Intellectual Conflicts of Interest Are Harder to Deal With Than Financial

A colleague of mine wrote a blog post on conflicts of interest that I want to expand upon and discuss my recent experience with.

I am a member of a guideline panel (sponsoring organization not to be named) on screening for prostate cancer. I am the only primary care/internist on the panel (as best I can tell). The majority are urologists. Recently a revised guideline manuscript was sent around for comment. From my biased point of view (my intellectual conflict of interest) I was against several of the recommendations not only because the evidence didn’t strongly support it but also because I have to deal with the unhappy patients who undergo prostate cancer screening and are found to have something and ultimately get a procedure that worsens their quality of life. The urologists just couldn’t understand how I could be against screening all men and getting a baseline PSA at age 40. At one point I was referred to as “pathetic” that I would have such thoughts and teach my residents to follow the UPSTF recommendation against screening for prostate cancer in average risk men. Even the American Urological Association takes the stance to participate in shared decision making with men about prostate cancer screening.


So why all the push back from my urological colleagues? The easy answer is financial. They make money from prostate biopsies and the surgical and hormonal treatment of prostate cancer. But I think it goes deeper than that especially since many are academic urologists and probably don’t have as great a financial incentive to evaluate and treat more prostate cancer (though I could be wrong). I think their intellectual conflict of interest is the main problem. Their research and academic beliefs are so strong that prostate cancer screening is good that they can’t see anyone else’s point of view (or view those views are equally meritorious). They can’t understand how I give greater value to the risk side of the risk/benefit equation. At least financial conflicts of interest are visible (when disclosed) and understandable. Intellectual conflicts of interest are usually subconscious and hard to overcome as I have found out. It will be an interesting face-to-face meeting this fall when we get together for another update.

One thought on “Intellectual Conflicts of Interest Are Harder to Deal With Than Financial

  1. Dr Shaneyfelt,
    I agree with both your assertions about the motivations of our urological colleagues. However, I think that there might be more to the intellectual conflict of interest that you outline here. And I don’t think it is entirely explained by the specialty-centric hubris we all know exists. Just as we primary care clinicians must deal with patients’ misfortunes that can accrue from invasive investigations and/or treatments, we must also realize that our urologist colleagues often see the worst that prostate cancer can dole out to patients with aggressive forms of the disease.
    I think that in addition to the self confidence that influences their decision-making process, urologists are also swayed by caring for the subgroup of patients with painful metastatic prostate cancer that ultimately leads to their demise. We see these folks far less frequently in our offices. Caring for these dying patients with their oncology colleagues no doubt skews their perceptions of pre-test probability and the risk-benefit tradeoffs. Perhaps they are influenced by an emotional COI that I think we can all empathize with.

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