Industry Support of CME Declining--Is There a Downside?

An important piece in this week's New England Journal:
http://www.nejm.org/doi/full/10.1056/NEJMp1114776
--by Drs. Michael Steinman, Seth Landefeld, and Robert Baron updates us on current trends in drug industry support for continuing medical education programs.

Major news flash is that industry funding of CME rose to a peak in 2007 but has since been declining. At the height, if you add in all sources of industry support, the drug and related industries paid for more than half the costs of CME in the US. Direct support of CME is now down to 31%.

The authors note, "These changes did not arise from one or two events. Rather, they resulted from shifting norms in the culture of medicine. It is doubtful that all industry involvement with CME will cease in the near future, and the recent decline in industry support may also reflect difficult economic times. However, we appear to be entering a new era in which earlier norms of acceptability no longer apply."

Will the result be a deterioration in the quality of CME? The authors suggest that the reverse is more likely: "Although reducing reliance on industry funds will not be painless, it remains highly feasible to do so in a manner that preserves (and in some ways enhances) access and quality. Costs can be substantially reduced by avoiding high-priced venues such as the hotel conference spaces where CME events are often held. ... Moreover, CME providers are de-emphasizing traditional lecture-hall–based teaching in favor of more interactive, interprofessional, and competency-based learning strategies. Such strategies include online teaching tools, point-of-care CME, and performance-improvement CME, which not only offer pedagogical value but in many cases can also be provided at relatively low cost. This trend is likely to continue as CME is increasingly linked to practice-improvement and maintenance-of-certification processes that require explicit practice-based learning."

Having decided that this trend is here to stay--they reject the hypothesis that shrinking CME support by industry is merely a reaction to the economic downturn--and having opined that on the whole this is a good development, the authors ask if there's any downside. Their biggest concern is the shift in marketing funds away from accredited CME and into activities such as dinner lectures, where the company can totally control the presentation because it need not meet any accreditation standards. The authors suggest that the impact on medicine would be deleterious if docs stopped going to CME sessions and instead went out with the drug reps for steak and wine.

I am less worried about this because there was a reason why the industry, which always had the option of the dinner lecture, nevertheless felt it advisable to shove so much cash in the direction of CME. Pharma knows that docs think differently about a program that grants CME credit and attribute a higher level of authority to such a presentation. Plus the pressures on docs to get a certain number of CME credits per year come from outside industry and have not changed--most physicians need CME to retain licensure and specialty certification. In short, I think that Dr. Steinman and colleagues have correctly assessed the positive about shrinking industry support for CME and have perhaps slightly inflated the negative.

Is Commercially Sponsored CME Biased?

I've addressed commentary by Thomas Sullivan, CEO of Rockpointe, a medical education and communications company with strong ties to the drug industry, in previous posts:
http://brodyhooked.blogspot.com/2010/08/reply-to-my-article-on-coi-coke-aafp.html
http://brodyhooked.blogspot.com/2010/09/my-long-post-on-donald-lights-study-of.html

I gave him high marks for care and thoroughness in arguing the opposing point of view. I'm not sure I can be so generous with regard to his latest:
http://www.kevinmd.com/blog/2010/12/commercially-funded-cme-programs-bias-removed.html#more-49396

Mr. Sullivan is upset because commercial support for CME programs has been on the wane in recent years, in part because of what he believes is unwarranted suspicion about commercial bias, a charge he considers baseless. He details all the safeguards built into the CME system which, if they worked as they are supposed to, would indeed guarantee very little if any bias based on who pays the piper. (I listed reasons both in this blog and in HOOKED to doubt that the system works so well much of the time.)

Here, for brevity, I'll just make two points.

Mr. Sullivan writes, "Despite these safeguards, critics point out that because many other professionals pay for their own continuing education, doctors should begin doing the same. These critics believe that industry funded CME 'is not education, but subtle marketing,' despite overwhelming evidence from three studies this year that showed almost no bias in commercially funded CME programs..." Now, just what is this overwhelming evidence? He proceeds to cite (and provide links to) three research studies. What did the studies show? When physicians attend CME programs, they have to check off boxes on an evaluation sheet, stating whether they do or don't think that the presentation they just listened to showed inappropriate or excessive commercial bias. What all three studies showed is that the vast majority of docs, most all the time, check the NO box. To me that suggests that either the docs are lazy about what boxes they check, or else that they may be unable to detect bias when it might actually exist. To suggest that a study that consists of these data show positively that no bias exists in CME programs seems a far stretch. (There might in fact be no commercial bias in CME programs, but you'd need far better methods than in these three studies to know that.)

In a more minor point, Mr. Sullivan goes on at length listing the conflicts of interest of Dr. Martin Samuels, a Harvard neurologist who's just announced that he's starting up a no-commercial-sponsorship CME program to address the supposed problem of bias. (Some similar firms have been running non-commercially sponsored CME programs for decades and have a great track record, but as they don't come from Harvard, apparently they're chopped liver.) It's interesting that Mr. Sullivan forgot to mention that as a MECC exec he might have a few conflicts of interest of his own.

More CME News, and an Important Correction

In a comment on the previous post:

http://brodyhooked.blogspot.com/2010/06/has-cme-pendulum-swung-too-far-or.html

--Dr. Michael Kirsch kindly calls our attention to a recent New York Times report by Natasha Singer and Duff Wilson:

http://www.nytimes.com/2010/06/24/business/24meded.html?scp=1&sq=university%20michigan%20continuing%20education&st=cse


--which in turn provides us with important news on the CME front as well as a critical correction to the comments I offered in that earlier post.


The news item is that the University of Michigan announced that as of next January, they will become the first medical school to accept no drug/device industry funding for any school-sponsored CME (continuing medical education) program. In taking this lead, Michigan follows its earlier trend in being one of the first schools to implement a strong "drug reps off campus" policy. (Somehow Stanford hired a better PR agent and so got tons of publicity when they did the same thing more than a year after schools like Michigan and Wisconsin had taken the first steps.)


In HOOKED I wrote that the average medical school, as of a couple of years back, received about 50% of overall CME funding from industry. That sum varied widely; some conferences had virtually no industry funding, which in turn meant that other conferences were funded almost totally by industry. Michigan estimates it will be giving up about $1M of funding annually by its new policy. That shows what most med schools have at stake in the relationship with industry.


Now for the correction. I ran my mouth last post about the different types of talks that industry speakers might give, and offered my concerns that by banning all talks by industry speakers, the recent rules of the ACCME might actually have gone too far. So I am pleased that the Times report corrected my misimpression. The Times reporters state that the rules are indeed designed to respect the distinction that I was worried about. That is, scientists or physicians hired full time by industry can speak all they wish to about any basic science research. What they cannot talk about is a product of their company. I think that's a reasonable dividing line. By the time a research idea or concept has gotten so far down the pipeline that there's an actual product being readied for the market, there ought to be sufficient published literature for a neutral sientist to be found who can assess its pros and cons. There seems little danger that physicians will be deprived of up-to-date but unbiased information merely because a company employee cannot give that talk.