Continuing Medical Education (CME): Flawed JAMA Report Blurs Line Between “Medical Communication Companies” and Accredited “Medical Education Companies”

Today, the Journal of the American Medical Association (JAMA) published a brief report (Medical Communication Companies and Industry Grants) as well as an editorial in order to explore “the financial relationships between MCCs and drug device companies.” The authors use a mixture of outdated figures, hyperbole, and blatant untruths to piece together their articles, which, according to CME Coalition Senior Advisor, Andrew Rosenberg, contain “so many inaccuracies and examples of unfounded innuendo” that “it is a challenge to enumerate them all.”

JAMA has decided not to make the report available to the public, but we have compiled the report’s content.

JAMA erroneously interchanges Medical Communication Companies with Medical Education Companies:

The most obvious sign of invalidity comes from the fact that the authors confuse “Medical Education Companies” with MCCs. Medical education companies are regulated by the Accreditation Council for Medical Education (ACCME). The two are different and practice different lines of work with different sets of rules. Medical education companies, such as those represented by the CME Coalition, are held to strict standards outlined by nationally recognized medical accreditation bodies designed to eliminate the potential for commercial influence in the content or provision of science-based curricula to physicians and other medical professionals.

The authors are correct that “Medical Communications Companies” work with pharmaceutical companies to help position products for the market, but medical education companies are regulated against doing the same. By lumping the two together, JAMA falsely inflates its data. Rosenberg added, “While the supposedly data-driven JAMA editorial writers assert that ‘(CME) that is tainted by promotion … can lead to inappropriate prescribing that can harm patients and waste money,’ they acknowledge in the same paragraph that there is no proof of any such taint due to an ‘absence of a systematic review of CME materials.'”

	Funds		Grants
Top Medical Education Company Recipients	Awarded	MEC %	Number	MCC%
Medscape	20,315,730	12	96	4.6
Postgraduate Institute of Medicine	11,274,544	7	91	4.4
Research to Practice	10,375,787	6	93	4.5
National Comprehensive Cancer Network (NCCN)	8,878,434	5	96	4.6
Medical Education Resources	7,749,794	5	40	1.9
PER Group	6,566,321	4	95	4.6
Network for Continuning Medical Education	4,704,447	3	16	0.8
Educational Concepts Group	4,464,220	3	52	2.5
Imedex	3,158,472	2	70	3.4
Med-IQ	3,430,104	2	19	0.9
Clinical Care Options	2,941,810	2	6	0.3
Pri-Med	2,884,215	2	33	1.6
National Foundation for Infectious Disease	2,499,475	2	19	0.9
Institute for Medical Education and Research	2,493,452	1	21	1
Curatio CME Institute	2,466,663	1	11	0.5
Primary Care Network	2,423,370	1	14	0.7
Scepter	2,347,355	1	13	0.6
Discovery Institute for Medical Education	2,232,059	1	18	0.9
Total*	101,206,252	59	803	38.7
*JAMA article had total at 101,566,252 – again Excel addition did not match their data.

Upon word of the JAMA article’s release, the National Comprehensive Cancer Network (NCCN), which is reported as a “Medical Communication Company” in the article, reached out to instruct the authors that this was, in fact, not true. They stated: “As a not-for-profit alliance of 23 of the world’s leading cancer centers, NCCN is a Medical Professional Specialty Society, not a Medical education or communications company (MECC).” National Foundation for Infectious Disease is not a medical education or communications company either.

Inaccurate Data:

Grant Recipients by Amount and Number of Grants Received
	Funds		Grants
	Amount	Percent	Number	Percent
Medical Education, Medical Communications, and Consulting Companies	170,803,675	26	2,077	11
Academic Medical Centers and Universities	140,928,677	21	5,427	28
Disease-targeted advocacy organizations	95,769,466	15	4,033	21
Professional Medical Associations	83,949,432	13	2,063	11
Other Organizations	80,745,433	12	1,697	9
Professional Associations	37,009,540	6	1,427	8
Hospital Systems and Independent Providers	26,339,514	4	2,040	11
Research Organizations	22,097,585	3	468	2
Total	657,643,322	100	19,272	100

The Report disingenuously categorizes the reported charitable contributions of several pharmaceutical companies as medical education payments in order to bolster the appearance of their magnitude. Furthermore, two of the organizations listed in the report and portrayed as “Medical Communication Companies” are not-for-profit foundation and do not operate as medical education companies.

It is worth noting that the authors report their conclusion as simply: “Medical communication companies receive substantial support from drug and device companies.”

In a statement from Pharmaceutical Research and Manufacturers of America (PhRMA) Senior Vice President Matthew Bennett

“As patients, we all want our physicians and nurses to be current on the latest medical technologies, including new medicines. Ongoing CME, closely regulated by accrediting bodies and government, is a valuable part of physician education – especially regarding innovative treatments for which there may be limited clinical experience – as well as an important asset to improving patient care. These contributions should not be overlooked by research and opinion pieces that exclude these important facts.

“The JAMA study and editorial make a number of assertions the authors describe as ‘indirect industry influence,’ but fail to mention strong industry rules and accreditation standards that limit such practices. For example, the ACCME (Accreditation Council for Continuing Medical Education) Standards for Commercial Support require that if a pharmaceutical company provides a grant for CME, the company is not permitted to provide content or help select speakers. Moreover, the PhRMA Code on Interactions with Healthcare Professionals expressly prohibits a pharmaceutical company from providing any advice or guidance to the CME provider, even if asked by the provider, regarding the content or faculty for a particular CME program funded by the company.

Misunderstanding and/or Distorting 2007 Senate Finance Committee Report:

The JAMA editorial lays the foundation for the entire report with a carefully plucked quote from 2007. The quote is taken from the 2007 Finance Committee Report, where the Committee noted that they “became aware through reports that pharmaceutical companies were routinely using educational grants to help build market share for the newer and more lucrative products….In 2004, Warner Lambert paid $430 million to settle claims involving off-label promotion of Neurontin.”

However, the authors left out the crux of the Finance Committee Report findings: that “the pharmaceutical industry is paying increased attention to educational grants and its compliance with fraud and abuse laws,” and that “major drug companies have limited the direct involvement of field sales representatives and sales and marketing departments in the educational grant-making process” (p. 15). The Committee staff also found “some promising trends in pharmaceutical manufacturers’ use of educational grants,” such as companies adopting “corporate policies that, on their face, do not allow educational grants to be awarded for unlawful purposes.”  Moreover, the report recognized that, “major pharmaceutical companies now conduct their educational grants activities in a way that is less likely to involve the direct transfer of remuneration from the company to physicians” (p. 16-17).

Not only did the Committee Report come out almost seven years ago, but the favorable remarks from the Finance Committee came only a short time after the Accreditation Council for Medical Education (ACCME) updated their Standards for Commercial Support in order to ensure Independence. In addition, the PhRMA Code on Interactions with Healthcare Professionals, which was strengthened in 2008, contains detailed provisions specific to the conduct and training of speakers. Under the PhRMA Code, company decisions regarding the selection of healthcare professionals are based on defined criteria such as medical expertise, reputation, knowledge and experiences in a particular therapeutic area, and communication skills. Many other subsequent settlements have enhanced the number of firewalls in place to prevent the potential for bias suggested in the articles.

JAMA Criticizes Data Policy of Medical Education Companies Despite Using the Same Policy:

JAMA strangely takes issue with online privacy in continuing medical education programs, despite the fact that JAMA’s own policy includes sharing data with undisclosed third parties. “Physicians who interact with MCCs should be aware that all require personal data and some share these data with third parties,” the article states. Ignoring the fact that internet “cookies” are as plentiful as google hits (and that JAMA itself discloses personal information to third parties), apparently JAMA did not do proper research in this part of their report either. NCCN responded to the accusation by saying: “NCCN does not sell or provide personal information to third parties for marketing purposes” as do all of the websites they listed. Also a quick check of the privacy policies of the authors websites Institute of Medicine as a Profession and Informuarly reveal both collect personal data or emails and neither has a privacy policy. Not sure why physicians should “trust” them and not medical education websites with defined policies.

Interestingly, JAMA takes issue with continuing medical education being provided in non-computer locations as well, the author positing that she would want “to go to Maui to discuss common issues in primary care.” First, that practice of paying for physician attendance at accredited events has been strictly prohibited for almost years. Second, if taking CMEs online at home doesn’t cut it for JAMA in terms of solitary learning environments, what does?

Additional Hypocrisy in the JAMA Report:

JAMA’s report concludes by revealing that the authors made no attempt whatsoever to evaluate if commercial bias actually exists in any of the programs they reported on. After publishing a report full of stale data, demands that someone “clos[e] loopholes” without a description of the loopholes to be closed, and repeated rallying cries against “for-profit” industries that have saved countless lives, this aspect was not too surprising.

Most disturbingly about the report is the blatant hypocrisy. According to the AMA annual report, in 2010 JAMA, a subsidiary of AMA, received over $25 million dollars in advertising revenue. Both JAMA and the medical education companies receive funds from the pharmaceutical industry for support of programs.

The report’s findings indicate solely that “[m]edical communication companies receive substantial support from drug and device companies. The authors unfortunately make no effort to elaborate on the content of the CME programs they attack, or the rigors of complying with the ACCME.

This is part of a long standing campaign that JAMA has undertaken to undermine access to medical information outside of medical journals. The report and editorial are disingenuous and JAMA should be ashamed of themselves for such blatant hypocrisy.

Placing unfounded doubts in the mind of physicians over data disclosure policies like those of JAMA is counterproductive and creates concern and confusion relating to the application of valuable information.

Disclosure: Thomas Sullivan an author of this report is a principle in Rockpointe and the Potomac Center for Medical Education, medical education companies which work exclusively on accredited education. They receive grants from pharmaceutical and device companies which demonstrate the supporting companies’ commitment to educating health care professionals to improve healthcare.