Thursday, January 24, 2008

CME thought police alert!

CME and its funding are objects of a brewing controversy. An increasingly vocal group of people is calling for radical changes in CME delivery, including an end to drug company support. A post form Retired Doc alerted me to the latest developments. The Macy Foundation has issued recommendations for reform of CME. The seven page executive summary has been released with a lengthier monograph anticipated later this year. Many opinions and assumptions were presented as “findings.” The long and the short of the recommendations is that there be an end to any form of drug company funding for CME and that CME offerings shift from didactic lectures to point of care learning activities.

Those who are familiar with my earlier postings on this issue know that I disagree with these recommendations on several levels. (For detailed commentary on what I think is wrong with such recommendations see my posts here, here, here and here. Such posts were usually inspired by my personal reflections after coming home from high quality lecture based industry supported CME programs like the Mayo Clinic update in hospital medicine and Bob Wachter’s UCSF/SHM sponsored hospital medicine course).

There have been some noteworthy reactions to the report on and off the blogs. Pathophilia questions certain assumptions in the report. Where’s the evidence, for example, that industry funding of CME leads to poor patient outcomes? Or that drug company interests and good patient care are always in conflict? The overarching premise of the report is that doctors lack the critical thinking skills necessary to evaluate educational presentations. But today’s information technology makes it easy to check CME presentations against primary sources. (Doctors who don’t care enough about the quality of their educational experience to do this probably read the New York Times health pages uncritically, too!).

According to the Carlat Psychiatry Blog Harvard neurologist Martin Samuels had a thing or two to say about the report. I wish I had a transcript of Samuels’s statements---we have to rely on the recollections of Dr. Carlat who was attending a meeting where Samuels made his remarks. I don’t know if Dr. Carlat’s account is a fair rendering of what was said. Carlat, who makes no bones about the fact that his blog is very biased, does not appear to be in sympathy with Samuels’s views.

So, at the risk of reading between the lines, I get that Samuels had two objections. First, he noted that one of the conference participants, Dr. Denise Basow, is an executive for UpToDate. That, Samuels said, is a conflict of interest that “should have been declared.” As Carlat points out Dr. Basow’s affiliation was listed at the end of the document but was not highlighted as a conflicting interest. Many readers of the report, such as members of the press, who are unfamiliar with UpToDate, would not realize what a potentially huge conflict of interest it really is. And I mean huge. The conflict exists on more than one level. First, UTD is in direct competition with free-of-charge on line pharmaceutical industry supported CME providers, one of which, emedicine, is a similarly formatted and ever improving point of care “look up” resource. Emedicine, which remains free of charge despite continuous updates and improvement in its content, could be seen as a growing threat to UpToDate’s market. And if industry support goes away emedicine might well go away.

And there’s another dimension to the conflict. Let’s examine that by looking in more detail at a few of the report’s “findings” and recommendations:

Insufficient emphasis is placed on individual learning driven by the need to answer the questions that arise during patient care.

CE does not make adequate or creative use of Internet technology, which can help clinicians examine their own practice patterns, bring medical information to them during patient care, and aid them in learning new skills.

Integrate continuing education into daily clinical practice.

Traditional lecture-based CE has proven to be largely ineffective in changing health professional performance and in improving patient care. Lecture formats are employed excessively relative to their demonstrated value.

Information technology is essential for practicebased learning by: Providing access to information and answers to questions at the time and place of clinical decision-making
(point-of-care learning).

The CE enterprise should shift as rapidly as possible from excessive reliance on presentation/lecture-based formats to an emphasis on practicebased learning.

To automate credit procedures for point-ofcare learning.

There is too much emphasis on lectures and too little emphasis on helping health professionals enhance their competence and performance in their daily practice. With Internet technology, health professionals can find answers to clinical questions even as
they care for patients, but CE does not encourage its use or emphasize its importance.

It’s interesting that these recommendations and opinions all refer to things provided by UpToDate. Without question UpToDate is the principal vendor of this type of point of care, practice based, automated CME tracking service, at least outside those which are industry supported (e.g. emedicine and Medscape). The report is chock full of recommendations that are favorable to UpToDate’s commercial agenda.

As Dr. Carlat pointed out UTD has no industry support. Heck, it is the industry, and a real cash cow at that. (For an eye opening look at UTD’s pricing and licensing tactics from a medical librarian’s point of view read this).

Perhaps if Dr. Basow had recused herself the outcome would have been the same. We don’t know the extent of her influence. Nevertheless the appearance of a conflict of interest is strong.

Samuels also seemed to object to the general tone of the document. He said: "I find this report to be self-righteous and self-serving. It is so hypocritical that it will fall like a stack of cards." Although that comment well characterizes the UpToDate issue it’s an apt criticism of the entire document which implies that doctors lack critical thinking skills, don’t care enough to consult primary sources and are unable to decide for themselves what their learning needs are. (Anyone who knows Dr. Samuels and his genius and passion for teaching and learning has to take his observations seriously).

Disclosures, disclaimers and personal reflections:

I have no drug company ties.

I have my own personal subscription to UpToDate. It is one of many sources I consult. I believe it is a useful resource with limitations, one being that doctors may over-rely on it as a “look up” resource, resulting in a simplistic and possibly dangerously formulaic approach to clinical decisions. See posts here and here for a more lengthy discussion of UpToDate.

I believe doctors have different learning needs and styles. It’s a bit insulting when outsiders think they know my learning needs better than I do. When I need outside help identifying weaknesses in my knowledge there are various self assessment tools I can use.

I believe learners should seek a balance between case oriented material based on focused clinical questions and background material which might take the form of didactic lectures, textbooks or narrative reviews. A strong shift toward practice based learning as recommended by the Macy report may slight pathophysiology and background material about diseases, thus dumbing down the CME experience.

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