For years, doctors like Arnold Relman and Marcia Angell, both former editors of the New England Journal of Medicine,
have been advocating drastic changes to the way the Accreditation Council for Continuing Medical Education
(ACCME) deals with pharmaceutical industry funding.
The ACCME is the body responsible for accrediting the institutions and organizations that deliver continuing medical education (CME)
to doctors after they have finished medical school and residency programs, but there are many doctors who view this continuing education as a “quasi-academic activity.”
Mixed in with the respected medical schools that provide CME are businesses, some of them essentially advertising agencies with no standing in the medical community until they become accredited by the ACCME.
So why do CME and pharmaceutical companies get such a bad rap? Pharmaceutical industry funding is not negative per se
; the relationship between doctors and drug companies can promote awareness of treatment therapies that are underutilized, “enhance the practitioner's knowledge base, provide updates and review, and expand professional skills.”
But many doctors think that there is a strong potential for bias if pharmaceutical companies are funding the source of their continuing education—not surprising considering that since 2003, pharmaceutical companies were providing about $900 million of the $1 billion
spent annually on continuing medical education in the United States.
The problem isn’t actually with pharmaceutical companies. That is, the pharmaceutical industry is a business, and they would be acting irresponsibly if they were not doing everything possible to maximize the profits of their shareholders (within the accepted standards).
Dr. Relman says that the pharmaceutical industry “is simply doing what the medical profession allows it to do. Industry has every right to market and advertise, but it supports accredited medical education only with permission (and often at the request) of medical educators.”
The problem, doctors contend, is with the programs that the ACCME allows to administer continuing medical education. Pharmaceutical companies fund their own “vendors,” or MECCs (Medical Education and Communications Companies) that are accredited to give CME credit. By paying around $12,000 and filing some paperwork,
advertising agencies have spun off companies and have become accredited to give CME that counts just as much as that from the top medical schools in the country.
Just a few years ago, it was not hard to follow the ACCME’s links of accredited providers to arrive upon sites describing themselves as “Your resource for off-site events, dining, golf tournaments, guest speakers, entertainment, themed events, spouse programs, etc.” and others offering to team with “Non-accredited healthcare organizations and other entities who are interested in offering Category 1 AMA/PRA physician credit…”
It looks like the ACCME has tried to clean up the content of the links, because today it’s a little harder to find links like that, but it doesn’t take to long to track one down offering a “Free iPod Nano with CME; The Way CME Should Be!”
Really? And that’s just it: this is exactly not what CME should be.
Here’s one reason why: at the University of Pennsylvania Center for Bioethics, Dana Katz and colleagues
found that “When a gift or gesture of any size is bestowed, it imposes on the recipient a sense of indebtedness. The obligation to directly reciprocate, whether or not the recipient is conscious of it, tends to influence behavior…Feelings of obligation are not related to the size of the initial gift or favor.”
BY THE NUMBERS
- 50: percent of medical school-produced CME supported by industry
- 3.66x: return on investment for doctor-led discussion groups calculated by Merck, versus 1.96 for a meeting with a sales representative
- 87: percent of initial applicants that are successful in achieving ACCME accreditation
- 40: number of states requiring physicians to supplement their practice with continuing education credits to retain their license
- 50: hours of continuing education a Connecticut doctor must complete within 24 months to retain a license
Since the 80’s and 90’s, professional medical organizations and journals began to establish guidelines to regulate the relationship between the pharmaceutical industry and medicine, and the ACCME continually reviews and updates its policies and practices in an attempt to deliver balanced CME.
In 2005, the Yale University School of Medicine, in order to “ensure as much as possible that the integrity of clinical decision making is not compromised by financial or other personal relationships with industry,” developed guidelines
for managing the relationships of faculty with the pharmaceutical industry. In formulating these guidelines, Yale received input not only from clinical faculty, but also representatives of the pharmaceutical industry.
According to the abstract of the guidelines, “In contrast to existing recommendations, the Yale guidelines…ban faculty from receiving any form of gift, meal, or free drug sample (for personal use) from industry, and set more stringent standards for the disclosure and resolution of financial conflict of interest in Yale’s educational programs.”
But doctors like Melissa Stiles and Bruce Barrett
at the University of Wisconsin still complain that they “continue to regularly receive a barrage of invitations to free dinners, offers to attend professional athletic venues, and all-expenses-paid consultant meetings at five-star hotels”—events that are sponsored by pharmaceutical companies as continuing medical education.
Doctors allow very little input from the pharmaceutical industry when it comes to their education in medical school or in the residency program, so why do they outsource their CME to pharmaceutical companies? Dr. David Blumenthal
, the Director of the Institute for Health Policy at Massachussets General Hospital, writes, “When a great profession and the forces of capitalism interact, drama is likely to result.”
Dr. Relman goes as far as to suggest that the pharmaceutical industry’s involvement with CME is “as inappropriate as its involvement with predoctoral medical education of students, or with the graduate education of residents,” while Drs. Victor Marrow and David Heaphy of Johns Hopkins University, liken this sort of interaction to "salespersons doing surgery in the operating room."
The basic problem, maintains Dr. Relman, “lies in trying to manage conflicts of interest that shouldn’t even be allowed to exist.”
In response to arguments against industry funded CME, Dr. George Dermksian,
an Internal Medicine doctor from New York, wonders if people like Dr. Relman have considered "the inherent intelligence of the physicians and their rigorous scientific and clinical training that allow them to make appropriate judgments of industry-supported CME. To think otherwise," he says, "would denigrate most physicians,” while Dr. Ton J. Cleophas,
President of the American College of Angiology, responds, “we as physicians have a responsibility to estimate the possible loss of objectivity in what we hear.” The reality is, if you eliminated all the conflicts of interest, there would be no experts left in the field. He points out that unsponsored programs are “equally at risk of loss of objectivity and manipulation,” just as are pharmaceutical industry-funded CME programs.
However, Dr. Blumenthal says, this implies that “physicians are different in fundamental ways from their fellow human beings.” In fact, this may very well be the case, considering that the professional training of a physician is meant to render him resistant or immune to the effect of bias: physicians tend to be “confident that they themselves are invulnerable to any bias inherent in educational content offered or supported by drug companies.”
But a 2005 study published in JAMA
presents a different picture: of 183 medical students surveyed who thought a gift from a drug company valued at less than $50 was inappropriate, 158 (86.3 percent) had accepted one. Another study in the American Journal of Medicine
found that 61 percent of medical residents believed that they were not influenced by the marketing efforts of pharmaceutical companies, but only 16 percent were equally as confident about their colleagues.
It looks like doctors, after all, are human.
Frusterated with CME? Have an experience you would like to share? Add it here!