Canadian Medical Association Journal Reviews Commercial Support of Continuing Medical Education

The Canadian Medical Association Journal (CMAJ) recently claimed that there is a “widespread perception that the cozy relationship between physicians and the pharmaceutical industry leads to conflicts-of-interest.” The result of this misperception, “among other things, has prompted a crackdown in industry funding of continuing medical education (CME).”

While the author neglects to talk about those “other things,” we have examined at length the negative impact, which this misperception has caused. For example, a recent MIT thesis acknowledged the overwhelming concern that “Massachusetts regulations increase the barriers between physicians and medical device companies, impairing physician-industry collaboration on technology development, new device training, and medical education.”

This impact has also affected the willingness of physicians and researchers in academia to continue in their role at academic medical centers, forcing at least two individuals to leave their respective positions (Harvard and Univ. of Wisconsin).

Consequently, this misperception has also chosen to ignore three studies conducted this year, which produced substantial data that demonstrate a lack of commercial bias in industry-sponsored CME (Cleveland Clinic; Medscape, and UCSF). Critics of industry-physician collaboration also conveniently forget to mention a study, which found that academic researchers who were paid a modest honorarium to teach more than 14,000 doctors around the country about new treatment guidelines for high blood pressure resulted in adherence to those guidelines rising more than 8 percent where the most sessions took place.

What this evidence demonstrates is that this so called “widespread perception that the cozy relationship between physicians and the pharmaceutical industry leads to conflicts-of-interest” is in fact not supported by any evidence, and is clearly a misperception.

Changes over the past several years have made it more difficult for industry to support CME, including new regulations and policies from medical schools, professional associations, companies and federal agencies. Nothing could more clearly demonstrate the impact these changes have had on the CME enterprise better than the Accreditation Council for Continuing Medical Education, (ACCME) 2009 report, which shows that since 2007, commercial support of CME has declined $355 million or 29.3%.

To anti-industry critics like Dr. Daniel Carlat, associate clinical professor of psychiatry at Tufts Medical School in Boston, and author of the Carlat Psychiatry blog, this trend represents a “gradual falling of the dominos.” The reality is, the less funding we have for CME, the real falling will be the levels of education and training our doctors receive, and the levels and quality of care our patients will get.

For Dr. Carlat, the decrease in commercial funding and changes in institutional policies represents a “positive response to the growing awareness of the influence that the pharmaceutical industry has on medicine.” He feels that CME is just another “marketing tactic.”

Tell that to the 14,000 doctors who adhered to guidelines 8% more after working with industry. Tell that to the 100,000 participants at the Cleveland Clinic who perceived almost no bias in hundreds of thousands of CME programs. We find it hard for anyone who has attended a CME program that improved the outcome of their patients to simply believe they attended a marketing tactic rather than an educational program. Just ask the doctors who attended a CME program that helped create a significant improvement in the mean time diagnosis of myelodysplastic syndromes (MDS).

As the CMAJ author points out, since critics of industry have no real evidence of harm to patients caused by physicians collaborating with industry, the only argument they are left with is that industry-funded CME creates “covert or indirect bias occurs.” Could anything sound more ridiculous?

Even if one were to entertain this absurd notion, who would determine the covert or indirect nature of this bias, Dr. Carlat? Everyone in the world has a bias one way or another. Doctors are highly trusted by the public and their patients. They are fully aware of the sponsors of the CME programs they attend, and they are trained well enough to address issues of potential bias if and when they appear.

The CMAJ article also tells us that Carlat analyzed 15 articles produced by providers accredited by the ACCME and found that sponsored drugs were mentioned six times more often than competing drugs. Not only is this not an official study to cite, the size of the sample is incredibly small and most likely non-representative. What was the methodology and controls? Moreover, the fact that Carlat acknowledges that none of the articles contained unfavorable statements of the sponsors’ drugs,” should clearly show their unbiased nature.

While the debate regarding industry-funded CME remains heated in the U.S., it’s less heated in Canada because “there is a more of a collaborative spirit when it comes to industry.” One physician said “the solution to perceived conflicts-of-interest, lies in close scrutiny of CME programs to ensure that they are as free from bias as possible.”

As Dr. Bernard Marlow, director of continuing professional development at the College of Family Physicians of Canada explained, the college now has two trained peer reviewers who examine all programs, using a new tool for detecting bias. Of the approximately 700 programs per year accredited by the college, bias is detected in 15% to 20% on the first review.

The programs “will not be accredited until all of the recommendations made by the reviewers occur.” He recognized that “most of them end up being accredited but some of them are dramatically changed from the first submission to the end.” A strategy such as this, which recognizes the importance of industry, seems very realistic and promising.

In the end, as the author pointed to my own quote, “there’s a misconception that somehow companies are controlling CME when in fact all they are doing is providing financing to meet public health goals and help better patient care.” The future of CME depends on adequate resources for designing and implementing innovative and collaborative ways to educate our healthcare providers. Since Canada already has a more collaborative spirit than the US it’s quite possible that the more we push industry away from CME, the more likely they will take their funding across the border.