Admission of our limitations is crucial to good decision making, it is time we openly acknowledge these, says Amitava Banerjee
In healthcare and health research, we spend a lot of time thinking about conflicts of interest (COI). The idea is that potential, perceived, and real influences on healthcare and research are declared and minimised, where possible. During the pandemic, the debate has ranged from vaccination, testing, personal protective equipment, government covid-19 advisory panels, and lockdown policies. There are clear guidelines for practitioners, and researchers on managing conflicts of interest, the latter explicitly based on the underlying principles of the Nolan committee on standards in public life. These seven principles are selflessness, integrity, objectivity, accountability, openness, honesty, and leadership. Although declaring competing interests fits under “integrity”, it plays a role in all seven principles. As well as managing competing interests, the “duty of candour” applies for all practising clinicians. Despite the Nolan principles, this kind of candour has not always been visible from our government. This week’s open testimony to MPs from Dominic Cummings, previously a special advisor to the UK government, was candid and concerning, including allegations regarding competing interests at the heart of the UK government. However, the more notable allegations were about the limited ability and capacity of those in charge of making key decisions in the first and second covid-19 waves.
In healthcare and public health, admission of our limitations is crucial to patient safety. I am an academic cardiologist, specialising in heart failure. Even within cardiology, I regularly defer to other colleagues with different subspecialist expertise and knowledge (e.g. heart rhythm problems) Outside of cardiology, whether in public health, primary care, or dermatology, I seek the input of specialist colleagues, as necessary. Moreover, I am a clinical academic, working 30% of the time clinically, and 70% in research and teaching. Although I am experienced in all aspects of cardiology patient care, there are some aspects where my colleagues who are clinically active 100% of the time may be better placed to advise than me, e.g. detailed cardiac imaging. In research, I am trained in epidemiology and informatics, but I will always need the help of colleagues in several other disciplines in almost every study in which I am involved. I voluntarily put this information on my “COI slide” in every presentation I am asked to give. My limitations are as important as whether I have accepted research grants from industry, in determining whether I am able to do my job. Whereas I am always asked about my COIs in my clinical and research roles, I cannot remember when I was last asked to declare my limitations.
Whether among government officials, policy advisors, clinicians, or commentators, every single individual has limitations in their experience and ability. If this was openly acknowledged rather than avoided, glossed over, or denied, gaps in capacity and ability could have been addressed earlier in the pandemic. For example, advisory committees have involved relatively few frontline healthcare or public health professionals, which affects the applicability and implementation of findings and recommendations. Misinformation is easier to dispel if we know the limitations in experience, knowledge, or ability of the authors or “experts.” However, experts are not required to declare limitations. Whether in science, clinical care, or in government responses to the pandemic, teams are required rather than individuals, and those teams rely on knowing the strengths and the limitations of the individuals involved. Perhaps it is time to make these limitations openly available.
Amitava Banerjee, associate professor in Clinical Data Science and Honorary Consultant Cardiologist, Institute of Health Informatics, University College London.
Competing interests: none declared.