Friday, June 13, 2008

Medscape's CME Corruption

As debate over the American Medical Association's upcoming vote on industry funding of CME builds up to a fever pitch (see here and here), the popular physician website Medscape is being unmasked as nothing more than a CME industry voicebox. Of even more concern for the company, some of its CME offerings have become blatantly corrupted by their sponsors' marketing goals.

I cover their corrupt CME below. First, note that Medscape has conducted this poll asking doctors if they would support the AMA proposal to ban industry funding of CME. The results are being used as ammunition by industry stakeholders. But this is a sham poll. Here is how Medscape introduces their survey:

"At its June 14-18 annual meeting, the AMA will consider its ethical council’s call for a ban on industry support of CME for physicians, medical schools, teaching hospitals, and societies. Critics say the ban would reduce the availability and quality of CME and increase its cost. Do you favor or oppose such a ban on industry support of CME?"

This would be analoguous to the Gallop organization introducing a poll by saying, "John McCain is running against Barack Obama in the upcoming presidential election. Critics of Obama say that he will increase our taxes, damage our economy, and will pull our troops out of Iraq, leading to civil war and instability in the Middle East. Do you favor or oppose Barack Obama?"

And here are the unsurprising results of Medscape's "poll":

In favor of banning industry funding:
19% (464)

80% (1907)

Medscape is a medical education communication company entirely dependent on drug company advertising and CME funding for its existence. Many doctors have noticed recently that the company has dropped even the pretense of objectivity. Yesterday, I received a letter from Medscape in my office; inside was a brochure from Forest Laboratories advertising Lexapro, and nothing else. It was creepy, like Invasion of the Body Snatchers.

If you want to judge for yourself whether Medscape is capable of producing unbiased CME, go to their main CME page. You'll find dozens of CME articles, almost all of which are sponsored by different companies.

Here's one that can serve as a poster child for all that is wrong with industry-funded CME. Entitled "Managing Schizophrenia in a Patient With Alcohol Abuse and Hepatic Impairment", it is sponsored by Janssen, maker of Invega, a "new" antipsychotic which is simply the active metabolite of their now off-patent drug, Risperidone. As I've written here in The Carlat Psychiatry Report, Invega is simply a patent extender, with no real benefit other than the fact that it is not metabolized in the liver, and therefore is easier to dose in patients with hepatic impairment. In the grand tradition of promotional CME, Janssen commissioned Medscape to come up with a case-based program focussing on the single clinical situation in which Invega has an advantage.

For Janssen, the key promotional message is found in a section where readers are prompted to check off which treatment option would be most appropriate for the hepatically impaired patient who is profiled. Here is how it is worded:

"Selecting Treatment in a Dual Diagnosis Patient

How would you treat this patient now?

Don't make any changes to his current medication regimen

Switch him from olanzapine to clozapine

Switch him from olanzapine to quetiapine

Switch him from olanzapine to paliperidone"

The right answer, of course, is to switch him to paliperidone, Janssen's product! Here is the CME-arketing copy that follows this question, just in case you haven't yet been convinced to start prescribing Invega:

"A retrospective chart review of psychiatric inpatients found patients receiving either clozapine or olanzapine had a higher likelihood of having at least one condition associated with metabolic symptom.[8] Further, both agents have been associated with weight gain.[10] The adverse effects associated with use of olanzapine indicates the need to change this patient's medication regimen to one with fewer metabolic and hepatic side effects. Some of the newer typical treatments and delivery routes are associated with fewer adverse metabolic effects while affording a means of achieving improved adherence -- particularly among patients with metabolic disturbances.[28]
Research suggests quetiapine is less strongly associated with adverse metabolic effects and weight gain than olanzapine[10]; nevertheless, the potential adverse effects profile of quetiapine makes it a less-than-ideal option. Aripiprazole and ziprasidone are reasonable choices for patients who have experienced weight gain and metabolic adverse effects, but both drugs are metabolized in the liver.
In contrast to the majority of available antipsychotic agents, paliperidone is not metabolized by the liver, minimizing the risk of hepatic adverse effects and other hepatic drug-drug or drug-disease interactions.[21] Clinical trials have shown paliperidone extended-release tablets to be safe and effective in improving the symptoms of schizophrenia, including personal and social functioning.[21] The patented OROS technology allows for once-daily dosing and minimizes the variations in peak-to-trough plasma levels, thereby reducing the occurrence of adverse effects. Clinical trials have demonstrated the high efficacy and tolerability of paliperidone ER in patients with acute schizophrenia, with a rapid onset of action, as well as in maintenance treatment.[21,29] Early studies indicate few metabolic side effects, including only small increases in body weight. These advantages facilitate its use for this patient."

Has Janssen--I mean, Medscape--said anything inaccurate in this puff piece? No. But is this blatantly promotional of the sponsor's product? Of course. If Medscape had followed ACCME's Standards for Commercial Support, they would have had an independent expert read the article to determine three things: 1. Is the article sponsored by a company that produces a product relevant to the topic? (The answer is yes.) 2. If so, does the article appear to be commercially biased in favor of that product? (Yes). 3. How do you propose to alter the content of this article to eliminate this bias?
Medscape may have done numbers 1 and 2, but they forgot about number 3, the management of commercial bias, which is the most important thing about the ACCME standards.

I intend to lodge a formal complaint regarding this activity with ACCME, and I will also forward this information to various members of the AMA as they are deliberating in Chicago this weekend.

Corruption is a bad thing. It's time to root it out of Medscape, and the rest of medicine.


Anonymous said...

Your last statement says it all. The question is, do most responsible doctors have the guts to say "enough!" and call those irresponsible to stand and accept the charges of poor judgment.

I know the answer from prior experiences, and it is no. We are a gutless crew, Dr Carlat, not you specifically. I ended my membership with Medscape a few years ago and have never looked back. It always comes back to what I say and practice: deeds, not words.

Have a good 10+ days.

James M. La Rossa Jr. said...

As a member of the Medscape Publisher's Circle, I have worked with the company for a number of years to provide them with independent, unsponsored, journal articles for its readers. (
I have been consistently impressed with their level of professionalism and expertise.

If bogus reader surveys and a new focus on industry-specific CME are emerging trends, as you well quantify, I hope Medscape will take this to heart and re-think its operating procedure. While they have been financially successful, they have, as well, made some original contributions to the medical literature. Thank you for bringing this to our attention.

Anonymous said...

The fact remains, Medscape presents itself as a newssource, but it's all about sponsorships.

Good job, Daniel.

Psychiatrist in Iowa said...

There is a very simple rule of thumb that I share with my medical students: "If it is free, it is probably commercial". I do of course make them aware of the excetions.

Once you begin to strip away the layers from the surface of these providers of free "eduation", you are going to find a drug company with a "message".

If they want to engage in this business, then let them have at it. But there should be full disclosure of commercial influence, just as we need to know what kind of toxic sludge is in our food before we consume it.

Anonymous said...

Dr. Dan:
Loved your post and my hat is off to you! I support you 1000 percent. You are so right; and there is much that is so wrong about Pharma-sponsored medical "education" in this country. But why, as I type this response, do the words of Pink Floyd's tribute to Syd Barret go through my mind: "Shine on You Crazay Diamond?" Best to you. You wre good on NPR today.

Bernard Carroll said...

For more on Medscape's ethics, see this on the Health Care Renewal blog.

James M. La Rossa Jr. said...

I would like to thank Dr. Carroll for his fascinating follow-up on DC's post about Medscape. Although I would like to offer one important clarification by way of the First Amendment. Your comment that "Both [the] APA and ACNP annual meetings are closed events, so how does a commercial CME outfit like Medscape get its hands on these restricted materials," is not entirely accurate. The APA invites each year credentialed press to cover its meeting. Once you invite the press, you cannot restrict its coverage.

Dr. Carroll is accurate about the ACNP convocation; it is an officially closed meeting. When I have attended the ACNP, I made the commitment to NOT cover the meeting as a journalist, which I have always honored. Perhaps the ACNP did not make the same request of Medscape.

Anonymous said...

“What does all this mean for Medscape and eMedicine, the largest single source of CE for health professionals? We are just going to keep doing what we are doing. It is good. We are clean. Our work is transparent,” insists George D. Lundberg, MD, Editor-in-Chief of The Medscape Journal, Medscape Core, and eMedicine.
“Responding to the American Siege Against Continuing Medical Education”, posted 06/12/2008, Available at

Disclosure: I am a freelance medical writer-editor who writes CME that is sponsored by pharmaceutical companies.

James M. La Rossa Jr. said...

Your question, Michael, goes to the heart of the debate. Who has the MORAL AUTHORITY to provide "clean" and "transparent" continuing education, in the words of George D. Lundberg, MD? My humble advice is to apply free market principles to this industry and let the docs decide where to dedicate their CME time. If CME is a choice and not a requirement, then only the best programs will survive -- whether they are sponsored by industry or not. The pharma manufacturers are not the problem. If it is clearly in their best interest to put on "clean and transparent" CME programs, watch how fast they'll work to outdo one another. The ACCME created this monster, not Wyeth or Pfizer or GSK. Let Doctors decide for themselves who has "moral authority" and who doesn't.

Anonymous said...

The School of Medicine will no longer accept support from pharmaceutical or device companies for specific programs in continuing medical education, as industry-directed funding may compromise the integrity of education programs for physicians, officials said.

The action on CME builds on a 2006 policy that banned gifts, including free meals, and industry marketing at the medical center.

Stanford is one of the few U.S. medical schools to enact such restrictions, which took effect Sept. 1. The policy is being implemented as part of the school's ongoing review, begun in 2005, of its interactions with industry in the educational and clinical arenas.

Continuing medical education programs are designed to help physicians stay current in their fields and are a legal requirement for physcians to remain licensed to practice medicine. Under the new guidelines, the school may accept commercial support for CME only if it is provided for broad areas, such as medical, pediatric and surgical specialties; diagnostic and imaging technologies; and health policy and disease prevention. Funding must not be linked to a specific course, topic or program. In addition, commercial exhibits will no longer be permitted at Stanford-sponsored CME activities on or off campus.