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)


Opposed:
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.