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Editorial IGR 12-4
From the Chief Editor
Caveat Emptor: Recognizing and Managing Bias and Conflict of Interest
R.N. Weinreb, MD, La Jolla, CA
The lecturer, a well-respected colleague, was asked ‘Why do we do it this way?’ in reference to some of the specific steps entailed in performing a certain surgical procedure. Almost reflexively, she responded that ‘it has been done this way for more than twenty years’. However, not only was there good evidence lacking to shape her judgment, but it also was apparent that inertia, or resistance to change, was shaping it. And then there were her own subtle biases that contributed, as well, to shape her surgical approach and other clinical decisions. These biases shape the routine clinical decisions of many other colleagues, as well. It always is perplexing how individuals, and also their organizations, often perpetuate less than optimal practices even when their original usefulness has disappeared and better methods have surfaced.
Adopting a new idea, even when it has obvious advantages, is difficult. Most medical innovations require a lengthy period of time from the time they first are available until they diffuse and are widely employed in clinical practice. As a result, a common problem for many individuals and many organizations is how to accelerate the rate at which a new idea is communicated effectively and translated into clinical practice. In clinical medicine, peer to peer diffusion in which there is doctor to doctor education is, perhaps, the most important means for dissemination of information, particularly the type that changes clinical practice.
Most doctors are highly educated. Those of us involved in patient care like to think that we are good clinicians who make good patient management decisions. We have been trained to weigh the facts and evidence, consider the alternatives, and select the best course of action. We generally also perceive ourselves as largely immune to the influence of others as we decide and act. And we have convinced ourselves that the facts and our experience carry the day, not the behavior of those around us.
Our own capacity, however, to assimilate new information is limited. And with the technology revolution that has just sprouted in glaucoma, we most likely will need enhanced methods for acquiring the torrent of new information that is emerging. We also will need to direct even more attention than we do today to the biases and conflicts of interest of those who are delivering the information. Decision-making, whether in the clinic or operating room or laboratory, is an inherently social exercise. Biases, conflicts of interest and the behaviors of those around us weigh heavily on our decision-making, frequently in ways of which we are unaware. Whether a message is delivered in a personal conversation, with a lecture, in print or on a list server, one should assume that there is a bias or conflict of interest. You cannot expect someone receiving an honorarium as a speaker by a commercial interest or paid as a consultant by them to be unbiased about their products anymore than you can expect a scientist to be unbiased about the importance of their research or a clinician about the benefit of their treatment. Ownership of ideas and self-promotion also are important sources of bias and conflict of interest. And it should be recognized that each of us has our own biases and conflicts of interest, as well. A thoughtful clinician needs to recognize these myriad influences, and should work to successfully manage them. And only by successfully managing them can we deliver the excellent care that is demanded by our patients and expected by society.
Robert N. Weinreb, M.D.
Hamilton Glaucoma Center
University of California,
San Diego
La Jolla, California
