AMA CEJA 2011: Association of Clinical Researchers and Educators Response – House of Delegates Should Reject the CME Report and End the Debate

In response to the American Medical Association Council (AMA) on Judicial and Ethical Affairs (CEJA) fifth attempt to hinder physician and institution relationships with industry, the Association of Clinical Researchers and Educators (ACRE) recommended that CEJA Report 1-A-11″Financial Relationships with Industry in Continuing Medical Education” be rejected by the AMA House of Delegates.

ACRE is an organization of physicians and colleagues engaged in promoting excellence in medical service, education, and innovation. Our members have records of achievement in these endeavors. 

While ACRE affirmed CEJA’s dedication to excellence in medical education, clinical research and patient care, they disagreed with the 2011 CEJA report because of its “self-defeating, misguided, and harmful strategy.  Moreover, ACRE rejected CEJA’s continued use of a framing bias that is defined by “conflicts of interest”—whether real, potential or imagined—and their fixation on subjective, ill-defined “perceptions,” because this reasoning cannot advance the goals that unite the house of medicine, namely, professionalism, excellence and a commitment to base policy on objective evidence. 

Specifically, ACRE recommended that CEJA Report 1-A-11 be rejected for the following reasons:

• Physicians overwhelmingly value industry grants to support CME and attendees overwhelmingly assert that commercially supported CME programs provide up-to-date, timely, useful, and reliable information about medications to treat particular conditions, and knowledge or skills helpful in their practice
• CME is already highly regulated to prevent undue influence from industry
• CME already has in place adequate provisions for transparency and independence
• Three very large studies conclusively show there is little bias in CME
• Commercially supported CME has been documented to improve outcomes in a number of subjects including COPD, Hypertension, ICU patients, Sepsis, and hospital acquired infections
• A large number of professional organizations and specialty groups find value in commercially supported CME
• CME is critical to educating doctors about new drugs and treatments

• The report relies on references and research that do not differentiate CME and commercial education
• The report too vaguely describes under what circumstances commercial support of CME would be acceptable by using the term “significantly undermine”
• Attempts to change CME to a system similar to continuing legal education (CLE) are unrealistic because (1) the volume of information in medicine is vastly greater than law, (2) changes to practice in medicine occur at a much faster rate than law, and (3) mistakes in medicine can lead to death, whereas mistakes in law can be corrected through other, less life threatening processes
• The best evidence of the perceived value of CME events is that doctors attend voluntarily, giving up Saturdays or evenings to do so

• Reducing resources in CME will result in less education of physicians
• With the adoption of Health Care Reform and the subsequent addition of 30 million new patients to the healthcare system, additional financial resources will be needed to educate a greater number of physicians and other healthcare providers not less
  • CME plays a vital role in promoting evidence-based medicine (EMB)
  • Failure to adopt EMB is estimated to cost hundreds of millions of dollars
  • CME is also the best means of disseminating comparative effectiveness research, the cornerstone of any sensible health policy

• Passage of the Physician Payment Sunshine Provisions in Health Care Reform eliminates the need for more detailed disclosure as recommended in the CEJA report
• There is no discussion in the CEJA report of the following issues:
  • The risk to patients because of reduced financial support of CME
  • The effects of their restrictions on rural and inner-city physicians
  • The effects on medical societies
  • The progress made by medical innovation from education
  • That diversity of funding leads to competition for better CME
  • That industry has a social responsibility to support education

Discussion

ACRE recognized that CEJA reports have consistently approached the issue of industry funded CME improperly.  First, ACRE noted that the funding of CME through commercial support is not an “ethics” matter as CEJA has repeatedly suggested over the years.  Commercial support of CME is about practical access to high quality health care education. 

The ACRE response noted that, industry makes life saving treatments, devices, and tools to help improve the health of people each day.  Through research and development, companies are finding ways to diagnose, treat and prevent serious, chronic, and rare diseases at a faster rate than ever before.  Accordingly, industry support of CME is one of the most effective ways to distribute this new information, to ensure that healthcare practitioners are aware of the benefits, risks, and uses of these new tools and treatments.  Research has shown that there is little bias in such programs.  

Consequently, the CEJA report explicitly recognizes that, “relationships between medicine and industry—such as pharmaceutical, biotechnology, and medical device companies—have driven innovation in patient care, contributed to the economic well-being of the community, and provided significant resources for professional education, to the ultimate benefit of patients and the public.”   Despite this recognition, CEJA asserts however that the “interests and obligations of medicine and industry diverge in important ways.” 

How industry’s obligation to support medical education diverges from that of medicine is unapparent, ACRE noted.  In fact, their response asserted that the opposite holds true: there is convergence of interests and obligations between industry and medicine, especially considering that the standard of care leads doctors to use the treatments and tools industry provides to them to improve the health of patients.  

Additionally, ACRE asserted that CEJA’s report clearly ignores the proven benefits and outcomes that commercially supported CME have caused in subjects including COPD, Hypertension, ICU patients, Sepsis, and hospital acquired infections.  CEJA’s report is led to a biased conclusion that does not reflect the actual data currently available on the subject.  The list of references in the CEJA report has not been updated to reflect evidence based research on this subject.  It uses similar references from previous reports to support the bias of the authors.  As a result, all CEJA’s report does is state opinions numerous times, without any evidence or factual support.

Moreover, ACRE recognized that CEJA ignores recent research that shows both Americans and physicians want industry-physician collaboration.  For example, a recent poll showed that 81 % of Americans support developing public-private partnerships between government, industry and universities to maximize resources and expertise in medical innovation and research in the U.S.

In addition, a recent survey found that 89% of physicians valued industry grants to support CME because such programs provide knowledge or skills helpful in their practice and information about medications to treat particular conditions that is up-to-date, timely, useful, and reliable.  Additionally, a large number of professional organizations and specialty groups find value in commercially supported CME.  These physicians recognize that commercially supported CME is critical to educating doctors about new drugs and treatments.

Finally, ACRE asserted that CEJA’s report fails to acknowledge that for over five years, CME has been highly regulated to prevent undue influence from industry.  CME already has in place adequate provisions for transparency and independence. 

As a result, ACRE recommended that the AMA House of Delegates reject the CEJA Report 1-A-11 to ensure that physicians continue to have access to appropriate, high-quality CME.