Questions beget more questions. A caution on phrasing of survey questions

Dear Editor, We read with interest the study by Khan et al. exploring foundation doctors’ perspectives on the new Preference Informed Allocation (PIA) system for the UK Foundation Programme [1]. As educators working across the undergraduate–postgraduate transition, we are regularly exposed to trainees’ experiences of, and concerns about, the allocation process. The findings reported by Khan et al. are consistent with a growing body of literature suggesting substantial dissatisfaction with the PIA system amongst medical students and foundation doctors [1–4]. We do not question the importance of these concerns, nor the value of gathering data from such a large cohort. We do, however, wonder whether aspects of the design of the survey warrant some caution when interpreting the findings. Survey questions should, as far as possible, be phrased neutrally so that respondents are not inadvertently encouraged towards a particular response [5]. Several of the questions reported by Khan et al. are framed as statements with which participants are asked to agree or disagree. This approach may introduce agreement bias, particularly where the statement presents only one side of a contested proposition. For example, asking respondents to indicate their agreement with the statement that PIA is “an equitable method of allocation” may privilege the notion that PIA is equitable. A more neutral formulation might ask respondents directly how equitable or inequitable they consider the system to be, using a balanced response scale.