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March 12, 2010

Continuing Education Reform: Are We Throwing the Baby Out With the Bathwater?

Recent evaluations of professional societies and accredited continuing medical education (CME) providers have “further questioned the legitimacy of industry physicians and biomedical scientists providing scientific information or participating in educational program planning.” These evaluations have “deemed that such participation is in violation of ACCME guidelines,” according to a recent article in Clinical Pharmacology & Therapeutics titled Continuing Education Reform: Are We Throwing the Baby Out With the Bathwater?

Specifically, the article looked at the practices of the American Society for Clinical Pharmacology and Therapeutics (ASCPT), who underwent a CME review in 2009. As a result of that review, the Society will no longer be in a position to provide CME and continuing pharmacy education (CPE) after the 2010 Annual Meeting. Accordingly, the article goes on to explain why such a decision was made, and how it affects the overall understanding of continuing education (CE).

 

Continuing Education

 

As we have written many times, CE or CME “is the process by which health professionals keep current with the latest knowledge and advances in health care.” Without CME, doctors and patients would continue to suffer from old and new diseases and symptoms, and be forced to choose outdated treatments, devices and medicines to help with their disorders and illnesses. Over the past few decades, the collaboration of industry and physicians who provide CME has resulted in numerous breakthroughs in patient care. Despite the obvious benefits gained from these relationships, the claim that “there are major flaws in the way CE is conducted, financed, regulated, and evaluated” raises serious concerns.

 

Such a claim is misguided, and to suggest that the numerous providers, researchers, physicians and accredited CME providers are “not optimally prepared to provide the highest quality of care to patients or to meet public expectations for quality and safety” is problematic.

 

As the authors trace the history of CME, they note its importance for addressing the issue of improperly trained practitioners (prior to World War I), and its use for helping well-trained physicians keep current with advancing knowledge (after World War II). It was shortly after this time that the pharmaceutical industry became involved with CME, and “professional product representatives were an important resource for providing physicians with new information.” Consequently, the present “construct of using CME to improve performance began in the late 1970s, when CME was suggested to be a continuous process based in practice settings.”

 

Over the years, criticism has gained momentum about the interactions industry has with CME, and as a result, a process of regulation “began largely as a method for the American Medical Association and state medical societies to monitor the pharmaceutical industry’s influence on physician education.” Another result from this regulation was that “CME increasingly became provided by a combination of specialty societies, state and local medical organizations, and pharmaceutical companies,” and not just one singular source.

 

In the arena of continuing pharmacy education (CPE), the landscape is a bit different, with “approximately 43% of CE programs for pharmacists receiving commercial support.” Such “high levels of support” have resulted in some to assert that CPE “are dependent on industry to assist them in covering administrative, educational, and non-educational expenses.” As a result, the “most recent iteration of these regulations from the Accreditation Council for Pharmacy Education assert that “the provider must plan all CPE activities independent of commercial interest.”

 

The result of such regulations have “systematically stripped CE programs of content that is necessary to ensure education and performance improvement of practitioners.” Consequently, CE programs have also suffered from these kinds of regulations because their goals have “been grossly misplaced such that the passive participation of professionals who must demonstrate evidence of CE to maintain certification/licensure is fostered more than the actual delivery of information amenable to translation into working knowledge.”

 

Industry Support

 

Criticisms that industry support biases or conflicts CME programs are unwarranted because the current CME “system has integrated sources of financial support, accreditation mechanisms, and CE methods in such a way that it is nearly impossible to analyze any of them independently.” In other words, critics cannot just point the fingers at industry because “CE funding comes from numerous sources.”

 

For example, “health professionals themselves, employers, commercial entities, and, to a much smaller extent, the government” all fund CE programs. “In 2007, physicians paid 42% ($1.05 billion) of the total $2.54 billion spent on CME, which resulted in approximately $1,400 per year of out-of-pocket costs per physician.” Such investments prove how “many organizations and employers see CE as an important investment in staff development and thus provide financial support for at least a portion of CE costs.”

 

What critics and opponents are not happy with is the reality of a glooming economy over the past year or two, and an economic crisis that saw rapidly “shrinking resources and increasing costs associated with both providing and obtaining CE credits.” As a result, while the need for CME only continues to grow as more patients fill our hospitals and more diseases are found, “continuing professional education within the health-care arena is quickly becoming a non-sustainable venture.” So then, as the authors ask: what could happen if commercial funding was totally withdrawn and no subsidies were provided by other sources?

 

On average, physicians would have to invest approximately $3,500 annually to continue to attend the same types of CME activities that are currently offered, with similar figures for nurses, pharmacists, etc. Of course these numbers don’t account for travel, lodging, and other associated expenses.

 

Potential for Conflict

 

Just because there is a “potential for conflict” does not mean there are conflicts within industry funded CME. Although countless efforts to develop safeguards meant to ensure that CME providers are free from conflicts of interest have been developed, “widespread skepticism remains about the intentions of entities that provide CME.”

 

This kind of worrying is misguided because CME providers need to “appropriately support the real costs (e.g., travel and lodging expenses, modest honoraria to compensate for effort in developing content of CE presentation) associated with the development of unbiased, high-quality CE.” Supporting these legitimate and legal costs is essential for medical education and pharmaceutical companies to “be able to retain the services of true experts capable of providing current and credible educational programs.”

 

Accordingly, “the considerable progress that has been made in the past 5 years toward protecting educational content from potentially corrupting influences and promotional intent, rigid, industry-wide adherence to current guidelines can eliminate commercial bias.” Examples of these protections include detailed regulations from ACCME to “ensure that commercial well interests are kept separate from learning activities and course content.”

 

“The regulations require CME providers to disclose conflicts of interest and resolve relevant financial relationships with any commercial interest among those in a position to control CME content. They also require that CME providers give a balanced view of therapeutic options and, with respect to education in clinical pharmacology and therapeutics, that any description of off-label drug use be disclosed as such, and that use of proprietary (trade) names for drugs be avoided.” These example clearly demonstrate that eliminating industry support is and overreaction, and would only hurt patients and doctors.

 

Moreover, the process for CME providers to become accredited also eliminates the potential for bias and conflict significantly because companies must be evaluated annually by the accrediting body with associated annual fees that increase each year. This “institution of processes enables continuous quality improvement (most of which introduce progressively increasing allocation of resources to ensure compliance), and continuing contact between the accrediting body and providers.” In fact, both ACCME and the ACPE adopted new accreditation policies and standards that went into effect in January 2009. These new policies require that “no employees of a commercial interest can serve as planners or speakers in any accredited CME activities if the content relates to the “business lines and products of its employer.”

 

Conclusion

 

With a growing population, and increasing number of elderly and sick, America needs “a workforce of competent health professionals” that can use and learn the best health-care practices that effectively cure and prevent disease and promote well-being. In order to achieve this success, an “integrated system of CE is an important contributing factor to knowledge and performance deficiencies that occur at individual and systemic levels in the United States,” one which includes industry support.

 

Today, it’s not just about short-term profits because companies are “funding programs that have the most impact on physician performance.” This kind of industry support provides immense value for all involved. Any attempts to “ban industry contribution from CE in a manner that lacks insight and careful planning is sure to be detrimental to academic medicine and, ultimately, to patients.”

 

Ultimately, “discounting legitimate and high-quality science and not offering it as part of CE because it originates from industry is not necessarily a good plan with the potential of disastrous long-term consequences.

 

Likewise, to imply that scientist’s present biased material merely because they are employed by industry is inaccurate and ill thought out.” As the author of this article correctly asserts, “some of health care’s greatest contributions have originated from industry-sponsored science,” and to eliminate them now would be detrimental to patients.

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