Wednesday, January 5, 2011

New Proposals for CME Reforms

Health law scholar Marc A. Rodwin of Suffolk U. Law School provides a very useful historical overview of drug industry involvement in continuing medical education and then offers some novel ideas for reform (subscription required).

In HOOKED I harp on the lack of historical perspective that infects most recent work on the pharmaceutical industry, and often portrays all the serious problems at the medicine-Pharma interface as if they first cropped up yesterday. Hence any thoughtful historical reflection is welcome, and Rodwin provides a comprehensive review of how drug advertising and CME evolved hand in glove through the 20th century.

Rodwin conducted interviews with CME managers, allowing him to make statements that put the lie to the comforting mantra that industry-sponsored CME is really education and not marketing. Perhaps the single most telling quote of this type is: "Moreover, CME providers traditionally sought funds from one firm per program because, as a manager of a CME provider explained to me, drug firms believed a provider supported by two or more firms with competing drugs would have a conflict of interest." Notice the obvious: if a conference were truly about education and not about pushing product, then having multiple industry sponsors would seem completely benign and indeed desirable. Also, as a secondary issue, notice that the naysayers who deny that "conflict of interest" exists or is a truly meaningful term of professional ethics, are apparently not joined by those within Pharma itself!

Rodwin joins those who criticized the 2004 ACCME guidelines as too wimpy--he notes that the rules say that a CME provider "cannot be required" by a sponsor to accept advice or direction regarding speakers or program content, meaning, "That language does not prohibit commercial supporters from offering advice, CME providers from soliciting suggestions from them, or CME providers voluntarily following suggestions of commercial supporters. My interviews with CME providers indicated that these were common practices."

So--what to do? Rodwin starts with a novel proposal. How about CME folks actually having to decide upon a curriculum? A medical school or a residency program that did not teach in accord with a standard curriculum decided upon by consensus within the relevant community of experts would speedily lose accreditation. Why, then, allow CME programs to be driven by the whims of who wants to speak on which topic, or which company wants to pay the freight? Merely having an agreed-upon curriculum based on science and real practice issues would go a long way toward correcting the tilt toward talking only about drugs, devices, and stuff that makes money for industry.

Past that, Rodwin would ban all direct and most indirect industry funding of CME, and ask Congress to impose a CME tax on all those who currently make profits off medical care (docs included). (Rodwin treats the idea that merely disclosing industry sponsorship of a CME program solves anything at all as hardly worth discussing.) If the anti-tax people start to howl about this, Rodwin reminds us that commercial firms that now pay for CME pass the resulting costs through to the end-purchaser anyway, so we all end up paying. If we did it via the tax, and allocated the tax proceeds to a federal agency who distributed them to non-profit CME entities, we'd have a greater likelihood that the same money would actually go toward improving our health.

Rodwin MA. Drug advertising, continuing medical education, and physician prescribing: a historical review and reform proposal. Journal of Law, Medicine and Ethics 38:807-815, Winter 2010.

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