You get what they pay for: Continuing medical education selections

Over the years, the federal government and physician and pharmaceutical organizations have set guidelines for governing the relationships between the medical profession and the pharmaceutical industry, in hopes of minimizing conflicts of interest.

But one largely unregulated area remains: how CME curricula are generated.

R. Van Harrison, PhD, director of the Office of Continuing Medical Education at the University of Michigan Medical School, believes it is now time to address conflict in that arena as well.

"CME subjects are distorted and biased toward topics related to medical products with a high financial yield," said Dr. Harrison, who wrote an article on this topic in the Journal of Continuing Education in the Health Professions in September 2003.

"The ACCME [Accreditation Council for Continuing Medical Education] has focused on an old model of commercial bias within a CME activity, asking, 'Is it balanced?' " Dr. Harrison said. "My whole point is that there is another level of bias in the system in what topics are chosen."

Courses on diseases treated with high-profit drugs are taught more frequently, Dr. Harrison said, because CME providers are able to get pharmaceutical funding for them. Speakers are easier to find because they're paid higher fees. More participants attend these courses because the commercial support makes them either less expensive or free to attendees. The sheer number of these courses, in turn, generates a false sense of their importance.

Federal guidance from the Office of Inspector General, ACCME standards, the Pharmaceutical Research and Manufacturers of America code of conduct and AMA policy address keeping pharmaceutical companies from improperly influencing the medical profession on several levels; however, none directly addresses CME curricula.

Commercial support and advertising and exhibit fees paid to accredited CME providers account for almost 60% of their income, according to data from the ACCME.

Money from industry has helped fill the void left by the loss of traditional CME funding from hospitals and medical schools, Dr. Harrison said. As funding for graduate medical education has failed to keep pace with the costs of academic medicine, CME budgets of medical schools and hospitals have been slashed. As a result, academic oversight of CME has been diminished.

According to the 2002 ACCME annual report, CME providers had a total income of $1.6 billion that year. Of this, $933 million came from commercial sources. The increase in this spending is so significant that a new class of CME provider -- for-profit companies financed largely by commercial companies -- has been created, according to the ACCME. The annual report showed total income for communications companies -- which have advertising and promotions divisions to accompany their education departments -- at $141 million, with 97% of that money coming from commercial support, advertising and exhibit fees. Businesses listed as education companies had income of $201 million, with 83% coming from those same sources.

Doctors must decide

Robert Raszkowski, MD, PhD, is one of three AMA representatives on the ACCME board of directors. He acknowledged that pharmaceutical-sponsored CME is having an overall impact on CME curricula, but he said physicians are sophisticated enough to make learning choices that best serve their patients.

"I'm a gastroenterologist, and as a practical example there have been multiple [courses] out on acid reflux disease in the last few years, along with a flurry of new products," he said. "I don't have to participate in all of those. I'm going to choose one, but I'm going to study other things as well.

"What a well-educated physician has to do is to balance a number of things as they continue to try to keep their knowledge current," Dr. Raszkowski said. "You have to balance the review of things you've heard since medical school, what's the new evidence for certain treatments and what's cutting edge. You balance all of that as you pick and choose," he said.

Whether most physicians follow Dr. Raszkowski's model is unclear.

"Physicians might be locked into the position of not knowing what they don't know," said Murray Kopelow, MD, ACCME executive director. "That's a common problem. People aren't aware of what's new."

That's exactly the problem, Dr. Harrison said. Medical students and residents must learn specific subjects and skills, but practicing physicians are left to sift through the slew of live courses, journal CME and online offerings on their own.

"No one is providing physicians any guidance on the new information that's come out in the last 12 months. No one is saying, 'These are the six new things you should know,' " Dr. Harrison said. "I think the profession of medicine has failed horribly in one of its key responsibilities of continuing medical education."

Bruce Spivey, MD, deputy executive vice president of the Council of Medical Specialty Societies, disagrees. The move to make ongoing education and testing a requirement for maintaining specialty board certification has made reshaping CME a priority for CMSS. The council is poised to release recommendations on how to do this, including establishing CME curricula.

"One of the first recommendations is that there needs to be a curriculum for each specialty and each subspecialty," Dr. Spivey said.

Curricula being developed

Several of member CMSS specialty organizations have been formulating CME curricula for their physicians, and several could release such guidelines this year.

At the forefront of such efforts is the American Academy of Family Physicians. Now that the American Board of Family Practice is requiring recertification every seven years, the AAFP intends to offer two new CME courses each year until it has a seven-year curriculum to help physicians prepare for the tests.

Norman Kahn, MD, AAFP vice president for science and education, said the AAFP also bases its CME choices on such things as the Institute of Medicine report on 20 key areas in health care, topics that have seen rapid change, subjects where disparities in health care have emerged and results of member needs assessments.

The AAFP highlights a specific clinical area each year. This year's focus is aging; in 2005, it will be genomics. A monthly CME bulletin is another way the AAFP alerts members to relevant subjects.

Dr. Kahn said commercial input into the AAFP's continuing education projects is limited. For live courses presented at the academy's national meetings, AAFP members dictate what courses will be produced, and commercial grants to help offset the cost aren't sought until after the curriculum is determined. "The truth is, we do most of our CME without commercial funding," he said of the live courses.

Only after the AAFP builds the modules does it solicit pharmaceutical sponsorship. Contributions are typically around $10,000 per sponsor, and many of the courses never get sponsored, Dr. Kahn said.

The AAFP does use commercial funding for enduring materials such as videos. At least one CME video will be produced on aging this year. If commercial funding can be found, two or three videos could be produced.

"We won't do the extra videos without commercial support," he said, "but the basic package goes out regardless."

Dr. Kahn estimated that $5.5 million of the AAFP's total budget of $64 million comes from commercial grants for CME. According to the ACCME, specialty physician organizations get 51% of their total funding from commercial support, advertising and exhibit fees, while nonspecialty physician groups get 47% of their income from these sources.

The AMA also produces CME. Barbara Schneidman, MD, AMA vice president of medical education, said commercial support is not used for live CME at AMA meetings.

Some suggestions

Dr. Harrison would like to see the medical profession inform its members of the overarching conflict of interest in their continuing professional education and then address it head on.

This could include developing a short list of new topics by specialty to guide CME development and participation, requiring disclosure of the amount of commercial funding involved in each CME event and putting a cap on speakers' honoraria.

Some argue that physicians alone should be the ones determining what they learn, and that by shedding the bells and whistles, plenty of CME still could take place without money from the pharmaceutical industry.

Dr. Kopelow, of the ACCME, said that scenario isn't out of reach.

"We could do the same amount of continuing medical education that is currently commercially supported for 20 to 30 cents on the dollar," he said. "The whole world is not going to come crashing down if we lose commercial support."