EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/176967
8 EW NEWS & OPINION September 2013 December 2011 Bias, conflict of interest, and CME presentations Roger F. Steinert, MD Gavin Herbert Eye Institute University of California, Irvine H aving just completed a nine-year term as program chair of the ASCRS•ASOA Symposium & Congress, as well as having organized many other CME meetings, I recently became involved with a discussion of the perception of bias and conflict of interest in our CME activities. This guest editorial is an outgrowth of those discussions, representing my personal perspective. In particular, the goal of this editorial is to stimulate thoughtful reflections and debate on the realities of bias and conflict of interest as perceived by an audience and the position of a lecturer who is asked to (or volunteers) to make a presentation on a commercial device. In an ideal and perfect world, educators would have no biases and no commercial interests. Audiences would receive pure and unadulterated information. This sounds like a worthy goal. But is it realistic? And, in stating such a goal, are we creating a veneer that is intellectually dishonest? In other words, if we deny certain realities, we create an illusion of truth that cannot be achieved. One might think that the legal system is designed to identify "truth." I am reminded of the book and subsequent movie A Civil Action. The plaintiff's lawyer, played by John Travolta, pleads to the judge that a defense motion, highly unfavorable to him, should be denied because he is seeking the truth. The judge, marvelously portrayed by an imperious John Lithgow, contemptuously declares "Truth? Truth? The last place you will find truth is a court of law!" As physicians who often hold the legal system in less than high esteem, we may all hope that medical education is achieving a much higher plane than the courtroom, but can we honestly lay stronger claim to "truth"? Can we hope and believe that the CME rules and regulations will give us an educational world without bias and with fully truthful content? Should an audience judge a presenter on a device or technique as "biased" because he/she is an acknowledged consultant for the company that is involved? Don't misunderstand—I favor transparent disclosure of commercial interests. But I argue that all (or pretty close to all) presenters have some biases and potential conflicts of interest, disclosed or not, conscious or subconscious. Let's see an example. Dr. A gives a favorable presentation on Device X. He acknowledges that he is a consultant for the manufacturer. The presentation explains what the device does, and data are provided on outcomes that are favorable. Mention is made of potential shortcomings, but the presentation is clearly favorable overall. Between 5 and 10% of the audience will typically say the presenter has bias. Dr. B gives an identical presentation, but he is not a consultant nor has any other disclosed relationship with the company. Is this presentation less bi- ased? Potentially. Few if any of the audience will rank him as biased. But if Dr. B paid for the device, does this not already bias him? He wants to feel he made the right decision. He wants to get referrals for the procedure. He wants to look like he has a cutting-edge practice. And maybe the company will be nicer to him in the future. And what about Dr. C? He bought the same machine and is disappointed. In his presentation, he follows CME guidelines by presenting (briefly) the data also presented by Drs. A and B, but then goes on to present his data on results that differ. Fair and proper, correct? But can Dr. C completely be uninfluenced by his feelings that he wasted his money and was misled? Won't this affect the tone of the talk and the amount of time devoted to the negative results? Virtually no one in the audience will rank him as biased. But if Drs. A, B, and C all sent their material to Dr. D, who knows nothing of the device but is asked to perform a review and give a summary, who among us thinks that the presentation of Dr. D will be a close match to any of the other presentations? So what are we to do? Go to meetings where all our education is presented only by the Dr. D model? I would argue that, even if this sounds desirable, it is both unachievable and undesirable. It is unachievable because the amount of work for hundreds of Dr. D presentations is enormous. Who would pay them for the effort? The meeting cost would be so high that no one could attend. It is also undesirable because in the real world of medi- the other dealing with managing in uncertain times," Ms. Rowland said. The meeting is an excellent resource for both physicians and administrators, fostering an open atmosphere where real dialogue can take place. Especially on the administrator side, attendees will learn that they are not alone in dealing with the many challenges in today's ophthalmic practices. "Attendees share their problems and solutions with all and have easy access to the experts," she said. She recommended that those interested in attending the meeting visit www.WinterUpdate.org frequently for the most up-to-date meeting and program information. EW ASCRS•ASOA continued from page 3 Tentative topics For the ASOA side of the meeting, tentative program topics include the administrator/technician relationship; legislative, regulatory, and Medicare updates; compliance plans; cybersecurity; accountable care organizations; meaningful use; human resources; and planning for implementation of ICD-10. "The program will also feature two facilitated discussions—one dealing with maximizing leadership skills through communication and Editors' note: Ms. Rowland is executive director of ASOA. Contact information Rowland: laureen@asoa.org cine, colleagues with experience who can hone in on essential issues are the educators who deliver quality teaching in a meaningful and compelling manner. Those are the speakers that fill the room. In my opinion, meeting attendees need to understand and appreciate the critically positive role in education by presenters who are conflicted and biased as an inherent part of their acquisition of special knowledge. The defined conflicts certainly must continue to be acknowledged, but these conflicts and the biases that come with them are simply "flags" to help the listener determine the credibility of the communication. Meanwhile, and equally importantly, the speaker without a standard disclosed "conflict of interest" is not necessarily without biases, both conscious and subconscious. As always, the rule of caveat emptor applies. Reply to "Bias, conflict of interest, and CME presentations" John Banja, PhD Center for Ethics Emory University, Atlanta Dr. Steinert calls attention to company-paid consultants delivering presentations at CME conferences and asks how much faith we should place in the credibility of such talks. I'd like to take his example a step further: Think of the career investigator in his or her lab, i.e., the scientist who is supposed to represent the quest for objective and unvarnished truth. How much faith should we put in this person's reports? Because if there's anyone who might be biased, it is very likely him or her. Assuming such a researcher is extramurally funded, when you consider how this individual's career, livelihood, professional survival, reputation, and overall success depend on continued on page 11