Wednesday, September 10, 2008

ACCME’s Latest Proposal: Docs on Speaker’s Bureaus should not teach CME

The ACCME has proposed a new policy that may actually do something significant about preventing bias in industry-sponsored CME. To quote from the proposal:
“Persons paid to create, or present, promotional materials on behalf of commercial interests cannot control the content of accredited continuing medical education on that same content.”

ACCME had been hearing about situations in which medical writers were paid to write promotional material for drug companies, and then were hired by MECCs to write CME for the same companies. In addition, often physicians are on speakers bureaus and advisory boards and are then also allowed to deliver CME content funded by the same companies. Obviously, this defeats the purpose of the firewall between CME and marketing. A firewall is essentially worthless if writers are allowed to shuttle back and forth between marketing and CME.

With this new policy, ACCME is saying to doctors: “If you want to be on speakers bureaus and advisory boards of drug companies, that’s fine. But you can’t double dip. You can’t then also get paid by the CME companies that are taking grants from those same companies.”

Of course this is a necessary policy, and many readers will find it amazing that this loophole even exists.

The ACCME has its heart in the right place, but is in an impossible situation. Its mission is to make sure continuing medical education leads to improvements in patient care that reflect the best medical science. But once the drug industry discovered ways to produce CME via the strategy of funding third party companies to do their bidding, ACCME became involved in a futile struggle against the inexorable logic of the market. When a system is structured to allow huge financial incentives to create biased education, the education will, in fact, become biased.

Nonetheless, over the past 15 years or so, ACCME has been gamely trying to swim against this current and has instituted progressively stricter versions of its Standards for Commercial Support. First, they required disclosure of industry ties. But this didn’t change the bias, and may have simply whitewashed the process. After this requirement, industry funding of CME skyrocketed.

Then, seeing that simply disclosing conflicts of interest did nothing to stem the tide of industry bias, they required that companies institute systems for identifying and neutralizing that bias. But the only thing that got neutralized was this new Standard. Companies gamed the system by using their drug company grants to hire “independent reviewers” who didn’t have ties to industry. These reviewers’ job description was to sign a form stating that every industry-funded CME activity crossing their desk was “fair balanced.” The bias continued, and industry funding grew some more.

Next, ACCME told MECCs that they could no longer get any advice from drug companies about topics or speakers to use. This didn’t affect anything, because MECCs don’t need to hear from sponsoring companies to figure out what topics they are interested in funding, or which speakers can be counted on to say good things about their products. There’s this new thing out called “Google” that allows MECCs to learn all this information on their own.

The latest proposal—no more double-dipping—is simply ACCME’s latest efforts to slap some duct tape over the porous firewall between MECCs and industry. Who could possibly argue against this? The MECCs are, and, once again, are making themselves look very bad in the process.

Among the various specious arguments I’ve heard against this policy, the most astonishing is the censorship argument. By forbidding doctors on company speakers bureaus from writing accredited CME, so the argument goes, ACCME is “censoring” them. At Policy and Medicine, for example, Tom Sullivan, president of the MECC Rockpointe, says that “banning certain authors from writing books and giving talks doesn't seem to accord with freedom of speech, but that is exactly what the ACCME is proposing.”

Come on folks. Let’s get real. ACCME is not preventing anybody from saying or writing anything they want, anywhere, at any time. They are simply withholding a lucrative seal of approval from speech that does not meet their requirements. When Good Housekeeping Magazine withholds its seal of approval
from a shoddy product, they are not preventing the company from making it. The shoddy product can still be sold; the company just can’t use the seal to market the product.

Similarly, ACCME is saying that medical communication produced by people who take marketing money from drug companies no longer meets its standards for high quality CME, and it will no longer accredit such communication. MECCs are still free to provide it, print it, circulate it in conferences, but it won’t be accredited information. How is this “censorship?”

The real issue is whether the new rule will have any effect on commercial bias in CME. I’m skeptical, if only because MECCs have shown themselves so adept at coming up with regulation work-arounds in the past. They will presumably have to groom a new generation of writers and speakers who have not taken money directly from industry. That’s not hard to do. All it takes is a lot of money and a little patience.

Clearly, the only real solution is to end commercial support for CME, and ACCME is actually requesting comments on this very proposal.
Who knows? Maybe they are finally tired of participating in this perennial dance of making rules that can’t stick. Only Murray Kopelow knows for sure!

1 comment:

Anonymous said...

Dr. Carlat wrote: ACCME had been hearing about situations in which medical writers were paid to write promotional material for drug companies, and then were hired by MECCs to write CME for the same companies.

I am a freelance medical writer-editor who prepares and polishes manuscripts to make them suitable for submission for publication in professional journals. I wonder about the impact of the ACCME’s concerns about the work that I do. I decided to send a comment to the ACCME, as follows:

"One of the two questions that the ACCME is considering is as follows:
'Should those who write promotional materials be excluded from having any role in writing CME content?'

"I ask that the ACCME define what is meant by 'promotional materials'. For example, is a medical writer-editor who works closely with an author to prepare a manuscript for submission for publication in a professional journal working on promotional material?"