There are a number of new and rapidly growing physician social networking sites, and two of the largest are Sermo and QuantiaMD. They both offer tempting packages of free information to doctors, including CME. When stuff is free to you, someone else is paying for it. That "someone" has a stake in the content, and the art of operating an ethical educational website hinges on creating a good firewall between product promotion and educational content.
In the spirit of full disclosure, I have an iron in this fire, since I own a for-profit publishing company (called, amazingly enough, Carlat Publishing LLC) and I have chosen a business model relying exclusively on users paying for content. That way, my readers know that there is no hidden promotional agenda. I don't have to deal with firewalls, because there is nothing to wall off. I hope that this leads to high quality, trustworthy content; I know for a fact that it is a hard way to make money. After 8 years in business, my company's gross annual income from two newsletters and some joint sponsorship arrangements is slightly over $500,000--which is probably what Medscape charges for a single sponsored web-page. Am I bitter? You bet.
At any rate, when a new medical education website comes on the scene, I give it a close look, both to check on the competition and to provide fodder for this blog.
QuantiaMD was founded in 2003, and describes itself as "an online physician-to-physician learning collaborative where 1 in 6 U.S. physicians engage, share, and learn from experts and each other, free of charge."
The site specializes in short video powerpoint presentations--some are CME accredited, others are not. The quality is usually good. They get top academics as well as just very good doctors to give mini-talks. There's plenty to learn on QuantiaMD.
Since there are no drug company ads on the site, at first I couldn't figure out how they were able to fund a site with so many bells and whistles. On their FAQ page, they explain their income like this:
"QuantiaMD generates revenue through sponsored content that is delivered to physicians as short, interactive, educational presentations narrated by medical experts. This content is always accompanied by sponsors’ logos, and the decision to view is at the physician’s discretion, with no associated penalties or rewards. QuantiaMD proprietary technology ensures that physicians will only be offered sponsored content that aligns with their specialty. Sponsors do not, in any way, influence the non-sponsored content that QuantiaMD members experience."
Okay, so they charge drug companies for a portion of its content, which should be clearly labeled as sponsored, and this money allows them to create unbiased content in the rest of the site. Sort of like Medscape without the ads.
But when you get on the site, it's far from clear where the sponsored content begins and ends. Navigating to the psychiatry section, the first thing you see is the "Expert Practice Series in Enhancing Psychiatric Care," and the featured presentations are on bipolar disorder. I watched some of them, and they were useful, by and large, and not clearly biased in favor of any particular bipolar medication. But I was perplexed that there were no industry disclosures listed in this section, although virtually all their featured experts have extensive industry relationships (Dr. Charles Nemeroff, for example, is one of the presenters).
In an email to QuantaMD's communication manager, Ross Homer, I asked him about this omission. He promptly responded:
"Thank you for your message. In terms of industry disclosures, I was aware that these need to accompany accredited content for CMEs, but I was not familiar with the need for these with unaccredited content. However, if this is an issue, I’d be grateful to hear more about your thoughts on this (and please excuse my naiveté) to direct how we incorporate industry disclosures moving forward. In terms of this TRD program, neither the Program nor the series had any direction or influence from a commercial entity. Both were conceived from our Primary Mental Health Interest Group, which was itself created to help address the problem that a great many of our PCP members told us they were struggling with: whether, how and when to diagnose, treat or refer their patients with mental health disorders. In general, all commercial content on QuantiaMD is clearly marked and opt out. All non-commercial content, like the TRD series, is developed by independent subject matter experts with the support of our internal editorial team. This content is developed in response to the measured needs and suggestions of our clinician community."
Ross was right. There is no need for disclosure if by "need" you mean a regulatory mandate. But I encouraged him to go the extra mile:
"Ross, I agree with everything you have to say below. But if I were you I would put that very same explanation on your Interest Group page (or a link to an explanation, like "Where are the industry disclosures?"). The mental health experts on your site are well known in the psychiatric community for their close ties to the pharmaceutical industry, so I'm sure I'm not the only doctor with the same question. You might also explain how these doctors are getting paid (presumably directly by QuantiaMD, out of funds obtained via pharma ads and CME sponsorship), because in these days of cynicism every doctor realizes that no high quality information is free, and if they are not paying for it someone else is. Inquiring minds might be eased by Quantia's acknowledgment that it's important to follow the money trail if we want to trust the objectivity of your education."
Ross responded diplomatically: "Thank you for this insight. As we grow as a physician community and begin to do more promotion of our programs to the outside world, input like this is very helpful. We truly believe in the value of our content and don’t feel that we have anything to hide in terms of our business model, but it is important that we provide as much information as necessary so that everyone else we speak with about what we are doing feels comfortable as well."
This email exchange was on March 9, and since then there was been no discernible "QuantiaMD Spring" of increased transparency. There are still no industry disclosures in the Expert Practice Series, nor does the site print an explanation of why.
Meanwhile, as I dug a bit deeper into the other sections of the site, I was disheartened to find that the CME activities I sampled were biased in favor of the commercial interests of the sponsors, if subtly so. For instance, PriCara, a Division of Ortho-McNeil-Janssen Pharmaceuticals, supports QuantiaMD's CME lectures on the management of chronic pain. PriCara markets the Fentanyl patch. One of the presentations, "Managing Chronic Pain with Opioids in a Primary Care Setting," reassures doctors that a positive opiate screen "does not diagnose drug addiction, physical dependence, or impairment." And on the final slide, one of the four "Take Home Messages" was that "the prevalence of 'true' addiction in patients treated long-term with opioids is unknown but appears low in a community sample." I'm certain that this is a debatable assertion among chronic pain experts, and that a "fair balanced" program would have better covered the range of views. Overall, the program portrays chronic opioid use as something that can be easily managed and for which the dangers of addiction are low. That's music to the ears of the Fentanyl Patch people who paid for this "CM-Ad."
Eventually, I found Quantia's explicitly "sponsored content". Within psychiatry, they seem to have worked out a lucrative deal with Pfizer, with Geodon pushed by both Charles Bowden:
Dr. Bowden may want to review UT Health Sciences Center's policy on relationships with industry, which states that "Clinicians should not deliver talks that support a drug or device manufactured or marketed by the sponsoring company." I don't know if this Quantia gig runs afoul of that guidance, but it's certainly treading the line. Dr. Masand's employer Duke also frowns on promotional speaking, but its policy reads less strict than UT's.
To sum up, QuantiaMD is a mixed bag of great unbiased content mixed with promotional brand messaging. Figuring out where the honest education ends and the promotion begins is a challenge. The cynic in me suspects that this opacity is purposeful, and is done to ramp up sponsorship fees. Drug companies love promotion that does not look like promotion, and are willing to pay a premium for it.
I give QuantiaMD kudos for trying to create a useful website with minimal commercial content, and they succeed much better than some of their competitors, such as Medscape. But there's still that familiar sneaky hidden agenda feel to their site. Is it possible to create a large, robust, technologically sophisticated medical education site paid for exclusively by physician users? I pray that the answer is yes.