Policy and Medicine

Macy Conference - Missed Opportunity

We see the Conference as a missed opportunity. This is how the chief executive officers of the major CE accrediting bodies describe the Macy Conference.

Last November a group of 40 academics gathered in Bermuda for four days to discuss the current state of Continuing Education in the Health Professions and their recommendations for the future.  In May they published their final conference proceedings:

Continuing Education in the Health Professions:  Improving Healthcare through Lifelong Learning. 

The Chief Executives of the three major accrediting bodies the Accreditation Council for Continuing Medical Education (ACCME), the American Nursing Credentialing Center (ANCC) and the Accreditation Council for Pharmacy Education (ACPE) issued a response to the Josiah Macy, Jr. Foundation. (Letter to Josiah Macy Foundation)

The CEO’s went out of their way to describe the report as flawed and “disagree with, or take exception to, most, if not all, of the Conference Proceedings.”

This is a reaction to the inflammatory language used in the report which goes out of its way to belittle medical education in the US.

Our concern stems from our observation that neither the Conference, its observations, its assumptions, its conclusions nor its recommendations seem to be based on the facts and circumstances that we know to be extant in our three professions’ continuing education, or continuing education accreditation systems, today.

According to the CEO’s many of the statements made in the report are outdated:

These statements reflect concerns that we, as CE accreditors, had 5-10 years ago. Over this past decade we have made significant changes to our systems to address these concerns. Therefore, we question the reliability and validity of the evidence base from which these statements are made.

Specifically they had issues with several of the key findings of the Macy Conference on the state of education:

Conference finding #1: Too much CE relies on a lecture format and counts of hours of learning rather than improved knowledge, competence and performance. 

The CEO’s found quite the contrary:

Data from our organizations show that the CE accreditation systems have integrated new formats of continuing education and that CE providers are utilizing these formats within their CE programs. For example, almost 50% of the continuing medical education enterprise is not didactic in nature.

Conference Finding #2: Too little attention is given to helping individual clinicians examine and improve their own practices.

Conference Finding #3: Insufficient emphasis is placed on individual learning driven by the need to answer questions that arise during patient care.

Again the CEO’s are firm in that: Continuing education is entirely about answering questions that arise in professional practice as the source of the needs data that drives the education.

Conference Finding #3: CE does not promote inter-professional collaboration, feedback from colleagues and patients, teamwork, or efforts to improve systems of care.

CEO’s take issue with the validity of this statement:  It is not valid for the Chairman’s Summary to say “CE does not promote inter-professional collaboration”. Our three organizations have worked productively and collaboratively for many years to bring order and efficiencies to CE accreditation.

Conference Finding #4: CE does not make adequate or creative use of Internet technology, which can help clinicians examine their own practice patterns, bring medical information to them during patient care, and aid them in learning new skills.

CEO’s rightly note that there is a plethora of internet based CME.  Published quantitative data, which we know the Macy conference participants had access to prior to the Conference, do not support these statements. For example, in CME since 1998, there has been a reported 24-fold increase in the number of Internet CME activities (to 93,582 in 2006); a 68-fold increase in physician participants (to 2.4 Million in 2006), and a 62-fold increase in non-physician participants (to 1.5 Million in 2006).

Also in this rebuttal includes the total bias of the Macy Conference towards “Point of Care CE”, they correctly pointed out that Up-to-Date, a commercial service that was very involved in the outcome of the conference epically the conference summary.

We find that the Conference Chairman’s Summary, the Conference assumptions along with the Conclusions and Recommendations directly and indirectly specifically promote “Internet point-of-care learning.” We observe that persons in a position to control the content of the Conference and its derivative written products have personal financial relationships with a proprietary entity marketing such product. These financial relationships were not disclosed in the Conference Chairman’s Summary although we note that the Proceedings now have a list of Statements of Potential Conflicts of Interest. We ask, “Did the Macy Foundation manage this conflict of interest during the conference development process? Were steps taken to resolve this conflict of interest prior to the Conference?”

Conference Finding #4: There is too little high quality scientific study of CE.

We are not sure of the validity of this statement. A “Pub Med” search on ‘continuing education’ produces over 35,000 citations which range through a myriad of relevant topics. We are not aware of a published meta-analysis of all this literature that has drawn the conclusion that “There is too little high quality scientific study of CE.”

Finally, we believe that the Conference presents broad opinions and offers some dramatic changes for the CE enterprise, yet provides little evidence to support the need for, or the desirability of these recommendations. Some of the conclusions and recommendations for the future of CE would be better characterized as expressions of what is already in place.

We find it disappointing that the Conference seemed to be unaware of the current state of continuing healthcare education.

We see the Conference as a missed opportunity.

The Macy Foundation Conference brought together a group of important people without a universal understanding of the current CE delivery system or its outcomes -- but with firmly held beliefs about what the deliverables of the system should be.

The CEO’s found that though they disagree with the recommendations, many of the deliverables described by the participants of the Macy Foundation Conference could have useful applications. They could easily be packaged as benchmarks by which we could evaluate and monitor our CE systems. They could provide a future framework for organizational and system self-assessment and improvement.

Our industry benefits from its broad range of participants and providers, the Macy Conference reflects only a small minority of providers (mostly academic faculty, no representation from specialty societies, medical communication companies, state level providers) and therefore the CEO’s were correct in firmness of their response. 

The CEO’s belief and position is that everything can be improved.

As we work together to bring about high quality medical education for healthcare providers it is important not to discredit the hard work and diversification that everyone before us has done to make this the best medical education system in the world.

We have written extensively on this issue:

Macy Report -- Filled in the Blanks

Macy Report -- The World is Flat

AMSA Medschool Scorecard: Focuses on Electives

What if Medical Students only focused on electives and not core studies? Would they graduate? Would you want them treating you?  Would you want medical students who only understand one perspective, only learned about one way of doing something and that way was based on feelings versus science?

Apparently this is what the American Medical Student Association did in releasing their  AMSA Pharmafree scorecard evaluating the policies of medical colleges regarding relations with the pharmaceutical and device industry.

The report made the rounds on usual suspect publications: Gardiner Harris at the New York Times, Pharmalot and Wall Street Journal Blog, as some type of important event but was it?

Several things are interesting about the scorecard:

They put a lot of effort into this report and the emphasis is not on scholarship, or strength of teaching, or faculty to student ratio which is how one would normally expect a report like this to be written.

So rather than help incoming students with valuable information on what is important to medical students, they only focus on non important issue: the schools policy for relationships to industry. They focus on the non essential of gifts and individual financial relationships with industry.   

These are their categories of importance:

1. Gifts and individual financial relationships with industry
   1A. Gifts (including meals)
   1B. Consulting relationships (excluding scientific research and speaking)
   1C. Industry-funded speaking relationships
   1D. Disclosure
2. Pharmaceutical Samples
3. Purchasing & Formularies
4. Site Access
5. Education
   5A. On-site Educational Activities
   5B. Compensation for Travel or Attendance at Off-site Lectures & Meetings
   5C. Industry Support for Scholarships & Funds for Trainees
   5D. Medical school curriculum
6. Enforcement

We asked some doctors what they thought was important for ranking medical schools and these are the criteria they came up with:

A)    Location of school (city, suburban, rural)

B)    Hospital affiliations (# of hospitals you rotate through, size of hospitals you rotate through, etc)

C)    Board scores and matching percentage (how the outgoing seniors did in the match) of attendees

D)    Cost… 

E)     Elective time, set up of rotation schedule, etc (this varies a lot from school to school, as does # of in-house call, etc)

F)     Size of school

G)    Size of classes

H)    Research opportunities

I don’t know about you, but I think the second list is much more useful and balanced and would have been considered core vs elective criteria.

The Wall Street Journal Blog had several comments but my favorite is from a medical student:

This is the reason people detest (pre)medical students so much. With absolutely no experience or perspective, they are all too willing to criticize and preach into their very institutions that educate them.

Then to top it off, they pat themselves on the back for it. Recently at my institution, a group of *students* decided they didn’t like the hospital’s cancer care policy and petitioned to change it.

Yes, students — with absolutely no experience in delivery of care, budgeting, or any other sort of management (90% of which will be at other hospitals in 3 years) — felt they should be consulted when developing hospital policy.

While I find my views in line with these groups occasionally, their manner is incredibly lacking. Students like these are the reason I neglect to mention my training when in the company of real researchers.

The fundamental failure in the studies touted by groups such as nofreelunch.org is that they falsely assume an ideal baseline. They assume that generics are inherently better than newer generation medications and any writ of non-generic RX is solely the result of gifts (most studies simply compare generic vs non-generic RX). A proper study would look at the influence of marketing AND patient outcomes. After all, do we care more about ridding hospitals of free pens and clipboards or pursuing the best patient outcomes?

.
A quick search of pubmed reveals no studies showing negative patient outcomes…

These students with AMSA are looking for excuses rather than focusing on patient outcomes.

Perhaps they should next time put the effort into more important grades which would be useful to incoming doctors and pre-med students instead of electives.

Macy Report -- Filled in the Blanks

The Macy Foundation published their full proceedings of the conference Continuing Education in the Health Professions:  Improving Healthcare through Lifelong Learning, six months after the initial release of the Macy Foundation’s controversial Chairman’s Conference Summary.

They filled in the blanks with two reports in one: 

A)   Report on how to improve continuing education in the health professions

B)   Report on why continuing education should live free of the burden of raising money for their activities and other encumbrances such as competition from private education companies.

The document opens with a letter from the Macy Foundation President, June Osborn, MD, who seems like a very kind person and who was convinced to do the conference by Susan Fletcher, MD.  She is retiring this year and wanted to go out with memorable report. Susan wrote a note about how she desires that this report is very influential and pontificated. She wanted to repeat the Flexner Report of 1911, a tall undertaking, given they had only three days in Bermuda to do it.

The conference summary (previously released) which we have written on extensively about (Macy Report -- The World is Flat, and Macy Foundation Conference Summary – Tip of the Iceberg?). Not sure how you summarize something that is not done, but they had an IOM event to present this at.

The two reports are:

Report A) Approaches to knowledge development – what works and what does not.

With the exception of the Up-to-date commercial in the middle (no product messages here).  The report goes into detail on how physicians learn and what questions we should be asking ourselves the stuff of good education.

Report B) Financing Continuing Education: Who, How and Why

They go into great detail on the breakdown of finances of CME programs. Some of their figures are based on how they chose to do the math, as opposed to actual figures.  Much of this is a re-hash of old arguments on why physicians should avoid any contact with industry.

They ended up with a discussion on how to change the system of learning, and a lot of this is good stuff.  It is a shame that on one hand they say – look what we could do with additional resources and on the other we despise the resources we have.

Couple of thoughts…

I spoke with one of the chapter writers yesterday and they were clear that

·         Many of the attendees were not in agreement with the anti-industry sentiments and tone of the program.

·         The chairman and steering committee had a pre-determined anti-industry agenda and were not going to deviate from that agenda.

·         This document is really just a report about what happened at their meeting in Bermuda, plus some additional work.

·         The prestigious list at the end of the document are the list of those who attended the meeting, (kind of like this is a list of who attended the any meeting that broke up into working groups) nothing more than that.

Ultimately, it is doubtful it will have the same effect as the Flexner report on Medical Education -- the seminal event that Susan Fletcher, MD was hoping for. 

We need to keep in mind that it is the prerogative of academia to pontificate about their vision of utopia.  Bermuda must have been a great place to do it.

SACME Responds to IOM

Society for Academic Continuing Medical Education (SACME) last week released their response to the Institute of Medicine Committee on Conflicts of Interest in Medical Research, Education and Practice. It is clear from what they submitted that SACME members rejected many of the controversial recommendations made by the Macy Conference Summary; and held to a general consensus that commercial support for CME is beneficial for the intuitions and their physician learners.

The report gave several challenges to changes in the present CME system. Their points represent major hurdles to changing our system:

Funding: “Many academic institutions provide little or no funding to CME, but rely on units to fund themselves or raise funds for the institution. Loss of current funding from commercial interests may result in fewer educational activities with increased cost to the institution.”

Institutional role “…continuing education is often not a focus of the educational system.  Expectations point more to CME’s marketing role in representing the institution…”

Cultural change “In addition to the issue of CME as a support for hospital activities, most physicians have been trained in an environment in which lectures and conferences are provided at no cost. Asking physicians to bear more of the cost of their professional development comes with the challenge of developing activities that are more effective. Though changing, many learning opportunities demand little of participants. Many physicians lack practice in learning using different modalities, and experience a level of discomfort.”

“…Lectures are a cost effective way to present information, requiring relatively little of planners and participants. Using approaches that have been shown to be more effective, and linking CME to quality initiatives, requires expertise on the part of planners as well as faculty. CME professionals with skills in instructional design, evaluation, and teaching/learning to support faculty are essential, but require more time and money.

In preparation for their response they conducted a survey of their members. Perhaps of most interest, just less than a quarter, (24.4 %) of the academic CME providers supported eliminating support for CME by commercial enterprises.

Here’s the question and responses Funding from commercial interests must be eliminated from academic CME .

Response Percent Count (actual number of respondents)

Strongly disagree 24.4% 22

Disagree 36.7% 33

Neutral 14.4% 13

Agree 12.2% 11

Strongly agree 12.2% 11

On a somewhat related issue, the group opposed by an even wider margin eliminating faculty members with commercial connections.

Only 19.8% of academic educators agreed with the idea of eliminating those with commercial connections.

Faculty must not teach in academic CME if they have relationships with commercial interests.

Response Percent Count (actual number of respondents)

Strong disagree 14.3% 13

Disagree 47.3% 43

Neutral 18.7% 17

Agree 13.2% 12

Strongly agree 6.6% 6

At the same time, a majority of the group (60%) opposed offering free lunches and gifts associated with CME activities. One can only wonder if this will actually serve the purpose of increasing the quality and participation in CME .

All gifts, including free lunches, must be eliminated from activities with CME credit.

Response Percent Count *actual number of respondents)

Strong disagree 5.6% 5

Disagree 21.1% 19

Neutral 13.3% 12

Agree 32.2% 29

Strongly agree 27.8% 25

SACME is the professional organization for educators and physicians in medical schools, academic health science centers, professional/specialty organizations, and other interested academically based professionals. SACME’s mission is to promote research, scholarship, evaluation and development in continuing medical education ( CME ) to enhance the performance of physicians and other healthcare professionals.

For a complete copy of the report: http://www.sacme.org/site/sacme/assets/pdf/SACME_Report_IOM_COI_April_17_2008.pdf

AAMC and Prescription Project --Telling the Future

Wouldn't you like to look into a Chrystal ball and see the future, apparently telling the future is an art at the Prescription Project

On April 25^th, several days in advance of the Report of the AAMC Task Force on Industry Funding of Medical Education the Prescription Project released “Toolkits to Guide Hospitals and Medical Schools with Conflicts of Interest”

The guides follow the same flow as the recommendations coming out of the AAMC taskforce. . 

From the titles of the tool kit modules along with the recommendations in the tool kit it appears that they had significant time to digest the AAMC recommendations and take them several steps further to advance their cause (this to be expected).   

No wonder the Prescription Project was able to provide insights about the report for the New York Times article Group Urges Ban on Medical Giveaways prior to the public release of the report.

All participants in the taskforce signed an oath not to pre-release copies of the report until it became public.

It is disappointing that the AAMC /or some of their participants provided pre-release copies of the document to groups like the Prescription Project. 

The timing is also suspect, the AAMC told several academic physicians and taskforce participants that the report was coming out in mid June.  The Prescription Project must have been fully aware of the change in schedule by the AAMC, which suggests some one(s) at the AAMC gave them the heads up.  Perhaps their webmaster posted their tool kits on Friday, thinking the AAMC report would be released that day, and made a "mistake".

This type of coordination begs the question what role if any did the Prescription Project and the Institute of Medicine as a Profession have in developing the drafts of the report that were submitted to the taskforce.

If the process is to be open for some, it should be open for all.

I guess for AAMC and Prescription Project transparency goes one way or maybe they don't believe that tranparency applies to them, they say transparency is not enough, what if it is not at all.

Or perhaps they were just looking into their chrystal ball.

AAMC Taskforce - Better than Reported

The AAMC Released today a comprehensive set of recommendations concerning conflict of interest and interaction with medical faculty at Universities.  The opponents of commercially supported CME (the Prescription Project, and Institute of Medicine as a Profession) took this report as an opportunity to bash our industry in the New York Times.  The report itself is significantly more balanced than the Gardner Harris Article.Group Urges Ban on Medical Giveaways

Report of the American Association of Medical Colleges Task Force on Industry Funding of Medical Education to the AAMC Executive Council (April 27, 2008)

Unlike previous reports on similar issue, this report starts out with the following pre-amble:

“An effective and principled partnership between academic medical centers and

various health industries is critical in order to realize fully the benefits of

biomedical research and ensure continued advances in the prevention, diagnosis,

and treatment of disease. Appropriate management of this partnership by both

academic medical centers and industry is crucial to ensure that it remains principled, thereby sustaining public trust in the proposition that both partners are fundamentally dedicated to the welfare of patients and the improvement of

public health”.

There was a section devoted to CME, and this is a summary of their recommendations.

For Continuing Medical Education (CME)

• Academic medical centers offering CME programs should develop audit

mechanisms to assure compliance with the standards of the Accreditation

Council for Continuing Medical Education (ACCME), including those with

respect to content validation and meals.

• Academic medical centers should establish a central CME office through which

all requests for industry support and receipt of funds for CME activity are

coordinated and overseen.

• To the extent that educational programs for physicians are supported by any

commercial entity, including pharmaceutical, device, equipment, and service

entities, the programs should be offered only by ACCME-accredited providers

according to ACCME standards.

In respect to CME these are all very reasonable recommendations, and most universities have already undertaken significant effort to achieve these goals.

The document covers many other things not directly related to CME including:

·         Gifts to individuals (Prohibiting)                                       

·         Pharmaceutical samples, (Central Distribution)

·         Site access by pharmaceutical representatives, (Limited to appointment or invitation, student participation limited, more MD’s, PhD’ and PharmD’s)

·         Site access by device manufacturer representatives, (credentialing, appointment or invitation, disclosure and consent of patients, student participation limited)

·         Participation in (Non CME) industry sponsored programs. (Discourage faculty, transparency of payment and fair market value, prohibit attendance, paying for attendance, accepting personal gifts)

·         Industry Sponsored Scholarships and other Educational Funds for Trainees (Giving Centrally, no Quid pro quo, selection sole responsibility of the university)

·         Food (only for ACCME-Accredited Events)

·         Travel (only for legitimate reimbursement or contractual services.

·         Ghostwriting (transparency of all involved in the process)

·         Purchasing (Disclosure of interest, and recuse from purchasing decisions in COI cases)

·         Boards of Directors, Advisory Boards and Consulting (Valuable and Compensation to Reflect Fair Market Value)

The report was accompanied by letters from the CEO’s of Pfizer, Eli Lilly stating that: 

·         They support all but one of the recommendations,

·         But do so without supporting all the arguments in the body of the report,

·         Issues addressed reflected perceptions rather than proven consequences

·         “We cannot agree with the report's suggestion that AMCs actively discourage academic physicians from participating in the defined speakers programs”

An additional letter from David Beier, President from Amgen stated:

Support of the explicit recommendations of the taskforce

“Our experience is that medical professionals who work in academic settings are dedicated professionals focused on the delivery of patient care and have not been inappropriately influenced in the manner, or to the degree represented in this report.

·         Engage healthcare professionals in appropriate fair-market value contractual relationships to participate in FDA Approved Speaker Programs.

·         Engage healthcare professionals as consultants with appropriate fair market value contractual relationships for defined interactions

·         Provide funding for Independent Medical Education to qualified recipients and, per a new policy, disclosing all Independent Medical Education and Healthcare Donations Publically

·         Deliver appropriate product and disease information to healthcare professionals via field based Representatives and Medial Liaisons.

IOM – Committee on Conflicts of interest:

On March 13th, the IOM held their third meeting of the Committee on Conflicts of Interest here is a link to the agenda and copies of the statements presented at the meeting http://www.iom.edu/CMS/3740/47464/49428.aspx

Favorite Quote: David Korn, MD Senior Vice President for Biomedical and Health Sciences Research, Association of American Medical Colleges

“ If I was an individual from outer space and didn’t really know anything about all of this—I would say that these conversations demonize Industry”.

Several organizations prepared responses and press releases to help influence the committee including NAAMECC and the Coalition for Healthcare communications.

NAAMECC : http://www.naamecc.org/News/tabid/56/Default.aspx

Coalition for Healthcare Communications http://www.cohealthcom.org/content/library/cc/IOM_CME_Conflict_Mar08.pdf

Macy Report -- The World is Flat

The Macy Foundation Conference Summary was a much discussed topic at the ACME meeting just held January 19-22 in Orlando, Florida.  Prior to the meeting Murray Kopelow, MD, the Executive Director of the ACCME, sent the conference summary out to all accredited CME providers and many company officials with the following note:

On January 10, 2008, the Josiah Macy Jr. Foundation released this executive summary of their November 2007 ‘Conference Convened to Address Complex Issues Concerning Continuing Education.’  It is important that we read it and understand what many people perceive is not happening in accredited CME. 

In all of our upcoming presentations and interactions, the ACCME will be talking about CME as a Bridge to Quality, and about what CME and the ACCME are already doing and what we can do about CME as a strategic asset to quality improvement in healthcare, CME as practice-based learning, and accreditation’s role in facilitating inter-professional education. 

When asked directly at the ACME meeting, Dr. Kopelow responded that the summary was sent out only to show “what some segments of CME are saying about our industry” and “the summary was sent out to promote dialogue . ”   

The report can be broken down into four areas:

• Improving education methods
• Elimination of commercial support for CE
• Limiting the types of organizations that offer CE
• Creation of a NIH institute to study CE

There are many good recommendations in this report which may lead to improvements in patient care. Many of the recommendations will require significant study and funding to implement while the report calls for an up to 60% reduction in CE funding without practical solutions to replace the lost funding. 

The conference summary stated that the practice of CE is in ‘disarray’ and “bias is woven into the very fabric of CE”. These opinions are offered without references or evidence to show commercial bias by manufactures of drugs and devices. 

The report fails to address the potential for other types of bias including academic, commercial (subscription services), governmental (VA, Medicare, SBIR Grants), journals, non profits including HMO’s, Trial Lawyer and George Soros Funding.

The report also recommends the elimination of all private CE providers with the exception of Point of Care, Multi Specialty Group Practices, Hospitals and Journals (the exception list accounts for every group invited to the meeting).    The report of course called for an end of commerically supported CME in five years (Altruism rules).

It is interesting to note while we were debating this issue in Orlando, Susan Fletcher, MD, chairman of the Macy meeting was at the IOM committee on conflict of interest giving testimony on the summary (explains why the summary was released 9 months in advance of the report with no citations)

Please read the  Macy Summary and the NAAMECC and Coaltion for Healthcare Communications Repsonse to the Macy Summary

You may want to read this report from our friends at Calbin and Nobs wrote about the report, it is very entertaining. Calbin and Nob thoughts on Macy Summary

Oh we are still trying to uncover the mistery of who left the the mask and snorkle behind in Brumuda.

Macy Foundation Conference Summary – Tip of the Iceberg?

The conference summary was released nine months in advance of the actual report at least in part  to influence an upcoming Institute of Medicine (IOM) report (2009) and the meeting of the Committee on Conflict of Interest in Medical Research, Education and Practice. The  next  public meeting is scheduled for March 13-14^th, 2008 in Washington DC (see attached IOM public Meeting Invitation).

The Institute of Medicine is an influential part of the National Academy of Sciences, which was charted by  Congress in 1863 to advise the government on important scientific and technical questions. 

One of the co-sponsors of the IOM committee on the conflict of interest is none other than the Josiah Macy Foundation. The makeup of the IOM committee contains 6 of 17 members (including the chairman) who have publicly stated strong pro-regulatory positions on faculty conflict of interest.   

The IOM program has the appearance of being stacked against the pharmaceutical industry commercial support for CME. First, participants were sent only one outside article as part of the conference packet: Health industry practices that create conflict of interest: a health policy proposal for academic medical centers, Brennan, JAMA 2006.  Second, Harvey V. Fineburg, MD, PhD, President of the IOM was a Macy conference participant and we have been told that IOM has rejected reasonable requests for presentations from academic views other than the Macy participants at the IOM meetings.  Third, the IOM committee itself is closely aligned with the Association of Academic Medical Centers and has many common members. Fourth, many of the prominent members of the group are consistent critics of pharma industry involvement in medicine, including,  David Blumenthal (Institute for Health Policy, Harvard), Jordan Cohen (President Emeritus AAMC), Catherine DeAngelis (Editor and Chief JAMA). 

The Association of Academic Medical Centers Conflict of Interest Taskforce is now in final editing of their new recommendations on faculty conflict of interest. It includes many Macy participants and will probably be similarly biased against the industry involvement with academics .