Post-Deception Medicine: Reform Picks up Steam

Last week’s announcement by the Wisconsin Medical Society that they are asking their 12,000 physician members to end marketing relationships with drug companies is part of a tidal wave of reform sweeping in a new era of what I call post-deception medicine.

The wording of their new ethics policy is straightforward:

Physicians shall accept no gifts from any provider of products that they prescribe to their patients such as personal items, office supplies, food, travel and time costs, or payment for participation in online CME. A complete ban eases the burdens of compliance, biased decision making, and patient distrust.

In their press release, they elaborated that their policy will follow the guidelines in the influential JAMA article published in 2006 which outlined policies for minimizing financial conflicts of interest in academic medical centers. Subsequently, the American Association of Medical Colleges formally endorsed these proposals, and a slew of medical centers have followed suit.

Steven Bergin, MD, an obstetrician/gynecologist who is the president of the Society, had some powerful things to say about the new policy.

“This policy is strong and clear. It leaves no doubt that the Society’s physicians want to prevent even the impression that a gift–no matter how small–could get in the way of a physician’s decision-making.”

As pressure builds in the various medical specialties to implement gift bans, many physicians have resisted, the most common argument being that physicians are too ethical and smart to allow small gifts to influence their decisions, despite a body of research pointing to many examples in which prescribing behavior is, indeed affected by gifts.

This debate will go on and on, and is unresolvable, because there is no conceivable study that could definitively answer this question. Cutting to the chase, Dr. Bergin believes that “individual physicians should take a bright line approach to accepting items from companies that make products or drugs that the physician might end up prescribing or recommending to his or her patients.”

In an interview with the Wall Street Journal Health Blog, Dr. Bergin made this point even more eloquently:

WSJ: What’s the point in banning gifts such as pens, whose value is trivial?
Dr. Bergin: There are certain people who would say a small gift wouldn’t affect someone’s judgment. But then again, maybe it would. And if there is no gift, there can be no question about it.

And that really is the point, isn’t it? Doctors make enough money to afford their own pens, books, and CME. As patients, we can all rest easier knowing that there is no possibility of commercial influence in their decision making.

But what about the specific issue of CME? The short version of the policy explicitly bans “payment for participation in online CME.” I’m not quite sure what they are driving at here, since I haven’t seen any CME providers actually paying physicians to take CME. Perhaps they mean that free CME is in itself of form of payment, and if so, I certainly agree. More clear is their official endorsement of AAMC’s policy, phrased in their press release in this way:

“CME providers should not accept support from health product companies directly. A CME provider may create a fund for medical education that may accept unrestricted donations from health product companies that is then dispersed according to institutional policy; this policy, financial contributors and the amount of their contributions shall be disclosed as public information on an easily accessible Web site.”

While this policy allows industry to indirectly fund CME, it would forbid the vast majority of commercially funded activities, in which companies support a specific course focusing on a topic area in which they sell a product. Instead, they would have to agree to donate educational funds into a pool of money, and the CME director would have sole discretion over how the money is used.

While I would prefer to keep accredited CME completely pure, and allow drug companies to provide product information in the context of promotional events only, I could certainly live with a pooled arrangement. The problem is that I don’t think drug companies will accept it, precisely because it provides a much more effective firewall between educational grants and promotion. While drug companies are enamored with the phrase “unrestricted educational grant” as a way of pretending that CME is not promotional, when grants become genuinely unrestricted, the companies balk. Why? Because they want to make sure that the CME they support will benefit their products.

Advocates of industry-CME, such as the blog Policy and Medicine, scoff at these pooled funding arrangements, calling them “blank checks” and “charity.” To be consistent, they should also point out that the word “unrestricted” when used with “educational grants” is a deception.

Kudos to Wisconsin. Which medical society will be the next to do the right thing? Let's hope it's the AMA.