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In recent years, industry sponsorship of continuing medical education (CME) has grown rapidly and now accounts for up to 65% of the total revenue of CME programs in the United States.1,2 In Canada and the United States, national guidelines state that “independent” programs should maintain scientific objectivity and independence of content and receive commercial support only through unrestricted funding mechanisms.3–5 Despite the technically unrestricted nature of such industry-funded programs, however, substantial conflicts of interest and the potential for undue commercial influence persist.6
Chief among these conflicts is the financial incentive for CME organizers to create educational programs that present companies’ products favourably. These conflicts affect medical education and communications companies (MECCs), many of which are for-profit and are funded almost exclusively by drug and device manufacturers. Such MECCs host accredited educational programs and many also service a variety of other industry activities, including hosting company-sponsored advisory boards and advising industry on marketing strategies and tactics.7 This presents a clear conflict, since the survival and success of both the educational and marketing arms of these companies depend on satisfying those who fund them to encourage their support of future programs.
Unfortunately, similar incentives affect academic providers of CME. Some specialty societies and university-based CME providers have assisted in potentially promotional activities, such as organizing industry-supported dinner lecture series and satellite symposia. Even university providers of CME who forego such relationships are not immune to financial conflicts. These universities often receive substantial industry support for their CME activities: in 2005, CME activities originating in US schools of medicine received 60% of their total income from industry, up from 43% 5 years earlier.2 These universities also rely heavily on industry grants for research funding and other educational initiatives.8
These connections create a web of relationships and financial dependency that can have subtle yet strong effects on the objectivity of “independent,” accredited CME. Event organizers can choose to present topics likely to favourably highlight sponsors’ products or discuss emerging clinical areas that sponsors are trying to penetrate. In addition, among a range of qualified experts on a given topic, event organizers can select speakers known to have attitudes favourable to sponsoring companies’ products. The commercial influence that results from these decisions is not necessarily acknowledged or even conscious, but might well reflect the cumulative effect of subtle influences and financial dependency that can affect even the best-intentioned CME providers.
In addition to institutional conflicts, speakers face their own conflicts of interest that arise from receiving educational or research grants from industry, from attendance at company-sponsored events, and from paid service on advisory boards and speakers bureaus.7 Although the great majority of these speakers do not intentionally teach in a biased manner, research suggests that the expectation of reciprocity, personal relationships, and fear of disrupting relationships with companies can dissuade lecturers from speaking ill of companies’ products and thus “biting the hand that feeds them.”9,10
Few published studies have evaluated directly the extent to which industry sponsorship of CME biases program content and in turn affects physicians’ behaviour.11 Corroborating data and a recent US government inquiry suggest, however, that industry uses CME for promotional purposes—with success.12 Several prominent investigations have revealed industry efforts to use educational activities to increase drug sales.7,13 In addition, drug companies track the effectiveness of marketing activities through the purchase of physician-specific prescribing data from pharmacies.14 It is unlikely that industry would contribute substantial resources to CME (approximately $1 billion [US] per year in the United States) if there were little return on that investment. Finally, some providers of CME have advertised their own educational services as having promotional benefits. For example, one MECC declared, “Medical education is a powerful tool that can deliver your message to key audiences and get those audiences to take action that benefits your product.”6
These problems require both short- and long-term solutions. In the long-term, commercial influence on CME could be minimized by eliminating industry sponsorship of educational programs or by funding CME programs from a general pool of industry support within each academic medical centre.15 In the absence of such sweeping changes, however, CME providers and doctors can take other steps to mitigate potential bias. Providers of CME can go beyond minimum accreditation requirements to institute quality-control mechanisms, such as declining to host events sponsored by a single company, using risk assessment tools to prospectively identify activities at higher risk of bias, and assessing potential bias through attendee questionnaires and direct observation of higher-risk courses.16 Individual doctors can minimize their exposure to potentially biased information by avoiding programs that are heavily subsidized by one company. These programs can often be identified by low or no registration fees. Physicians can also be mindful of other risk factors for bias, such as the presence of course faculty who are representatives of or closely allied with industry, including members of companies’ speakers bureaus.
Continuing medical education is critical for disseminating new advances in medicine and improving the quality of care that physicians provide to their patients. Commercial intrusion into CME threatens the reality and perception of scientific objectivity and best practice. Substantial changes in the structure and regulation of CME activities are needed to correct these problems. In the meantime, individual physicians need to be aware of and to minimize commercial intrusion into their CME.
This work was supported by a Research Career Development Award from the United States Department of Veterans Affairs, Health Services Research and Development Service.
Dr Steinman served as an unpaid expert witness in United States of America ex rel. David Franklin v. Pfizer, Inc, and Parke-Davis, Division of Warner-Lambert Company, litigation that in part alleged that Parke-Davis used educational activities to promote gabapentin (Neurontin). Dr Steinman also participated in the creation and development of an online, searchable archive of documents from the gabapentin litigation (http://dida.library.ucsf.edu). Seed funding for this archive was provided by a gift from Thomas Greene, lawyer for the whistle-blower plaintiff in this litigation, to the University of California Board of Regents. Drs Steinman and Baron are coinvestigators on an educational grant administered through the Attorney General of Oregon that was funded through a settlement fund from the aforementioned litigation. Dr Baron is Associate Dean of Graduate Medical Education and Continuing Medical Education at the University of California in San Francisco and in this role has participated in the organization of CME courses that have received educational grants from industry.