Wednesday, November 18, 2015

Industry supported CME: asking the wrong questions

Larry Husten's latest rant on industry supported CME is a confusing, frustrating read. It asks the wrong questions and makes unwarranted assumptions. Though he is correct in his particular criticism of a handful of industry supported offerings on testosterone replacement he is wrong in his overall view of industry supported CME. The testosterone courses, which I won't elaborate on here, speak for themselves as a bad example. Shameful as they are they're just a collection of anecdotes not representative of the overall situation. But Husten seems prone to hasty generalization.

Let me digress here for clarity. Husten's use of the phrase “continuing medical education” (CME) has a dog-whistle meaning that differs from its meaning in plain language. In plain language it's the pursuit of life long learning physicians engage in after completion of residency or fellowship. Though mostly informal and self directed it's the most important part of a physician's education post formal training. One of my medical school mentors, the late Thomas E. Brittigham, in a memo to his students, described it this way:

Dr. Carl Moore, chairman of the Department of Medicine at Washington University, tells me he finds it necessary to read medicine 3-4 hours every day...

In the dog-whistle meaning, CME is more restricted. It's a set of officially sanctioned activities in which physicians claim credit hours to meet minimum requirements. It is, or should be, relatively small in the grand scope of a physician's career learning. Put another way, as a practicing physician, if your studying is confined to what you are required to do for credit for you are in trouble. That's not to say accredited CME is unimportant but it's not nearly enough. We lose perspective with undue emphasis on minimum requirements.

Husten's post opens with:

Does anyone really think that commercially supported continuing medical education (CME) is truly independent?

That's confusing even beyond the use of dog-whistle words. Commercial support means dependency by definition. Many educational offerings would cease to exist without industry support. Few on either side of the debate would disagree so why the question? It obfuscates by substituting a tautology, requiring no thought, for real questions that are nuanced and could be debated vigorously, such as whether support degrades education or negatively impacts patient outcomes.

Though not made clear at the beginning of the post, Husten thinks accredited CME is OK as long as it is not done in collaboration with another industry:

Let me be clear: I don’t oppose CME in general. In any profession, and medicine in particular, CME is absolutely essential. But commercially supported CME is another matter entirely..

Well, if there is a distinction between supported and non supported offerings beyond mere perception it's not based on evidence. Husten ignores that. From his post:

Let’s first look at that “proven track record” claim. To be clear: there are no good studies showing the value of commercially-funded CME.

He's right. But he neglects to point out that neither is there good evidence showing the value of non supported CME. Despite today's obsession with course evaluations, feedback and attempts to link educational activities with outcomes there's no robust evidence either way. Education is a multi-layered, complex interaction between teacher and learner that doesn't lend itself to measurement to the degree we would hope, at least outside the closely structured environment of medical school and residency. Husten is correct in pointing out a burden of proof but he, like others who call for the elimination of industry supported CME, also has a burden of proof. It is unsustainable.

Husten is critical of the accrediting body for CME, the ACCME. Sure, we'd all like for the ACCME to do a better job but there is no basis for the extreme claims made in the post. He writes:

But let’s be very clear here: these “protections” are just window dressing, designed to give the appearance of objectivity and transparency. The ACCME is supposed to be a watchdog but everyone knows that it is the commercial CME industry’s lapdog.

Again, burden of proof. Evidence please. It's true that the accreditation process under ACCME is imperfect, as exemplified by the testosterone courses, but Husten provides no evidence that this happens any more with commercially supported activities than with non supported activities. I'm an extensive consumer of both types and can just as easily point to questionable examples of unsupported CME [1] [2] [3] [4] [5].

Concerning the motivation of commercially-funded providers he asks:

Or does anyone really think that it has the primary goal of delivering quality medical education?

The answer of course is no, whether supported or unsupported, because virtually all CME providers have a proprietary interest, even those popularly revered as “clean.” (Just look at Up to Date or MKSAP and their business models). Very few do it as a labor of love. The few who do are mainly in social media, and hardly any of those activities are accredited. Fact is, the entire world of accredited CME is its own industry. It's all a business, but Husten and others seem to think it's fundamentally different when there is collaboration with a second business.

It astonishes me that so many participants in this debate take the intellectually lazy way out by turning to simple litmus tests. Industry supported means bad. Non supported means good. It isn't that easy. Every offering, regardless of the business model, should be evaluated on its own merits.

I recently returned from a hospital medicine course run by Mayo Clinic. It had all the quality and scientific rigor you'd expect from Mayo. It also had industry support. There were numerous drug company displays in the exhibit area. Of the 18 or so credit hours offered, I noted only one half hour lecture that was questionable. Its content area was not represented among the displays or supporting companies. I thanked a couple of the exhibitors because I realized that this course would not exist in anything like its present form without their support. The inquisition against industry supported CME is restricting doctors' options. That's why this discussion matters.

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