EDITOR'S PAGE
Continuing Education, Industry, and Physicians
Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology*
* Address correspondence to: Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112 (Email: ademaria{at}acc.org).
In no other profession is lifelong continuing education as valued and pursued as in medicine. Our profession is one in which the fund of knowledge is constantly increasing. We physicians pride ourselves on keeping abreast of new information and providing patients with the best possible treatment.
The traditional vehicle for staying current has been certified continuing medical education (CME). On any given day, scores of conferences are conducted on virtually every aspect of cardiovascular medicine. Acquiring the latest knowledge requires both time and money. Over the years, the pharmaceutical and device industries have become major supporters of CME and have offset the cost to the profession. Obviously, supporting CME has not been entirely altruistic. The industry clearly hoped to benefit not only by an informed profession, but also by the opportunity to deliver a message about their products. Now that support may be coming to an end, the American Medical Association (AMA) and Accreditation Council for Continuing Medicine Education (ACCME) are considering proposals to eliminate all commercial support for certified CME. I have very mixed feelings about such an action.
When I began my career, some 3 decades ago, the interaction between industry and physicians was primarily promotional and solicitous. Often this interaction had little to do with clinical practice or even the commercial product. I was taken to sporting events and hosted on the golf course by industry. Lavish receptions were held with expensive food, open bars, and the opportunity to meet celebrities like the Dallas Cowboy Cheerleaders. It was not always obvious how such activities increased medical knowledge or enhanced clinical care.
It was in this setting that the concept evolved that supporting medical education could elevate the level of practice and benefit industry at the same time. The importance of medical education was reinforced by the requirement for CME credits for many medical privileges. Soon commercial interests became major supporters of CME. This support has been estimated to amount to nearly $1 billion per year and has enabled us to have the breadth and depth of learning opportunities we currently enjoy.
From the beginning, it was recognized that the educational goals of conferences should not be unduly influenced by commercial interests. The AMA and ACCME credentialed providers of CME. Over the years, guidelines separating industry from the process of determining the need for and the content of CME were strengthened. In 2002, the Pharmaceutical Research and Manufacturers of America published their own code defining appropriate interaction of industry with health care professionals. In general, the guidelines consisted of entrusting the responsibility for program content and speakers to the agency granting CME, and full disclosure of relationships with industry on the part of presenters.
Most will agree that the separation between the composition of educational programs and commercial interests has not always been perfect. Perhaps it shouldn't be. It seems to me unreasonable to think that a company that produces angioplasty catheters would be interested in sponsoring a program on obstetrics. As pointed out in a statement from the Council of Medical Specialty Societies, the Gerber Foundation, dedicated to advance the quality of life in infants and young children, would not likely be interested in supporting programs on Alzheimer's Disease. However, whether the result of conscious or subconscious actions, program content has sometimes appeared to primarily serve the interest of its supporters.
As stated above, the potential influence of industry in CME has received increasing attention from accrediting agencies, specialty societies, and academic institutions. However, likely stimulated by the increasing cost of health care, scrutiny reached a new level when the Senate Finance Committee and the Office of the Inspector General of the Department of Health and Human Services became involved. Both groups are concerned with the potential of commercial entities to exert undue influence upon physicians which results in increasing health care costs. The effects that this scrutiny had upon others cannot be certain. However, whether a coincidence or not, recently both the AMA and ACCME have developed draft documents that propose alternatives for the role of industry in CME, including the elimination of all commercial support for CME activities. Needless to say, the effect of such an action upon medical societies, physicians, and perhaps even journals, could be substantial.
My first reaction upon learning of these proposals was to agree with their underlying principle. I think it is critical to distinguish between certified CME and promotional events. The need for, content of, and presenters for a CME activity should be determined solely based upon educational objectives. The Program Directors should be responsible for these decisions. Events that deal with the use of specific drugs or devices should be clearly designated as promotional and adhere to Food and Drug Administration requirements. A physician attending a certified CME event should feel confident that the material presented represents the objective opinion of the faculty, free of commercial influence.
That having been said, I worry that termination of all commercial support is a major overreaction. The goal that underlies eliminating commercial funding—that is, to insure program objectivity—can be accomplished by existing CME-granting agencies. Certainly medical societies and academic institutions should be capable of excluding inappropriate industry impact. In addition, is not clear how or if the financial support for CME provided by industry could be replaced. Without these funds, important opportunities to increase knowledge might be unavailable to busy clinicians, thereby denying their patients the benefits of this learning. It is not known what industry would do with the money they are currently directing to CME. However, it would likely go to more promotional events and/or direct-to-consumer advertising, neither of which addresses the concerns that have been raised. In fact, such alternate venues would probably only serve to further increase the use of products.
I have a further, even more basic, reservation about the proposal to end commercial support for CME. Inherent in such an action is the idea that physicians are like sheep: easily led and without the ability to recognize biased or slanted information. I find this demeaning to the profession. In my experience, physicians are more skeptical than naïve; by nature they are not anxious to accept, but rather are waiting to be convinced. Given the competitive demands entailed in becoming a physician, we are likely intelligent enough to recognize bias when it is present.
So, I view the proposal to eliminate all industrial support of medical education as throwing the baby out with the bath water. I agree that certified CME should be objective and free of all bias, and I am not naïve enough to think that this has been fully achieved. However, I think there are other ways to accomplish this goal, and that we have the structure in place to be successful in the ACCME, medical societies, and academic institutions. Tightening existing guidelines and greater diligence to adherence should be adequate. Equally important, I think physicians are intelligent, savvy, and independent enough to know bias when they see it, and to resist recommendations that are not based on firm data. Physicians may not be perfect, but in pursuing continuing education, we have set an example for other professions to follow. Industrial support has helped to make this possible; let's think long and hard before we upset the cart.
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