Monday, August 18, 2008

Commercially supported CME: my response to Daniel Carlat

Daniel Carlat, M.D., author of the Carlat Psychiatry Blog and the Carlat Psychiatry Report, kindly responded to my criticism of his postings on Medscape’s commercially supported CME His reply, a little more nuanced than some of his earlier posts, provoked me to think and examine my own arguments more carefully. I have some further thoughts, but first a disclosure---I have written a few Roundtable Discussion pieces (non CME) for Medscape, and a disclaimer---I make no attempt to defend all of Medscape’s CME offerings.

Dr. Carlat acknowledges that most commercially supported CME is accurate. The problem, he argues, is bias. I think Dr. Carlat would agree that commercial bias isn’t the only form of bias. We’re all a little biased. The problem he’s citing is bias that is pervasive and systematic to a degree that produces distortion. That’s a problem, for example, with television news. It’s accurate for the most part, but, in the general public perception, systematically biased. If the Medscape CME articles he criticizes suffer from similar bias there’s an important difference from television news: disclosure. Disclosure does not fix the problem but it addresses it in significant ways. CME has accuracy, transparency and bias. The news has accuracy and bias but lacks transparency. Imagine how the public perception of television news would change if producers, writers and reporters had to disclose their political leanings.

Using Medscape’s Invega CME article as an example, Dr. Carlat implies that it is little more than an advertisement. He points out that although advertisements are required to be accurate they are very biased. I agree. CME must distinguish itself from advertising. But the bias in the Invega piece and other CME offerings Dr. Carlat cites results from the way the clinical questions are framed. A narrowly focused case scenario is presented which fits a unique niche for the sponsor’s product. Carlot notes:

Medscape's CME article on Invega is accurate, but is nonetheless promotional and commercially biased, because it focuses on the one clinical situation in which Invega offers an advantage over its competitors.

If that disqualifies the piece form accreditation it raises important questions about case based CME. What if a clinical problem under discussion has only one commercially available treatment, or one drug which is clearly superior to the alternatives? Many topics come to mind in my own areas of interest: Thromboembolism prophylaxis and the risk of heparin induced thrombocytopenia in a post cardiac surgery patient. (Arixtra, the only available anticoagulant with a clear advantage, would be featured). Improving outcome in a patient with severe sepsis: modulating the inflammatory and coagulation cascades. (Gotta be Xigris). Or how about Options for basal insulin coverage in a brittle type 1 diabetic. (Lantus and Levemir would be the clear choices). While Carlat might not think these topics worthy of CME they are common clinically important issues. I just made them up but they are typical of offerings we are likely to see more of given the recent clamor among some academics for more focused, case based CME.

Dr. Carlat raises another point. Some of Medscape’s offerings my not be in compliance with ACCME standards. Section 5.1 reads:

The content or format of a CME activity or its related materials must promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

On the surface that is so obviously true it’s a cliché, but a literal reading of the words would restrict comments on benefits of drug treatment to coverage of generics and orphan drugs! That’s not what the ACCME intended, so there has to be room for interpretation.

Section 5.2 reads:

Presentations must give a balanced view of therapeutic options. Use of generic names will contribute to this impartiality. If the CME educational material or content includes trade names, where available trade names from several companies should be used, not just trade names from a single company.

Again there’s room for interpretation. Dr. Carlat has opined in no uncertain terms that Medscape CME violates ACCME rules. Although the case is less clear to me we may have an answer from ACCME soon, as Carlat has recently announced his intention to lodge a formal complaint.

While we all agree on the importance of quality educational offerings the debate over CME will go on. My take? Medscape CME may have quality problems. I differ from Dr. Carlat in that I think its offerings should be adjudicated case by case. I do not want to put Medscape out of the CME business. In general the offerings I’ve seen (and am qualified to comment on) are of good quality. Dr. Carlat has challenged me to pay more attention not only to accuracy but also balance. I intend to comment on this aspect of future Medscape CME offerings I link to.

I would be interested in what Dr. Carlat thinks about other forms of commercially supported CME, particularly meetings sponsored by national professional organizations and academic medical centers which are arguably protected by better firewalls.

Finally, I would be remiss if I didn’t point out that identification of the payer source is not a litmus test for the quality of a CME offering. No one has demonstrated a general correlation based on high level data. Dr. Carlat offers a few interesting anecdotes. I can easily counter with some of my own. Recently I attended a prestigious accredited course with no support from device companies in which a speaker promoted numerous non evidence based uses for inferior vena cava filters. I’ve seen similar clean, pharmfree and unbalanced promotions of coronary artery bypass surgery and angioplasty. More concerning examples (all ACCME accredited) can be found here, here and here. I could trot out many others. You get the idea.


Anonymous said...

I must respectfully disagree. I have followed Medscape information since 2003 and regularly find inaccuracies or ommissions, it to be uncritical, and always spun in favor of its sponsors. The CME is generally less extreme than their articles, but it is still not a source I would ever trust or recommend for the full story or base my practice on.

R. W. Donnell said...

Anon 7:22 AM---
Know that I intend to view future Medscape CME articles to which I link with a critical eye and comment accordingly.