What do studies on important medical topics, such as the percentage of African countries that belong to the United Nations, a US News and World Report study on who should pay legal costs, counting coins and accounting decisions, doing in JAMA?
The answer is simple. The Editor of JAMA, Katherine De Angelis, MD thinks this unrelated research means that doctors are corrupted by physician-pharmaceutical relationships.
In a commentary published this week in the JAMA tilted: Everyone’s a little bit biased (even physicians)
“Medical schools and professional medical associations have developed policies and guidelines in response to increasing concerns over potential conflicts of interest.
While many physicians agree with these concerns, some view conflict-of-interest policies as affronts to their integrity and an indictment of the ethical conduct of the profession as a whole. These individuals believe that their training as scientists and their devotion to professionalism protects them from external influences that might bias their opinions.
However, this view may be based on an incorrect understanding of human psychology. Conflicts of interest are problematic, not only because they are widespread but also because most people incorrectly think that succumbing to them is due to intentional corruption, a problem for only a few bad apples.
In this Commentary, we argue that succumbing to a conflict of interest is more likely to result from unintentional bias, something common in everyone. We review studies in neuropsychology, behavioral economics, cognitive psychology, and clinical epidemiology to illustrate this point.
What this commentary and all others on this issue have failed to point out, is why only conflicts of interests due to interaction with commercial interests are the only ones that are “problematic”. They all ignore all the other biases that may exist. We should consider other biases before we call for the elimination of just one type:
A) the bias for ordering patient tests and procedures to prevent lawsuits
B) the bias for staying on managed care formulary to avoid additional paperwork (regardless of whether the patient may be served by another treatment)
C) the bias of those physicians who are serve as paid legal witnesses either for the plaintiffs or the defendants
D) the bias to gain an NIH grant
E) the bias by faculty to publish regardless of weather or not they have anything important to say
F) the bias by the government purchasers to save money on medical expenditures
G) the bias created by physicians in managed care organizations to follow “prescribed medicine”
H) bias to prescribe or perform procedures based on what you learned in medical school, regardless of how long ago that was
I) the bias created by being part of a group, taken to resort location at the expense of foundation to specifically write a report against bias
J) the bias of a doctor with a small prescription CME business, who advocates elimination of commercial support of CME, which in the end would help his business
This is by no means an exhaustive list. Is there any logical reason why these biases should not be considered as “problematic”?
For instance, once I took my son to a day clinic for an ear infection. The physician (must have been 80 years old) pulled out a card with 10 drugs listed on it (apparently whatever you come in with to his practice you get one of the 10 drugs). He wrote him up for Accute Otitis Media and sent me home with a prescription for a strong anti-biotic, which I threw in the trash and the ear ache resolved on its own. That doctor had a bias towards those ten drugs. Does that make him evil? It is doubtful that any of those drugs were pushed on him by a pharmaceutical rep at least for a very long time.
I agree, everyone has biases, but I think that it is ridiculous to think that they can’t be managed.
If we were to spend all our time trying to eliminate bias, we would not be able to live, as we would say: hey I have a bias against spinach….
One very amusing instance is that I won’t wear pink shirts. Yesterday, I was away at a meeting and wanted to work out. I forgot to pack my t-shirt. I was on the way out the door of the hotel where I was staying to go buy a t-shirt down the street. A colleague offered to loan me an extra polo shirt he had. After dinner he loaned me the shirt to use and yes, it was a pink polo. The next morning I worked out rather uncomfortably in the pink polo. I was uncomfortable at first but got over it. I have overcome that bias (at least for the time I worked out) needless to say we can all manage our bias. That is what we do every day.
The article goes on to challenge disclosure as a means of managing conflict and quotes the study on students counting coins and estimating them as justification for why disclosure is inadequate.
Full disclosure, by itself, may have the perverse effect of making professionals more biased rather than less. This is not to say that conflicts of interest should be hidden but rather that disclosure may not be the solution. Even where disclosure does not make advice worse, the huge body of research on anchoring (where advice is often disclosed as being randomly generated, yet it still impacts judgment) suggests that disclosure is often unlikely to serve as sufficient warning. If a disclosure that some advice is randomly generated does not completely undo the influence of that advice, other disclosures (especially those in fine-print legalese) might similarly fall short. Moreover, even where disclosure is better than no disclosures, it may cause indirect harm by replacing more effective solutions. Surowieki13 summarized this problem by noting, "Transparency is well and good, but accuracy and objectivity are even better. [The profession] does not have to keep confessing its sins. It just has to stop committing them."
Unfortunately the evidence they provide has very little do with physicians and practice. Sort of like saying that the results of a study of mechanics show they like 57 Chevy’s and this translates that all doctors (male or female) like 57 Chevy’s.
The writers go one to summarize that:
“Bias is not a crime, is not necessarily intentional, and is not a sign of lack of integrity; rather, it is a natural human phenomenon. Like the research participant with the split brain, everyone is likely capable of rationalizing beliefs and denying influences that bias them. The most important action physicians can take as a profession is to recognize this.
So now that we have established that everyone has biases, that it is not a crime (oh, how benevolent of them to do so) that it is a “natural human phenomenon”, perhaps we should all take a deep breath and say hey, I can overcome that bias and I don’t have to eat that spinach after all.
This article is not exactly the kind of research or commentaries one would expect from a serious journal such as JAMA, but perhaps the editor Katherine DeAgelis, MD may be a little bit bias herself. Just a little.