Criticism surrounding commercially supported continuing medical education (CME) has remained constant over the past several years, despite growing evidence that such support creates little if any bias. However, as Jeffrey R. Binder, President and CEO of Biomet, Inc. recently posted, the logic of industry critics who argue against commercial support of CME and graduate medical education (GME) is flawed. As Mr. Binder explains, the logic of critics unfolds as follows:
– Industry funds CME courses.
– Industry would only do this to gain financial benefit.
– That benefit can only be realized from increasing sales.
– Education can only increase sales by promoting inappropriate utilization.
– Therefore, industry funding of CME must be eliminated.
Based on these premises, Mr. Binder asks, why do companies fund medical education? In the eyes of critics, he notes that opponents of commercially supported CME presume there “must be a self-serving reason.” However, looking at commercially supported CME from this narrow perspective is problematic.
As Binder points out, in America we enjoy a free enterprise system where companies maximize profits. In order to maintain this system, Binder notes that we must “preserve and encourage corporate public-mindedness, including charitable giving and responsible stewardship.” He further asserts that, America “must allow for a theory that companies can engage in ethical contributions that are generally beneficial to both the corporation and its customers without being unethical or illegal.”
However, over the past several years, reports from institutions like the Institute of Medicine (IOM) and the Association of American Medical Colleges (AAMC) have begun to threaten this system, which has enjoyed much success from industry-physician collaboration. Some assume that these reports and headlines about conflicts of interest suggest that there is a widespread problem regarding commercially supported CME. This concern however is misplaced, considering industry funded CME has dropped almost 30% over the past two years.
In calling for the complete elimination of industry funded CME whenever possible, these organizations and industry critics have “erected a straw man.” Binder traces the making of this straw man back to 2009, when the Senate Special Committee on Aging convened a hearing provocatively titled: “Medical Research and Education: Higher Learning or Higher Earning?” It was during this testimony that critics maintained that industry funded education is just marketing, and is an aggressive way or promoting drugs. Nevertheless, as Binder points out, where was the evidence of such bias?
Binder correctly recognizes that even in the April 2009 IOM report, evidence of systemic bias in medical education is scant. The report itself states that the “empirical evidence relevant to financial relationships and conflicts of interest is limited. On many topics related to conflicts of interest, no systematic studies are available. For other topics, data are suggestive rather than definitive.”
In a follow-up report on CME, IOM reported that “It is not clear, though, precisely how the content would change in the event conflicted funding sources disappeared because the content and types of [CME] that are biased and sponsored by conflicted sources is not well-defined.” Additionally, Binder pointed to three recent studies that we have covered numerous times, which indicate that physicians as a general matter do not appear to perceive bias in industry-funded CME courses (Cleveland Clinic; Medscape, and UCSF).
Despite all of this conclusive data, critics respond to this evidence by stating that the bias is “unconscious” and “subtle.” In other words, the bias is there-but it’s invisible. Such a farfetched argument is absurd, and there is no need to address such a pre-determined conclusion that has no basis in logic. Arguments such as these are fundamentally flawed in light of clear and convincing contradictory evidence from these studies, and demonstrate that industry critics have their own bias.
Interestingly, Binder does a great job explaining why the bias is undetectable: because there is none! He points out that there are “numerous overlapping guidelines in place to ensure objectivity in CME, including the Accrediting Council of Continuing Medical Education (ACCME) guidelines and the PhRMA and AdvaMed Code of Conduct. Binder explained that he is a member on the AdvaMed Board of Ethics and how the new Code is far more stringent today than it was in its initial 2003 iteration by requiring companies to give grants only for objective education.
Part of the problem Binder recognizes, is that past abuses of industry, although overwhelmingly unrelated to accredited CME, create a suspicion that everything when industry is involved is evil. However, Binder used his company’s own example of funding GME and the impact it has. He explained that Biomet has donated almost $4 million to the Orthopaedic Research Education Foundation for GME, which has helped train new surgeons, without any perception that the company is inducing or training people to use their products. He added that the company has no control over who the money supports or if fellows are trained on their products. “The whole arrangement is strictly hands-off.”
Despite these safeguards, critics think industry funding of fellowships create overuse of products and creates customers. However, Binder correctly refutes these claims by noting that such funding has not “created demand” because over the past several years, there have been a significant percentage of unfilled fellowships in total joint arthroplasty, and the number of fellowship programs has diminished. He added that patients suffering from joint disease, not funding, drive the availability of such fellowships. Accordingly, he asserted that “eliminating industry funding of fellowships would only serve to ensure that fewer surgeons are trained to treat increasing patient need.”
In the end, Binder points out that the “dogmatic narrative coursing through academia and the media assumes that industry funding, by definition, creates bias, a premise supported only by slim anecdotal evidence, and repudiated by the extensive studies cited above.”
A company such as Biomet, and numerous others, support medical education because it helps to ensure that there is “a foundation of trained surgeons and physicians who are successful in using a company’s product to treat patients.” This training and education leads to high quality patient outcomes, and may tend to lead to more use of products. So what! Isn’t that what Americans want? Better health care and healthier and happier lives? Patient’s don’t just get healthy off of air and fresh water.
If orthopedic companies followed the advice of critics and withdrew all educational funding, Binder states that these critics would then “attack industry’s greed in retaining profits as opposed to contributing to improving patient care, and blame industry for contributing to a shortage of trained physicians.”
Accordingly, if critics want to change the status quo and remove the beneficial support of industry, he challenges them to “first come up with sound evidence that existing guidelines are ineffective, that bias is a significant problem in industry-funded CME programs, and that patients would benefit by eliminating over $1 billion in annual funding.”
Ultimately, Binder notes that “absent that evidence, industry and CME stakeholders respectfully suggest that critics focus their energies on issues of substance that can actually help the patients on whose behalf they purport to advocate.” We could not agree more. There will be 30 million more patients entering the U.S. health care system. We have a severe shortage of primary care physicians as well. We need to address the real problems our system is facing and find the best solutions to educate our providers only, not eliminate a major resource that will help solve them.