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September 17, 2010

Boston Globe a CME Startup Criticizes the Industry


The growing criticism of industry funded continuing medical education (CME) over the past several years has had a number of significant effects on the CME community. As the Accreditation Council of Continuing Medical Education (ACCME) annual report showed, from 2007 to the present, commercial support of CME dropped 29.3%, and the number of directly sponsored CME activities decreased over 7% between 2008 and 2009.

CME funding is extremely important because States require physicians to take continuing education courses to retain their medical licenses. Without CME doctors cannot practice. Consequently, what has concerned some over the past several years is that industry has been partly funding such programs so that doctors often pay “little or nothing for the instruction.”

Those who disapprove of this practice believe that “the reliance on industry funding allows drug and device companies to influence what is taught, potentially misleading physicians about the best treatments for patients and pushing up spending on prescription drugs.” There are numerous problems with this assertion.

First, the Accreditation Council of Continuing Medical Education (ACCME) has clear and strictly enforced guidelines which prohibit industry supporters from having any control whatsoever of the content being presented, as well as the speaker chosen to present the materials. In addition, the Department of Health and Human Services (HHS), as well as the Office of the Inspector General at HHS, have a number of well established guidelines regarding the proper role industry can play in supporting CME.

Second, the multiple stakeholders involved in every aspect of producing industry funded CME abide by the ACCME Standards of Commercial Support. Additionally, CME providers fully disclose commercial support in each program, and any potential conflicts of interest by the speakers.

Despite these safeguards, critics point out that because many other professionals pay for their own continuing education, doctors should begin doing the same. These critics believe that industry funded CME “is not education, but subtle marketing,” despite overwhelming evidence from three studies this year that showed almost no bias in commercially funded CME programs (Cleveland Clinic; Medscape, and UCSF).

Dr. Martin Samuels, a Harvard Medical School neurologist, announced the start of a new company, known as Lighthouse, that he says will provide CME to doctors across the country — without funding from the pharmaceutical industry.  A majority of the products coming out of medical publishers are being produced without industry funding.  This is the equivalent of a story about a new medical publisher putting out a twist on commercial support to get press coverage.

One of the main motivations for creating this company, according to Dr. Samuels, was that “doctors have lost confidence in CME and the public has lost confidence.” While he cited no evidence to substantiate this claim, Dr. Samuels, who is the head of neurology at Brigham and Women’s Hospital, told the Boston Globe that within the CME community, there “is a feeling that everything is tainted.” Consequently, from the numerous programs we have conducted, and as the above cited studies clearly show, we are unaware of this “tainted feeling.”   

Doctors by and large value the collaboration and innovation industry provides in all aspects of medicine, especially CME. Without the support and partnership with industry, CME programs would not be able to keep doctors up to date on new treatments, drugs, devices, and clinical data and they would not be able to get the hands-on, interactive experience they gain by attending such events.

While the company is still being pieced together, Samuels noted that “the work will be paid for by the sale of the curriculum to hospitals, medical societies, insurance companies, and other organizations that provide professional education to doctors.” This means that organizations will pay more so that the company can say they provide education free of industry influence.” But in catering to insurance companies, this will create a curriculum that focuses on formularies, generic drugs and cheaper treatments.

Consequently, Lighthouse has neglected to consider that it will be extremely difficult to “be completely pristine,” because insurance companies can pay doctors’ tuition to attend certain courses, and it will be impossible to hire faculty who have no relationships to industry whatsoever.” In fact, Dr. Nissen went as far as saying that “The biggest name people, the people who have the most expertise and are going to draw an audience — they are people who work with industry.”

The company first has to find customers, then they can decide who to hire. They will realize early on that doctors who teach CME don’t just show up and teach. These individuals have to know what they are doing to provide CME, which means finding an educational gap and meeting that gap, and the people best suited to do that are the individuals who have identified such needs and gaps by working with industry. This is a fact that Lighthouse should be familiar with considering two of the company’s founders “once had ties to M/C Communications, a company that accepts industry funding for CME.”

In fact, one thing the Globe does not disclose is that the husband and wife team of Dr. Samuels and Susan Paoli, both worked on M/C Communications (PriMED) programs, Additionally, the third cofounder, Jon Leibowitz, also worked for M/C.  According to my understanding they have all received significant amounts of money for commercially supported CME for many years it never bothered them before.  If now they think it’s bad, then they perhaps they should consider returning the money they earned, including the profits from honorarium and ownership positions.

The Globe story also does not include the facts or specific examples of what could have been the problem, which caused Samuels to leave.  

MC Communications (Pri-MED) over the last two years has reached 45% practicing primary care physicians, and Dr. Samuels is a neurologist. The story only points out that Dr. Samuels tried to start a neurology program while at MC Communications, but it was not successful.   

Accordingly, as Dr. Murray Kopelow, executive director of ACCME asserted, the criticism of industry supported CME is overblown because the “vast majority of providers comply with ACCME rules, which forbid industry funders from influencing the content of courses or who presents them.” Accordingly, with 42 percent of accredited providers not taking commercial support for their educational programs now, Dr. Kopelow acknowledged that Lighthouse’s approach is not unique. They just become another provider to compete with Jerry Avorn by utilizing Harvard resources to enrich their own pockets.

Ultimately, as Dr. Richard B. Reiling, Medical Director for the Presbyterian Cancer Center in Charlotte, NC pointed out in a Globe editorial; “what the physician learns at any venue, with or without commercial support, might well benefit patients and, in the long run, reduce costs.” While there may be concerns about how the pharmaceutical industry could taint a physician’s education, “the industry could also augment it.” He explained in a reply to the Boston Globe that while there “have been abuses, most CME has been beneficial to doctors and patients, and physicians in general are not easily swayed by deceitful practices, and can recognize them when they occur.”

As for Dr. Samuels’s new company, he posed the question of who will make sure that there is no bias in those presentations. He explained that “commercial support does not obviate good approved CME; nor does approval guarantee valuable CME.” As a result, he recognized that since community hospitals cannot afford to provide quality CME without outside financial support.  Whether Samuels’s company, while started in good faith, will be here next year remains an unanswered question.  We wish them the best.

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My work as a Certified Personal Trainer requires that I pay out-of-pocket for a majority of my continuing education. Due to budgeting constraints, this means I must be highly selective of the workshops I attend and the post-tests I submit.

I have always admired how effortless it is for physicians to collect CME credits, and I would participate in far more continuing education than I do now if the costs were lower. For example, I would happily pay an additional $20-$30 for my annual membership dues if I knew it included free CE in the journals.

I would have no problem attending a CME workshop subsidized by a pharmaceutical company or device manufacturer if the information I received was fair and balanced, and in accordance with independent guildlines established by the community.

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