CME Coalition: Congressional Briefing on HIV and CME

As part of its mission to raise awareness about the importance of continuing medical education (CME), the CME Coalition held its second policy briefing earlier this week. The second program, entitled “Continuing Medical Education:  A Focus on HIV Breakthroughs,” included experts in the fields of CME and HIV treatment, including

• Dr. Jonathan Sackier, Visiting Professor, University of Virginia
• Dr. John Bartlett, Professor and Chief of the Division of Infectious Diseases at Johns Hopkins; Internationally renowned authority on infectious diseases and recipient of the prestigious 2005 Maxwell Finland Award for scientific achievement from the National Foundation for Infectious Diseases; and
• Dr. Alan Wasserman, The Eugene Meyer Professor of Medicine and the Chairman of the Department of Medicine at The GWU School of Medicine and Health Sciences; Chairman of the Board of Trustees and President of The George Washington University Medical Faculty Associates.

The first meeting, we noted earlier, focused on CME and breast cancer.   Dr. Sackier gave similar presentations both days.

Dr. Bartlett – HIV

Dr. Bartlett began his presentation by showing the audience a brief history of HIV from 1980 through the present.  He walked the audience through the various stages and decades of research, discovery and medical progress.  After discussing the political landscape and coverage of HIV over the years, Dr. Bartlett showed various pieces of evidence demonstrating how drugs and treatments reduced the number of AIDS cases for children under the age of thirteen.

In fact, because of the breakthroughs and treatments discovered by the pharmaceutical industry, the diagnosis rate of AIDS in children under 13 went from just under 900 in 1992 to under 70 in 2005.

Dr. Bartlett then dove into some of the data he works on at Johns Hopkins University and discussed some of the findings and lessons he has learned through his years of experience and breakthroughs.

Importantly he noted the changes in the average duration of life after AIDS diagnosis in a 25 year old man.  He noted that in 1995, the age of death was 28 years, and that treatments only added an additional 3 years.

However, because of the advances in AIDS treatment, he noted that between 2000-2005, the age of death was 64 years, giving men 47 added years. 

Last, but not least, Dr. Bartlett gave an overview of how complex treating HIV is and how complicated caring for patients with HIV can be.  He noted how the Department of Health and Human Services (HHS) has guidelines of 106 pages, with new additions annually.

Moreover, he recognized how there have been major challenges in HIV care. For example, there are 25 drugs, in 6 classes, and these drugs have:

• Adverse drug reactions
• Drug interactions
• Resistance
• Co-morbidities
• And the cost can be $16,600 per year.

Ultimately, based on these complexities, Dr. Bartlett recognized the significant importance of have continuing medical education to educate doctors about HIV treatments, the breakthroughs and the challenges, and most importantly, to keep up with the new drugs and clinical data.    It was clear that with help from industry there would be no way that HIV physicians would be able to keep up with these guidelines.

No other medical problem so directly affects the poor in America as HIV, the incidence rates in poorer areas are staggering.   The need to educate healthcare workers on this disease is vitally important to identifying those with the virus who are not treated.

He noted that we are near a time when HIV can be eradicated either trough prevention or a eventual vaccine.  Because the virus does not spread from treated patients the incidence should be going down if everyone with the virus was treated.

Additionally, Dr. Bartlett shared an important story.  He noted how, because he writes the US guidelines on HIV, he is no longer permitted to do work with industry.  While we agree in principle that such a restriction is reasonable and logical, there are nevertheless broader problems with physician-industry collaboration that Dr. Bartlett recognized.

Dr. Bartlett values the relationships he had with industry.   At one time, he sat on advisory boards for two major pharmaceutical firms.  At these meetings, he would have discussions with the best of the best in HIV.  They would debate issues and learn from each other.  He would learn the future of science coming from these companies. 

Since the rules banning his participation, he attempted to stay on these boards in a volunteer role or where the money he would have earned, is given to a charity on his behalf.  The company’s legal departments would not permit him to participate.  So he has for several years not been exposed to that part of science at the loss to patients and a loss to the guidelines he works on.  This is just one example of how overregulation and strict guidelines hurt patient care and benefit no one.

Dr. Wasserman – Acute Myocardial Infarction (MI)

Dr. Wasserman opened with a description of the CME program at George Washington University Medical Center with 50 grand rounds attended by 200 practicing physicians each week.  His access to experts from outside the immediate area has been seriously diminished because he can no longer ask companies to help support his programs. 

Similar to Dr. Bartlett’s presentation, Dr. Wasserman began by tracing the history of Heart Attack treatment back to 1912, when James B. Herrick, MD, published an essay on coronary thrombosis in the Journal of the American Medical Association (JAMA), nothing that, “clinical features of sudden obstruction of the coronary arteries.”

Moving along, he traced the kinds of treatment that took place for heart attacks between 1950-1985, noting things such as:

• Bed rest
• Oxygen
• Sedation
• Quiet room
• Prophylactic lidocaine
• Soft diet
• Stool softener
• Morphine

Then, he began to trace the steps of the advances in treating Acute MI, noting the improvement in flow restoration and overall reduction in hospital (21-day) mortality.  His presentation was very focused on presenting clear data and evidence, which has shown improvement in mortality in treating Acute MI over the years, largely because of the devices, medicines and technology industry, has provided to clinicians.

Dr. Wasserman noted that for twenty years he spent many days/months educating physicians around the country on the importance of timely treatment of patients with heart attacks.  Every minute a patient waits for treatment to clear the clot in the coronary arteries translates to loss of heart muscle and heart function.  If it were not for the collaboration that he had with industry in supporting the CME courses around the use of thrombolytic therapy lives would have been lost. 

Changing the medical system to adopt treatments that save lives, yet pose risks took tremendous effort.  Dr. Wasserman wondered, if given the changes in rules around CME and the diminished commercial support of CME, would the uptake of new revolutionary therapies like as reperfusion still take place at the same rate as before.

Discussion

There was a question around the billions in fines that pharmaceutical and device companies have paid for off label marketing.  The response from Dr. Sackier was that companies have not paid fines but rather had settlements with no one admitting guilt.  It is Dr. Sackier’s opinion that if there is malfeasance it should be dealt with, including prosecution.  But the vast majority of those working in the pharmaceutical and device industry are honorable people who devote their lives to bringing on new medications that save lives.  They should not be shamed because of one or two bad apples.  The same holds true for congress, though there have been bad members of congress, the vast majority of the members of congress are honorable and this does not justify banning congressman from participating in public events.

“Implicit in the staffer’s question, however, was a failure to acknowledge the very real “chilling effect” that is suppressing industry support of CME that can be directly attributable to government implication of widespread taint.  Dr. Wasserman responded that “the pendulum has swung too far” in favor of onerous reporting requirements and disproportionate media attention, and that it was having the effect of keeping experts like himself from even engaging in the practice of CME, to the ultimate detriment of patients.”

Conclusion

After the two days of policy briefings hosted by the CME Coalition, it is clear what direction the CME community and CME stakeholders must go.  We must push harder for public funding by Congress and from federal health agencies.  CME providers need the proper recognition for their important role in the health care system, and collaboration with industry must be encouraged and applauded, not criticized and shamed.

CME providers must emphasize and publicize the good work we do, the quality outcomes we produce, and the tremendous efforts we all take in ensuring that our CME and educational programs are of the highest quality and integrity.  Moreover, we must emphasize and explicitly point out our commitment to transparency and reducing any kind of appearance of potential bias, and our dedication and full-fledged allegiance to following the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support.

As we get closer and closer to realizing some of the major pieces of the Affordable Care Act, and Congress and the federal health agencies begin to implement new programs, CME will be critical to reach the true promise of health care reform.

We cannot just expect our healthcare workers to be more efficient, more cost effective, more collaborative, without additional training and education.  We can’t expect our health professionals to work as teams, in interdisciplinary environments, and communicate together, over the internet, using electronic health records and health information technology (HIT) without CME and additional medical training. 

Accountable Care Organizations, medical loss ratio, the Partnership for Patients, reduced medical errors, reduced readmissions, reduction of hospital acquired infections, and numerous other objectives that will SAVE LIVES, cannot just up rules.

We need education. We need to educate our doctors in practice now, the next generation of our medical students, and the health care system as a whole.  The health problems we will continue to see in the next decades will only continue to grow exponentially with an aging population and a growing epidemic of chronic diseases such as diabetes, obesity, and heart disease.  We can eliminate HIV either through treatment or prevention.  Either way there will be a strong need for education.

Now is the time to support CME.  We as Americans should not be focused on who is supporting the education because the proper firewalls are in place to ensure quality, integrity and independence.  We as Americans should be focused on educating our doctors, before it’s too late.