Industry-funded CME: Is Commercial Content Ever Appropriate?

Dr. Robert Donnell (the writer of Notes from RW ) and I have been debating some key topics related to commercial funding of CME.

In his latest post on the issue, he focuses on a core issue. When an industry-funded program highlights the sponsor's product, does this inherently imply bias? What if the sponsor's product actually is the best treatment for the condition under discussion? To quote from his post:

What if a clinical problem under discussion has only one commercially available treatment, or one drug which is clearly superior to the alternatives? Many topics come to mind in my own areas of interest: Thromboembolism prophylaxis and the risk of heparin induced thrombocytopenia in a post cardiac surgery patient. (Arixtra, the only available anticoagulant with a clear advantage, would be featured). Improving outcome in a patient with severe sepsis: modulating the inflammatory and coagulation cascades. (Gotta be Xigris). Or how about Options for basal insulin coverage in a brittle type 1 diabetic. (Lantus and Levemir would be the clear choices). While Carlat might not think these topics worthy of CME they are common clinically important issues. I just made them up but they are typical of offerings we are likely to see more of given the recent clamor among some academics for more focused, case based CME.

There are definitely a few situations in medicine in which there is one and only one reasonable treatment, and in those cases a sponsored and an unsponsored program would have essentially the same content. But these are exceedingly rare. In psychiatry, I can think of no examples at all. In most of medicine, there are multiple competing treatments, none with any clear advantage for most patients (which is a good thing for medical choice and progress). I suppose that one policy implication of Dr. Donnell's argument is that we might create a list of those few one-best-treatment topics, and allow industry funding for these topics only. It sounds unworkable to me, given the pace of medical progress and the disagreements among academics regarding treatments of choice.

Another point from Dr. Donnell's post:

Dr. Carlat raises another point. Some of Medscape’s offerings my not be in compliance with ACCME standards. Section 5.1 reads:

The content or format of a CME activity or its related materials must promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

On the surface that is so obviously true it’s a cliché, but a literal reading of the words would restrict comments on benefits of drug treatment to coverage of generics and orphan drugs! That’s not what the ACCME intended, so there has to be room for interpretation.

I disagree. This section does not prevent industry from funding discussions of both branded and generic drugs, as long as the discussion is not slanted toward one particular agent. If there is no slant, then the CME activity does not promote a “specific proprietary business interest.” The problem is that medical education companies have become specialists in the techniques of subtly slanting programs in the direction of the sponsor’s product. Such programs, indeed, are non-compliant with ACCME standards.

While we all agree on the importance of quality educational offerings the debate over CME will go on. My take? Medscape CME may have quality problems. I differ from Dr. Carlat in that I think its offerings should be adjudicated case by case.

By “quality problems,” does he actually mean “bias problems?” The problem with the idea that the solution is to “adjudicate case by case” is that the ACCME will never have the resources to even begin to do this. Working as a volunteer, it takes me hours to unravel the mechanisms of commercial bias in a single psychiatry CME program, and I can do this only because I have a very good familiarity with the literature in the field. How can ACCME hope to monitor these programs in all the different specialties of medicine with a staff of 12, most of who are not physicians? There are literally thousands of commercially-sponsored programs per year.

As an example of how ACCME is doing, I lodged a formal complaint about a course on drug interactions in psychiatry well over a year ago, a case involving such blatant manipulation of content that one of the authors called it a “piece of commercial crap.” ACCME is apparently still examining the issue, and will not respond to emails requesting an update. They have no formal process for complaint resolution.

Case by case adjudication is, I fear, a way of ensuring that there will be no reform.

Finally, I would be remiss if I didn’t point out that identification of the payer source is not a litmus test for the quality of a CME offering. No one has demonstrated a general correlation based on high level data. Dr. Carlat offers a few interesting anecdotes. I can easily counter with some of my own. Recently I attended a prestigious accredited course with no support from device companies in which a speaker promoted numerous non evidence based uses for inferior vena cava filters. I’ve seen similar clean, pharmfree and unbalanced promotions of coronary artery bypass surgery and angioplasty. More concerning examples (all ACCME accredited) can be found here, here and here. I could trot out many others. You get the idea.

Yes, it’s true that lack of industry funding does not guarantee unbiased presentations. However, presence of such funding almost guarantees a lack of balance. Interestingly, the three activities he cites as “concerning” are programs that would never receive industry funding. They are all courses on integrative or complementary medicine, offered by UCLA, Yale, and NIH. Each covers the clinical evidence for these treatments using evidence-based teaching, but because these techniques have little commercial potential, doctors are poorly informed about them. As an example, few physicians are aware that an NIH consensus statement declared acupuncture to be effective for both post-operative nausea and post-dental procedure pain.