Objectivity and post-it notes

Over the last few years, evidence-based practice has become a standard expectation of Western health care systems, rather than a topic whose value is debated by clinicians. Concurrently, rules of convention have developed, and it has now become politically correct in some circles to acknowledge in articles whether the author has any interests which might compete with their ability to be objective about the issues discussed.

This is, in principle, a jolly good thing. It is logical to assume that a person whose  research (or holiday) is funded by a company manufacturing drug or technology products may feel duty-bound to present those products in a good light. Where objectivity is seen as paramount in producing and evaluating evidence, the well-behaved researcher and clinician will attempt to avoid all bias, or at least declare her bias so that others can decide for themselves whether the information presented may be tainted by the author’s interests.

However, it seems we are beginning to realise that there are some problems with this idea. In what appear to be efforts to highlight this, authors of papers in the British Medical Journal have recently declared the following tongue-in-cheek competing interests:

  • Their friendship with carpet factory managers who may lose out from research which causes asthma sufferers to consider installing wooden floors (Seaton 2003, who shares his pride about the fact that, in 30 years, he has received nothing but plastic biros from pharmaceutical companies).
  • Their feelings about the relationship between keeping up-to-date with ‘the scientific literature’ and whether this leaves them with enough time to practise medicine (Lagnado and Kholl 2003).
  • That they like hammers and power tools (Michelson 2003; in the context of being an orthopaedic surgeon who does not feel he needs an RCT to tell him that hitting his thumb with one will be painful).

All of these articles (as you might guess from their titles in the reference list) are discussing the merits – or otherwise – of evidence-based practice. By contrast, the authors of those articles that evaluate the hard-core clinical and pharmaceutical interventions remain relatively silent about their competing interests. Only the most blatant interests – such as membership of a related committee or pressure group – are declared.

Now, I used to be as guilty as anyone of being tempted by the free post-it pads and CD holders. Following some research I did into a particular pharmaceutical substance, it entertained me (in an ironical kind of way) to assemble as much stationery with the name of this product on as I can. (I should perhaps add that this stationery was used strictly in the privacy of my own home and never in front of pregnant women!) But small items of stationery aside, I can think of far more important competing interests which can impact what somebody writes than I have ever seen acknowledged in print. Nobody ever declares that they have a uterus (or a penis), or are pregnant, or have been pregnant, or have a partner who is pregnant, or might one day become pregnant, and that what they write might be affected by their experiences or affect the options that are open to them and their family in the future.

While I have seen papers which declare that the authors see birth as a natural and normal life event, I have never seen a declaration that openly stated that the personal philosophy of the researcher was rooted in the fear of disaster or litigation. (Although I can think of some very famous and well-cited examples where this is probably the case). In fact, I can’t recall many pieces of research which admit that the author is even a member of society, and so might have an interest in the way that society is run, or the way health and ill-health are viewed and treated, or the ethical principles on which health care practice are based.

But then we’re all so busy trying to be objective that it is easy to forget that we are also human, and that being alive and having experiences, thoughts and feelings are competing interests in themselves. Perhaps it is just not our competing interests we should be declaring, given that we all have so many of them, but our opinion about the extent to which we feel we can be objective about developing or evaluating evidence in the first place?

This article was first published as: Wickham S (2003). Objectivity and post-it notes. TPM 6(6):41.

References
Lagnado M and Kholl S (2003) Seven steps to evidence based general practice. BMJ 2003: 326:933
Seaton A (2003) “There’s none so blind as the double blind.” Discuss. BMJ 2003;326:889
Michelson, J (2003) Evidence B(i)ased Medicine. BMJ 2003: 326:6
photo credit: greenplasticamy 04.21.2011 via photopin (license)

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