Debating medical promotion and education 1

Back in June (Listening to industry: what’s the ROI of medical education?) I commented on some statements made by Bill Cooney, the President & CEO of Medpoint Communications, which is, in its own words, “a global leader in diversified communications services for leading pharmaceutical and biotechnology companies.” Cooney recently commented on my post, and this has provoked a debate which I hope may continue. In any case, I’ve copied and posted here the two rounds of debate. Readers are invited to join the discussion.

Bill Cooney, on August 13, 2010 at 1:41 PM:

As the “industry defender” cited in this blog, I’d like to clarify a few things.

1. My column, quoted above, does not have anything to do with CME. Rather, I discuss a whole different animal: within-label, company-sponsored speaker programs. My column is accessible only through an industry e-newsletter, and everyone within industry understands the category. I use the word “education” just once, as in “peer education activities,” but I use the terms “virtual speaker program,” “peer-to-peer programs,” and “speaker events” 20 or 30 times. I don’t know how any reasonable person could possible think I’m referring to CME in my column.

2. Regarding ROI, I think it’s pretty clear that I’m a “defender” of NOT linking ROI to within-label speaker programs. Is that a bad thing? I also simply make the point that whatever the ROI, using virtual formats lowers overall costs by 67%. This is presumably in-line with the goals of “industry critics” that drug companies should lower overall spending on promotion so drugs can be made more affordable. To my complete bafflement, Mt. Husten implies that my comments on lowering costs are somehow a bad thing.

3. Regarding the Physician Payment Sunshine Act, I speculate that the Act may disincent physicians to attend dinner meetings, and I offer up that this may lead to more virtual speaker programs. Clearly, this means that industry would NOT be providing free dinners, but instead would provide virtual meetings that focus on the speaker and medical information. Once again, I would think that industry critics would see the elimination of dinner “gifts” is as a good, not bad, thing. And I think that is “shaking things up” quite a bit!

4. Regarding the final two points raised by Mr Husten above, it’s important to remember that all my comments have to do with within-label speaker programs, not CME. So the “content” Mr. Husten mentions is FDA regulated, and has no relationship with the “duties of the sales rep” as he states. These programs are defined by the FDA as promotional activities, and they are one of the informational resources that sales reps offer to physicians. Mr. Husten uses the quotes “the program supports the rep” and “the pharma rep gets invaluable time with the HCP” with an implication these comments are revealing some hidden agenda on the part of industry. These speaker programs invariably include full disclosure to all physicians that they are directly sponsored by industry and can only present within-label information; it’s abundantly clear this is not independent CME. Although these are overtly company-sponsored programs, they include distinguished speakers and are valued by the physicians who chose to attend. These programs are among the best examples of industry bringing “good” value to physicians in the form of peer education (dare I use the word?) that must reflect fair balance on safety and other issues, as regulated by the FDA. Again, I’d expect that industry critics would much rather see pharma bring this kind of value to physician offices, instead of free meals.

I have a lot of respect for the viewpoints of many industry critics, and much of the reform towards more ethical marketing practices over the last decade has been beneficial and often fueled by the critics. But industry critics needs to resist the temptation to interpret everything they see as wrong-doing, and confuse meritorious actions by industry with vaguely subversive schemes, as Mr. Husten so clearly implies.

To address the comment by Mr. Hartung, you’re right, MedPoint is NOT a CME provider! We don’t claim to be, not even close, and if you or others are confused, it may be because Mr. Husten fails to make the distinction when he talks about “the ongoing debate over industry influence in medicine,” which has often been a debate about CME.

For the record, two years ago our company divested PeerPoint Medical Education Institute, LLC, which now is an independent company with no connection to MedPoint. Since that time, PeerPoint has been re-accredited by the ACCME under the latest, most rigorous accrediting regime. PeerPoint achieved re-accreditation “with distinction,” the highest category of accreditation received by only 5% of CME providers. I am very proud that I had a hand in founding PeerPoint over a decade ago, and if you wish to take a look at PeerPoint programs, I am sure you will find that its education activities greatly benefit the medical community, devoid of any bias to industry, with no involvement by pharma sales reps. That’s not to say that Mr Husten won’t imply that something dark and subversive is going on at PeerPoint, too.

Larry Husten, on August 13, 2010 at 2:37 PM:

Dear Mr. Cooney– Thanks for your long and thoughtful response. I am sorry if anyone reading this made the assumption that you were talking about CME activities.

Nevertheless, the fundamental points remain unchanged. If this is not CME it is still a type of education, and the fact that you utilize speakers with academic credentials and thought leaders is hard proof of this. The real problem here is that industry should not be involved in educating or training physicians in any direct way. With CME it’s worse because there is a pretense of objectivity that is simply not the case.

I take your point about virtual programs doing away with the problem of industry-funded meals. But the meals were never the real problem, only a symptom. And virtual programs have the virtue– from industry’s point of view– of being less likely to attract notice or bad publicity. Or so they think.

Regarding the main point about return on investment (ROI): you can slice and dice this however you like but there’s still a cat-and-mouse game going on here. Just because industry isn’t allowed to calculate the ROI of a speaker program doesn’t mean that they are not intensely interested in the ROI, or, in fact, that the ROI is not the essential motivation for the program. It was this aspect of your interview that first caught my eye and why I thought it might be of interest to my readers. Are you seriously willing to argue that industry-funded events are not ultimately motivated by the business purposes of the companies?

I will be very happy to continue this discussion and debate if you are willing.

Best,

Larry

Bill Cooney, on August 16, 2010 at 1:25 PM:

Mr. Husten – I do think the headline of “… the ROI of medical education” is misleading to readers because “medical education” strongly implies CME. I didn’t use the term “medical education” once in my column. I think these distinctions in terminology are not just parsing, but quite important. The entire rest of your criticism of ROI is set upon the false premise that I am discussing medical education. I’m not implying that you purposely made this error, but I think it matters and you should consider correcting it.

Legally and quite overtly to the faculty and audience involved, speaker programs are sponsored, within-label activities, not independent medical education. The FDA does not view them as any less susceptible to regulation than journal advertising or sales rep promotion.

Counter to what you say above, industry IS allowed to calculate ROI for speaker progams. I am aware of no legal or regulatory prohibition. Most companies voluntaily refrain from doing so out of an excess of precaution, as they do with so many practices these days.

You evidently believe that speaker programs are conducted with a false pretense that they are “medical education” and I can understand your concern..These programs involve speakers with academic credentials, and in some ways are similar to indepedent education. In the past, the line was not always so clearly drawn with some CME activities. The blurring of lines between CME and promotion has been massively reformed and stopped happening about 8 years ago. It’s unfortunate that it occurred, and perhaps the distrust among you and others is due to this legacy.

But I disagree that, today, industry plays a “cat and mouse game.” Should you familiarize yourself with how these programs are currently conducted, you’ll find that sponsors go out of their way to clarify that these are not independent education, but rather, within-label, company-sponsored events. It’s made very clear, and physicians are smart enough to understand the difference. It’s really not fair to accuse industry of engaging in deception.

To address the question you pose, yes, I do think industry-funded events are motivated by business purposes. Those purposes include building positive relationships with the medical community, as well as supporting product sales, without which they have no business.

I’d like to ask you, what’s so inherently bad about ROI? I believe that one can “do well by doing good” and both profit while benefitting other parties in non-monetary ways. I think that today, speaker programs are generally great examples of that win-win. The opposing school of thought is that the profit motive generally corrupts and excludes good deeds. Perhaps that difference is why you and I won’t see eye-to-eye on this issue.

Larry Husten, on August 16, 2010 at 8:15 PM:

Mr. Cooney,

I want to thank you again for the thoughtful tone of your remarks. It’s nice to engage in a debate that doesn’t sound like a Cable news screamfest.

Nevertheless, I feel compelled to dispute the underlying basis of your argument. If I understand correctly, you are arguing that “sponsored, within-label activities” are completely distinct from “independent medical education.” Although problems may have existed in the past in both these categories, you appear to believe that these have now been largely resolved, and that promotional programs conform to reasonable and appropriate regulatory restrictions while supporting the legitimate business activities of its sponsors, and that industry-supported CME programs exist independently of the commercial interests of companies and contribute significantly to the medical education needs of practicing physicians.

I disagree with both sides of the proposition. My main point is that promotional activities are “successful” to the degree that they emulate legitimate education programs, and that CME programs are “successful” only to the degree that they support the commercial interests of the sponsor. I will make only a few key points right now.

Regarding sponsored activities, I have little problem with advertising, promotional literature, etc. I believe quite strongly that pharmaceutical and device companies should profit from their products. But I don’t believe that academic and practicing physicians should be involved in any way with these promotional activities or that they should be compensated for speaking or writing on behalf of industry products. Quite simply, the interests of academic and practicing physicians should be 100% aligned with the interests of their patients. By engaging in promotional activities physicians are inevitably compromised. And, it follows, physicians should not listen to their colleagues who are paid to speak on behalf of a product or a company. Whether these activities occur at a dinner at an expensive restaurant or in the physicians’ office computer (with or without a sales rep by the side) makes little difference.

Regarding CME, although some of the worst abuses have indeed been curtailed, there is no question that CME continues to serve primarily as a marketing tool for industry. I do not argue that all CME is pure marketing, or that good CME programs don’t exist. But I do argue that the fundamental reason for the existence of the vast proportion of sponsored CME programs is to provide marketing support for commercial products. In addition to the commercial purpose of CME programs– as evidenced by the astonishing ~ $1 billion spent each year by industry on it– CME has several additional, pernicious side-effects that seriously damage contemporary medical culture.

The first side effect is the impact of CME on the agenda of medical education. The overwhelming vast majority of commercially supported CME is product-related and squeezes physicians into the uncomfortable and unnatural role of pill pushers or device implanters. Medicine– and therefore medical education– needs to be much more than that.

The second side effect is the impact of the showering of CME dollars on physician finances. For many physicians who are frequent CME speakers, the income boost helps alleviate the depredations associated with the (relatively) low wages of academic medicine. As the CME income becomes vital to pay for the the college tuition and the like, the independence of the physician is threatened. How likely is it that a physicians critical of a product will continue to receive speaking fees from that company? (I should also point out that the near complete absence of industry critics in CME programs is perfect evidence of why, in fact, commercial CME is biased. If it were truly unbiased it would fully embrace its critics!)

I’ll stop for now, but will be happy to continue this interesting debate.

Best,

Larry

One comment

  1. Pingback: The debate over CME and industry influence continues « CardioBrief

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