Tuesday, February 24, 2009

Rank and file doctors want industry support for CME to continue

In his latest jab at industry supported CME Dr. Daniel Carlat cites a survey of Mayo Clinic attendees published a couple of years ago in the American Journal of Medicine. He takes, to put it kindly, considerable license in his interpretation of the study.

First a look at the study. Mayo CME planners, who receive lots of feed back from participants, wanted formal data on doctors’ attitudes about industry support. Investigators surveyed attendees from two Mayo industry supported meetings and two of their non-supported meetings. Some of the results:

In response to question 3, “Do you believe CME courses should accept industry support if doing so reduces the overall cost of the course?”, 62.3% of respondents answered “yes”…. Responses to this question also differed significantly by course attended (P less than .001). A majority of industry-supported course attendees (71.5%) answered “yes,” whereas the attendees of the non-industry-supported courses were more evenly divided (48.7% answered “yes,” 33.1% answered “no”).

So how does Dr. Carlat spin the results (my bold)?

The bottom line of this survey is that opinions about commercial support of CME depend entirely upon which physicians you sample. If you choose to sample doctors who are in the midst of a free conference with the nicest meals, the flashiest slides and the biggest names that industry money will buy, they will defend the wisdom of their choice. But if you sample physicians who choose to pay for their own medical education, you will find that doctors overwhelmingly reject industry funding of CME.

Not quite. The majority of physicians in the survey, 62.3%, all of whom paid for their CME, favored industry support. The little detail Dr. Carlat leaves out of his analysis is that all of the survey respondents paid a pretty penny for their CME whether it was industry supported or not. I checked the Mayo CME web site and found information about three of the four courses in question. All three are very expensive. One industry supported offering, the Mayo Internal Medicine Board Review, costs $1050! The other supported offering, Mayo Clinical Reviews, costs $725. One of the non-supported offerings, Mayo Selected Topics in Internal Medicine, costs $839. There’s not much difference in the price per hour of CME among these offerings. I doubt that tuition fees alone would cover the non-industry supported offerings---they’re subsidized from somewhere. (Mayo, singular in its ability to do this is, after all, awash in cash).

Dr. Carlat posted the American journal of Medicine article in order to take issue with another study which found physicians overwhelmingly in favor of industry support. Concerning that study he concludes:

I find it sad, though quite revealing, that the CME industry has found it necessary to latch onto this non-peer reviewed survey in order to further its political aims.

Well, with all due respect, Dr. Catlat, I find it rather amusing that you have to misrepresent the aforementioned peer reviewed study in order to advance your agenda against sponsored CME. By the way, the authors of the Mayo study acknowledge in their discussion that doctors want industry support to continue and believe that current safeguards are adequate. They conclude:

How should concerns about industry support of CME be addressed? First, CME organizers should explicitly acknowledge that the primary function of CME is to improve the welfare of patients by enhancing the knowledge and skills of physicians,6 not to facilitate physician–industry interactions. Several professional organizations, including the American Medical Association,10 the ACCME,13 and the American College of Physicians,9 have made recommendations regarding industry support of CME programs. Taken together, these recommendations can be summarized as follows:

•Industry support must be completely unrestricted;

•All CME faculty conflicts of interest must be declared before the program begins;

•The industry sponsor should have no role in the planning or evaluation of program content;

•The topics should be presented without bias, particularly if the products of the industry sponsor are discussed; and

•Support should not be given to participants but to the program organizers to reduce registration fees.

Adherence to these recommendations should prevent most inappropriate industry influence or bias in CME programs.

The two studies in question are not the only ones showing favorable attitudes towards industry support. Here are two more.

Dr. Carlat, we can’t cherry pick the data. None of the studies are perfect. The Mayo clinic sample you cited is a select group of doctors who are willing to pay relatively large sums of money for their CME (yes, even the ones attending the industry supported courses; they’re just as expensive).

Finally, a digression for a word or two about bias. Dr. Carlat talks a great deal about bias in his anti-industry postings. It’s an important issue but one which has become the subject of considerable obfuscation and selective outrage. It’s also one in which my own position has been mischaracterized. Neither in my recent back-and-forth with Dr. Carlat nor in any other discussions have I ever made the claim that industry supported CME is unbiased. I have challenged detractors to come up with evidence of pervasive and systematic bias (they can’t) but I realize that absence of evidence does not equal evidence of absence.

On the subject of Mayo CME, when I attended their industry supported 2007 hospital medicine course I made some real time blogging observations about bias. There were three presentations I felt were biased. The speakers were promoting treatments they themselves provided for a living. One was acupuncture, one was Yoga and one concerned IVC filters for thromboembolism. None of these biases could be attributed to the pharma companies supporting the meeting.

The point is that bias in medicine is pervasive and not restricted to the influence of the pharmaceutical industry. It would be simplistic and naïve, not to mention non-evidence based, to assume that industry is the only, or even the major, source of bias.

These questions suggest the appropriate burden of proof for this debate:

Is there systematic evidence that the bias in industry supported CME is worse than in non-supported CME?

Is the bias pervasive and systematic in favor of industry products?

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