Bias in Medical Education

The American Orthopaedic Foot & Ankle Society® (AOFAS) mobilizes our dynamic community of foot and ankle orthopaedic surgeons to improve patient care through education, research, and advocacy. As the premier global organization for foot and ankle care, AOFAS delivers exceptional events and resources for continuous education, funds and promotes innovative research, and broadens patient understanding of foot and ankle conditions and treatments. By emphasizing collaboration and excellence, AOFAS inspires ever-increasing levels of professional performance leading to improved patient outcomes. I recently participated in an industry-sponsored, nonCME educational program. Although on the surface, the meeting appeared to be nonbiased, there was subtle beneath-the-surface censoring that avoided highlighting competitors’ products. This very subtle bias stimulated my thinking on the important responsibility of our journal Foot & Ankle International and the educational responsibility of the American Orthopaedic Foot & Ankle Society. It is crucial that the journal and the AOFAS work in concert to provide the best possible nonbiased education for our members and readers. When investigators submit their research to Foot & Ankle International, we ask that all of our authors and presenters declare all of their potential sources of bias. We additionally expect that the information that they provide for us has been vetted by their local institutional research board of ethics, IRB. Bias goes much deeper. There are those who suggest that it is ethical to reject a paper or a presentation because we disagree with the treatment advocated or the device or implant used. Remember that in the days of Columbus, the key opinion leaders opined that the world was flat. We can vet by the quality of the methodology, but we should not vet based on the treatment employed or the suggested outcomes. We set a lower bar for presentations at educational programs, simply because the program committee is forced to select papers for presentation based on the limited information included in a submitted abstract. The risk of bias becomes far more substantial in educational programs, textbooks, or journals when the author or presenter is invited to present their interpretation of the available evidence. The program chairperson has a very important responsibility to balance the known opinions of the speakers. Much like the electoral process, the information should be presented to the consumers of that information in a balanced unbiased fashion. The so-called ballot box will be measured by the sales of the individual devices discussed or papers presented or published. The educational platform of the American Orthopaedic Foot & Ankle Society potentially provides a very strong influence on our membership as well as other providers who care for similar patients. This places a substantial ethical responsibility on our leadership. We head into uncharted territory where information becomes available immediately and textbooks quickly become obsolete. As we have seen in our political lives, nonvetted social media plays an extremely important influence on the practices of our younger colleagues. As our mission statement implies, not only is AOFAS a strong social influencer, it also has the responsibility to present that information and education in an unbiased fashion. The demands on educational organizations and medical journals will become greater as we head into this uncharted territory. The Foot Forum would like to hear your ideas on necessary changes or adaptations that will be required to address these important issues. Please send your comments to mpinzur@aofas.org.