JAMA: Industry-Free Continuing Medical Education is Not Without Challenges

 With a growing number of medical institutions and organizations responding to concerns about potential biases in industry funded continuing medical education (CME), a recent article from the Journal of the American Medical Association (JAMA), assessed the successes and challenges that have emerged from efforts to shift away from industry-funded CME.


According to the author, although efforts to limit industry sponsorship of and influence of CME thus far are proving feasible, “industry-free CME is not without challenges.” In particular, “individuals involved with these efforts are now facing funding and other challenges, such as determining where to draw the line on industry involvement.”


But at a time when we are preparing to bring 30 million people into and understaffed health care system that is already without adequate resources, does challenging the way our CME system functions really make any sense? We should be encouraging more funding of CME to help address gaps in care and shortages of physicians, and to keep physicians up to date about new treatments.


Yet institutions are making it more difficult to determine where to draw the line by ignoring the fact that the Accreditation Council for Continuing Medical Education (ACCME) already has stringent standards to limit commercial influence on accredited CME programs. Despite these effective measures, which include preventing marketing messages from being delivered as part of continuing education for clinicians, critics of industry still believe these changes are necessary by portraying industry funded CME as corrupt.


What is also problematic about this portrayal of industry-funded CME is the author’s use of outdated evidence. For example, she cites $1.5 billion spend on industry funded CME in 2007, which means she obviously did not do her research that would show that since 2007, the total percent of commercial support as part of the overall CME budget dropped from 47.5% (2007) to 39.0% in 2009.

Such a reduction in funding means that institutional funds would have to be used toward the balance [previously covered by commercial funds], and/or registration fees for CME activities that involve outside physicians,” according to Robert Wittes, MD, physician-in-chief at Sloan-Kettering’s Memorial Hospital, who spoke at an anti-industry conference in June.


Although the center has not banned all consulting or collaborations between staff and pharmaceutical companies, since 2002, Wittes, Memorial Sloan-Kettering Cancer Center president Harold Varmus, MD, and Thomas J. Kelly, MD, PhD, director of the Sloan-Kettering Institute, have chosen to decline any industry consulting to avoid the appearance of conflicts of interest among key decision makers at the center.


According to Dr. Wittes, in light of their choice to not accept such funding, “physicians have been willing to pay the registration fees, and attendance at the programs has not suffered.” But reducing industry funding has forced organizations to control or cut costs of CME programs more strictly by hosting them on site or soliciting bids for catering.

The problem with this approach is that many organizations do not have the resources, space, staff, or logistics to host CME events, especially not large events or programs tailored to specific specialties. His observation also ignores the fact that physicians who are willing to pay may have no other choice but to pay the registration fees based on convenience and geography.


The reasoning behind critics of industry funding such as Dr. Wittes is flawed however, because it assumes that the goals of physicians and institutions that work with pharmaceutical companies are different because companies have commercial interests that may differ from the interests of the physicians or investigators. The reality is, companies and physicians have exactly the same goal: progress in health, science and medicine in whatever way possible to help the greatest number of patients in a safe and efficient manner. This goal clearly aligns itself with physicians and institutions whose main goals are to improve public health. In fact, the Bayh-Dole Act was specifically created so that discoveries in academia could be brought to patients and commercialized sooner for their safe and effective use.


Another institution, who has also recently adopted a ban on commercial funding of CME, also uses faulty logic in attempting to justify their decision. For example, the University of Michigan medical school dean asserted that “the shift away from commercial funding is part of a larger effort at the school to revamp medical education to better meet the needs of clinicians and patients and to take advantage of emerging knowledge and technology.” Just exactly what evidence does Michigan have to show that reducing commercial funding will provide doctors with better access and exposure to emerging knowledge and technology?


Without acceptance of commercial support, pharmaceutical and medical device companies who developed the technology, and the physicians who helped test it, certainly will not be able to teach doctors at Michigan about their emerging knowledge and technology. Consequently, since almost all of the emerging knowledge and technology comes from industry or in collaboration with industry, it will be only a matter of time before Michigan doctors report that their learning and education has been negatively affected by this policy (similar to what has already happened in Massachusetts).


While Michigan would like to believe that its policy is ensuring that CME is “free from bias or the perception of it and that it is balanced and evidence based,” the evidence shows their concern is completely misguided (e.g. Cleveland, Medscape, UCSF).


Interestingly, Michigan continues its unusual logic by suggesting that two ways to make up for less CME as a result of reduced commercial funding would be charging its doctors more to attend CME events, and online-based activities. The first idea, charging doctors more, is particularly troubling for academics who already make minimal salaries for significant amounts of work, and who for the most part, are essentially banned from any outside work. Second, this simply punts the ball to commercially supported internet based CME.  Creating internet CME is prohibitively expensive for universities, and those that do in-house programs the quality of online-based programs is uncertain.


But as a patient, would you want your physician to learn how to treat you over the phone or computer, instead of hands on at a hospital or company that created the device or drug they are going to use?


Unfortunately, all of the actions taken by institutions thus far to ban commercial support of CME have been unnecessary, and will only harm patients and widen gaps in care. Specifically, there is no need for institutional policies to ban commercial instruction for two simple reasons. First, there has been no reliable evidence to show any harm to patients that has come from commercial funding of CME.


Second, ACCME regulations adopted from 2004, and recently revised in 2009, provide significant standards for the involvement in CME of pharmaceutical companies and manufacturers of medical device and other medical product makers. Among other things, these standards prohibited commercial interests from directly controlling the content of CME. Moreover, with respect to product-related presentations by industry, if CME providers choose to have an industry employee present, they must institute measures to independently vet the content of such presentations. Such safeguards would include establishing a rigorous peer review of the research and its results and conclusion, changing content on presentations to ensure appropriate balance, and ensuring that the selection of content for presentation is made by individuals free from relevant financial relationships.


Ultimately, if only industry critics had taken the time to sit down with CME providers, physicians, academic medical centers, industry and patients to have an open discussion about the proper role of industry funded CME, we wouldn’t be faced with any challenges about who is going to fund the legally necessary and required CME our doctors must have.


This discussion is necessary because as Dr. Wittes pointed out, institutions like Memorial Sloan-Kettering Cancer Center will “never completely ban collaborations between faculty and industry because such interactions help to improve commercial science, products, and product testing.” Accordingly, since he also asserted that “for the public good, it doesn’t make sense not to work with companies,” policies now being adopted by institutions that restrict commercial funding of CME must be reconsidered immediately before physicians are left with less education, and patients less options.

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