Does anyone really think that commercially supported continuing medical education (CME) is truly independent? Or does anyone really think that it has the primary goal of delivering quality medical education?
A few weeks ago John Fauber and colleagues wrote an important story in the Milwaukee Journal-Sentinel and MedPage Today about the role of CME in helping to fuel the explosion of use of testosterone. Responding to the article in an Op-Ed piece, Andrew M. Rosenberg, a senior advisor to the CME Coalition, said that Fauber’s article and previous articles in the “Slippery Slope” series seek “to undermine CME’s role as an essential tool for doctors to hone their craft and stay up-to-date on cutting-edge treatment techniques.” Rosenberg goes on to write that “CME is among the most valuable — if unheralded — components of our healthcare system and has a demonstrably proven track record of improving patient outcomes and saving lives.”
Let’s first look at that “proven track record” claim. To be clear: there are no good studies showing the value of commercially-funded CME. The studies that do exist are pathetic CME-industry funded attempts to justify their existence. They could never pass the muster of serious review. (I would be very happy to debate the virtues of any study that Rosenberg or others care to put forward.) Moreover, the very idea that CME proponents seek to use these studies to justify their existence is a perfect example of why these groups should not be entrusted in any way with anything related to genuine medical education. The distorted use of data to support their business interests mirrors the distortion of data that we see so often in commercial CME programs, in which existing data, often weak or inconsistent, is manipulated to support a commercial position, with little or no acknowledgement of opposing positions. Simply stating that CME has a “proven track record” is not by any means the same thing as actually having a real track record.
Like previous defenders of CME, Rosenberg blithely cites “the extensive protections put in place by the Accreditation Council for Continuing Medical Education (ACCME) to prohibit commercial bias or involvement in the development of curriculum or selection of participants. These protections that make up ACCME’s Standards for Commercial Support are specifically designed to mitigate bias and generate a high degree of transparency, and are among the most restrictive limitations against stakeholder conflict of interest in any context imaginable.”
But let’s be very clear here: these “protections” are just window dressing, designed to give the appearance of objectivity and transparency. The ACCME is supposed to be a watchdog but everyone knows that it is the commercial CME industry’s lapdog. And everyone knows that CME programs are biased– it’s often clear just from the title of the program and the makeup of the faculty. Here’s one ultra simple test: is there a participant in the program who opposes the commercial interests of the sponsor?
Here’s another question: even if the program is scientifically “accurate,” is it necessary, does it respond to a genuine medical need in a physician’s practice, or does it rather serve the interest of the sponsor? The perfect example of this is the “Low T” example in the stories cited by Rosenberg. There has never been a “low T” problem that requires broad physician education. The medical community– or at least that portion of it that hasn’t taken money from the testosterone manufacturers– knows this fact.
Finally, another argument often invoked (and implied in Rosenberg’s remarks) is that sponsor involvement is severely restricted under the current regulations. But of course this is purely for show. The sponsor doesn’t need to be involved because the commercial CME company and the faculty members know exactly where the money is coming from. Since companies like to stay in business, and faculty members like to send their kids to college, they are in it for the long haul. And if they want to stay in business they will give the sponsors what they want to hear.
Rosenberg writes about the “Low T” campaign that “some CME courses cited the efficacy of the treatment in a variety of contexts because that was the science at the time. It was only earlier this year that a scientific consensus began to emerge against testosterone therapy…” Simply put, Rosenberg couldn’t be more wrong. It appears that he’s been drinking from the CME Kool-Aid, and so again showing why this issue is a perfect demonstration of the problem of commercially supported CME. The plain fact is that there was never any good or reliable evidence to support the broad programs instigated by the testosterone manufacturers. “Low T” was an invented disease to sell a product. But of course you wouldn’t know that from the CME programs on testosterone. Those programs gathered all the preliminary or low quality studies to cobble together an excuse to sell low testosterone. There was no attempt to present any other view in these programs, though this was by far the mainstream medical perspective.
Let me be clear: I don’t oppose CME in general. In any profession, and medicine in particular, CME is absolutely essential. But commercially supported CME is another matter entirely, and should not be confused with noncommercial CME, though of course the advocates for commercial CME try to do exactly that. They hide behind the banner of education, though in fact they are an arm of the sales and marketing departments of pharma and device companies.
An education curriculum should not be designed by pharmaceutical companies or the medical education or communications companies that service them. It should be designed by people whose primary job is medical education. Have we really arrived at a stage where something this obvious needs to be stated?