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Disclosure is “good” for the soul
For a number of years I have been a reviewer for The Journal of Bone and Joint Surgery and the
Journal of Pediatric Orthopaedics (I often wondered why), and now I have a chance to use these
skills in reviewing an article from The New England Journal of Medicine (NEJM).
I realize that the NEJM is a highly revered journal, beyond reproach, and
is thoroughly peer-reviewed. It is frequently cutting edge and, to my
mind, sometimes a bit far to “the left,” but always “Bostonian.” The
original articles are always highly scrutinized by an excellent editorial
staff and reviewers. So it is with great thought that I make any critical
comments about the article “Conflict of Interest Disclosures Reported by
Physicians” (NEJM, October 8, 2009). (See “Are orthopaedists
trustworthy?”)
First of all, the objective part of the article cannot be challenged: only 71.2 percent of payments
made to orthopaedists from five orthopaedic device companies were self-disclosed prior to the
AAOS 2008 Annual Meeting. I think the first point that ought to be made is that the online
reporting by the companies was done under very specific requirements imposed by the
Department of Justice (DOJ) in 2007. In contrast, the disclosure statements made by the
orthopaedists, although required by the AAOS, were self-reported.
I understand the authors’ method of determining relatedness: directly related payments (79.3
percent of which were disclosed), indirectly related payments (50 percent of which were
disclosed), and unrelated payments (49.2 percent of which were disclosed). I also agree with
the statements that those receiving more than $10,000—especially those receiving more than
$100,000—were most likely to disclose and that payment to an individual physician was more
likely to be reported than payments to a company or organization or with an “in-kind”
component. All of this is hard to argue with, and it is what it is. We should have done better.
The AAOS has been constantly improving its disclosure policy over the years. It is progress, not
perfection. I know of three problems—and I think I have a solution to each. One is compliance
by the fellows (too much trouble). I think the authors are correct in suspecting that legislation
requiring all drug and device manufacturers to publicly disclose payments to physicians will

ultimately be passed. I am sure physicians would prefer self-disclosure to having disclosures
made by a third party. This is what the AAOS is trying to achieve.
Second, although I believe most orthopaedists want to do the right thing, some are uncertain
about what to disclose. At the time, each author was not required individually to report. The
primary author on a paper, poster, or exhibit was asked to contact the other authors and get
their disclosure information. This may have created some confusion.
In addition, in the follow-up survey conducted by the authors, 38.9 percent of responders said
that their reason for not disclosing was that the payment was unrelated to the topic presented.
The solution, I believe, is one the AAOS has already developed: to require each author to
individually disclose all potential conflicts, regardless of whether or not the relationship is
“relevant” to the presentation.
This eliminates both sources of confusion. First, one doesn’t have to decide what to
disclose—one simply discloses everything. Second, one doesn’t have to decide how relevant the
relationship is—one simply discloses everything. How much simpler—and more honest—can it
be?
The third problem may have been that some researchers and educators simply did not disclose
prior to the meeting itself. They may have included their disclosure on slides at the beginning of
their presentation, as required, or admitted to conflicts under questioning by the session
moderators, but because the disclosure was not included in the final program, the researchers
could only assume that it was not made at all.
The AAOS has a mandatory disclosure policy; if you don’t submit the disclosure forms, your
poster or paper will be removed, and, if you are a faculty member, you will be replaced. (See
“Annual Meeting participant guidelines”)
I must admit that I am a bit underwhelmed and disappointed by the variables that were not
controlled in the authors’ follow-up survey. When one considers the total number of
orthopaedists who participated as presenters, faculty, board, or committee members, the 91
who did not disclose is a small number, and the response rate of 39.6 percent (36 physicians)
may not be valid to come up with any conclusions of why orthopaedists did not disclose. Much
was made of statistics in the findings, but little was said about the statistical validity of the
survey, which was mailed more than a year after the date to disclose had passed.
I was also bothered by the way the survey questions were written. No one is going to answer
“Intentionally omitted” when questioned about reasons for not disclosing. As you might guess,
the number giving this answer in the survey was zero. This, coupled with the fact that those
most likely to disclose payments were those who received large sums, would seem to indicate
that the omission was not done to conceal payments but occurred as a result of
misunderstanding. We should have known better.
Unfortunately, publication of this “exposé” may help further legislation, resulting in greater
government oversight and involvement in medicine. Additionally, I use the term “exposé”
because I believe the article went “over the top” in its reporting of the amount of money not
disclosed. Was this really necessary, especially since the amount of money received is not
disclosed at the Annual Meeting?

The image of the orthopaedic community and the AAOS have recently suffered because of the
DOJ investigation. I think the article gave the orthopaedic community another “black eye” in a
healthcare environment that is filled with monetary worry and concern. It could have been
done better.
Ah, but it’s a new day. The AAOS continues to update and refine its disclosure policy, to close
loopholes, and put some real bite in their punitive actions concerning disclosure at the Annual
Meeting. We can’t afford to do otherwise, and I applaud our Education Council and Annual
Meeting committees for their ongoing efforts to make educators as transparent as possible
concerning disclosure, to make guidelines for disclosure clear and concise, and to eliminate
commercialism and bias. It will get better.
I will conclude with my “Disclosure is good for the soul” prayer: Lord, we should have known
better; we could have done better. But Lord, we are better than we used to be, and we will get
even better—and that’s good for the soul.
AAOS Now
November 2009 Issue
http://www.aaos.org/news/aaosnow/nov09/youraaos2.asp
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