Sunday, June 17, 2007

How to Sniff Out Bias in CME Programs

Most of us have an intuitive feel for when we are being hoodwinked. Industry-funded CME programs are a case in point. It takes most doctors about 60 seconds of sitting through an industry-sponsored symposium or reading a ghost-written CME article to guess the sponsoring company.

Some of you may want to improve your nose for bias, and here are my top three tips for determining whether a talk or an article is so hopelessly promotional as to be better suited for the trash-heap than for your fertile brain. These tips are derived from a longer article published in The Carlat Psychiatry Report in 2004, which you can access here.

1. Determine the funding source. Nothing in medical education is truly free. If it's free to you, somebody else is footing the bill, and it's usually a pharmaceutical company. Funding sources are listed in small type somewhere in the first couple of pages of CME articles. Typically, the statement is a variation on “supported by an unrestricted educational grant from ....” While the term “unrestricted” implies that the company had no strings attached to its money, the reality is that any physician or MECC (medical education communication company) who receives drug company funding knows that their lecture or article will be closely perused by those with the cash, and that future “gigs” will be dependent on whether the company feels their product is shown in a favorable light.

2. How is the topic framed? Companies will fund only those educational programs that play to their strengths. For example, at the 2006 annual meeting of the American Psychiatric Association in Toronto, several industry-sponsored symposia covered antipsychotics. The recently completed CATIE trial highlighted the effectiveness of Zyprexa, and thus it is not surprising that the symposium sponsored by Eli Lilly was the only industry symposium focusing explicitly on the effectiveness findings of CATIE (Symposium 21, “Effectiveness of Antipsychotic Drugs in Chronic Schizophrenia: Complete Results of the CATIE Trial”). In this symposium, none of the abstracts focused on metabolic side effects, even though this is recognized as the major liability of Zyprexa. By contrast, in the comparable symposium sponsored by Pfizer (Symposium 9, "Differentiating Atypical Antipsychotics in the Treatment of Schizophrenia: From Theory to Practice") the discussion of the CATIE study did not mention effectiveness findings (Pfizer's Geodon performed poorly in this regard), but extensively discussed the metabolic and weight gain liabilities of its competitors.

3. Which studies are featured? GlaxoSmithKline just released a web-based CME slide show entitled, "Improving Outcomes in Patients with Bipolar Disorder: Exploring the Distinction Between Efficacy and Effectiveness," which you can view here. Terence Ketter of Stanford gives the talk, but all the content was created by medical writers paid by GSK (via an educational grant to that well-known academic institution, The Center for Medical Knowledge, LLC). Download their slides and peruse them. Beginning on page 21 of the workbook, there are some slides focusing on treatment of bipolar disorder. A total of three studies are highlighted: #1: An unpublished study showing that Lamictal resulted in longer recovery in bipolar disorder than atypical antipsychotics; #2: A NEJM study showing that adding an antidepressant to a mood stabilizer doesn't help in bipolar depression; and #3: A small published study showing a numerical (but not statistically significant) advantage of Lamictal over inositol and Risperdal in recovery from bipolar depression. That's it, people: three studies, that's all we get. And each study endorses the value of Lamictal, directly or indirectly. Unmentioned, of course, is the fact that Lamictal has been tested for bipolar depression in eight studies, and that it failed to separate from placebo in seven of them. The seven negative studies have never been published, but the results are available to the diligent by searching through GSK's clinical trials register here.

So now you have all the right tools. Get out there and be a bias-buster!


TBTAM said...

Just the post I had been planning to write! Great job...

Dr Peter Mansfield said...


Congratulations on all your good work including this new blog!

You wrote: "Most of us have an intuitive feel for when we are being hoodwinked." That is true when persuasion is not done skillfully. When misleading promotion is done effectively we don't know we have been misled. Skillful persuasion leads to false beliefs that we genuinely believe to be true.

Overconfidence can make us more vulnerable to being misled. See:

Chloe said...

Thanks for the link to the GlaxoSmithKline Clinical Trial Register. Great info!