Thursday, July 4, 2013


A DEFINITION OF BIAS- A predisposition or preconceived opinion that prevents a person from impartially evaluating facts.

We are all biased.  Knowing this we can work really hard to remain open to information and do our very best to identify bias, acknowledge it and sometimes move beyond it.  The scientific method is a process that attempts to limit bias.

A conflict of interest is a situation where an organization or individual is involved in multiple interests that might influence the ability to be objective.  I have conflicts of interest that have impact on what I choose to do or not do within the massage profession.  Because I write textbooks used to teach both entry level and advanced practice massage I refrain from organizational board service and instead contribute behind the scenes on committees or as a subject matter expert.  Before I agree to be involved I question my biases and disclose my conflicts of interest.   With my textbook writing the publisher requires all my work to undergo extensive peer review that is blinded so individuals can be frank with their observation and opinions.  For last revision of Fundamentals of Therapeutic Massage I had 17 reviewers and let me tell you they had no problem telling me about errors, bias, when I was on a “soap box” and so forth.  I depend on this so that the textbooks are as current and objectively reflective of the massage profession at the time of publication as possible.  However—in spite of all the checks and balances there are still biases and opinions found in the textbooks— not just mine but in textbooks in general.

There are two projects that have or are attempting to describe entry level massage therapy.  The Massage Therapy Body of Knowledge (MTBOK) released in 2010 and currently the Entry Level Analysis Project (ELAP).  As the massage therapy community, we must analysis for bias and conflict of interest.  To do this we need clear disclosure from all individuals directly involved with supervision, data collection and interpretation and project management. 

I strongly encourage you to revisit the MTBOK document at and specifically read through the vision and information provided in the FAQ tab.  Personally---( and I am biased) I thought the outcome of the MTBOK was  good in relationship to how entry level knowledge was described and how a common language used to describe massage was developed. The content was developed by mining through textbooks used in massage therapy schools all over the country as well as data from professional organization and state regulators. There were no surveys or original data collected to my knowledge. There was opportunity for comment by the massage community.  Most of the conflict and push back from the profession related to the scope of practice statement so I just ignored that ( bias) and concentrated on the knowledge, skills and abilities identified for entry level massage education.  The Alliance for Massage Therapy Education  (  did a comprehensive review of the MTBOK entry level educational recommendations and I served on that committee  and we all had our biases which hopefully evened out the end result, which was reviewed by the Alliance board and then went out for public comment and remains on the website for review. .  I am biased but it is a very good guide for curriculum development.

 Now the ELAP project.  I don’t have as much information about how the vision of the project was determined. I have been kind of confused in general.  I am not opposed to the project however in the beginning I did point out the potential for bias and conflict of interest not that I think any of the work group would intentionally do this but even the appearance of bias and conflict of interest would be detrimental to the validity of the project.

 I repeatedly recommended that an objective group of educational experts outside of the massage profession guide the project.   I thought that if the project was conducted in a specific way that controlled for bias using individuals outside the massage community, but experts in education, there would be a more accurate outcome and less suspicion from the massage community.  I suggested that the MTBOK also be part of the data as well as other information from the various JTA’s (job task analyses.)

 My biased little self- became a pest I think as I pointed out the problems of bias and conflict of interest.  When the original survey came out (as an add on to the Federation of State Massage Boards JTA relating to the MBLEX ) I felt uneasy with the way many of the questions were designed. As I have pointed out before- Swedish massage was the ONLY term presented for the concept of general relaxation massage.   Also it was hard enough to get through the JTA survey let alone the ELAP add on. I communicated with the work group and the leadership  group about this  in my typical pesky biased manner.  

Research bias, also called experimenter bias, is a process where the individuals performing the research influence the results, in order to portray a certain outcome. ( . Bias is so pervasive because we want to confirm our beliefs  and the scientific methods are organized around proving itself wrong not right in an attempt to limit bias.

 In my opinion the ELAP survey process was and continues to be flawed and displayed the following forms of research bias:

·         Confirmation Bias is the tendency for us to favor information that confirms our belief about something.

·         Design bias is introduced NOT when the study fails to control for threats to internal and external validity  but rather when the study fails to identify the validity problems OR when publicity about the research fails to incorporate the researchers cautions.

·         Measurement bias exists when researchers fails to control for the effects of data collection and measurement. Often the problem is not the sample, it's the failure to acknowledge the bias the sample brings.

·         Procedural bias exists most often when we administer the research interview or questionnaire under adverse conditions ( the multiple surveys as part of the ELAP as well as not being able to go back and review content or seeing the project as a whole and or in paper form plus the videos can be seen as procedural bias in my biased opinion.  

·         Bias via assumptions is the failure to adequately identify more problematic background assumptions. For example, in the ELAP document there is the assumption that the content is presented by an effective teacher.  There are other imbedded assumptions in the questions on the surveys.

·         Bias in Survey Sampling: Bias often occurs when the survey sample does not accurately represent the population. The bias that results from an unrepresentative sample is called selection bias. A good sample is representative. This means that each sample point represents the attributes of a known number of population elements. I contend that The ELAP survey respondents are not representative of the massage community.

·         Voluntary response bias. Voluntary response bias occurs when sample members are self-selected volunteers, as in voluntary samples.  The ELAP has problems with this type of bias. The resulting sample tends to over represent individuals who have strong opinions. LIKE ME

·         Bias Due to Measurement Error. In survey research, the measurement process includes the environment in which the survey is conducted, the way that questions are asked, and the state of the survey respondents and leading questions. The wording of the question may be loaded in some way to unduly favor one response over another.  I have no idea how the original survey and the current one on the curriculum map was developed or how they controlled for bias.

I would hate to see the work of the ELAP group discounted. To counter this I recommend that the ELAP process be evaluated by experts outside the massage profession that can identify the inherent biases that have and will occur.   This recommendation in no way reflects of the integrity and the commitment of the ELAP work group.   My bias is that the massage profession is biased, suspicious and frustrated with projects such as this.   For the ELAP project to be useful for the future of massage therapy it must be valid and if the unintentional biases and conflicts of interest taint the project it will sit on the shelf along with the MTBOK and that will be very unfortunate. – My biased opinion.

 Bias definitions adapted from

1 comment:

  1. So I did find were the group used an outside consultant ,Donna Tatum. She worked on the MBLEX fit the Federation.I would like to know more about the ext ed by of her involvement.