ( 05:09 ):
But I-

Margaret Flinter ( 05:09 ):
Say JAMA.

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Mark Masselli ( 05:09 ):
Think it's such a powerful name. But maybe take us behind the scenes, behind the curtain, 13 Journals,
the relationship with the AMA. How does that all work? What should our listeners understand about
what goes on behind the scenes?

Dr.Kirsten Bibbins-Domingo ( 05:24 ):
Sure. So thank you. So we're 13 journals strong. JAMA, the flagship journal, 141 years old, a general
medical journal, one of the top journals in the world, 13 journals that includes 11 subspecialty journals
that are each led by their own academic editor and a big open access journal of JAMA Network Open.
We are each in our categories amongst the leaders in those categories. So sought after by both authors
and readers. And we're a network of journals that wants to work together to be sort of the best
platform for communicating the science that affects health.
( 06:04 ):
So when I started, and I've been in this job two years. When I started I found a remarkably strong
organization, really energized and deeply committed to the science and to the science that improves
health. I think about what JAMA and the JAMA Network has to do right now is do the core functions the
same way we've always done it. Vetting the science, making sure this is science you can trust, putting
the stamp of approval in that way on it and then publishing it. And then we have to do something that I
think all journals need to do better and certainly we do. And that is being a modern communication
vehicle, sort of thinking about all the ways we communicate. We are all overloaded with information.

Mark Masselli ( 06:04 ):
That's right.

Dr.Kirsten Bibbins-Domingo ( 06:51 ):
We are all looking at our phones for information. We are all getting ads and things like telling us what
we should believe and what we should think. We have to be in that space. We have to use videos and
podcasts and images. We have to use social platforms. We have to think about how we use that
technology to help you to find what exactly you want to read and you to find what you want to read and
then have the ability to discover something new that you might not have known you should read, but
we should help you to find that as well. And that modern... Being a communication platform in a
modern era is what journals have to get better at and it's what we're relentlessly focused on.

Mark Masselli ( 07:30 ):
All right, getting modern, I'm going to ask what my kids are asking, are you on TikTok?

Dr.Kirsten Bibbins-Domingo ( 07:35 ):
Well, I have to say I personally am on TikTok. And that was the experiment to see whether JAMA should
be on TikTok. So stay tuned. Obviously, TikTok is one of those platforms that's being bandied about in
the political arena.

Mark Masselli ( 07:50 ):
That's right.

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Dr.Kirsten Bibbins-Domingo ( 07:50 ):
But I think-

Mark Masselli ( 07:50 ):
But it's what people... Young people are-

Dr.Kirsten Bibbins-Domingo ( 07:53 ):
If you ask, I have a good young colleague who just finished in public health school. She shows me the
videos that she watches and people are using shorter forms of communicating and platforms for
communicating. And lest we say this is all an age issue, I have one of my most cherished board members
tell me, he's like, your abstracts are too long, everything is too long. It needs to be shorter. We need to
get to the bottom line faster. And I think that reflects the space all of us live in.

Mark Masselli ( 08:28 ):
Absolutely.

Margaret Flinter ( 08:29 ):
Well, there's a few things that stay with you over the course of a long career as kind of a brand or a
trusted brand, I would say. And if you're a clinician as I am, JAMA is one of those. So that's really
important. But it's also important they're constantly be fresh and new material. And you recently
remarked that you were invigorated by reading some of the articles that you're publishing in the journal
from artificial intelligence to something maybe very provocative like the future of clinical trials. So
maybe share with us just a couple of your best picks or favorite articles that really gave you energy
reading them as they went to press.

Dr.Kirsten Bibbins-Domingo ( 09:08 ):
Sure. So first of all, there's really an explosion of science. I mean, what you can see here at this festival
here is just the discovery science. It's really pushing the boundaries on new therapeutics for Alzheimer's
disease and tackling obesity and things like that. And so that is an exciting time for discovery. Our goal as
a clinical journal is to be at the forefront of publishing those, but also to put it in context because things
are complicated. We don't exactly know how to use all of these medicines in which patients they will
work the best, how we're going to pay for them, how we're going to figure out how they really impact
the conversations we have in clinical practice. But they're so exciting and you can't help but be excited
by what our basic science colleagues are really helping us to bring to the forefront. I think AI is one of
those things that is a little daunting.
( 10:05 ):
One of the things that I launched about a year ago is just conversations with leaders about AI. Again, the
goal was to bring more people into the discussion. Because there is no doubt that AI will transform how
we practice medicine, how we conduct science and how we publish. And we have to all understand that
so that we can get the best out of it and also figure out where the guardrails should be. So I'm excited
about that. We launched a communication series at JAMA because we thought in this era of mistrust
where we know the frontline clinician is the person that patients trust. We want clinicians to be as good
as they possibly can-

Margaret Flinter ( 10:49 ):

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And that's a science too, which I don't think most people realize.

Dr.Kirsten Bibbins-Domingo ( 10:52 ):
Exactly. And so we worked with communication scientists to bring their approach to how we think about
having the conversations in healthcare. Because we know in the one-on-one encounter, you know this,
that we know that you can talk about nuance, you can talk with people who have a different point of
view than you. And so giving clinicians more tools in this environment to have hard conversations is also
I think just as important.

Margaret Flinter ( 11:20 ):
Very exciting. I can see why you're invigorated. Those letters to the editor will tell you what people are
invigorated about that are reading your articles.

Dr.Kirsten Bibbins-Domingo ( 11:20 ):
Oh, yes.

Mark Masselli ( 11:28 ):
Let me connect the dots between mistrust in clinicians. You're a general internist, a cardiovascular
researcher, an epidemiologist, and you were brought on to the Journals a couple of years ago to really
restore trust. There had been a serious breakdown within that and you started to talk about some of the
things you're doing, but maybe expand a little on that. I think the reasons you were brought in were very
serious concerned about the impact that racism has in medicine. And this is something our audience is
very concerned about and I know you are as well.

Dr.Kirsten Bibbins-Domingo ( 12:01 ):
Yeah. I think JAMA had a very public incident in 2021. I think JAMA had a public incident and that
uncovered what is true across healthcare, across medicine, and certainly true in medical publishing. And
so I think that it was an important time. It was an important time when all of us were having
conversations about race, about inequity, about inequality, about and how we as institutions can be
worthy of the trust that we hope others will place in us. And so for me, I think it was an interesting time
to come onto a Journal. My view on this is that I am not the keeper of trust for the Journal. I'm not the
keeper of our focus on equity. In fact, the Journal and our sets of journals have always put equity at the
forefront of how we have thought about this.
( 12:59 ):
But my goal was to put more processes in place so that we could collectively have those conversations,
be more transparent about them, think about the processes that help us make sure we're always trying
to be the best we can be. Make sure that all people in our organization have voice so that they can say,
well, yeah, that we don't think is exactly the right way to approach it. That we can be more transparent
with our readers and our authors so that they also can take part in the conversation. We are not always
going to get it right. I know that. But we as a communications platform, we always have to be a place
where people say, I don't really like that. But I trust that they are working to making sure that different
voices are heard in this. And that's what we have to be.

Mark Masselli ( 13:47 ):

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And I think it's so important we have within our organization, somebody leads up justice, equity,
diversity and inclusion. And we remind everybody it's not one person.

Dr.Kirsten Bibbins-Domingo ( 13:47 ):
It's not.

Mark Masselli ( 13:56 ):
It's got to be all of us. And sort of that inclusive message is so important.

Dr.Kirsten Bibbins-Domingo ( 14:00 ):
Yeah. Yeah.

Margaret Flinter ( 14:02 ):
Well, among the many things that you're known for, you're known as a leader in prevention and in
addressing health inequities. As we were just talking about some of those issues, and I think it was about
two years ago that you remarked that you thought in many communities the Gulf was getting wider, not
closing. And this is particularly concerning where years past the ACA. And so many things that should
have been closing the gap, not widening it. What are the strategies on your mind these days to make
more progress in that area?

Dr.Kirsten Bibbins-Domingo ( 14:33 ):
Yeah, I think we obviously saw it during the pandemic, the pandemic exposed a lot of the preexisting
health inequities. I think it is the thing that concerns me, the pandemic was one of the reasons I got
energized to be part of Journals thinking about the communications in this space. I think that concerns
me a little bit as we also have a little bit of fatigue on these issues. We quickly snap back to saying, okay,
well we know they're out there, but we have other things we've got to move on to. And I see the Gulf is
widening. There's no doubt about it. There's doubt about it. There's no doubt about it.
( 15:09 ):
And it's widening to the point that when you look at the statistics of what we think makes the US wrong,
you see across so many different factors, increasing mortality in children, you still see the high maternal
mortality rates. You see a shortening of the life expectancy and you see all of those disproportionately
affected in poor and minoritized communities. And so those numbers are what the US puts forward. And
we are not anywhere close to our peer countries at this point. And so we have to have those
conversations. We have to have those conversations as a country, but also it starts very locally. What we
see is that both the gaps are very different by location, but also the solutions happen on a very local
level.
( 16:04 ):
And that's what I want us to be able to give more voice to, not just the big problem, which we all have to
deal with, but also where are those areas where people really have tackled this issue for a sustained
period of time. And there is evidence of dressings-

Margaret Flinter ( 16:20 ):
And systems.

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Dr.Kirsten Bibbins-Domingo ( 16:21 ):
In which that has happened, which gives us a bigger bang for the buck. Exactly right. Exactly right.

Mark Masselli ( 16:26 ):
One of the areas that we're very concerned about is primary care. And we've seen really a retreat in
terms of the resources that are being spent. Want to ask why isn't there a journal on primary care? That
you have a lot of journals, but primary care is missing. And I think that's a real problem because we've
moved people away from the relationship with a primary care clinician to a specialist. We need great
specialists, but at the same time, there's a real assault on primary care. What voice are you trying to give
to that topic?

Dr.Kirsten Bibbins-Domingo ( 16:58 ):
Yeah. Well, as a primary care provider myself, I totally agree with you. I think primary care was
particularly hard hit during the pandemic. I think when we hear talks about burnout amongst clinicians,
we hear that a lot in primary care. We know people are leaving this field. It's been true before the
pandemic, but the pandemic certainly didn't help. I think we at JAMA, I think have published quite a bit
on the policy issues that relate to this. I think if you look at our journal, JAMA Internal Medicine, it isn't a
primary care journal, but I will say that the editors of JAMA internal Medicine are all very active primary
care clinicians. And so if you look at how they publish what they publish, their focus, it is much of the
primary care.
( 17:48 ):
And what we want to do is take our top journals. There's always a tendency to think that we need the
journal of primary care, which one could argue that might be a better journal to give voice to that. JAMA
and JAMA internal Medicine are really our top and most widely circulated and red journals. They're
journals where the editors have a strong interest in primary care. And I think you see that in the content
that's there. I want to make sure that the primary care providers and clinicians can find that content if
they're only looking in primary care. But I do think we have to publish both on the policy issues as well
as on the issues that are taking place in practice so that we can continue to be a voice on these issues.

Margaret Flinter ( 18:35 ):
Well, your host institution, the University of California at San Francisco certainly has created much of the
research in primary care that has guided those of us in the field, particularly in community health
centers. So we know you come from that very strong and noble background. But I want to do a bit of a
shift to something that I had not realized until recently was as much of a problem as it apparently is, and
that's the amount of research that's being done and published on that cannot be recreated, what some
call useless research. I had not heard this until recently. We spend close to 30 billion, I think $26 billion a
year on research. And a lot of it just can't be reduced, which by definition... Except for qualitative studies
sometimes by definition would make you think it wasn't really solid, valid research. What are your
thoughts on that and what's the screen as you're thinking about publishing and accepting articles?

Dr.Kirsten Bibbins-Domingo ( 19:29 ):
Yeah, so I think the NIH has called it the reproducibility crisis, right? So that you want science to be
published and hopefully someone else can reproduce it. That's how we have more confidence in it. And
over, I think at least the last decade, but probably longer, there's been a growing awareness led by
certain fields where the reproducibility crisis is particularly stark, that there's lots of studies that are

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funded. There are lots of studies that are published that when we look deeper really can't be
reproduced. Now, on the one hand, you could say, well, that's part of science. So you publish and then
you put it out there and somebody else should try to produce-

Margaret Flinter ( 20:09 ):
Getting different results is different than not being able to do-

Dr.Kirsten Bibbins-Domingo ( 20:12 ):
100%. That's what we're talking about. And when you have entire fields... There's certain branches in
psychiatry, for example, where you have entire fields where you're like, well, the most prominent
people have results of their experiments that can't be reproduced. So this is a problem. What you see in
those fields is that they have taken it on themselves to basically understand how can scientists say
ahead of time what question they were really trying to answer. How can we make our data more
available to others ahead of time so that we can see? Because some of these things are very obvious
that the data, it is unlikely to be reproducible.
( 20:50 ):
And I think you see this move towards openness, transparency for registering questions ahead of time,
so we know what you intended to ask, not what you... As you got closer down the road, so decided you
just wanted to focus on. And I think journals play a role in helping to create the opportunities to
document those things about registration, about your ability to share data and those things. I will say we
have to be even better at this and we have to be better with other sectors of the biomedical ecosystem.
Journals can't do it alone.
( 21:23 ):
Academic institutions have to play a part, the funders have to play a part, and then each field has to play
a part. I do worry that this wonderful power of AI just makes the ability to sort of shift things a little bit
or commit out-and-out fraud easier. Fraud was there forever. But AI allows you to scale things and to do
that in a way that is just so much easier. And so it means all of us have to be better at what we're doing
and we all have to take it more seriously because we started with this issue of trust.

Margaret Flinter ( 22:05 ):
Trust. I was just thinking that-

Dr.Kirsten Bibbins-Domingo ( 22:07 ):
And we cannot be starting with like, well, I don't really trust this. We cannot be there. I think JAMA and
our JAMA Network Journals, we have systems in place. We are a very high touch journal. We have both
the technology as well as the editors who are really focused on these issues. So I worry less about our
journals because we're just hyper focused on it. I worry about the mass of journals that are out there
because the entire scientific literature doesn't have the luxury of all the great editors and all the great
technology that-

Margaret Flinter ( 22:39 ):
All the peer reviewers that you have.

Dr.Kirsten Bibbins-Domingo ( 22:42 ):

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Exactly. But to me, when the quality of everything is poor, it comes back to our journals as well. And so I
think it is something all of us have to take seriously.

Margaret Flinter ( 22:51 ):
Thank you.

Mark Masselli ( 22:51 ):
I want to talk a little bit about research publishing and the infrastructure. Part of our audience are
federally qualified health centers. We've been involved in that movement for over 50 years. And one
thing that we saw was that there was a lack of research and publications going on. One thing that
Margaret headed up was the formation of the Weizmann Institute, which is really trying to address this
issue for so long. We had the patients, we had the questions, we lacked the methodological tool, trying
to think about how we strengthen the infrastructure at federally qualified health centers. What's the
role that JAMA can play or for the larger research industry to really be partners in helping build this
capacity?

Dr.Kirsten Bibbins-Domingo ( 23:32 ):
Yeah. You're speaking my language. So I think that JAMA recently held a summit on clinical trials and
clinical trials are really our highest form evidence for what works. But we wring our hands all the time
about clinical trials because they don't enroll enough patients and it's hard to enroll. And they're so
inefficient and they're not pragmatic, they're not done in real world settings. And they also oftentimes
are studying a patient population that is not representative of who the patients ultimately that we are
taking care of. There are many ways in which investing in infrastructure in the types of healthcare
settings that you are talking about can help to address some of these issues. They're not the entire
solution. But just as you're saying, I really feel strongly that real venues where people are getting care,
like federally qualified health centers, patients and communities that are oftentimes excluded from
research, if we make it easier, people will participate in research.
( 24:45 ):
And that participation in research is in fact part of the trust issue. It is part of that, yes, I'm participating.
I know and I trust that this is what happens. It's a virtuous cycle when we think about it. But as you say,
these are not one-off investments. They're not one-off transactions or I have this one study, let me go
find that Federally qualified health center. This is a commitment, has to be to investing in infrastructure.
And so we've been thinking about a lot of the themes that came out here in some of our conversations
and we've addressed earlier is like should the funding for some of the federally qualified health centers
be deliberately added for being involved in research? We know other countries like the UK, they're very
good at conducting research because they give money to the hospitals to be involved in research.

Margaret Flinter ( 25:37 ):
That's right.

Dr.Kirsten Bibbins-Domingo ( 25:38 ):
And if we say we have a commitment to diversifying our study populations to asking more pragmatic
questions of relevance to real-world settings, we have to invest in those so that there's sustained
infrastructure, not one-off study by study.

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Mark Masselli ( 25:51 ):
And thinking about relevance, I'm listening to a session earlier this morning about gun violence. And
asking about evidence-based research that might exist there. Is that an area that JAMA has in its horizon
of focused in on? And I know again, these are some of the controversial areas that will come to you as
an editor-in-chief that you'll have to make some decisions on.

Dr.Kirsten Bibbins-Domingo ( 26:14 ):
Yeah. So early on in my tenure, we did a theme issue on the issue of gun violence. It ends up being a...
When you just say that people think of it as a polarizing issue. One of the themes that came out in this
session is that this is a public health issue. And that we at JAMA, this is in our lane because it is a public
health issue. And I think the approaches we will be doing... Convening a JAMA summit on gun violence.
( 26:44 ):
But it really will be focused on not the politics, but really what are those things that we need to be doing
on a one to five year time horizon to really shift the impact of gun violence in our communities. And so
many things came out this morning on suicide being one of the main scourges of gun violence of this
really affecting rural communities and older-

Margaret Flinter ( 27:15 ):
Veterans.

Dr.Kirsten Bibbins-Domingo ( 27:16 ):
Men, veterans farmers, in addition to the urban violence that oftentimes is what people hear about. But
what we need to do is just take the public health approach to thinking, not the politics, but how
clinicians and those who want to think about research and the evidence can address this issue.

Mark Masselli ( 27:34 ):
Can I get one last question in here about the day in the life of the editor-in-chief, and also the role that
you take on in terms of nurturing the next generation, hopefully of a diverse leadership that will
hopefully make changes. But I think people would know the rigor that is required in the work that you
do.

Dr.Kirsten Bibbins-Domingo ( 27:53 ):
Yeah, so thanks. Luckily this isn't the work of one person. We have a remarkably strong team at the
JAMA network. There are 250 people in Chicago who are devoted to the editorial work and the
publishing work of our 13 journals. That doesn't include our academic editors who are dispersed across
the country who lead our other 12 journals. So this is a big team and as is often the case, the day in the
life is the hard decisions oftentimes will come back to me.
( 28:29 ):
The problems will come back to me, but my job is to make sure that we have the right people in those
positions who are making... And the right processes in place so that we can have confidence in the
decisions and how we publish. For me, I have been more... Doing these interviews, been more out there.
Mostly because I think that the conversations about trust, about how we communicate during this time,
how people get their information, are those things that I want to engage in and I want to engage in with

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others. You are right that the next generation, we want them to be involved in publishing. We've
launched fellowships across all of our journals.
( 29:11 ):
We just finished a great inaugural group of junior, they're early career folks who are nurses, PhDs, and
physicians who basically came and spent 6 to 12 months with us at JAMA. I want to demystify the idea
of what journals do because we are just one part of a big biomedical ecosystem that we all care about.
We all have the same goals. We all do different parts of this to make this all happen, but we all have to
understand how the different parts work so that we can achieve some of these pretty lofty goals that
we've been talking about today.

Margaret Flinter ( 29:52 ):
Well, I'm sure that there are a lot of young and not so young people here at this conference that are
looking to you as a role model. And congratulations on getting that fellowship up and running. And Dr.
Kirsten Bibbins-Domingo, we want to thank you so much for joining us today on Conversations on
Healthcare in this beautiful setting here at Aspen Health in Colorado. And to our audience, thank you as
always for joining us. And don't forget, you can find us on Facebook and Twitter, and we'd love to hear
from you. Kirsten, thank you again so much for joining us today.

Dr.Kirsten Bibbins-Domingo ( 30:21 ):
Thank you for having me.

Mark Masselli ( 30:21 ):
Absolutely.

Margaret Flinter ( 30:25 ):
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