Sunday, August 10, 2008

More fallout concerning Medscape CME

A mainstream media outlet---Business Week---has piled on in an article that draws heavily from Daniel Carlat’s controversial post titled Medscape’s CME Corruption which I previously referenced here. The article discusses Carlat’s criticism of a CME activity which gave favorable mention to Invega, one of the sponsor’s products.

From a recent Carlat post, quoting the article:

A spokeswoman for J&J's Janssen unit says in an e-mail that the company has no influence over its CME providers' selection of course content or faculty. "The accredited provider is solely responsible," she says.Talk about turfing the blame to someone else!

Assuming that their’s any blame to be turfed, all the statement says is that the company is in compliance with ACCME’s standards for commercial support.

From the article:

----Dr. Steven Zatz, Medscape's executive vice-president of professional services. He adds that in polls, 99% of Medscape users say they perceive no bias in the company's online courses.

That refers to a question about bias asked in the post course evaluation of every Medscape activity. Are 99% of Medscape users mind numbed idiots who can’t spot bias?

Concerning the Invega article, cited in his post on Medscape’s “CME corruption”, Carlat wrote "Has Janssen--I mean, Medscape--said anything inaccurate in this puff piece? No." That, we are to believe, is not important. In Carlat’s way of thinking the fact that the CME article is favorable to a product of the sponsor is damning enough without regard to the accuracy of the piece.

Carlat, who is very up front about his conflict (he runs his own for pay CME site), restricts his criticism of Medscape to its psychiatry offerings. In another post he gives two more examples, here and here. I would gladly defer to Dr. Carlat’s expertise in psychiatry concerning the accuracy of the content of these programs, but he doesn’t offer that. His problem with the first offering, about bipolar disorder, which mentions Lilly’s Prozac-Zyprexa combo, seems to be that its discussion of Zyprexa’s well known metabolic risks is too nuanced:

True to form, here is the only discussion of weight issues in this article:“Dr. Thase: Well, the good news on both OFC [Symbyax] and quetiapine is that they do not cause switching, do not induce cycling, and the primary metabolic consequence is weight gain, which is very reliably, accurately measured sequentially and you see it coming. No one will gain 5 kg without first gaining 2 kg, and particularly when they're warned ahead of time. So I would say 1 thing for the interest of primary care prescriber would be to gain some comfort with at least these 2 members of the atypical antipsychotic class, engage the patient in collaborative care and follow-up, watch weight gain closely.The diabetes risk independent of weight gain is rare. It does happen, but you will need to treat well more 100 patients before you actually see someone who develops new-onset diabetes out of the blue, so it is a real consequence, but a rare one and the dyslipidemia is almost entirely weight dependent. So if there is no weight gain, there will be no dyslipidemia.” This is the gentlest discussion of Zyprexa’s side effects that I’ve ever seen.

Gentle compared to media hype, to be sure. I have followed the diabetes story because of my interest in cardiovascular disease and this discussion squares pretty well with what I’ve read in the literature. If the discussants worded the risks much more strongly they would have to recommend a ban of Zyprexa. Would that be the more balanced view Dr. Carlat is looking for? His case would be stronger if he would cite inaccuracies in the discussion. Is their thinking wrong? Are their numbers wrong? Is there anything wrong with the content other than the fact that it’s gentle?

Dr. Carlat then makes an accusation for which he presents no evidence:

The activity is ostensibly a discussion between luminaries in psychiatry, and I’m sure that’s how it began. But the editors can cut and paste interviews to achieve a variety of results--I should know, because I do this every month for my own CME newsletter. When I edit my interviews, I do so for clarity and conciseness—but when Medscape edits, they do so to push the sponsor’s product.

He goes on to profile another CME piece on new approaches to treatment of ADHD, starting with: “There isn’t even an effort to provide the illusion of balance in this CME article.” That’s odd considering his cimplaints about Medscape’s lack of transparency. Again he focuses on the favorable portrayal of the sponsor’s products without commenting on the accuracy.

By the way, concerning the complaint that Medscape is not transparent, Carlat seems to contradict himself again here, in an interview hosted by Psych Central (italics mine):

One of the things that he said was that Medscape is “good, clean, and transparent.” And that bothered me because the real issue, and where the rubber meets the road in this entire debate, is when you look at the actual educational courses, are they biased, are they promotional, or aren’t they? I can give you a lot of rationales for why these things might become promotional, but if you look at them and they are just perfectly good unbiased education, then it really doesn’t matter who’s paying for it.

But when I looked at the psychiatry offerings after Dr. Lundberg published that editorial, I was astounded at how transparently and blatantly commercial and promotional all of the psychiatry CME courses that I reviewed were.


Dr. Carlat is an expert on psychiatric drugs. He is well qualified to offer a nuanced, science based critique of Medscape’s CME offerings in psychiatry but chooses not to. Instead he delivers a dose of his extreme cynicism. Here’s the logic. Drug company sponsors activity. Content is favorable to company’s product. Company stands to benefit. Ergo, “Note to Dr. Lundberg and Medscape: what you are doing is not clean, not good, and most definitely not transparent.” Dr. Carlat might as well type in ALL CAPS. This is not an appeal to scientific evidence and reason. At best it’s an appeal to a certain philosophical bent. At worst it’s an appeal to popular emotion and prejudice. Maybe Dr. Carlat thinks the disclaimer, prominently displayed in his sidebar, that his blog is very biased, gives him license to do this.


I have recently taken on the challenge of evaluating all Medscape CME offerings to which I link for accuracy of content. Eventually I’ll find some inaccuracies or unsupported claims. No CME is perfect, no matter who pays for it. (If you want an example of non industry supported questionable content put on your baloney detector and get a load of this, H/T to PharmedOut).

What does the future of CME hold? Unfortunately, McCarthyism is winning. In that same interview Dr. Carlat was asked about the future of Medscape:

That’s true, Medscape would be out of business, if they felt they needed to continue to produce accredited CME. However, the amount of money companies spend on accredited CME is 1.2 or so billion dollars a year. The amount of money companies spend on non accredited medical education, i.e., various forms of advertising, promotion, dinner talks, dinner programs, web based non CME programs is in the tens of billions of dollars. There’s plenty of money out there for a company like Medscape if they decide that they want to continue to depend on pharmaceutical money. They simply could no longer call their offering “accredited” CME.

I agree with Dr. Carlat on that point. If the inquisition wins, what’ll be left of Medscape if it stays in business at all? Meanwhile CME will get more expensive and harder to obtain. It remains to be seen whether the quality will be better. There’s not a shred of evidence, nor is there any reason to think, that it will.

H/T Kevin MD

1 comment:

Daniel Carlat, M.D. said...

Dr. Donnell, I enjoyed this discussion as always. I've posted my thoughts about this important issue of accuracy in industry-funded CME on my blog: http://carlatpsychiatry.blogspot.com/2008/08/can-cme-be-both-biased-and-accurate-of.html
I look forward to hearing your thoughts.

Regards,
Daniel Carlat, M.D.