What do we mean by bias?

To continue the analogy, we can potentially get a free (or reduced fare) trip if we accept the cab driver's recommendations.

Let's assume we're comfortable that Cab Driver A is paid an amount of money by a restaurant (the amount of which you are currently not privy to). In exchange for the cab driver disclosing the arrangement, we willingly pay a lower fare.
  • Do we lose some control over where we are going to go?
  • Will our chance of going to the best restaurant be lessened?
  • If you know the cab driver was paid a certain amount, say $50 vs. $500 vs. $5,000 vs. $50,000, would that change your answer? (Note that currently you can't find this out and folks typically won't tell you.) 
In other situations, we understand that the less control we have, the cheaper it gets--hotel shuttles work just this way. But most of us would assume that we've lost something when we agreed to the lower fare.

But surprisingly enough, most physicians in one study (88% in Tabas 2011) believed that commercial support introduces bias, however when asked if bias exists most physicians said no (Kawczak 2010, Steinman 2010).

The key to a discussion of bias is not to attack the integrity of the recipient of funds, but to ask ourselves as experts in human nature if we believe there is a relationship between compensation and recommendations. Or perhaps, conversely, do we believe there is no relationship between compensation and recommendation?
  • If CME is 1/2 the price as usual, is that just a good deal or have we lost some control?
  • Is "free" CME offering equal value to CME that costs us some money?
  • If the speaker is paid more, does that increase the chance of bias?
Findings from review panels:
  1. "In general, industry financial relationships do not benefit the educational missions of medical institutions in ways that offset the risks created." (IOM 2009).
  2. Conflicts created by a range of common interactions with industry can for "medicine generally, and for academic medicine in particular … have a corrosive effect on three core principles of medical professionalism: autonomy, objectivity, and altruism" (AAMC 2008).
References
  1. Jeffrey A. Tabas, MD; Christy Boscardin, PhD; Donna M. Jacobsen, BS; Michael A. Steinman, MD; Paul A. Volberding, MD; Robert B. Baron, MD, MS, Clinician Attitudes About Commercial Support of Continuing Medical Education, Results of a Detailed Survey Archives of Internal Medicine, May 9, 2011; 171(9): 840-846. (archinte.ama-assn.org/cgi/content/abstract/171/9/840). Pubmed ID 21555662
  2. Kawczak Steven MA; Carey, William MD; Lopez, Rocio MPH, MS; Jackman, Donna, Academia-Industry Relationship The Effect of Industry Support on Participants' Perceptions of Bias in Continuing Medical Education , Academic Medicine: January 2010 - Volume 85 - Issue 1 - pp 80-84. http://www.clevelandclinicmeded.com/academic-med-article.pdf PMID: 20042829
  3. Steinman MA, Boscardin CK, Aguayo L, Baron RB. Commercial influence and learner-perceived bias in continuing medical education. Acad Med. 2010 Jan;85(1):74-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801075/?tool=pubmed. PMID 20042828
  4. IOM (Institute of Medicine). 2009. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: The National Academies Press.  Accessed April 5, 2010. Available online at: http://www.nap.edu/openbook.php?record_id=12598
  5. AAMC. 2008. Industry Funding of Medical Education. Washington, DC: AAMC. http://www.law-lib.utoronto.ca/ghostwriter/AAMC%20report_DavidKorn.pdf (accessed October 10, 2008).
  6. Carolyne Krupa, Industry-supported CME offers potential for bias, study says: Despite perceptions, few physicians would eliminate commercial support of continuing medical education. amednews staff. Posted May 30, 2011 (http://www.ama-assn.org/amednews/2011/05/30/prsb0530.htm).
  7. Harriet Washington, Flacking for Big Pharma: Drugmakers don't just compromise doctors; they also undermine top medical journals and skew medical research, The American Scholar, SUMMER 2011 http://theamericanscholar.org/flacking-for-big-pharma/
  8. John W. McMahon, Sr., MD, Chair, Financial Relationships with Industry in Continuing Medical Education, REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS, CEJA Report 1-A-11, 2011 (http://www.acme-assn.org/imis15/aCME/PDFs/Advocacy/2011_AMA_CEJA_Report_1-A-11.pdf)
  9. Todd Dorman, MD; Ivan L. Silver, MD, MEd, FRCP, Comment on 'Clinician Attitudes About Commercial Support of Continuing Medical Education,' " Archives of Internal Medicine, May 9, 2011;171(9):847-848 (archinte.ama-assn.org/cgi/content/extract/171/9/847). Pubmed ID 21555663 
Copyright 2011, Bradley Tanner