Wednesday, September 3, 2008

JAMA Commentary: Physicians Must Take Control of their Education

There are three excellent commentaries in the current issue of JAMA (Journal of the American Medical Association). Of most relevance to CME is Dr. Arnold Relman's review of recent actions by the AMA and the AAMC relating to industry-physician relationships. He calls for a joint meeting of the AMA and the AAMC to come up with a new direction for CME, and believes that only physicians should be invited, because "There is no reason that the pharmaceutical industry or its proxies" should be making decisions about the future of CME.

Relman concludes with the following eloquent call for an end to industry involvement in accredited medical education:

"It is time for the leadership of the medical profession to make clear to an increasingly skeptical public that physicians, and not the pharmaceutical industry, are in charge of the education of physicians. There is an evident and very important distinction between accredited professional education and the information about new drug products the pharmaceutical industry distributes to physicians for marketing purposes. The responsibility for medical education should be entirely in the hands of the medical profession and funding should not compromise, or even call into question, the integrity and independence of what is taught or of the physicians who teach. Marketing drugs, on the other hand, is industry's job. Industry likes to call this education but it is not. It is marketing.

Some firms may want to assist the medical profession with educational programs in areas not directly related to drugs. However well-intentioned, that would be unwise. The public relies on the medical profession to evaluate the products that industry wants to sell, so the profession should not be beholden to industry for any reason. To be trusted, medicine must be free of all such dependency; it should be accountable only to the society it serves and to its own professional standards.

Industry and the medical teaching institutions should each recognize their separate and distinct responsibilities, and should not encroach on the other's sphere. Properly regulated cooperation between the 2 in research sometimes furthers the public interest by advancing medical progress, but the medical academy and its salaried staff do not belong in pharmaceutical marketing any more than the pharmaceutical industry belongs in medical education. More respect for this distinction by both the academy and industry would lead to healthier and more honest relationships between the 2, and there would be fewer embarrassing ethical missteps and boundary violations, which have been undermining public trust and lowering the reputation of both the pharmaceutical industry and the medical profession."


James M. La Rossa Jr. said...


Excuse the repeat, but...In 1997, I attended the APA meeting, where I got my hands on an APA CME workshop list and after doing the math, figured that MEMBERS were paying, on average, $127.00 per credit hour. (Not including travel and hotel costs.) Soon thereafter, we began to offer free CME, and many journals followed. I am not sure if many of the top journals still offer free CME.

Academic journals, like Psychopharmacology Bulletin, are hard-pressed to put CME within the journal because many of our articles are original research which should not be the subject of "testing." We do have an agreement to put a few articles per issue on-line for FREE CME credit, as you can note from my former posting.

I have spoken with DC about this. I would love to see him develop an electronic "CME Filing Cabinet" software where physicians can pull CME from a variety of electronic sources and store the tests on a database if they are ever audited. (I wanna see at least one of you guys get rich on figuring out this CME morass before I die!)

My view, as I've stated before, is that CME should NOT be mandatory, but should be treated like Category 2 CME—via the honor system. (Do you know that you are required to have credits every three years in Category 2 CME as well, but you are not audited on this because your journal reading and writing is assumed?! Isn't participating on this blog "education?")

Let "Free Market Principles" dictate who keeps up with the literature and who does not. I believe that physicians will always want to gather with colleagues at meetings, grand rounds and the like, where new medical information will be discussed. Doctors who don't keep up will be challenged by patients, who (like it or not) are becoming highly educated themselves. And God-forbid you are ever sued, the first thing the opposing lawyer will ask you on the stand is about your level of ongoing education. So, it is in everyone's best interest— legally, socially, and financially—to keep up with the literature. If society can't hold physicians (who've spent seven years of higher learning as is) to the honor system regarding their continuing medical education without worrying about a dimming of medical services, than we have more problems that the APA, the WPA, or the AMA can handle. Note there is no mention of the ACCME in the last sentence. They should be abolished. And that, friends, will be the end of that. Regards, j.

Anonymous said...

I agree that pharma shouldn't be the arbiter of what is worth learning. But I'm not sure that "the free market" is necessarily the best alternative. Many people currently go see doctors only in cases of emergencies, when they aren't likely to have the luxury of searching out the MD who's kept up with their CME. The most likely advocates for such patients would be the malpractice lawyers, eager to swoop after damage has been done.... so instead of the control via the blandishments of pharma and advertising companies, you'd have control via fear of being 'caught out'.

Somehow that doesn't strike me as a great improvement in the level of professionalism among MDs....

James M. La Rossa Jr. said...

My point is not to inflict malpractice on patients who "aren't likely to have the luxury of searching out the MD who's kept up with their CME," but to submit the opinion that CME is unnecessary (and has become a burden to physician standing in society), since physicians will continue to meet (yes, voluntarily) at medical convocations, grand rounds, and the like, because it is in their best interests socially, financially, and, yes, legally. CME should not be a requirement because a very few doctors don't care about getting better at what they do in their careers. I would go so far as to submit that some patients -- ever more educated -- will know that their physician is "coasting" and move-on.

Physician-education does not need "regulating." It is an insult that you are caught in this regulatory morass. If CME is based on the honor system and not mandatory, doctors can use their own judgment as to what CME events they go to -- whether that be pharma-sponsored or university-hosted events. I'll pack-in a case of vintage Brunello and you can meet in my living room. I respectfully submit that the CME problems written about so passionately on this blog will never be solved until Washington has been flushed from the system.

unKommon Sense said...

If we take control do we have to foot the whole bill. Personally I think that the cost returned back to the physician adds one more intangible cost of being a doctor like malpractice insurace.

My wife is a teacher and she gets paid to go to professional development workshops to learn new teaching techniques

Check out my article "Drug Wars" on my blog

James M. La Rossa Jr. said...

To unkommon sense: The rampant hypocrisy in all of this "regulation" is duly noted. I enjoyed reading your blog. Thank you, j.