Reducing industry support of CME has unspoken consequences

I have worked in continuing medical education for 12 years and the argument over industry support of CME has grown tired and wearisome. Truth be told, I’m sick of it. I have always been a staunch defender of industry support of CME – and still am, for the most part – but listening to the same old arguments on both sides of the issue has become akin to the Elmo CD my 5-year-old daughter listens to every night at bedtime: so much background noise.

So, when the CME community made a kerfuffle over the recent perspective piece in the New England Journal of Medicine (Industry Support of CME — Are We at the Tipping Point?), it took me awhile to work up the motivation to click on the link and read it. As expected, the authors clearly favor restrictions to the funding of CME by industry, though they do not approach the issue with the zealotry of others I have read. However, one sentence in particular struck a chord with me. At the very end of the sixth paragraph, the authors state,

… in addition, removing the financial conflicts of interest of CME providers 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.

Probably. Will “probably” yield a more balanced mix of content. This is my problem with the anti-industry support argument – the reliance on vernacular like “probably” and “might” and “possibly” and “perceived.” If we remove speakers with conflicts of interest, content will “probably” be better balanced. If there are more restrictions on industry support, there will “probably” be beneficial effects on CME. I don’t know about you, but in my work, “probably” isn’t good enough. “Probably” isn’t acceptable.

Prove to me that content will be better balanced if we remove all speakers with a financial conflict of interest. Prove to me that a decrease in industry funding will have beneficial effects for CME. Show me research. Show me data. Enough with opinions – show me something.

Why does this issue matter so much to me?

(This is the part of the narrative where I’m supposed to launch into a diatribe about how these restrictions will hurt CME because it will mean that top faculty will not be used and innovation will be suppressed due to lack of funding. I’m not going to do that.)

People are going to lose their jobs because of it. People are losing their jobs because of it (trust me, I know). If there is less money to fund CME, there is less money to pay the people who develop it. These people are my colleagues and friends. They are dedicated professionals who have given their careers to the education of physicians. They are the human element no one thinks of whenever the issue of reducing or eliminating industry support of CME comes up. They deserve to have their fate decided by evidence stronger than “probably.”

It is easy to sit in an ivory tower and opine over the probable outcomes of reducing commercial support in CME. Just remember, these opinions, and the decisions that they affect, are not done in a vacuum. They have dramatic, real life consequences beyond those normally discussed in medical journals and editorials in the New York Times. There will be layoffs because of them. Companies will shut down because of them. Departments will close because of them. People will go on unemployment because of them. Not maybe. Not probably. They will. They are.

But, I’m a reasonable person. If you can show me evidence that the incorporation of these restriction in CME will improve physician practice and patient care, how can I argue against that? If more people are healthier and more lives are saved because of less industry dollars rolling around in CME, then maybe the loss of jobs and affect on personal lives in the CME community will be worth it. Right now, though, I’m not seeing that evidence.

You can tell me that reducing industry support will “probably” be beneficial to CME. I can tell you it “definitely” means a reduction in the CME workforce. If this is the path we’re going to go down, you better be right.

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

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  • Marc Frager

    If conventional CME is damaged, then the educational bureaucracy pushing MOL and other institutional forms of education will have much less competition. Just think how much they can charge for their programs then! The bureaucrat professors will have a nice salary increase at the expense of the lowly physician masses. And the educational freedom of the lowly physician masses will be significantly more compromised than it is now. .

  • Anonymous

    I think there’s plenty of evidence that big pharma slants the “education” it provides, but if the alternative is brainwashing by hospitals, SNFs, and managed care companies, as it seems to be, it’s still probably a wash.  Medical education is broken on a much more profound level. CME is at most, the tip of the iceberg.

  • http://twitter.com/jimeddypa Jim Anderson

    If we are truly a data driven field, then we have to respond to the evidence showing the negative impact on patients of vendor contact.

  • http://profile.yahoo.com/I4ECGBXM3U2BYYLIWS6M5VQT6U Vagus

    I have presented at several industry-funded CMEs before early in my career, but have made a personal and professional choice to no longer do so. I am unconcerned about the effects of funding on the content of the talk as I don’t think this to be a real issue. However my reasons for being against this is simple. The money eventually comes from my patients’ pockets. Every dollar pharma spends eventually comes from a patient. The money used to fly a specialist in to a conference. And to hire a driver/limo to pick him up from the airport. Food/lodgings. Honorarium.
    And so while I also recognize the benefits of these, it’s a personal choice to not be associated with these anymore.

  • Thomas Fischer

    Well said Dr Warnick .  I too have worked in CME for now 28 years and I have failed to become rich or junket poisoned.  The real truth is that upon return from  a recent course in Asia where they  still have a fun and unstifled learning environment, I was taken as to how valuable the innovation and the incredible deep analysis that takes place during the give and take of the course was apparent to me.  Little was said about how much we wanted to buy the latest and greatest, more was said about the principles of surgical care.  It is not the arrow it is the archer.  The senseless overburden of regulation that has gone up faster than the rise on the spending graphs. Smothered is the exchange of ideas and the moments where you can imagine your next dream. Rather those moments are replaced by the worry about how to comply with a new regulation or what the consequence might be. .   The amount of burden incurred upon sensible people because the regulators and those who create regulators is all formed up in the idea that “I feel it is this way” or “we probably” or ” we might” get this result.  I am so heartened that someone is standing and delivering the idea that we want EVIDENCE and not some inflammatory statistics that are at best a superficial swipe at a true analysis of some of these costs.  
    Where is it analyzed that cost of transportation, venues, licensing, legal costs, travel expense, parking, informational technology has all skyrocketed in the last ten years.  Just the abhorrent cost of the surgical instruments themselves for practical courses has risen dramatically hence reflected on the in – kind support for these venues and courses.  There is only so much you can learn online when its a practical exercise.  The simulators themselves for many courses did not exist 14 years ago.  
    I grow weary of every regulator in CME believing the default value that graft and corruption exists in every venue and industry is the bogeyman that drives these misadventures.  I see honest, hard working, talented  people being judged by feelings and suppositions in an age where we are forced to teach by evidence based medicine.  It is an abomination that these assumptions can cause a regulatory overburden that is smothering CME in the USA and in the CE.  Using words like “junket” the NEJM article just poisons the well of reason.  Name calling is an art form for those who wish to discredit the good that is done for the price of CME.  It is a business transaction, done by people with sharp discerning minds.  Disclosure is so important but discernment and and analysis of what is taught is even more valuable than regulation

  • Frank K

    If doctors can be swayed and influenced by pens and post-it notes – it would not be a quantum leap to suspect (how do you PROVE influence?)  that speakers who are being supported by Pharma could be swayed.  I’m sorry – I disagree with you that  a significant number of lecturers (probably not you) would be affected by being paid a significant fee for their talk.

    Funny thing is that the bureaucratic professors are also on the circuit for Pharma!

  • Coachpatrickv

    The industry and providers have spent so much time battling each other that, ironically, it is the patient that truly suffers.  The moral and ethical high ground does not rest solely within the medical community.  For patients to truly benefit, industry and providers need to work together.  Industry needs providers to prescribe and providers can not treat without industry. With greater regulation, reduced reimbursement, and fewer resources, industry and physicians need each other more than ever.  There is a way to improve the system if people will ask the question, “How can we work together?” rather than, “How can we distance ourselves?”

  • http://twitter.com/INHQE IHQE

    Our organization has a grave concern with industry influence over the practice of medicine and its influence over how “evidence-based research” is integrated into clinical practice  For years, peer-reviewed research has demonstrated that mammograms are ineffective for women with dense breast tissue, detecting as few as 27% of cancers (film) and 59% of cancers (digital).  Despite this, if no cancer is detected on her mammogram, a woman with dense breast tissue (40% of women overall) will receive a report stating that her results are normal. 

    Milliions of women will receive these false and misleading mammogram reports each year.  40,000 to 50,000 of these women will receive and rely upon a false negative report when they do have breast cancer, and their detectable breast cancer will be allowed to spread.  We calculate that of these women, 10,000 will be dead within a decade due to the preventable delay in diagnosis. 

    There are other screening modalities that can increase invasive cancer detection to over 95%; some of these methods are less expensive and more accurate at detecting invasive cancer than the mammogram.  However, this information is deliberately withheld from patients.  The referring physician receives a report which indicates the woman’s tissue density using the ACR’s BI-RADS Density Scale.  The ACR argues that it is up to the physician to discuss with the patient if there is need for further screening.

    However, most referring physicians are not educated about the impact of tissue density on the reliability of the mammogram, nor do they discuss other screening methods with patients (with the possible exception of MRI, which is overkill for most purposes).  Even the ACR, which advocates withholding this information from women, released results early for its ACRIN 6666 trial because it would have been unethical to withhold the significant benefits of combining ultrasound screening with mammography for women with dense breast tissue.  However, this information has not been well-disseminated, despite the near ubiquitous mammography screening for women over the age of 40 in the US.  

    This is one area in which patient advocates have had to battle industry forces and well-funded medical organizations to ensure that physicans are educated and that patients are properly informed of this material medical information.  If referring physicians had been properly educated in these medical developments, which are neither new or groundbreaking, there would have been a shift towards more effective, and probably less expensive, breast cancer screening in the US, baseed on the needs and preferences of the individual patient.   However, there are billions of dollars at stake in the breast cancer screening industry, which relies heavily on maximizing “throughput” to make mammogram (and now MRI) equipment profitable.

    Julie Marron
    President
    Institute for Health Quality and Ethics
    http://www.inhqe.com

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