Dr. Arnold Relman Takes On Industry Support Of Medical Education (again)
In a commentary released today in the September 3rd issue of the medical journal JAMA, Dr. Arnold Relman, Professor of Medicine Emeritus at Harvard and former editor of the New England Journal of Medicine, takes on the issue of industry support of medical education once again, and offers his suggestions for ending the medical profession's dependence on industry support. Should pharmaceutical companies be allowed to fund medical education? Should they be allowed to give doctors gifts? Should they even be allowed to pick up the tab for lunch? No, no, and no, says Dr. Relman, adding that if “busy physicians believe that detailing visits by industry representatives are worth their time and want them to continue, let them at least not accept the gifts, food, and other favors from industry, which make it appear as if physicians’ interest and brand loyalty are being purchased.” If doctors really do think that they need to interact with industry representatives over lunch, let the doctors foot the bill for their food. Dr. Relman urges the medical profession to "make clear to an unceasingly skeptical public that physicians, and not the pharmaceutical industry, are in charge of the education of physicians." And judging by the brand new reports from medical professional groups and even guidelines from the industry itself (all mentioned in his commentary), it looks like the push for professional independence may be stronger than ever in the near future. More on the reports later. Relman says that there have been "embarrassing ethical missteps and boundary violations," from the medical profession that have been "undermining public trust" and "lowering the reputation of both the pharmaceutical industry and the medical profession." He is right. The public is beginning to second guess doctors in part because of the doctors’ questionable ethical practices, and considering that medicine is a profession—a vocation—into which doctors are “called” and which is “inherently a moral activity, founded in a ‘covenant of trust’ between patient and physician,” this is embarrassing. A study from Johns Hopkins recently found that one in four patients are now skeptical of their doctor, and it doesn’t (or does?) help the cause of doctors when such a study gets widespread public exposure in places like the New York Times. A quick look at a bioethics blog like this one only reinforces Relman’s claim that people don't trust their doctor. Back to the reports. The first report, published in June 2008 by the American Medical Association’s Council on Ethical and Judicial Affairs (CEJA), suggested that “industry support of professional education has raised concerns that threaten the integrity of medicine’s educational function.” The report recommended that individual physicians and medical institutions should not accept any industry funding to support professional education, and recommended that "the education of physicians is a public good and should not be shared by the profession alone." It sounded bold coming from the CEJA, but perhaps too much so; while the authors said that achieving these goals would be "profession-defining," their recommendations as they appeared in June 2008 were rejected and sent back for re-evaluation. The report raised two critical questions: what is the best way to educate physicians, and how will it be financed? On the one hand, the authors of the report say that there is potential for innovation and improvement in patient care if physicians maintain ongoing and productive relationships with pharmaceutical, biotechnology, and medical device companies. These relationships are tricky, but if dealt with appropriately, can yield improved patient outcomes. However, these relationships, in their current state, have "raised concerns that threaten the integrity of medicine’s educational function. Existing mechanisms to manage potential conflicts and influences are not sufficient to address these concerns." “Marketing drugs,” says Dr. Relman, “is industry’s job. Industry likes to call this education. But it is not. It is marketing.” He suggests that is would be helpful for both industry and the medical profession to know where they stand with each other. The second report, written by an American Association of Medical Colleges task force, took a strong stand against marketing by industry representatives in academic medical centers. But unlike the CEJA report, it did not actually reject industry support. Instead, the task force recommended that academic institutions prohibit the acceptance of all gifts from industry representatives to physicians and students. The task force also recommended that drug samples and financial support for CME be managed via a central office at the institution. And while the task force felt that pharmaceutical sales representatives should still meet with physicians, they should only be allowed to meet by appointment in non-patient areas. These recommendations were approved unconditionally by every Task Force member. Well, almost every member. Kevin Sharer (Amgen), said that he was “not in a position to endorse the text” of the report. Mr. Sharer further stated that “It is understandable that industry and academe will not agree completely on the final wording of any report given our differing roles in health care." Two things are clear, according to Relman: 1) professional medical organizations are reluctant to cut off industry support of CME because they currently see no other source of funding to replace it, even though 2) there seems to be a “slowly gathering consensus” among physicians, residents, and medical students that this sort of funding, and the gifts, food, and other rewards that come with it, are “unprofessional and unseemly.” This may seem like just another commentary opining why industry support is a negative thing and why doctors must be especially vigilant in recognizing it as such, but two things make this commentary special: first, as a leader in the medical profession, Dr. Relman has a pretty loud voice, and second, Dr. Relman offers some ideas to actually mend the situation (though even Dr. Relman agrees that it won’t be an easy or quick fix). For example, he suggests that, for several reasons, CME need not be as expensive as it is now. CME need not be held at expensive resorts or need not be administered by a pharmaceutical company through a third party middle-man who must also make a profit. Then, physicians attending CME programs “ought to be willing and able to pay something for their continuing education,” he says. Dr. Relman also suggests that, as part of a physician’s job, “full-time salaried clinical faculty at schools and teaching hospitals should be expected to teach in the CME programs sponsored by their institutions, just as they teach in medical student and residency programs.” This would put CME on level terms with the training a doctor receives in medical schol and during the residency program. Time—and the new crop of medical professionals—will tell how Dr. Relman’s view is received into the medical profession. For a previous review of industry support in continuing medical education from this author, click here.