Monday, August 25, 2008

New JAMA History of CME: "When Will We Ever Learn?"

The current issue of JAMA (Journal of the American Medical Association) contains this interesting history of the relationship between the pharmaceutical industry and medical education.

It turns out that the rancorous CME debate that we consider to be modern is anything but, having its origins in the late 1950s, and early 1960s, when direct marketing to physicians in the guise of education heated up.

In 1961, for example, Charles D. May, the editor of the journal Pediatrics, wrote the article, “Selling drugs by educating physicians,” in which he bemoaned the body-snatching of medical education by the pharmaceutical industry:

A vicious cycle is created by a mad scramble for a share of the market: the doctor is made to feel he needs more “education” because of the prolific outpouring of strange brands but not really new drugs, produced for profit rather than to fill an essential purpose; and then the promoter offers to rescue him from confusion by a corresponding brand of “education.”

Now, nearly 50 years later, Dr. May’s quote still captures the essential damage done to medical practice by industry funding of CME.

Given recent events, it is ironic that one of the most outspoken advocates of industry sponsored medical education was a psychiatrist: Arthur Sackler, who was also a partner (and later owner) of the William Douglas MacAdams agency, a prominent pharmaceutical advertising firm.
In his 1957 reply to reformers of CME, using an argument that has not changed in a half century, Sackler argued that physicians are fully able to read pharmaceutical marketing critically. “Pharmaceutical advertising,” he wrote, “has made one of the major contributions in the rapid dissemination of new therapeutic information.”

The JAMA paper also reminds us that long before Charles Grassley and the Senate Finance Committee began its current investigations, two congressional hearings had already led to some reforms: the Kefauver Hearings of 1959-1962, and the Kennedy hearings of the early 1990s. The Kennedy hearings forced PhRMA to develop its “voluntary” ethical codes, and also led ACCME to issue the first version of its Standards for Commercial Support.

However, the JAMA authors note that these reforms have accomplished little:

Nonetheless, the standardization movement of the 1990s did little to stem the growth of the medical education and communication industry, and instead may have helped to legitimize and create a legal defense for the industry, which has increased steadily since that time.

In concluding, the authors rightly lay the blame squarely in the lap of physicians, who have thus far been unwilling to bite the bullet and pay for their own medical education:

As advertising executive Pierre Garai noted in 1963: “The drug business is today, and will be tomorrow, what the doctors cause it to be. Drug advertising too.”Any responsible analysis of the role of pharmaceutical promotion in CME must account for the process by which individual physicians, organized medicine, and the regulatory state allowed and even encouraged this process to take place. Garai finished with the question: “We know what the doctors are today. What will they be tomorrow?”

Indeed, what will we be tomorrow? It is up to us.

As George Santayana once said, "Those who cannot remember the past are condemned to repeat it."


Anonymous said...

It is nice when someone of authority/experience/credibility says it and it is printed.

Psychiatric Times, Aug 2008, page 6, bottom of first column:

Alan A Stone, MD, Touroff-Glueck Professor of Law & Psychiatry at Harvard University, "...these entanglements [between medicine and the pharmaceutical industry and medical device industry as well as other parts of corporate America] have occurred, in part, he said, because doctors have had to find other ways to make money, NOW THAT THEIR INCOME IS LIMITED BY MANAGED CARE." (you know him, Dr C?)

So, we will continue to waste our time going after the effects, when we continue to ignore/minimize/rationalize the real culprit that has allowed the pharma industry to corrupt our field specifically, i.e. the cause, third party reimbursements that have redefined slavery and resentments among any hard working, committed clinician.

If we as a collective do not stand up and fight the insurance beast, we will lose, even if we "win" this battle with pharma's role in CMEs, residency program influences, and in clinical practice decisions in commmunity and private practice offices.

Am I the only one who remembered being taught treat the problem, not the symptom? Too many people around here seem to have swept that concept not under the rug, but just dumped it in the trashcan and threw the can in the dumpster.

I want change, not a lull!

Anonymous said...

I hate to say it but this reminds me of psychiatry in general, not just CME. The field of psychiatry is littered with a legacy of discredited "solutions" to mental illness including insulin comas, lobotomies, tranquilizers and now antidepressants and antipsychotics are coming under fire. Every twenty-five years or so there is a new wonder cure that wreaks havoc on one generation at a time before it's discredited and yet no one seems to learn and the profession embraces each new solution as if finally they have it right. Just saying and I don't mean to offend . . .

Anonymous said...

No, I was also taught to "treat the problem" and not just the symptom. But ever since psychology and analytic/dynamic psychiatry were tossed on the ash heap of history, and ruled out of court by biological psychiatry chairs that rule "academic" departments, this truism holds no place in "modern" psychiatric residency training. And we all (including our patients) suffer as a result.

Psychiatrist in Iowa said...

As a psychiatrist, if you really think that it is necessary to take drug money to supplement your income, then you have lost your way. Yes, managed care has had a negative impact on our profession. But we still do much better than many of our non-physician colleagues do (at least in Iowa). If you needed to make the big bucks, then you should have chosen a specialty where you cut on people or run machines.

Taking this logic a step further, perhaps we should allow underpaid teachers to sell a bag of weed on the side to their students. Or encourage our police officers to sell Avon to the folks in the house after they quell the domestic disturbance.

Take a step back and think for a moment how that looks to the average guy who makes $40K/yr working in a factory: His doctor is only making $150/yr instead of the $200K that he deserves and thus he is compelled to take bribes from drug companies to make up the difference.

We need to regain our perspective...

Anonymous said...

With all due respect to Iowadoc, I disagree with perspective means I should be content to be happy making $150K while others are making $40K, when the comparison is apples to oranges.

I have no problem stating my income: I made a bit more than $130K last year working two part time salaried positions totalling 38 hours a week. Now I have joined a private practice to replace one of those part time positions, and after 4 months, I am still not netting even half the month's income from the job I left, because the insurers the group advised me to join pay 20+% less than what should be fair and reasonable reimbursement rates for the area I work. So, I should be happy I make more money than someone else who did not put in the 12+ years of education, internship, and residency I did while this other person finished high school and is working a job that fits the skill level and job demands expected with their backround? I think not, and I am not looking to be making $200K or more as well. In my opinion, this is the mind set of too many physicians who feel the status quo is acceptable when we are nickled and dimed further and further every year.

Maybe Iowa is a great place to practice psychiatry, and I am truly glad you have advantages. I believe, as I said above in the first posting, we as a collective should be refuting the degradation of the field because people who have no ability or interest in providing care want to make a buck off the system. I think sociopathy has blossomed at our expense, and we allow our dedication to care and benefit to the community at large be used against us. Well, I say if psychiatry as a whole is willing to sell out and use pharma as a substitute for lost income, the field deserves to die and be shamed into non-existence. I'm not riding this boat into the proverbial iceberg and going down, though. I hope our fraudulent and careless colleagues go down painfully.

You have good points to your comments overall; I don't accept the premise "be glad you have more than others". I would like to earn what I realistically and rightfully should pocket. If you could know me, you would see I live responsibly and am fully committed to patient care. It's time psychiatry told managed care to f--- off. But, we as a profession are too full of whores and cowards.

Sorry, but that's my opinion.

therapyfirst (board certified since 1997)

Anonymous said...

"In concluding, the authors rightly lay the blame squarely in the lap of physicians, who have thus far been unwilling to bite the bullet and pay for their own medical education."

In all these discussions, I don't recall seeing where this money will come from. Will insurance companies start paying for more than 15 minutes of "medication management" so that physicians can afford to pursue pharma-free education?

Why does everyone let the insurance companies off the hook? Why is no mention made of their mega-lobbies?

Anonymous said...

"But ever since psychology and analytic/dynamic psychiatry were tossed on the ash heap of history, and ruled out of court by biological psychiatry chairs that rule "academic" departments..."

If the psychodynamic crowd had been willing to see gray--that is, that some neurocognitive disorders were being seriously undertreated due to their refusal to acknowledge brain science--they might have survived. Instead, they fought fought fought psychiatry's medical progress for years. In the process, I say they did vastly more harm than good, and so good-bye and good riddance.

Moreover, the pop-culture legacy they left behind, full of unproven theories and narcississtic projections, will continue to haunt our interpersonal relations, probably for generations.

It's downright creepy to look back and see what whacko theories were accepted as fact, without any study or debate. And see how many lives were wasted, even if a minority were helped.,

James M. La Rossa Jr. said...

You are on to compensation now, and whether psychiatrists are remunerated justly according to their advanced degrees and the important place in medicine in which they occupy. My opinion is NO -- you simply don't make enough money. But that is one man's opinion; just that. What I might be able to contribute to this conversation is a jumping-off point, so-to-speak.

In my capacity, I have reviewed the tax returns of a number of noted psychiatric thoughtleaders and can tell you that the breakdown of their income is, to the person, one-third academic/hospital salary, one-third private practice, and one-third pharmaceutical honoraria. How important that last third is ... you can take it from here my beleaguered friends.

Anonymous said...

With all due respect, Gina Pera, you do protest WAY too much. Of course analytic psychiatry over played their hand (and their jaded views and biases). Indeed, they ignored or at least downplayed the biological and neurological factors involved in many psychiatric disorders. To blame schizophrenia on "schizophrenogenic" mothers is just one example among many. But truly, the baby has been thrown out with the bath water. Biological ideology and hegemony (the symptom is the disease, and that's all we need to know folks)is doing just as much, if not more, harm to our patients now. And Ms. Pera, with all due respect, you do seem to have an ax to grind as your posts clearly seem to suggest that interpersonal factors (e.g. parenting, relational experiences in development) have NO influence on adult development or pathology. And have no role in treatment! And that is patently absurd. Really, you make a straw man's arguement. Read up on Harlow's monkey studies for Christ's sake!