Over the past several years we have seen a precipitous decline in commercial support of University continuing medical education (CME) activities. The CME enterprise in academic medicine is changing rapidly because of 1) changes in CME rules by the Accreditation Council for Continuing Medical Education (ACCME), 2) refinement of the criteria for maintenance of certification (MOC) by the American Board of Medical Specialties (ABMS), and 3) alterations in patterns of commercial sponsorship for educational events by pharmaceutical and device industries.
Consequently, a recent article published in Academic Psychiatry looked at how alterations in the patterns of commercial support for educational events at academic medical centers and universities are changing the CME opportunities for faculty and trainees associated with academic departments of psychiatry.
Although commercial support of CME used to be in the majority, it has been significantly reduced over the past several years, and now makes up less than half of all CME funding. Specifically, since 2007, commercial support has declined $355 million or 29.3%. Moreover, the total percent of commercial support as part of the overall CME budget dropped from 47.5% (2007) to 39.0% in 2009. Fewer companies are funding CME programs as well.
Commercial sponsorship of CME can take several forms. Commercial companies have supported Grand Rounds speakers and have also helped underwrite the costs of CME conferences sponsored by academic departments through their universities.
Through “medical education and communication companies,” which frequently partner with academic departments, industry has supported educational activities with online options, teleconferences, and videoconferences and the development and production of CME events in conjunction with professional-association meetings.
Over time however, concerns about ethics issues and the educational implications of marketing biases and academic leaders’ industry ties, raised by public scrutiny,
Congressional investigations, and leaders in the medical profession, have led pharmaceutical and device companies to revise their funding patterns and practices.
Many of these concerns are unwarranted considering three recent studies from last year produced substantial data that demonstrate a lack of commercial bias in industry-sponsored CME (Cleveland Clinic; Medscape, and UCSF). Moreover, we know of no evidence to date showing that commercially supported CME has harmed any patients.
The change has led to a severe curtailment of industry funding of CME activities. Academic departments and organizations that relied on commercial largess have been increasingly deprived of the funds previously available for CME activities. According to industry sources, many providers now receive at least 30%–40% less funding from industry sources for CME than previously. Decreased industry spending on CME has been of substantial concern to the field of psychiatry and to organized medicine as a whole.
The authors offer their commentary to describe innovative opportunities for providing CME and how the profession might best move forward with respect to both CME accreditation requirements and the development of forums for lifelong education that promote learning and better health outcomes. The authors essentially surveyed a number of chairs of academic departments of psychiatry, and asked them to write down ways in which funding changes had affected their CME programming and how their departments were contending with these changes.
Decreased Funding Has Significantly Affected Management of Grand Rounds, Extended CME Events, and Other Educational and Social Functions in Academic Departments
As a result of decreased support, many departments reported that they engage fewer nationally-renowned, out-of-the-geographic-area speakers for Grand Rounds and
CME conferences. Departments have less or no support for meals associated with Grand Rounds and other departmental functions and have less discretionary support for varied conference expenses. Many departments have entirely eliminated industry funding for any educational retreats. This has significantly affected many different aspects of departments, including residents’ conferences, holiday parties, and graduation ceremonies.
Such a consequence must be addressed immediately because participants find tremendous value in such programs. Grand rounds provide participants with the most clinically interesting and challenging cases, presented to the highest tier of experts for discussion. They also present cutting-edge research or reviews of emerging areas of interest and provide attendees with opportunities to see and hear well-known authorities in the field. Decreased opportunities for Grand Rounds results in less opportunities for clinicians to get CME credit and to learn valuable information to help improve patient outcomes.
CME Activities Are Not the Same as CME Category I Credit
The costs of providing Category I CME credit has led some academic departments to reduce or abandon providing Category I credits for attendees at Grand Rounds and/or other CME conferences. Changed circumstances have required faculties to rethink the functions of CME, adaptively address these functions with fewer resources, and creatively attempt to increase resources for CME. In addition, charges for Category I CME have been substantial for many departments.
Other Department-Sponsored CME Activities
Several departments described how their traditional annual CME conferences, ordinarily scheduled for 1 or 2 days, sometimes over a weekend, designed for local, regional, and occasionally national audiences, had become too costly to maintain in their previous forms. Because industry contributions frequently made the difference between making and losing money on such activities, the cuts in funding over the past few years have forced retrenchment, and, in some cases, abandonment, of these activities.
Several programs described reducing the number of high-profile, out-of-town speakers in the line-up, relying more heavily on their own faculties, and reducing meal-service at these events. Several departments found these 1–2 day conferences increasingly to be money-losers and reported that they were discontinuing them entirely.
With respect to funding, several participants suggested that departments should be able to adjust their budgets for CME, allocating funds from clinical revenues or other sources. However, the authors noted methods described by participants for increasing resources for Grand Rounds, including:
- Develop “named” lectures, for example, by having various donors such as former chief residents contribute to endow visiting professorships.
- Avoid speakers’ bureau presentations by arranging for multiple companies to contribute to an educational funding pool controlled by the department.
- Levy a tax on faculty who give industry-sponsored CME talks.
- Cut back on the amount of money offered for honoraria.
- Fund-raise by “bake sale,” sponsoring concerts or other entertainment events, and by using similar models from charitable organizations.
- Apply for grants, sponsorships, and/or advertising from local treatment facilities, insurance companies, & managed-care companies to support CME activities.
- To spread out costs, seek out high-profile speakers who will be attractive candidates for joint departmental sponsorships (e.g. Psychiatry sharing costs with Family Practice, Internal Medicine, Neurology departments).
- For presentations by psychiatrist “superstars,” consider selling tickets to the local community or post “amount of suggested donation” at the door. Arrange commercial sales of some CME presentations via MP3 podcasts or DVDs.
One of the consequences of decreased commercial funding seen by the authors was that departments now increasingly rely on their own faculty and residents to present at CME conferences. Relying on one’s own faculty required departments to focus resources on issues such as confidentiality and HIPAA compliance, heavily disguising patients whose information is presented, and more restrictively limiting conference attendance to their own faculty and students who may legitimately participate, rather than to broader professional audiences. Several smaller departments, because of decreased funding, show psychiatrically informative films and videos followed by a discussion led by a faculty member.
Workshop participants reported that most of their departments no longer permit industry representatives to provide meals for Grand Rounds or other in-house academic functions. However, it was acknowledged that food remains an important social reality for conferences scheduled around mealtimes.
The authors of this study suggested that “although traditional models of Grand Rounds presentations and case conferences may serve some useful social (if not necessarily educational dissemination) functions, they are not necessarily the most effective methods for ensuring that practitioners sustain and increase their professional competence.” Instead, they noted that for maintaining practice competence, and for learning new skills, exposure to information and repeated practice of skills via individual or small-group “academic detailing” is more effective than one-time exposure via lectures or conferences.
Nevertheless, the issue of obtaining financial resources to fund CME and other educational missions will always challenge academic departments. While the authors suggested that current academic CME program designers should be encouraged to be creative, adapt, and think outside the (lunch)box—by having bake sales to raise money for CME—the authors failed to discuss any of the standards and guidelines in place that ensure commercially supported CME is objective and free from bias. Specifically, the authors failed to discuss any of the ACCME Standards for Commercial Support, FDA/HHS OIG Guidance, or PhRMA Code of Ethics, which all provide significant provisions for transparency and integrity in commercially supported CME.
At the end of the day, do we want our physicians—the men and women who will have our lives, literally in their hands—going hungry when they are trying to learn new ways to save our lives and make us healthier? Do we want our physicians to be learning from videos and discussions online, or do we want hands-on, interactive programs? Would you want the doctor performing your next operation to be taught by the world’s leading expert because, or by an adequate surgeon who is convenient as the authors suggest?
Ultimately, CME and commercial support have coexisted for decades and are constantly evolving. The data from this study clearly shows that there are significant concerns from CME departments in academic medical centers from the recent changes in CME funding, and these concerns are affecting the quality of the education clinicians are receiving. It is only a matter of time before these effects will have negative results on patients. Before it is too late, stakeholders in the CME community should look at these results, and consider where our resources can be invested best: selling cookies or educating doctors in collaboration with industry.