This was first published as a BJSM special feature on 6 November 2018.
By Zachary Y Kerr, Sports Injury Epidemiologist, University of North Carolina, Department of Exercise and Sport Science
It is with great pleasure that I read the commentary by Casals and Finch on the role of the Sports Biostatistician in injury prevention (1). Thank you to the authors for considering this important area of focus. With that said, I hope my additional comments, despite being a relatively new Sports Injury Epidemiologist in the field (receiving my PhD in 2014), can continue the discussion and dialogue that the authors have generated since this publication.
First, as noted above, I prefer to describe myself as a “Sports Injury Epidemiologist” and not the term Casals and Finch use (“Sports Biostatistician”). Casals and Finch are forthright in denoting that their term is not well known and includes “the combination of statistics and epidemiology and public health or medicine and sports science (1, p.1457). Still, I am hesitant to use this term myself as my training was in epidemiology and not in biostatistics (although the expectation is that I have a good working knowledge of the latter as much as the former). I would not feel comfortable using a term that describes a role for which I was not trained. And although I cannot express the opinion of my former advisor and mentor, Dr. Steve Marshall, I would believe that he would agree, particularly as his faculty webpage describes himself as an epidemiologist and not a biostatistician (2).
The term “epidemiology” originates from 3 Latin roots – (1) epi (Latin for ‘‘on,’’ ‘‘upon,’’ and ‘‘against’’), (2) demos (‘‘people’’), and (3) logos (‘‘study of’’) – and roughly translates to ‘‘the study of that which is against people.’’ Today’s modern definition of epidemiology is the “study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems” (3, p.61). This modern definition captures the extent of thought that epidemiologists must consider alongside their multidisciplinary research team. My role involves the careful deliberation of study design with as many decisions made a priori; it considers the control of confounding via methodological control as much as statistical control; it pushes for both internal and external validity, while minimizing the risk of committing a Type I or Type II error; and most importantly, it weighs what is good science and what is doable science, all the while staying committed to working with the assumption of the null hypothesis being true.
Furthermore, I worry that incorrectly identifying myself as a “biostatistician” will continue to undermine the true value of a biostatistician. In an ideal setting, all research teams would be inclusive of both epidemiologists, who would help lead study design, and biostatisticians, who would help lead data analysis development and implementation. These roles would complement one another to ensure both study design and data analysis are well-planned and considered concurrently throughout the entire research process. However, too often, a biostatistician’s role is mischaracterized and seen as someone who simply comes in after data collection occurs and is expected to analyze the data; in the worst cases, it is someone who is expected to “make lemonade out of a lemon”. I am constantly worried my role will be seen as such as well. Neither a biostatistician nor an epidemiologist should be relegated to such a role. I wholeheartedly appreciate Casals and Finch emphasizing that our work “should start at the beginning of the study design process, well before data have been collected” (1, p.1458).
When I was pursuing my master’s degree in epidemiology at The Ohio State University, a professor I much admired jokingly stated that at parties, he seldom introduced himself as an epidemiologist (but rather a biostatistician) in order to not scare and confuse people at social functions. Throughout my doctoral work, I personally found that the use of either term at parties set me up for an evening on the couch with only the host’s dog to keep me company. However, as I’ve maneuvered through this world of sports injury prevention, I find myself more willing to take this chance of social exile and to proudly proclaim myself as a sports injury epidemiologist. I have also found that I have had to vocally emphasize the value of both sports injury epidemiologists and biostatisticians. Our constant nagging about good study design and study limitations, sometimes much to the chagrin of our colleagues, is not meant to annoy. Rather, it is meant to allow our colleagues as well as our readers the ability to carefully consider the validity and generalizability of research. We are a valuable component of any research team. And to jokingly paraphrase Dr. Evil from the Austin Powers film series, “I didn’t spend six years in evil [public health] school to be called ‘mister,’ thank you very much.”
Perhaps, my argument is more about semantics than anything else. However, I believe pooling both parties into one term undermines the true value that each of us brings to the table. Still, I appreciate that Casals and Finch have boldly taken the first step to address this issue. I hope my commentary addresses my concerns, but also encourages continued dialogue regarding the necessity for multi-disciplinary teams inclusive of sports medicine professionals, methodologists, and analysts.
Conflicts of Interest
1. Casals M, Finch CF. Sports Biostatistician: a critical member of all sports science and medicine teams for injury prevention. Br J Sports Med 2018;52:1457-1461.
2. University of North Carolina Injury Prevention Research Center. Leadership and faculty. https://iprc.unc.edu/about-us/our-people/leadership-faculty/. Accessed November 6, 2018.
3. Last JM. Dictionary of Epidemiology. 4th ed. New York, NY: Oxford University Press; 2001.