Profession

CME must be untainted -- no matter who's paying

Should physicians pay for their own continuing medical education to avoid ethical entanglements?

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Nov. 9, 2009.

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CME has long been subsidized by pharmaceutical companies and medical device manufacturers. Over the last decade, that funding source has generated increasingly intense ethical debate.

Reply: When I joined the faculty at the University of North Carolina at Chapel Hill 35 years ago, there were few rheumatologists in North Carolina. I proposed to the person in the dean's office responsible for continuing medical education that we serve the state's physicians by holding an annual rheumatology update.

He was encouraging and suggested that I forgo the notion of a tuition-free session. He said that "if you don't charge, docs undervalue the exercise and don't attend."

We charged a pittance and held well-attended, highly interactive sessions for a few years, until our down-home efforts were superseded by the iron grip of the CME industry. Within a decade, I understood that CME was engulfed in an ever-more-sophisticated marketing exercise benefiting all sorts of stakeholders.

The effectiveness of modern CME has been studied systematically; any proof that it leads to important modifications in clinical practice, let alone recall of teaching points, is elusive. I have eschewed any role in this enterprise ever since, from speakers' bureaus to free anything. I settle for writing long, often-referenced letters to doctors who refer patients to me and spend much time conferring with colleagues regarding particularly challenging cases. We learn piecemeal, but we learn.

I firmly believe that interactive peer learning is a pillar of our profession. There is no expert worth his salt who doesn't need to gain in expertise. There is no specialist whose purview is so constrained that considering uncertainties outside that discipline is irrelevant; even patients of ophthalmologists have hearts and joints. We all need CME enriched by peers with special perspectives and knowledge. "Keeping up" is not optional; our patients trust us to do so, and we are morally committed to it as physicians.

There must be a way to make the peer learning experience efficient without compromising its sole rationale -- the continuing improvement of the quality of the care we afford our patients. None of us should have to wonder if the expert is actually hawking a drug, procedure or widget. And none of us is so financially stressed that he or she needs a free meal or a briefcase with a logo.

Our "teachers" must consider teaching as much a moral obligation as do their peers who come to question and learn. Since "students" bring to the exercise experiences and perspectives that facilitate active and interactive learning, any fee for educational services goes both ways and cancels out. Hence, the expense of peer-based CME should be minimal.

I envision a system of live Web seminars held frequently at every medical school. A few expert conveners and a dozen physician learners sit around a table discussing a topic. Anyone can register to listen in, even to submit queries beforehand. Links on the Web site can take any participant directly to the primary references and supplemental readings. Since we live in a country of bean-counters, the registering "counts" -- but it is the learning that matters.

The stumbling block to such a simple change in the concept of CME would surprise the laity, but not those of us who understand the ethical lapses that plague the American institution of medicine. The work of medical schools is barely discernible in the academic health centers, and medical education is a cost center. Academic health centers are nonprofit corporations with market agendas as crass as any we denounce. Too often, clinical thought leaders are hired to create profit centers; marketing their latest technique, regimen or gizmo is requisite to competing with profit centers in neighboring academic institutions. Can the academic rheumatologist or oncologist speak about biologic and other drugs without the infusion clinic's spreadsheet looming, at least subliminally? Can the cardiologist look objectively at the door-to-catheter data without considering the volume of his own catheterization lab? The only protection against ethical blind spots are from peers at the seminar table who are duty bound to hold all assertions up to the clear light of day.

If you want a reunion with like-minded physicians or a networking event on the golf course of some resort, go ahead, but you pay for it -- not fellow taxpayers or someone trying to buy your approach to patient care. And if you want a speaker or entertainment, that, too, is your nickel.

Nortin M. Hadler, MD, professor of medicine and microbiology/immunology, University of North Carolina at Chapel Hill School of Medicine; attending rheumatologist, University of North Carolina Hospitals

Reply: Has CME come to stand for commercial medical education? Many physicians recognize that the curriculum and content of continuing medical education are largely determined by those who pay for it.

We currently face a rather fierce debate on the question of who should own the CME agenda. No one would suggest that the only education physicians receive after leaving residency training should be in "product placement" or in understanding disease categories created to serve marketing needs. Yet many CME activities, as well as our professional associations, are heavily dependent on drugmakers' and device makers' funding.

Pressure is coming from major reimbursers of health services, especially government payers, such as the Centers for Medicare & Medicaid Services, to limit the accrediting of marketing as education. CME accrediting bodies have developed firewalls between commercial interests and the education they fund, as a way to protect both patients and third-party payers from undue marketing influences.

Those who develop and sell drugs and devices clearly have economic reasons to motivate physicians to use the highest-price proprietary items -- and to discourage critical thinking or public health approaches. These commercial firms, for their own reasons, are reducing funding for some CME activities and expanding the use of nonaccredited marketing strategies.

Which leaves us with the question: What is the direction of the CME enterprise, and who should pay for it?

What is apparent immediately is the new role of government and public health interests and a trend away from uncontrolled marketing of expensive treatment strategies. Witness the popularity of comparative effectiveness research. The direction for education favors quality improvement, practice systems enhancement, a culture of safety and interprofessional education, as well as lifelong maintenance of certification.

We have the tools to accomplish this, but such education is unlikely to occur "on spec." Installing new tools for new forms of education is capital intensive, and the cost of education that accompanies new tools is not trivial. Add the cost of measuring effectiveness, which is mandated by groups such as the Accreditation Council for Continuing Medical Education, and we have an enterprise that cannot succeed without focused external funding and appropriate business models.

Contemporary CME requires attention to the details of medical practice and to patient outcomes, woven into the fabric and design of educational efforts. Measurement of more than the most basic administrative data is complex and time-consuming, and ultimately has a real cost.

And how do we pick the agenda for CME? CME professionals talk about "learner-centered education" and "needs assessments," and yet, before the education occurs, the learners are not necessarily aware of the country's evolving health needs. Do doctors automatically prioritize education about domestic violence diagnosis, or community interventions to prevent obesity, as educational needs? Happily, the Institute of Medicine has published a list of prioritized comparative effectiveness research topics, which is a good start for a CME agenda. The agendas favored by those who pay for health care and their economic interest in better and more efficient patient care strategies lead to a new and different set of content areas and teaching methods.

This context gives us some answers to the question of who should pay. First, payers, whether government (already the majority payer), nonprofit or for-profit health plans, should finance the education and practice-transforming techniques to improve care. Equity and transparency mandate such funding to support an educational approach to the improvement of patient care systems. Otherwise, only large institutions could afford practice-improvement CME for medical staff.

Second, doctors should have a stake in their education, and, by paying some of the cost, gain some control over the agenda. By avoiding massive destination conferences with expensive venues and experts, academies and academic medical centers can develop education at a lower cost. Computer-based education, although expensive to design and maintain, can be scalable and help reduce costs. Peer educators also can be inexpensive. My personal bias is for social learning in group interactive settings, a singularly productive and inexpensive strategy with a good track record in quality improvement projects.

But the capital required to develop and sustain truly ethical, academic CME should be guaranteed by payers, who can be taxed to support consortia of educators. One can easily imagine a National Institute of Continuing Professional Development that creates curricular priorities and manages research funding for the CME enterprise. Such an institute also would create the conditions for interprofessional outcomes-based education.

After all, improved care should lead to lower health costs, fewer mistakes and a more sophisticated health team that can change as conditions warrant. But commercial entities that contribute financially should have little or no say in the CME agenda; this should remain in the hands of our academies and public health organizations, with the collaboration of the academic medical centers.

Robert Morrow, MD, community family physician; clinical associate professor, Albert Einstein College of Medicine of Yeshiva University, Montefiore Hospital, Bronx, N.Y.; northeast regional representative for CME with the Group on Educational Affairs, Assn. of American Medical Colleges

The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.

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