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Academy News: January 2006 Lifelong Learner Bill of Rights reduces bias in educational activities The speaker takes the podium and gives a riveting discussion of hot-off-the-press data showing that the new drug, Goblemup, is far superior to all other cholesterol lowering agents on the market. Dr. S is mesmerized. Later that same day, another presenter shows similar studies but comes to the conclusion that Vacumuchol is a far better drug than Goblemup. When Dr. S expresses his dismay at the two disparate presentations, his colleagues simply shrug and say that the first presenter is known to give talks and do research for the maker of Goblemup, whereas the second presenter is involved with the maker of Vacumuchol, so maybe they view the various research through rose-colored glasses. Dr. S complains to the program organizers that he felt the talks were biased, but they simply say that it is up to the listener to make that call, and they are not in any way responsible. As a medical practitioner we are always studying and trying to keep up with the latest and greatest developments in our field. This often involves going to national meetings and conferences. At these meetings, whose responsibility is it to make sure that the presentations are free of bias? The short answer is caveat emptor, let the buyer (or in this case, listener) beware. However, without appropriate disclosure of potential conflicts, the listener cannot make an educated guess as to the potential or real bias found in a talk. The Accreditation Council for Continuing Medical Education (ACCME) has updated guidelines that make it clear that the organization planning the event bears the responsibility for identifying and resolving conflicts that could lead to a biased talk.1 Recently the American Academy of Allergy, Asthma & Immunology (AAAAI) developed a “Lifelong Learner Bill of Rights,” which broadly outlines what a participant should expect from an AAAAI-sponsored CME event.2 The first part of the bill deals with the right of a participant to have an educational experience that contains information that is valid and accurate, supports improvement in patient care, and is balanced, amongst others. The second component of the Bill of Rights deals with supporting an appropriate learning environment without influence from “promotional, commercial, and/or sales activities.” The third part promises the participants that there will be disclosure of “relevant financial relationships planners, speakers, and authors have with commercial interests related to the content of the educational activity,” as well as the source of funding for the event (provided it is from a commercial interest). The Learner Bill of Rights is a good start. But in order for its precepts to be enacted, the AAAAI has set up a process by which potentially conflicted speakers can be identified and prevented from presenting. The hallmark of this system is to require disclosure from potential speakers before they are allowed to participate. Without a completed disclosure, the individual simply will not be allowed to present at the meeting. This rule effectively ends the practice of some speakers to not provide any disclosure information. A special committee reviews the disclosures of invited speakers. To avoid conflicts within this committee, the members of the committee have had their own disclosures reviewed by the AAAAI Board of Directors, with the Board's disclosures reviewed by this committee. When a potential conflict is identified efforts are made to limit or mitigate the conflict, and when this is not possible, a new speaker is identified. This system, while not perfect, goes a long way towards providing some level of institutional protection against severely conflicted presentations. It does not by any means prevent any bias in the presentations. Detection and reporting of the more subtle biases remains the job of the learner. In many ways there should be a corollary to the Learner Bill of Rights: the learner responsibility to be aware of the reported disclosures and to report biased presentations to the organizing group. In the case of the AAAAI, disclosed conflicts are provided to the learner before the educational activity, and the learner is expected to fill out a report on whether each speaker provided a biased presentation or not. In our vignette, this type of system of checks and balances would have prevented Dr. S from being caught off guard. It is unlikely that two presenters, who were widely known to “be in the pocket” of a commercial interest, would be given carte blanche to speak about their favorite drugs. Indeed, in the system devised by the AAAAI, the speakers might still be allowed to speak, but their topics might be limited to areas where the commercial interests have no involvement. Of course, in a more appropriate system a disclosure of the potential conflicts would be made to the audience. While this might be in the form of a booklet (such as the AAAAI does), my preference is for a slide immediately before the talk (such as the ACAAI does and the AAAAI is considering). This guarantees that the audience sees the potential conflicts at the time of the presentation. Finally, as Dr. S did, it is imperative that learners report perceived bias to the organizers so that these situations can be avoided in the future. Will the Learner's Bill of Rights lead to the removal of all bias in educational activities? Probably not. Every speaker imparts their own spin on the data and the importance of their area of expertise. But this type of conflict is clearly stated (after all it is the investigator's own research), and we are aware of it. What the Learners Bill of Rights (and the review of conflicts) does is to set up a basic expectation of identifying, preventing, and/or mitigating conflicts that might be much less clearly perceived (especially those dealing with commercial interests). It is a great start. References
The Ethics Committee provides these discussions as a way to open a dialogue on the various ethical issues that confront our specialty on a daily basis. These issues are often quite complex and do not have simple “right” or “wrong” solutions. The articles are meant as a way to highlight the various issues that are involved in these ethical dilemmas, they should not be viewed as the Ethics Committee or the Academy's particular stance on an issue.
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