Monday, October 27, 2008

Observations on the CMPI conference on industry supported CME

A shrill minority of critics are calling for a ban on drug company support of CME. Though devoid of evidence and not shared by the vast majority of practicing doctors their arguments are getting a lot of attention in popular media, medical journals and public policy discussions. Concerned about this non-evidence based back lash and the threat it poses to CME, the Center for Medicine in the Public Interest (CMPI) recently held a symposium to examine the issue. Having gone through the audio presentations, transcripts and PowerPoint slides (all available here) I would like to highlight what I think are some key points.

The inquisition against industry funded CME is censorship. It is based on the premise that practicing doctors lack the skills to critically appraise content and are too lazy to look up primary sources. So, the reasoning goes, give intellectually lazy doctors an intellectually lazy solution: a simple litmus test---the presence or lack of industry support.

Medscape Editor in Chief Dr. George Lundberg said in his keynote that the arguments of the CME inquisitors are ideological (doctors ought to have to pay for their CME, doctors are being bought, drug company sponsorship is dirty, etc.) rather than evidentiary.

One of the arguments for doing away with industry support is that cliché about the medical profession needing to take control of its continuing education. If only the profession, with adequate representation of its rank and file members, would! Survey after survey, according to Lundberg, shows that doctors overwhelmingly favor the preservation of industry support. (Later in the program Marissa Seligman, Chief of Clinical and Regulatory Affairs at Pri-Med, a CME provider, presented some of the actual data).

One of the audience respondents to Lundberg’s remarks pointed out that by a ratio of eight to one doctors’ on line medical reading is NOT for CME credit. State requirements for CME hours are insignificant compared to the actual reading doctors do. Many doctors, when they go on line, already have their required hours and don’t bother seek additional credit. So what happens if the McCarthyites have their way? While the quality and choices of accredited activities will shrink dramatically the influence on what doctors read on line will be insignificant.

One of the speakers was Dr. Jack Lewin, the President of the American College of Cardiology (ACC), a major provider of industry supported CME. Addressing the question of whether existing safeguards enough, he gave this example:

….just in the last six months, two extremely prominent cardiologists in this country who inadvertently did not disclose their conflicts, they were removed from the faculty of the program they were going to participate in, banned for a year, publicly admonished on our website and instructed they could not serve on any committee function for that whole subsequent year and that if it happened again it was a permanent situation. Neither of these, these are both very distinguished academic individuals who had no intention of this, but that’s how serious we take it.

The ACC has sponsored many live CME events through the years. Lewin points out that the technology that supports these meetings is expensive and that without industry funding it would entail a cost of $2000-$3000 for each attendee to maintain that level of quality.

Under increasing pressure to deliver CME that impacts clinical practice education providers are finally collecting data. Marissa Seligman presented data collected from hundreds of thousands of Pri-Med CME encounters. These data indicate that Pri-Med’s CME offerings, the majority of which are industry supported, result in increased adherence to guidelines for a variety of clinical situations. Comparisons of attendees’ ratings of CME offerings demonstrated that industry supported activities were perceived as more balanced, scientifically rigorous and clinically relevant than non supported offerings. How could that be? Seligman offered this explanation:

…our thesis on this is that the faculty who are in commercially supported education are very sensitized by working with us and other organizations about the ACCME requirements and the standards for commercial support, the need for disclosure transparency, the need to do the education that is fair, balanced, objective, and scientifically rigorous, and in doing so, that translates them to education that is perceived by the attendees as, in fact, meeting all those requirements, as well as contributing to patient care.

Some final thoughts:

Policy mandates have unintended consequences. The unintended consequences of a ban on industry supported CME have not been adequately discussed. Are the arguments for such a ban meritorious enough to outweigh any unintended consequences? The burden of proof should rest on the purveyors of those arguments. Those arguments, so far, have consisted of little more than personal attacks and appeals to popular hatred of industry. They have no evidence.

What little evidence there is suggests that industry supported CME under today’s regulations and firewalls enhances evidence based practice and is perceived by participants as at least as rigorous as non industry supported CME.

The importance of CME accreditation is grossly inflated in public perception. State requirements are inconsequential compared to the actual reading doctors do. Doctors read and attend lectures primarily to learn, not to acquire credits.

I agree with the CME inquisitors on one point: The medical profession should take control of its own continuing education. This should be done, however, with fair representation of its members and not just a few of the most vocal academics. With such representation the profession will overwhelmingly choose to preserve industry support.

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