UCSF Editorial: Industry Support of CME are We on the Tipping Point – Doesn’t let the Facts Get in the Way of Their Opinion

Accredited continuing medical education (CME) refers to those educational activities that have been deemed to meet the requirements and standards of a CME accrediting body (ex., the Accreditation Council for Continuing Medical Education (ACCME); the America Osteopathic Association, the American Academy of Family Physicians). 

“Certified CME” refers to those activities in CME that carry CME credit offered by one of the three grantors of CME credit in the US: the American Academy of Family Physicians (since 1948), the American Medical Association (since 1968), and the American Osteopathic Association (since 1972). 

All organizations involved in Accredited and Certified CME in the US have adopted and operate under the strict firewalls which are promulgated, monitored and enforced through the “Standards for Commercial Support (SCS): Standards to Ensure the independence of CME Activities” of the ACCME, to which the entire profession of medicine adheres.  The SCS (most recently revised in 2004) set standards for relationships between Accredited and Certified CME Providers and the pharmaceutical companies, which may provide grants to CME Providers. 

Faculty of certified Continuing Medical Education (CME) programs are selected, directed, reviewed, evaluated and paid by the Accredited CME providers, and have no relationship with the manufacturers.  Indeed, not only is this a requirement of SCS, but also of the “Code on Interactions with Health Professionals” of the Pharmaceutical Research and Manufacturers of America (PhRMA Code). 

Despite the significant firewalls in place, over the past several years, there has been a growing criticism surrounding CME that is commercially supported by pharmaceutical manufacturers.  In light of all of the positive outcomes industry-supported CME produces—in both improved patient care and physician knowledge and competency—these critics believe that the “potential” for bias or “conflict of interest” warrants the removal of industry supported CME. 

As a result of criticism from anti-industry groups and close scrutiny by the media and Congress, coupled with large legal cases that have lowered the reputation and integrity of pharmaceutical companies, the funding of industry supported CME has declined significantly over the past several years.  In fact, in 2010, commercial support of CME was down to 31%.   

Consequently, a recent editorial by Michael A. Steinman, M.D., UCSF published in the New England Journal of Medicine (NEJM) attempts to take credit for this decline of commercial support.  After citing various developments in the CME industry—such as the AMA CEJA Report adopted this past spring, and the Physician Payment Sunshine Act—the authors noted that CME has “reached a tipping point.”  They predicted that the “slow, uphill progress in limiting industry involvement appears to be accelerating, and further restrictions are likely to become more widespread.” 

Ironically, the authors come from the University of California, San Francisco (UCSF), where the University recently received $85 million dollars from Pfizer for a joint drug discovery center and the Chancellor of the Medical School, Susan Desmond-Hellmann has no such qualms about physician-industry collaboration.  In fact, Desmond-Hellmann said that she tells professors and researchers who will not work with industry that it’s a “huge mistake,” because if you want to get your discovery to society, you either need to start a company or work with a company to commercialize a product.  Clearly, these UCSF professors never got her message.  

The authors claim that these changes “resulted from shifting norms in the culture of medicine.”  The article fails to acknowledge, however, that there has been equally shifting norms in the culture of medicine and CME with respect to transparency, management of conflict of interests, and a tremendous amount of rules and regulations to ensure evidence-based CME.  

In addition, the article is troubling for a number of reasons.  First, the article ignores the significant financial hurdles that CME providers continue to face in light of decreased commercial support, increased regulatory and accreditation standards and requirements, and an unstable economy.  While the cost of producing CME is increasing, and more organizations are calling for greater measures and more evidence-based content, the number of CME providers, faculty, and institutions with adequate resources is rapidly declining.  

The authors also clearly ignore the statistics, which demonstrate the impact this reduction in funding, and other factors are having on CME providers.  While the authors believe it is “highly feasible” to continue offering high quality CME without commercial support, they fail to recognize recent data showing the contrary.   

For example, in 2010, accredited providers produced more than 81,000 activities, a 14.2% decrease of activities from 2009, and a 27.8% decrease in activities since 2007.  Also in 2010 there were over 660,000 hours of instruction which is 29,000 (4.2%) fewer hours than in 2009.  In 2010, 1.5 million physicians participated in live courses this is down from 1.6 million in 2009 a 8% reduction.  A  recent survey conducted by the Society for Academic CME (SACME) Research Committee and the Association of American Medical Colleges (AAMC) also found decreased access to high quality or appropriate CME.   

The author’s assertion that costs can be reduced by avoiding high-priced venues fails to recognize that such venues are rarely used by other commercially supported CME providers, and various AMA, AdvaMed and PhRMA regulations prohibit industry support such lavish venues.   But perhaps lavish venues are not that unusual for UCSF CME.  A simple perusal of the UCSF CME Website lists course titles such as Quintessential Imaging in Quebec, Women’s Imaging in Wine Country, Cannabis Therapeutics in Tucson. 

Additionally, the article fails to recognize that although the number of ACCME-accredited providers grew steadily until 2007, the ACCME lost 42 national providers (6%) since 2007, including 13 providers (2%) between 2009 and 2010.  The number of accredited providers now is at its lowest level since 2002. 

Moreover, health professionals will also face challenges accessing appropriate, high quality CME because the economic climate, coupled with decreased commercial support, has affected state-accredited CME providers, universities, and even the federal government.  For example, at least one medical school^[1] and the Department of Defense (DOD) closed their continuing education offices this past year, and the number of CE providers accredited by state medical societies fell by 18.7% to 1,450 between 2003 and 2010.^[2]  AMA’s Council on Medical Education noted that unabated, this trend could “impede the delivery of cost-effective, quality, accessible certified CME” dealing with local health issues.  

Second, the authors clearly ignore the fact that physicians are already reporting a decline in the quality of CME they are receiving.  Moreover, physicians are spending more time and effort locating appropriate CME.  For example, a recent survey revealed that over 25% of doctors found CME quality decreasing and 52.2% of physician respondents said they have lately had to spend more time and effort locating appropriate CME. 

Third, the authors fail to cite any orginal evidence and alternative sources or viewpoints, which demonstrate the positive value of commercially supported CME.  For example, the authors failed to mention a recent study which showed that physicians who attended an industry-supported educational activity were 50% more likely to provide evidence-based care for COPD than nonparticipants were.^[3]  Another program showed that the patients of physicians who attended an industry supported educational activity were 52% more likely to receive evidence-based hypertension care than those seen by health care providers than nonparticipants were.^[4]  

In addition, the results of a recent study showed that “heart disease patients whose general practitioners participated in an interactive, case-based CME program had a significantly reduced risk of death over 10 years compared with those whose doctors didn’t receive the education.  Commerically supported CME also was recently shown to improve treatment for myocardial infaraction.  

Discussion 

When CME providers, academic institutions, and industry are not able to work together, physicians will lose a valuable source of information and scientific evidence about new treatments and therapies.  CME is necessary because new drugs are complex chemical products that require a close understanding, and because research and development often involve the creation of new products.  However, the creation of new products will produce enduring social gains only if physicians are properly trained and educated about them. 

The producers of pharmaceutical products and medical devices need the ability to collaborate with CME providers and academic medical institutions to offer objective and independent CME programs, which follow the ACCME SCS.  CME also provides the function of making sure doctors are aware that new therapies, indications or treatments are actually on the market.

Today’s CME professionals have the experience, expertise, and long-term commitment to manage the challenges posed by an increasingly complex healthcare environment.  Additionally, many stakeholders that comprise the CME enterprise have taken significant steps toward quality improvement.  CME programs with commercial support are no different from other CME programs because the audiences are the same.  CME programs are not provided to “naïve audiences.”     

Commercially supported CME programs speak to physicians who face their own reputational and liability risks when they prescribe drugs.  In most of these sessions, physician questioning plays a prominent role, and there is little reason to think that a commercially supported CME program would push improper risk-making claims given the risk the provider could have of losing its accreditation or other legal sanctions from the FDA, ACCME, HHS OIG, or DOJ. 

The authors claim that experts will continue to contribute to CME if commercial support is removed or continues to decline.  They assert that reducing financial “conflicts of interest” will probably “yield a more balanced mix of content, since the existing system provides incentives for developing symposia focused on drug therapy so as to attract industry sponsors.”  However, the ACCME guidelines ensure that the content of all accredited CME is evidence based.  Moreover, physicians do not have the time or means to provide CME without some form of reimbursement, which is at fair market value.   

Physicians overwhelmingly value industry-supported CME and attendees overwhelmingly assert that industry-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.  In a recent survey of physicians, 89% of participants valued commercially provided grants to support CME.  According to the survey, 76% of participants said they attended an industry sponsored education program.  About 9 in 10 attendees said information provided at educational programs is up-to-date and timely, useful, and reliable.  More than half of attendees said they often gain knowledge or skills helpful in their practice and those who practiced in rural areas (86%) were especially likely to attend. 

Conclusion 

Ultimately, the authors believe that that CME will be better for the decline in industry support, however, the industry must find ways to avoid “unintended consequences in other aspects of physician–industry relations.”  As noted above, however, the reduction in commercially supported CME has already had an adverse effect on the CME industry.

In light of all the health care reform goals an initiatives to improve health care quality and patient outcomes, while reducing health care costs, and using new payment models, care systems, and new technologies, physicians and health care professional will need high quality continuing education.  At a time when our country is facing booming epidemics in obesity for children and adults, diabetes, and other cardiovascular diseases, now is not the time to be advocating for removal of a source of funding to keep our physicians educated and up to date. 

The authors of this article failed to adequately consider the research and evidence in existence, which overwhelmingly show that commercially supported CME is not biased.  Specifically, evidence from three large studies including one from the same author at UCSF and not quoted in his editorial, show that there is almost no bias in commercially supported CME (Cleveland Clinic; Medscape, and UCSF).  Moreover, the authors failed to recognize the significant literature, which shows that CME—both commercially and non supported—improves patient outcomes. 

In the end, the health care community and CME stakeholders should be advocating for more funding and greater collaboration between industry, academia, government and CME providers.  Separating industry and other CME stakeholders into separate silos will only delay further treatment to patients and knowledge to health care professionals.  The adequate firewalls and regulations are in place to ensure the high quality, integrity, and evidence-based nature of commercially supported CME, and therefore, old concerns are no longer valid.