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February 09, 2011

A Decrease in CME Support Equals Less Innovation

CME -- Course 
 
In response to an article we posted last fall about the continued criticism of industry funded continuing medical education (CME), and the creation of a CME company that will not use funding from the pharmaceutical industry, Dr. Howard Brody wrote a response on his blog last month asking whether Commercially Sponsored CME is Biased.

While Dr. Brody thinks that the arguments I put forth about the “unwarranted suspicion about commercial bias” are motivated from being “upset” about losing commercial support for CME programs over the past several years, this assertion is misguided.

CME providers are concerned about the decreasing support for CME programs because it means fewer programs for health care practitioners, less innovative and collaborative programs, greater inconvenience for doctors in both timing and geography, larger and less interactive programs, and broader programs that do not address the specific needs of target audiences. Factors such as these could eventually lead to the education and training of doctors falling below the standard of care and will produce suboptimal outcomes for patients.

Less commercial support of CME also means that health care practitioners will lose an extremely valuable source of information from industry-physician collaboration at a time when pharmaceutical and device companies are making revolutionary discoveries that need to be explained and presented to health care practitioners in order to improve patient outcomes.

Despite the potential negative consequences that can result from less commercial support of CME, Dr. Brody’s concern is about the “subtle bias” that comes from industry sponsored CME. This concern however, is problematic. While there is no question that commercially sponsored CME had its origins in the marketing world years ago, things like gifts and industry control of content and speakers are long gone.

Moreover, a number of new regulations promulgated by the Accreditation Council for Continuing Medical Education (ACCME), the Food and Drug Administration (FDA) and the Office of the Inspector General (OIG) for the Department of Health and Human Services (HHS), have strengthened the independence and integrity of the CME system. The pharmaceutical and device industries have also created newer and stronger standards and guidelines concerning funding of CME to ensure independence and objectivity.

However, Dr. Brody discounts these new regulations or alternatively, believes that industry funding of CME is so subtle that it is not even worth risking the use of commercial support. In fact, he suggests that not all the safeguards built into the CME system that we discussed in our article work “as they are supposed to.” This assertion is problematic because his argument does not specifically explain how current CME safeguards do not work “as they are supposed to.” As a result, his attributions or allegations of bias ignore the developments in the CME enterprise noted above, which many CME providers strictly adhere to.

Consequently, Dr. Brody addresses three studies from last year that we presented in our article, which showed almost no bias in commercially funded CME programs (Cleveland Clinic; Medscape, and UCSF). He tries to discredit these studies by claiming that all the data showed was that “the vast majority of docs, check the “no” box.” To Dr. Brody, this data suggested that the “docs are lazy about what boxes they check, or else that they may be unable to detect bias when it might actually exist.” As a result, he claims that the data are a “far stretch” from showing positively that no bias exists in CME programs, and that the studies need “far better methods.”

This argument is troublesome because critics of industry and commercially supported CME such as Dr. Brody use the same methods as those used in the three studies above to bolster their arguments. Critics such as Eric Campbell, PhD, frequently employ surveys of medical students, residents, and physicians about the perception of bias, industry influence, gifts, etc. In fact, the centerpiece of evidence for industry critics, the Wazana study, was merely a synthesis of dozens of surveys of physician-industry interactions.

Interestingly, Dr. Brody does not mention what “better methods” could be used to measure bias, presumably because the bias is so “subtle,” there is no way to measure it. Accordingly, if he wants to discredit the three studies above, then every study supporting his position is likewise a “far stretch” at showing there is bias in commercially supported CME.

The second point that Dr. Brody puts forth is that I forgot to mention in my article that I am President of Rockpointe. This was not an omission. Readers of this blog have a full disclosure statement available to them here. Interestingly, Dr. Brody has his own conflict of interest in his post by telling readers that the reasons supporting his arguments against commercial support of CME are in his book, which he sells through his blog.

What Dr. Brody also does not discuss in his article is that outcomes from CME—both commercial and non-commercial—are improving clinical care and patient outcomes tremendously. For example, a recent CME program entitled “STOP Hypertension NOW! Recognize & Manage Your High-risk Patients,” produced by Rockpointe and accredited by the Potomac Center for Medical Education (PCME), showed that physicians who attended the program were “52% more likely to practice guideline-driven and evidence-based medicine than those who did not participate in the CME activity.” The results of this program were published in Journal of Clinical Hypertension.

The outcomes of another CME program accredited by PCME—presented last year at the American College of Chest Physicians annual meeting, Chest 2010, in Vancouver, British Columbia—showed that participants in the CME program were 50% more likely than non-participants to provide evidence based care for COPD. Clearly, based on just the outcomes from these two programs, the impact CME is having on clinical care is significant, and regardless of funding, will improve patient care. To call for an end or elimination of commercial funding for programs such as these would deny physicians the access to valuable information and training that will improve their skills, knowledge and competency, and ultimately hurt patients.

Conclusion

Critics of commercially supported CME and industry-physician collaboration such as Dr. Brody, essentially believe that CME providers are hiding secret promotional messages in the background of slides that when magnified x5000 they can be seen in a microscope. Or they believe that if you play CME programs backwards you can also find hidden health messages like drink more Starbucks and pizza is really good for you, and that only an expert can detect such hidden bias. As a result, Dr. Brody’s continued insistence on bias, when large quantities of data indicate that CME participants do not perceive bias, reflects prejudice.

The reality is that the overwhelming majority of CME providers who work with industry produce programs that are in compliance with ACCME guidelines, and the doctors and practitioners who attend these events voluntarily, often giving up a weeknight or weekend to attend, do so because they find value in such programs. 

As a result, those who continue to criticize commercial support of CME will only create unnecessary obstacles for physicians and CME providers to work with industry to provide unbiased and high quality CME, which may result in less education for physicians and worse outcomes for patients.  

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Excellent points. I would just add that in his long paragraph addressing the three studies you cite he employs two classic fallacies: circular reasoning and shifting the burden of proof. I plan to elaborate in a post of my own later.

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