The relationships between doctors and the medical industry have been under constant debate for the past fifteen years. These discussions have led federal agencies, pharmaceutical companies, state and federal governments, professional associations and academic institutions to change their policies regarding the proper role of industry in medicine. A recent example of such changes includes the decision of the University of Michigan Medical School to become the first to decide that it will no longer take any money from drug and device makers to pay for coursework doctors need to renew their medical licenses.
According to the New York Times, university officials at Michigan “voted to eliminate commercial financing, beginning next January, for postgraduate medical education,” because members of the faculty “wanted education to be free from bias, to be based on the best evidence and a balanced view of the topic under discussion,” according to Dr. James O. Woolliscroft, dean of Michigan’s medical school.
This shift in policies regarding industry funding will also be discussed on Friday, when critics of industry funding will “debate” whether the medical profession should develop an industry-free model of postgraduate education. The conference, which is titled “Prescription for Conflict,” is being held at Georgetown University, and is supposed to “highlight the arguments on both sides (20 minutes out of seven hours on the side of commercial support) through presentations by federal health officials, professors from leading medical schools, hospital executives and a Senate investigator.” But this conference will be far from a debate.
The event will be decidedly one-sided because this week Adriane Fugh-Berman, an alternative and complementary medicine specialist and organizer of the conference told the Pink Sheet, a regulatory newsletter covering pharmaceutical issues that “the title of the conference (Prescription for Conflict: Should Industry Fund Continuing Medical Education?) is rhetorical” because it is her belief that "industry and education should be separate, and that industry has no place in the education of health care professionals."
This kind of attitude, to create new restrictions on industry involvement in CME courses has already led to a controversial interpretation of a policy from the Accreditation Council of Continuing Medical Education (ACCME), who recently said it would no longer grant credit to doctors for attending medical meetings that feature industry employees presenting product research.
Beliefs like those of Dr. Fugh-Berman, and policies such as ACCME’s have been heavily refuted for years, and were recently “met with howls of dissent this month from prominent physicians, including the director of the National Institutes of Health and the president of the American Heart Association, who said it would unfairly cut physicians off from scientific knowledge.” But Dr. Murray Kopelow, chief executive of the accrediting council, said the “policy applies only to company employees who talk about products, not those who lecture on basic science or research methodology.” He also added that “Science done by industry can be reported by industry if it isn’t anywhere close to advertising, promotion or making a market for a product.”
The ACCME since this statement has requested input on this policy and worked it out with the AHA to allow industry scientific presentations.
Critics such as Dr. Bernard Lo, lead author of a 2008 Institute of Medicine report on conflicts of interest, believe that the ACCME prohibition did not go far enough. In his opinion, “private doctors and academic physicians who are paid to speak for drug companies should be barred from presenting educational material at accredited conferences” because they act as “mouthpieces for their products.” This statement reveals Dr. Lo’s true intention which is to create a system of censorship on medical information.
In response, Dr. Rafael Fonseca, deputy director of the Mayo Clinic Cancer Center in Scottsdale, AZ, asserted that such an “accusation that there is bias is not substantiated,” especially since industry has no control whatsoever of the content of CME programs and guidelines for accreditation ensure that programs are evidence based activities, not simply marketing.
Moreover, as I noted in my own interview with the Times, “the accreditation system is built with checks and balances to prevent industry influence over course selection or content. The courses themselves are intended to improve patient care, not to promote a particular brand of treatment because CME providers are really not trying to increase prescriptions, they are focused more on giving better care.”
In fact, “many private medical education companies, which receive money from drug makers to produce such courses, and some doctors who lead the courses, disagree that industry financing or speakers lead to bias.” And they have the evidence of three studies this year (Cleveland Clinic, Medscape, and UCSF), which showed extremely low rates of bias in industry funded continuing medical education (CME), to support their arguments. What CME providers assert is that “company-financed programs provide a vital service, keeping doctors up to date on the latest and most effective treatments.”
Moreover, as Dr. Fonseca, who gives 20 to 30 such courses a year, about half for universities and half for commercial medical-education companies noted, doctors involved in CME programs “present what they think is the state-of-the-art of the management of the disease.”
It is hard to imagine that the Times could have characterized CME as a “big business in the United States, with more than 700 accredited providers,” and 1600 state providers. The health care system in the US is a two trillion dollar enterprise, CME making up less 1% of that industry.
Because at the pace medicine and innovation in science are advancing, doctors need to be kept up to date. The fact that industry funding has declined since 2007 as ACCME introduced new limits on industry involvement is thus troublesome because it will mean doctors have fewer places to go to learn about such breakthroughs.
Ironically, Dr. Michael Steinman, an associate professor of medicine at the San Francisco V.A. Medical Center who conducted one of the studies showing minimal bias in industry funded CME activities, essentially ignored his own data in his interview with the times. While his study found that “the vast majority of CME activities were perceived by participants to be free of commercial bias,” he told the Times that “the course providers have a subtle and probably unconscious incentive to put on courses that are favorable to industry because they know where their bread is buttered.” Additionally, his attempt to use “related research in social science, which demonstrates that people who receive gifts often feel obliged to return the favor,” is also misplaced considering his own research found that “rates of perceived commercial bias were consistently low regardless of the presence or absence of risk factors for commercial bias.”
Left out of the debate is the lack of support for continuing medical education from other parties in medicine including government, insurance and health systems. All one has to do is ask any CME department at a local hospital, association or university or even a medical education company and they will relate to you that it is not that there are too much resources to educate physicians but in many cases a scarcity. With the addition of health care reform and 30 million patients added to the medical roles we will need additional financial resources to not less. Industry should not be demonized for supporting CME in contrast the deficient support by other participants in the health care system is the real root of most contentions.
The CME system is voluntary, physicians select their courses based on merit, CME providers submit grants for funding for projects. Companies do not fund CME activities that are not requested of them to fund. There is nothing to stop the University of Michigan from not submitting for educational grants. This is a far better solution than making what sounds on the outside as a high moral proclamation and more times than not there is a political story that leads to announcements like this.
Ultimately, banning the involvement of companies would hinder significant and peer-reviewed scientific advances that will only hurt patients and physicians. In addition, as medical groups continue to “shun some industry money doctors may face higher course fees.” This will also mean that companies will chose to take their educational, research and clinical grants elsewhere, resulting in a significant decrease in funding for associations and academic medical centers, which will chill the progress and innovation of medical science.
These negative consequences must be avoided and are unnecessary because the accreditation system is built with enough checks and balances to prevent industry influence over course selection or content. Courses themselves are intended to improve patient care, not to promote a particular brand of treatment. Ultimately, the main goal of CME providers is to give better training and education to physicians so that patients can have better care. To squash the science that’s going on in the private sector that achieves this goal is not in the best interest of patients because “company-financed programs provide a vital service by keeping doctors up to date on the latest and most effective treatments.”
We are grateful to the Times for including both side of the argument on commercial support in their article as it shows the commitment of fair balance by the Times writers.