Thursday, June 18, 2009

AMA: Council Cuts CME Baby in Half; Delegates Aren't Buying It

Thanks to the Healthy Skepticism listserv I was guided to this news piece from the family medicine academy (AAFP):

The AMA's Council on Ethical and Judicial Affairs (CEJA) came out with a report on the funding of CME programs by industry that seems to have attempted to Solomonic task of cutting the baby in half to satisfy the warring factions. The AAFP president spoke in favor of the CEJA report, but ultimately the AMA's House of Delegates returned the report to CEJA for some fine-tuning before it could be adopted.

The Solomon business consisted of developing two categories: "ethically preferable" and "ethically permissible." In a nutshell, "ethically preferable" corresponds to what in HOOKED I called the divestment strategy, of getting financial conflicts of interest out of CME, period. That strategy also happens to match what the recent IOM report called for in CME funding. "Ethically permissible" corresponds to an optimal management strategy, allowing some conflicts of interest and attempting to create strict rules and firewalls to control them.

Critics of the report immediately pointed out that CEJA had never previously issued a report with these two categories before. The thrust of the testimony against the report appeared to focus on the heavy dependence that CME programs now have on industry funding. In reply, Richard Frankenstein, a pulmonologist and past president of the California Medical Association, said that physicians should get into the habit of paying for their own CME themselves, and realizing that industry would not fund CME unless they saw a direct dollars-and-cents benefit on their balance sheet. As best as one could intuit from reading this report, the delegates did not cheer wildly at that speech.

The article, adopting the reticent tone of most in-house medical journalism, steered clear of the critical question, "In sending the report back to CEJA for refinement s0-called, what changes did the majority of the delegates wish to see, really?" The final paragraph of the story gives the broadest hint--the delegates did not like the terms "ethically preferable" vs. "ethically permissible" because they suggest that one set of practices is ethically less good than the other. (Well, duh.) The delegates wanted to see a report that did not use those categories.

If CEJA cannot cut the baby in half and get off the hook that way, then what do the delegates want of them? Apparently it is not that they would state flatly that industry support of CME is unethical. So the only alternative would be to give the full ethical seal of approval to the status quo--where conflicts of interest are "strictly managed" and we continue to pay for more than half of all CME with industry money.

We bioethics folk have seen this move before. Every time CEJA acts responsibly and professionally (as they most generally do, having decent members and an excellent staff), and tries to call the medical profession to a higher ethical standard than commonly exists in the community, the House of Delegates is likely to take umbrage--"what! me unethical?" -- and force them to back off. Short version: don't expect real ethical insight about controversial aspects of CME any time soon from the AMA.

My own personal plea to CEJA would be not to "fine tune" the report and to let it die. If the House of Delegates in its infinite wisdom does not want ethics, fine--let them not have it. But don't pander to the bottom feeders by watering down the report even more.

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