The ACR’s annual meeting serves many purposes. First and foremost, it is the premier scientific meeting in rheumatology—a chance for those of us in academia to come together in one place to exchange ideas, develop collaborations, and plant the seeds of new investigations. It is also a chance for us to see and be seen, hopefully impress our colleagues with our newest research, and gossip about who is doing what.
For clinicians (by far the largest group in attendance) the meeting is an opportunity to discover the cutting edge of research and review and consolidate their understanding and approaches to therapy of rheumatic diseases. For everybody who attends, the meeting is also a social occasion—a chance to see old friends who share an interest in rheumatology but who are geographically distant from you.
Influence for the Price of Chow Mein
Among the many old friends whom I saw in Washington last November was someone who had left academia for employment at a pharmaceutical company. We chatted in the halls of the convention center and had an opportunity to have lunch together at one of D.C.’s fine restaurants.
At this lunch, I did something that was highly unusual for me and certainly for the attendees of the ACR meeting: I picked up the check. It is not often that I have the opportunity to subsidize the pharmaceutical industry or influence an employee of major pharma, although I readily admit that lunch in D.C.’s Chinatown doesn’t make much of a dent in anybody’s budget. Nonetheless, by the logic of the people in charge of continuing medical education (CME), I could be exerting undue influence on this pharmaceutical employee because even the smallest gift (e.g., a pen) carries more than token influence. Fortunately for my friend in pharma, I didn’t intend to fill out any disclosure forms or put up a slide disclosing our lunch at his next presentation to management.
There have clearly been instances when the covert influence of the pharmaceutical industry on the content of CME has been documented and the clear implication has been that medical practice was negatively influenced. But if CME has as little effect on actual practice as Medicare seems to suggest, does the commercial influence matter so much?
Clearly, the bulk of the advertising and promotion funds spent by pharmaceutical companies is directed at physicians, and the industry must think that it is getting value for its money. Much of the pharmaceutical funding goes to supporting CME events for physicians, and the majority of outside speakers who visit any institution are funded, at least indirectly, by pharmaceutical company donations. Moreover, from the Frank Netter illustrations that were used widely when I was a medical student to the PowerPoint images used by many medical-school lecturers today, basic teaching materials have also emanated from the pharmaceutical industry. Thus, the continuing education of clinicians, evidence for which is a condition for licensing and renewal of hospital privileges, is highly subsidized by the pharmaceutical industry. Critics of this system often seem aghast because the continuing education system for physicians could be susceptible to disguised (and not-so-disguised) commercialism.
Regulatory Burden on CME
In response to the potential for abuse inherent in this system, the Accrediting Council for Continuing Medical Education (ACCME), the accrediting body for continuing medical education, has developed a series of regulatory requirements that govern the provision of CME. Not least of these requirements is that all presentations be vetted for undue pharmaceutical company influence. According to the ACCME, speakers must make a full disclosure of any potentially conflicting commercial interests prior to any presentation.
If the organizers of a CME activity believe, based on what the speaker has disclosed, that the speaker has a commercial interest that may conflict with the goal of giving an honest and unbiased interpretation of the data and clinical recommendations, they may take several approaches to resolve this problem, including prior review of the material to be presented and labeling or elimination of offending portions. Alternatively, the organizers may instruct speakers to “…reference the best available evidence,” although why you would invite somebody to speak who does not do that is beyond me. Finally, the audience can be polled for their opinion on the objectivity of the presentation, an approach most commonly taken on an informal basis since most physicians seem to have fairly strong opinions on the subject. [To learn more about the ACCME’s policies on resolving personal conflicts of interest, visit www.accme.org/index.cfm/fa/faq.detail/category_id/6a4a0ce7-1e62-4fc9-a437-1e6e7eedecb2.cfm.
Needless to say, these regulations are often resented and compliance can be quite burdensome. As a director of a CME program, I have had to take a course in writing educational objectives—not something I would like to repeat and not something for which I see much value, either. Indeed, for a time, the NYU Division of Rheumatology dropped CME credits for rheumatology rounds because the regulatory burden seemed too great. I have yet to hear of or see a study documenting that all of these requirements add anything meaningful to medical education or (more to the point) influence the prescription of new or expensive drugs. Indeed, the studies, which suggest that undue commercial influence of CME leads to increased prescription of proprietary agents, never include an appropriate control (e.g., Is there a concomitant increase in diagnoses of a given condition following the presentation?).
Inherent in the proliferating regulations for CME is the view that the audience for CME talks is a mass of clinicians who uncritically receive information from speakers who themselves have uncritically received and then presented information from the pharmaceutical companies. An unscientific survey of people leaving medical lectures does not support this view. A more scientific examination of the written comments made by attendees at the NYU Course in Advanced Rheumatology also suggests a great deal of skepticism and strong basic knowledge of the subject matter on the part of people in practice in rheumatology.
Trading the Carrot for the Stick
More tellingly, Medicare must not believe that CME successfully indoctrinates physicians, either, because it now pays physicians to document adherence to standards of care.1 For example, it has been known for years that individuals who have had a myocardial infarction should be administered beta blockers and aspirin, and lecturers throughout the country stress this information to residents and attending staff at CME events. Nevertheless, compliance with therapeutic guidelines by physicians remains limited unless a variety of other measures are taken (computerized automatic ordering and the like).
Similarly, handwashing in hospitals unfortunately does not seem to increase after lectures and discussions; increasing handwashing seems to require the prospect of penalties. Studies on the effect of CME on the practice of medicine indicate that CME exerts only minimal effects on medical practice.2 More extensive programs and automated ordering systems have been put into place by hospitals to improve compliance with recommended guidelines for medical practice. Thus, the evidence suggests that not only are we impervious to brainwashing but that we don’t seem to listen, either. So, Medicare will now pay physicians to document adherence to guidelines and it is likely that pay-for-performance is the future for many common conditions.
What Does CME Teach?
If CME does not change the way physicians practice, what is it good for? CME plays many roles. In some states, evidence for minimal attendance at CME events is a necessary condition for maintaining a license to practice. Many physicians also take home new ideas about treating specific difficult patients from CME events and can become familiar with new approaches to therapy. Moreover, CME is good for morale: knowing there is progress in the treatment of difficult diseases makes it easier to face the patients who come to us for help with those diseases. Finally, medicine and—in particular—rheumatology, are cognitive pursuits, and education is at the very center of how we perceive ourselves as professionals. Continuing education is as much part of the fabric of our profession as the stethoscope; CME makes us more than just “healthcare providers.”
Continuing education is as much part of the fabric of our profession as the stethoscope; CME makes us more than just “healthcare providers.”
Traditionally, medical schools and hospitals were the main distributors of CME, but over the past few years CME has burgeoned into an industry with nearly $1 billion in revenues providing nearly 67,000 CME activities in 2003. That year there were 697 accredited providers of which 100 were for-profit organizations generally hired by pharmaceutical companies to arrange CME events.3 What can we make of all of this educational activity that is regarded so lightly by Medicare, among others? And what are we to make of all of this economic activity in pursuit of such ephemera?
It is obvious that much of the funding that drives and supports CME comes from the pharmaceutical industry and—to many observers—pharma funding taints most CME. There have clearly been instances when the covert influence of the pharmaceutical industry on the content of CME has been documented and the clear implication has been that medical practice was negatively influenced. But if CME has as little effect on actual practice as Medicare seems to suggest, does the commercial influence matter so much?
Fortunately for my guest at lunch at the ACR meeting, I left my PowerPoint slides at the hotel. Not only did I not have the opportunity to bore him and ruin an otherwise pleasant meal, but I also did not have to bring anybody along to review what I had to say before I said it. I did not even have to offer a post-prandial evaluation of my conversation.
Dr. Cronstein is Paul R. Esserman professor of medicine at NYU School of Medicine in New York.
- Pear R. Medicare, in a different tack, moves to link doctors’ payments to performance. New York Times. December 12, 2006.
- Davis D, O’Brien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA.1999;282(9):867-874.
- Steinbrook R. Commercial support and continuing medical education. N Engl J Med. 2005;352(6):534-535.