Bias in CME due to the presence of commercial support is overrated

So I missed out on the whole CME outrage that came up earlier this year in a Archives of Internal Medicine study, but I do have a theory about it that I’d like to try out.

I’m not interested in getting into the “perceived potential bias” vs “actual bias” argument – which is a good one and one Tom Sullivan wrote about extensively – but would rather take a look at two commonly held beliefs which were supported by data from this study and then postulate my own theory.

Here are the two beliefs supported by the study:

  • A CME activity with multiple funders has less potential to be biased than a CME activity with a single funder. Both of these have more potential to be biased than an activity with no funding from industry.
  • The greater the percentage of an activity’s overall costs covered by a single commercial supporter, the more potential it has to be biased.

And here is my theory: the number of commercial supporters and amount or percentage of commercial support has little impact on the potential for bias.

I got myself into a little hot water awhile back for using the phrase “I’m going to let you in on a little secret.” Throwing caution to the wind, I’m going to let you in on a little secret: CME providers don’t talk to commercial supporters about content. We don’t talk to them about speakers. We write our own needs assessments. We write our own learning objectives. We develop the content ourselves and pick our own speakers. There could be one commercial supporter or twenty commercial supporters; the content is still going to be the same.

Why? The ACCME. Scoff all you want, but it’s true. Any financial gain that might be earned by slanting a CME activity to appeal to a single funder is not worth the risk of losing your organization’s ACCME accreditation. That seems to be a point that gets lost whenever discussions of CME and the inadequacy of the ACCME are brought up. No, there are not a lot of organizations that have lost their accreditation status, but there doesn’t have to be. Just having one is enough to put the fear of God into the hearts of any accredited organization.

Look, there certainly are challenges involved in putting together a balanced, unbiased CME program, and there are elements involved that could increase the potential for bias. Working with third party organizations or faculty unfamiliar with the ACCME’s Standards for Commercial Support is one example. I have worked on programs in the past that were primarily funded by participant registration fees and were much more challenging in terms of bias and balance than programs entirely funded by commercial support. But then, that’s why people like me have a job: to teach those who don’t understand the standards involved in producing CME and assure its balance and validity.

My main point is this: the potential for bias in CME due to the presence of commercial support is vastly overrated by those not intimately involved in the production of CME on a day-to-day basis. The perceptions revealed by this study are not congruent with my reality as a CME Director.

Derek Warnick is a CME Director who blogs at Confessions of a Medical Educator.

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  • Bradley Evans

    There are reasons to worry that bias is present in commercial CME activity. Often the presenting physicians have financial ties to the medicines they discuss. Second, trade names of the medicines are mentioned in these presentations. Third, presenters are allowed to discuss off-label indications for these drugs. This is what I find when I examine publications of commercial CME companies.

    Pharmaceutical companies take their marketing seriously. Medical journals publishing articles about misleading statements or bias in drugs ads will lose their funding. In one case, one journal replaced their entire editorial board in order to regain pharmaceutical company funding. In other words, a person may say “I am not biased,” but bias exists because the companies actively prevent any opposing views from being aired.

    Finally, Mr. Warnick’s appeal to ACCME accreditation ignores the very real possibility of regulatory capture of this organization. An additional problem with ACCME accreditation and disclosure requirements is that these are proxies for what you are wanting to achieve. They lose their value. People even use these proxies to certify that bias doesn’t exist, when, in fact, it does. This characteristic of proxies losing all value once they start being used is called Goodhart’s Law. I assume this is what Arnold Relman was referring to in his recent criticism of the NEJM’s disclosure policies.

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