In response to the “torrent of recent literature decrying the role of industry support for postgraduate medical education,” Melvin M. Scheinman, M.D., from the University of California, San Francisco, wrote an editorial in the Journal Pacing and Clinical Electrophysiology highlighting the importance of industry-supported continuing medical education (CME) from the perspective of cardiac electriophysiology trainees.
Reflections on Industry-Supported-Continuing-Medical Educational Activities for Cardiac Electrophysiology Trainees examines the recent “guidelines instituted to regulate industrial funding of medical education” by first discussing the roles of professional societies who have addressed the issue of industry support of CME: the Association of American Medical Colleges (AAMC); Accreditation Counsel of CME (ACCME), as well as the Council on Ethical and Judicial Affairs (CEJA) of the American Medical Association (AMA).
To date, ACCME regulates accreditation of medical centers to provide CME programs through a set of voluntary guidelines. CEJA’s proposal to regulate industry funding was sent back to committee for a third time. Dr. Scheinman however, discusses the AAMC guidelines in more detail, specifically the provision, which states that “Academic centers should prohibit their faculty, students, and trainees from attending non-ACCME-accredited industry events billed as Continued Medical Education.”
His discussion of this guideline is simple: he believes it will cause “grievous harm to the education of cardiac electrophysiology trainees,” an area that is very familiar to him. Where does his fear come from?
As a clinical cardiac electrophysiologist with over 40 years devoted to teaching cardiology trainees, Dr. Scheinman has received a host of teaching awards, both from his own institution, as well as from national cardiology societies. He has proudly “participated in a number of industry-sponsored CME programs for cardiac electrophysiology fellows, and he encourages fellows to attend courses that he feels are particularly worthwhile.”
His experience however does not include “serving on any advisory boards, consultative positions, ownership in stocks, membership on speakers’ bureaus, or receiving research grants from any industry that sponsors CME activities.” The only grants he has accepted are for the annual CME program at his medical school, and speakers’ fees for faculty participation in industry sponsored courses.
Consequently, after reviewing available studies on industry support of CME, he could only find articles “related to the effects of gifts and/or CME courses given by pharmaceutical companies.” In particular, he did “not find any studies that focused on the effects of CME courses and physician behavior related to use of catheters or devices.” As a result, he concluded that the “new guidelines related to industry-sponsored cardiac electrophysiology CME activities are, therefore, based on perceptions extrapolated from other industry activities.” In other words, apples and oranges.
Perception vs. Reality
Dr. Schienman explains this misunderstanding by portraying three common perceptions of industry support, and describing the reality he has experienced.
Perception: If industry is willing to spend large sums for CME activity that teaching activity must be poisoned by self-interest and is set up to induce physicians to use their products. Often cited are the vague neuro-biologic studies, suggesting that people are conditioned to be favorably influenced by those who bear gifts or favors.
Reality: The programs that Dr. Schienman, and many other physicians participate in are conducted with the highest academic and professional standards. These programs teach a great deal of material through interaction with peers and fellows, and the faculty members who participate in these courses are clinical scientists from outstanding academic centers, with impeccable credentials as clinicians and teachers. Rather than self-interest, these individuals are of exceptional integrity and consider it an honor to be invited to these CME courses.
Perception: Faculty members who participate in these kinds of activities lack a sense of professionalism because they lend their prestige to these courses.
Reality: From the courses Dr. Scheinman attended, the programs were centered around an objective exposition of material tailored for trainees, as are most CME courses. Not only did he state that critical appraisals of presentations are encouraged but, he also acknowledged having never witnessed any attempt by the industry sponsor to, in any way, interfere with the program substance or style. In fact, he even asserted that there was not one “scintilla” of commercialization during these meetings. Ironically, he even pointed out that by trying to narrowly prescribe teaching students the science and practice related to the sponsor’s products, new guidelines are actually creating more commercialization.
Perception: Cardiac trainees are relatively naive and their behavior can be modified to act in a manner contrary to the best patient care practices.
Reality: From 40 years of experience, he believes that trainees are especially critical and are urged to actively interact with the faculty at these courses.
Dr. Scheinman also notes that trainees are motivated to attend these courses and sacrifice what little time they have by choosing courses based on “the invited faculty as well as course material.” Such an environment creates a highly competitive group of CME programs that does not allow for bias because it would put them out of business.
Another argument to prohibit industry funding of CME he addresses is the idea that funding should come from physicians. As is the case for the overwhelming majority of all medical students, Dr. Scheinman notes that cardiac fellows “accumulate enormous debts from their medical training and are in no position to pay for travel, meals, hotel expenses and tuition for the type of courses currently offered by industry.” So then who can pay? We have yet to see any CME funding in the current health care reform, which is pretty ironic considering CME is required to keep physicians licensed each year. As a result, Dr. Scheinman offers his own recommendations to address the issue.
(1) The CME medical course director must be given absolute authority to choose both faculty and subject materials without interference from the industry sponsor.
(2) Courses should be monitored by either representatives from the Heart Rhythm Society and/or cardiac electrophysiology directors from the locale where the course is given. The purpose of these audits is to assure the public and our medical colleagues of the absolute professionalism of course content.
(3) Part of such an audit is an assessment review of course content by both teachers and fellows.
In the end, because industry provides “innovative teaching methods,” Dr. Scheinman encourages continued industry support of these programs, particularly because they “allow for fellow exposure to leaders of his discipline, with impeccable academic credentials.” Moreover, since there are no realistic alternatives for funding these kinds of programs presently, and because fellows cannot afford the costs and departments of cardiology do not have the resources to put together these programs, industry needs to stay.
As is the case for all specialties and areas of medicine, “current teaching in cardiac electrophysiology must emphasize both the scientific underpinning as well as the practical execution of best patient care.” This kind of teaching can be accomplished through “An effective and principled partnership between academic medical centers and various health industries, which is critical in order to realize fully the benefits of biomedical research and ensure continued advances in the prevention, diagnosis and treatment of disease” (a statement from the AAMC report).
In the end, Dr. Scheinman noted that “imparting knowledge to trainees, both with respect to understanding basic mechanisms, as well as with practical clinical applications,” is the best way to achieve the ultimate goal of medicine: healing patients.