Author + information
- Valentin Fuster, MD, PhD∗ ()
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
- ↵∗Address correspondence to:
Dr. Valentin Fuster, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, New York 10029.
Over the past several decades, there has been a concerted effort for health care systems, professional societies, and medical peer-reviewed journals to establish policies that require caregivers and authors to declare “relationships” with industry (1). This Editor’s Page will not focus on the policies themselves or their effectiveness. Rather, I wish to reflect for a few minutes as a cardiologist, as a cardiovascular investigator, and as an educator. These disclosures with industry or others, in my opinion, always come down to our own moral integrity. It is our obligation to be honest about whatever conflicts cause us to be biased—and those biases may not only originate with industry. Importantly, it is our responsibility not to become conflicted in a way that impairs our clinical decision-making or our judgments about research.
Considerable attention has been focused on the effect that “relationships with industry” have on an investigator’s objectivity when conducting research and on the subsequent publications that result from those analyses. One survey of faculty (1,156 respondents) at 33 U.S. medical schools sought to assess how industry sponsorship and involvement with research affects the individual investigators (2). Although they wrote that relationships with industry were important to conducting research, the authors reported that a significant number of the respondents who receive industry support noted compromises to research initiatives (economic or otherwise) (35%), to publication (28%), to interpretation of data (25%), or to overall scientific advancement (20%) (2). These types of findings and additional speculation about such influence have led nearly all heath care providers and medical journals to establish policies that seek to add transparency to these relationships. Specifically, in hopes of distancing themselves from any potential relationship with industry, some journals have instituted policies so stringent that they have limited their access to expert reviewers and authors—forcing them to later reverse those policies (3).
While these policies originated with the proper intentions, I am proposing they can do little to eliminate deep-seated, personal biases. For example, from the context of the editor, bias—whether industry or not—in the peer review process can take on various forms, including prestige, nationality, language, sex, or the most prevalent, content-based biases. Content-based bias involves partiality for or against a submission by virtue of the content (e.g., methods, theoretical orientation, or results) of the work (4). When content experts are selected to serve as reviewers on a paper that contradicts their own research pathways or clinical understanding, they are either going to embrace the integrity that they should and assess the manuscript impartially or oppose it without even examining the work. Unfortunately, there is no policy or disclosure form that will liberate our profession from this type of biased predisposition. With this understanding, the JACC associate editors and I often have to consider the potential bias of the reviewers in our decision-making. Psychological research has shown that some biases are so ingrained that they are subconscious (5).
Medical journals are not the only bastions of science that have to contend with these considerations. In my experience, scientific committees—which are often tasked with guiding research and practice and are bound to the same moral standards—may contain considerable biases, even if the individuals are not involved with industry relationships. The reason that industry relationship disclosures have become the gold standard is because they are quantifiable, but the type of personal bias about which I am speaking is not quantifiable, and in my opinion, may be far more pernicious to the purity of medical research and clinical practice.
Based on my lifetime experience with journals and committees, there is a nonquantifiable bias that is unrelated to industry. Amid this scrutiny, we cannot forget that industry remains an integral partner in clinical practice and research—and does not necessarily have to bias the individual, if the person maintains his or her moral personal integrity. Again, the purpose of this Editor’s Page is to partake in an unwritten agreement with the fellow clinicians, investigators, and educators: we need to seek contentment in our lives and life choices, and once we do, we must remember and prioritize our moral integrity and commitment to the betterment of patients (6). From this objective, it is much easier not to be overtaken by bias.
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- Institute of Medicine Committee on Conflict of Interest in Medical Research, Education, and Practice