Commentary: The importance of bias in education

Prestigious medical journals continue to publish one-sided editorial pieces extolling the evils of commercial interests and their relationship and effect on medical education (N. Engl. J. Med. 2012;366:1069-71; Circulation 2010;121:2228-34; JAMA 2010;304:729-31; JAMA 2014;312:697-8). A comprehensive review was written regarding industry-academic relationships in four high-impact medical journals published between the 1980s and 2008 (Nature Biotechnology 2012;30:320-2). Of the 108 articles that met the reviewers’ strict criteria, only 12 (11%) were published that were either neutral or emphasized some benefit. Of these 12, all addressed the opposing points of view, and 50% critically emphasized and attempted to refute the alternative points of view.

On the other hand, 16 research articles (15%) emphasized the risks of a relationship with industry, and none critically analyzed and attempted to refute the alternative points of view. The majority, 80 (74%) of the articles published were commentary articles that emphasized the risks of a relationship with industry, and only 7 (6%) articles critically analyzed and attempted to refute the opposing points of view.

The authors conclude that a major anti-industry publication bias exists and that a conformity cascade – where policy does not emerge from objective weighing of evidence but from social pressure – may be a factor for this major bias from medical journals that are influential in affecting policy.

Amazingly, a profession that prides itself on using scientific studies to reach conclusions has used little science and relies predominantly on emotion and scare tactics, to conclude that an industry-provider relationship is bad for health care outcomes.

Anti-industry authors mainly focus on “studies” directed at the effect of marketing. Marketing does increase the likelihood that a product will be used. However, data on how this translates into health care outcomes, the important issue, are lacking. Common sense would suggest that using newer, frequently better, products and vaccines is more, not less, likely to improve these outcomes. Further reductions in the relationship between industry and education will certainly lead to fewer, not more, potentially educational interactions. On the other hand, genuine collaboration could lead to opportunities to improve education beyond what CME [continuing medical education] alone offers.

The “Sunshine Act,” renamed the Open Payments Act, may be particularly harmful. Many of the few remaining academics that still have a relationship with industry will sever this relationship for fear of being a “target.” Restrictions imposed on faculty by many academic institutions, reducing the faculty members’ exposure and interactions with pharmaceutical scientists and other faculty, also are not helpful. Past speaker and advisory sessions were attended by an eclectic group of specialists and generalists, and were filled with fertile discussions and debates regarding disease and treatment perspectives. There are no winners when these bright educators are kept away from potential learning and teaching situations.

More than 22 years of chairing the CME Committee of an extremely active American Academy of Pediatrics (AAP) Chapter and cochairing the CME Committee of an AAP District has given me the privilege of intimate interactions with hundreds of nationally recognized speakers, some with and some without industry affiliation. Myths, frequently perpetuated by those with little or no real-world contact with these programs or by people with anti-industry bias and peppered with words like “perceived” and “potential conflict,” need to be corrected.

Myth:Faculty with a pharmaceutical relationship are inferior to faculty without this relationship. They are privy to much more data, have frequently been involved in the product research, often freely duel with industry scientists and others about the data generated and how the information needs to be disseminated, interact with others researching the topic, and present newer, not-yet-published information (and disclose this) to attendees.

Myth:Education is better off without the pharmaceutical industry. At a time when medical knowledge is rapidly expanding, and it is becoming increasingly more complicated, and greater dissemination of the latest, best information is desperately needed, pharmaceutical financial support can help. Pharmaceutical support allows us to invite – free of charge – all University of California, Irvine-Children’s Hospital of Orange County pediatric residents and U.C. Irvine medical students to every CME program. Industry restrictions already in place are sufficient to promote more educational opportunities and less-expensive attendee costs. No new restrictions are needed.

Myth:Only faculty without industry relationships are unbiased and should be allowed to influence policy regarding education. This nasty, modern-day expression of “McCarthyism” attacks those with industry relationships, dismissing their contributions, intelligence, and sincerity with the “of course they support so-and-so; they are being paid by industry.” A 5-year evaluation of CME programs sponsored by California Chapter 4 AAP from 2009 to 2013 reveals the following data: 23 CME programs, 24 of 55 speakers listed a potential conflict of interest (44%). There were 1,995 attendees and 1,370 returned a response on whether or not a commercial bias was in the presentation; 1,342 responded “No” (98%) and 28 responded “Yes” (2%). Although almost half of the faculty had a potential conflict, only 2% of attendees felt their presentation suggested a commercial conflict. Interestingly, some of the “yes” responses were for faculty with no conflict to disclose.