It is unusual to read an article that critiques CME activities based on evidence that came out after the courses were produced and rehashes old reports. However, this is essentially what MedPage Today did with CME providers last week. MedPage Today ran a series of articles about the industry-funding of Continuing Medical Education (CME) courses.
The first article, Slippery Slope: Testosterone Muscles its way to Profits, the most excoriating and least-researched part, references testosterone courses and claims that a majority of faculty experts providing CME courses "were on the payroll of drug companies as speakers, consultants, and advisors." Not only did the author fail to reach out to two of the CME course providers referenced in the article for their comments and defense of CME courses, but the cited CME provider who was painted in a negative light was bullied and pestered with misleading and difficult questions.
The second article, Slippery Slope: Academia Takes a Step Back from Industry CME, begins with attacks on pharmaceutical companies who help to fund CME courses, and highlights the University of Wisconsin. The University of Wisconsin received $3.5 million in grants for CME courses in 2010; today, the program is decimated – receiving only $60,000 in 2014. The author of the article believes the reduction of industry funding of CME courses is because of a perceived conflict – that pharmaceutical companies were giving CME providers funding in return for the advertisement of their pharmaceuticals. The author somehow misses the great CME programs that took place back several years ago, when the University of Wisconsin had a robust program. They also seemed to go out of their way to bring back every negative report they could think of.
CME: Controversial Curricula Draw Fire focuses on CME courses on obesity. The author claims that hypoactive sexual desire disorder is an "invented" condition that was designed to sell drugs. Adriane Fugh-Berman believes that the free CME courses provided in 2010 for educating doctors on hypoactive sexual desire disorder were nothing more than a marketing ploy to increase "doctor acceptance of the condition."
The Dark Money of Medicine, the last part of the article, is an infographic that aims to compare total income for course providers and the income from the pharmaceutical industry.
The Truth About CME Activities
Continuing medical education courses are a necessity in the medical field, where new innovations are made daily. CME content is developed, reviewed, and delivered by faculty who are experts in their individual clinical areas. Similar to the process used in academic journals, any potentially conflicting financial relationships for faculty members must be disclosed and resolved.
Graham McMahon, MD, President and Chief Executive Officer of the ACCME, cleared the air by stating, "CME activities are not promotional. They're required to be evidence-based. They're required to be independent of commercial support." Dr. McMahon pointed to more published or web-based courses rather than live events as the impetus behind the decline in medical schools providing less CME courses.
For a crash-course in accreditation requirements, the author of the MedPage Today article should have visited the ACCME website, which lists thirty different standards CME courses must meet. Those standards cover a wide range of topics, including independence from commercial interests; resolution of any personal conflicts of interest; appropriate use of commercial support; and content and format without commercial bias.
New Data and Old Courses
A careful look at the references provided by the Medpage Today in the article titled Slippery Slope Testosterone Muscles its Way to Profits to support their argument that the CME courses on testosterone were biased, shows they were largely from science published after the CME courses were produced. The studies they reference were published in 2010, 2013, 2014 and the summer of 2015. The CME courses they referred to in their article were from 2011-2012.
CME providers should not be held to a standard of promoting science that does not exist. There is no course on telepathic medicine in which you can predict the outcome of future clinical trials.
A cursory review of the MedPage Today website lists articles both promoting and discouraging the use of testosterone. Several of the titles promoting the use of testosterone on MedPage Today, all which encompass CME Credit examples include: Revisiting Testosterone Treatments In Prostate Cancer: men with low-risk prostate cancer and symptomatic hypogonadism had no evidence of disease progression during long-term testosterone therapy, results of a small clinical trial showed (04/25/2011), No VTE Risk Seen With Testosterone Therapy: findings may help men make benefit-risk assessment for treating testosterone deficiency (07/27/2015), Review Finds No Evidence of Testosterone Harm Testosterone: defenders found "no convincing evidence" of heart risks (01/30/2015). This small sampling of articles is further confirmation that the use of testosterone is by no means a scientifically settled issue.
The Problem with Numbers
The numbers they used to describe this "dark side of medicine" were selected out to match their narrative. It should also be noted that this "original investigation" used the same set of numbers and conclusions that an equally biased Boston Globe article covered. Both of these articles ignore the fact that commercial support for CME has dropped by more than 45% since 2007. This represents a stabilization of the industry, not a huge rise as the articles attempt to imply. After facing such a significant depression in commercial support, CME providers should not be bludgeoned by the media for finally recovering.
Often, stories like this are driven by trial attorneys promoting class action cases in an attempt to discredit potential witnesses and companies. When filing a class action complaint, attorneys tend to throw in the kitchen sink. In one section of the story, the authors dedicated space for information on their class action suit, which is essentially fishing for clients. If they can help lead the readers think that since they took testosterone and also had a problem with "x," they too can join the class action suit, making a larger class of plaintiffs for the attorneys.
The physician they interviewed fell into a trap by the reporter by backpedaling on his previous statements and confessing, "I am not an expert," which gives credence to those discrediting anything he may have said in any courses or statements.
The Dangers of Public Databases
The data on which the MedPage Today article is based was collected through public information, such as the Lilly Grants database and the Open Payments database.
This article outlines the problem with taking payments out of context. The fact that some of the faculty of the CME activities taking place from 2010-2014 that discussed testosterone have according to the Open Payments database in 2014 financial relationships with companies that manufacturer testosterone therapies. This provides no context on nature of those relationships or that those relationships even existed when they participated as faculty. CME providers go through extensive work to ensure that faculty with disclosed conflicts of interests are excluded from content that may help the companies they have an interest with.
The articles chooses selective quotes largely taken out of context to demonstrate bias, but perhaps were unaware of the existence of large studies ((Cleveland Clinic; Medscape, and UCSF)) and a report in which bias in CME was determined not to be an issue.
The article was written by John Fauber, a reporter who has long been critical of the industry, who has seemingly made a career out of writing leading articles and bashing the industry. Mr. Fauber spent a good portion of time in 2009 and 2010 attacking the University of Wisconsin system to reduce their spending. We wrote about those attacks as they happened. (For a refresher, you can find the articles here, here, and here.) Those articles resulted in the University of Wisconsin School of Medicine and Public Health stepping away from some educational opportunities that would have not only benefitted the school, but the community at large. Several years ago the head of the CME department an important thought leader in CME packed his bags and moved to another university. Perhaps it is kismet that the school now only receives $60,000 in commercial support versus the $3.5 million they earned before Mr. Fauber went on the offensive.
This article is just one of a series entitled, "Slippery Slope." All articles within the "Slippery Slope" series tend to paint a wide brush against innovative and largely effective therapies for diseases such as leukemia and lymphoma, obesity, diabetes, and atrial fibrillation.
Biting the Hand that Feeds?
Oddly enough, the primary advertisers on the MedPage Today website in this "Slippery Slope" series are CME providers and Life Science Advertisers. Not only do the authors of the series make unsubstantiated claims, but they are also biting the hand that feeds them. If MedPage today truly thinks payments from industry is the "Dark Money of Medicine" than we encourage them to either give up asking for commercial support and advertising dollars from those CME providers and Life Science Companies or disclose to the world how much they receive in funds from each company. A quick look at the second quarter earnings for Everyday Health, the parent company of MedPage Today, reported advertising and sponsorship revenue of $50.2 million, a 36% increase from the prior year period. Extrapolated out for the full year, that is somewhere in the range of $200,000,000 dollars--equivalent to approximately 1/3 of the total commercial support for all CME providers combined.
As has been made clear from many years of research and education, science is constantly changing, and advocating for less research and fewer new drugs, as the authors of the "Slippery Slope" series are wont to do, is a dangerous pastime. We cannot use yesterday's science on today's problems. Medical research and continuing medical education are two important factors in making sure our healthcare providers are as up-to-date and efficient as possible.
The CME Coalition has issued a strong response to the MedPage Today/Milwaukee Journal Sentinel Slippery Slope articles and gracefully MedPage today published them.
Rockpointe, publisher of Policy and Medicine owns a medical education company and accredited CME provider in addition, they are members of the CME Coalition. We believe that CME plays an important role in educating our healthcare providers on important aspects of medicine.