Dear Editor:
Dermatology has always been a family, even a cult, as I have said, and we all miss our family members horribly as meetings continue to fall like dominoes. Anyone who doesn’t get it either isn’t part of it or probably wants to destroy it. And like it or not (another Genesis song), it is going to happen on our watch. Aside from watching the house burn down from behind the closed doors of quarantine, we have watched a complete meltdown of America, as well as perpetuation of the “cancel culture” where opinions are neither to be seen nor heard. My kids are wondering why PAW Patrol is now forbidden, all news and social media are on fire, and nobody can say anything without risking being called an “-ist” of any kind.
Unfortunately we are all being pulled into riptides of not just political correctness but where guilt is not only presumed, it is accepted often without proof. What is worse is we are dealing with an old theme of bias against those who are perceived as biased, which is an even bigger bias and a hypocrisy beyond description. Most, if not all, of us trained in some academic center as residents or even stayed on at some point in our career as teachers, calling many of our professors “mentors” and being proud of our institutions as badges of honor. Most of my role models and current friends wear maize and blue from Ann Arbor, Michigan, but Badgers eventually just deal with that.
But there is an unsettling movement that calls out the very best of us as biased if we have any “conflicts of interest,” even to the point of depriving leadership positions because of the perception of guilt. The problem with the hypocrisy of bias is trying to be above one’s own bias, which doesn’t work when judgment is subjective and without proof of any deviations.
Let’s be clear about “conflict of interest”—in the purest of definitions, a conflict of interest is “a problem caused by having official responsibilities that involve things that might be helpful or harmful.”1 But guess what? According to those in the investment and business world,2 “a conflict of interest occurs when an entity or individual becomes unreliable because of a clash between personal (or self-serving) interests and professional duties or responsibilities. Such a conflict occurs when a company or person has a vested interest, such as money, status, knowledge, relationships, or reputation, which puts into question whether their actions, judgment, and/or decision-making can be unbiased.” OK, so doesn’t that define a job, a position to derive income, or anything where reimbursement is possible?
From where I sit, that’s what all of us do every single day in our jobs, unless of course you work for free, then my apologies. Anyone who does research, sees patients on a salary as an employee, or writes only generic medications thinking that they are saving society—guess what, those are conflicts of interest to the gain of the institution you are representing, the generic drug company that is being represented with the volume of prescriptions of generic medications, and even worse, the inherent judgment of guilt against someone who is just as qualified to perform a leadership role but has been automatically presumed is getting paid on the side and cannot make a clear decision on what is best for the task at hand. And that is a shame, because in this world of judgment, there is no defense when guilty is the new normal.
I know most institutions have gone out of their way to thank all of the generic companies that have supported their grand rounds, state society meetings, research grants, and residency education initiatives—oh wait, that didn’t happen, did it? I find it sad that the family of dermatology continues to be fragmented by the conflict of interest of those who judge, who assume the guilt in those who actually can maintain a healthy balance of working with industry and doing what is best for the cause, and even worse, creating a climate of exclusion of even the most accomplished of experts and colleagues.
I was just on a conference call listening to a rather inexperienced yet confident dermatologist who made the claim that committees that create guidelines could not possibly be objectively led by anyone who has disclosed conflicts of interest, no matter if they have written the books or participated in the research that we read or interpret as standards today. After a few minutes of rhetoric, the questions of bias were not against those presumed conflicted, but against those who were biased against the conflicted, because this bias of convicted guilt of making bought and sold decisions not only lacked merit and evidence, but was directed to exclude many of the experts who were or are some of our deepest and most trusted voices.
Soon after that, it was evident that this was not just a different kind of bias because that would have closed the door on the chance to actually perform a task, but it wasn’t just “influence bias,” which is the cause or effect of being led down a path of persuasion relying on the opinions of others to make decisions.3 Sadly, this was just plain old “prejudice,” which is defined as “an adverse opinion or leaning formed without just grounds” often unusually resistant to rational influence.4 Because the difference between bias and prejudice here is that bias involves a comparison to a way of execution, in this case comparing those who are involved with industry doing a job with those who do not, unlike prejudice which simply states those who work with industry must not be able to clearly perform a task because they are guilty of not being able to give a clear opinion.
Now, if I weren’t bummed out before, the sad reality that some of our next generation of leaders in dermatology are tainted by prejudice really is a gut punch. I thought it was bad enough when the brightest of medical students were not allowed to make decisions about any interactions with industry by universities because of their inherent bias, but apparently we are moving further into prejudicial assessments of our colleagues. Maybe it is time for a reset of priorities to follow the lead of our country into times of acceptance and fostering unity rather than letting philosophical rhetoric ruin our family. Or, maybe those who truly believe what they preach should just own their opinions and not just rent them for convenience.
With regard,
Neal Bhatia, MD, FAAD
Affiliations. Dr. Bhatia is a dermatologist based in San Diego, California.
Funding. No funding was provided.
Disclosures. The author has no conflicts of interest relevant to the content of this article.
References
- Conflict of Interest. Merriam Webster Dictionary site. https://www.merriam-webster.com/dictionary/conflictofinterest. Accessed July 10, 2020.
- Conflict of Interest. Investopedia site. https://www.investopedia.com/terms/c/conflict-of-interest.asp. Accessed July 10, 2020.
- Muchnik L, Aral S, Taylor SJ. Social influence bias: a randomized experiment. Science. 2013;341(6146):647–651.
- Prejudice. Merriam Webster Dictionary site. https://www.merriam-webster.com/dictionary/prejudice. Accessed July 10, 2020.