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The widespread perception that the cozy relationship between physicians and the pharmaceutical industry leads to conflicts of interest has, among other things, prompted a crackdown in industry funding of continuing medical education (CME).
The Association of American Medical Colleges adopted a zero-tolerance approach in 2008 to industry handouts within US teaching hospitals and 129 medical schools (CMAJ 2008. DOI:10.1503/cmaj090780). Medical schools have dutifully lined up to sever their ties to industry dollars, which are not insubstantial. According to the Accreditation Council for Continuing Medical Education, its accredited CME providers received US$2.2 billion in revenue in 2009, including US$856 million from industry.
Among institutions which recently pulled the plug were the University of Michigan, in Ann Arbor, which announced last January that its medical school would no longer accept industry monies for CME, and Harvard University, in Boston, Massachusetts, which indicated it would prohibit medical school faculty from giving promotional talks for drug and device makers and accepting personal gifts, travel, or meals.
It’s a “gradual falling of the dominos,” says Dr. Daniel Carlat, associate clinical professor of psychiatry at Tufts Medical School in Boston, and author of the popular Carlat Psychiatry blog.
It’s also a positive response to the growing awareness of the influence that the pharmaceutical industry has on medicine, he adds. “The spotlight is being put on the entire range of marketing tactics and CME happens to be one of them.”
Defenders of industry-funded CME say there is no evidence that pharma monies bias physicians toward sponsor products. But critics claim that covert or indirect bias occurs.
Carlat analyzed 15 articles produced by providers accredited by the Accreditation Council for Continuing Medical Education and found that sponsored drugs were mentioned six times more often than competing drugs. None contained unfavourable statements of the sponsors’ drugs, he says. “The problem is that if a typical doctor who is not really looking for bias reads these articles, they are going to end up thinking they are balanced because the articles are good at throwing a lot of references and a lot of data at you,” Carlat explains, adding that physicians then often get the impression that the sponsor’s drug is better.
“They are going to see that as an accurate depiction of the literature. What is happening is that the company is being very careful about making it appear as though they are providing a balanced program, when in fact, they are pruning away the negative studies and enriching the presentation of the positive studies,” he says.
Producers of CME programs will have none of it.
“There’s a misconception that somehow companies are controlling CME when in fact all they are doing is providing financing to meet public health goals and help better patient care,” says Thomas Sullivan, owner of Rockpointe, a medical communications company in Columbia, Maryland, and author of the Policy and Medicine blog. In one post, he accused the Association of American Medical Colleges of creating a “COI [conflict-of-interest] police state.”
The debate is less heated in Canada, says Dr. Bernard Marlow, director of continuing professional development at the College of Family Physicians of Canada.
There is a more of a collaborative spirit in Canada when it comes to industry, says Marlow, who says the solution to perceived conflicts of interest lies in close scrutiny of CME programs to ensure that they are as free from bias as possible.
Marlow says the college now has two trained peer reviewers who examine all programs, using a new tool for detecting bias.
Of the approximately 700 programs per year accredited by the college, bias is detected in 15% to 20% on the first review, Marlow says. “They will not be accredited until all of the recommendations made by the reviewers occur. Most of them end up being accredited but some of them are dramatically changed from the first submission to the end. We have some pretty good measures in place and I don’t think there’s much getting through with the College of Family Physicians seal on it that one would declare as biased. It would be interesting if [Carlat] did his study on our programs.”
Still, Dr. Howard Brody, a bioethicist at the University of Texas Medical Branch in Galveston, recommends that all universities divest themselves of industry-funded CME in order to truly resolve conflict-of-interest issues. “Medicine must disengage from most fiscal entanglements with the pharmaceutical industry.”
Marlow favours a middle road in which industry doesn’t provide direct funding for CME but has a role in matters relating to logistics, needs assessments, evaluation and patient safety. The most important thing, he says, is to get past viewing industry as “evil” because at that point the discussion stops and everyone retreats to their trenches.