Monday, May 16, 2011

A Review of QuantiaMD: Good Content, Murky Firewalls, and Hypo-Disclosure

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: 
 

and by Prakash Masand:


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.

10 comments:

SteveM said...

Danny,

You take in 500 Grand a year writing a couple of newsletters and it's a hard way to make money? Half a million bucks is embittering?

Man, what would it take to make you happy? A million dollar reality TV show that documents the arduous, furrowed brow trials and tribulations of your newsletter production?

Daniel Carlat, M.D. said...

SteveM--don't get too worked up. After payroll for 4 fulltime employees, paying the printer, the post office, the writers, the proofreader, the transcriptionist, the web consultants, the rent, etc..., my take home is a 5 figure salary. Which is fine--the point of my financial disclosure was that publishers who take drug company money exist in a different kind of economy. I'm bitter because the playing field is as level as the Grand Canyon.

Joel Hassman, MD said...

I have to say, Dr Carlat, while I appreciate your honesty in what your income stream is about, it is hard to be sympathetic about CME issues after learning your perspective in the matter. You have to pay your expenses, that I respect, but if you are running a business that creates a half million dollar income stream, don't plead a poverty type of attitude with readers. My advice, for what it is worth, run up the costs it takes to educate and inform colleagues of clinical matters, but don't try to challenge others who are whores and cowards if you are profiting above what is reasonable and fair from your work.

Maybe I am out of line by that last sentence, but I come from the raising as a doctor and person that you are in the profession to help people help themselves, you don't profit from the effort, and if you are going to take the risk in criticizing and challenging others in poor judgments, don't do anything that gives your enemies ammunition. I doubt you would intentionally do anything that would paint yourself in a poor light, but that admission doesn't help your cause. Just my opinion.

Sincerely,

Joel Hassman, MD
avid reader and colleague

moviedoc said...

"you are profiting above what is reasonable and fair from your work."

Dr. Hassman sounds a little jealous. Who is he to say what is "reasonable and fair?" Does he pretend that there are not substantial numbers of physicians making considerably more money with little or no connection to clinical work? Michael Crichton for starters.

Dr John said...

I agree with moviedoc. Dr Carlat is hardly getting rich and if he was I would applaud him. At least he gets his income from people who pay for the newsletter not some third party who is paying to advertise under the pretense they are educating.

This is EXACTLY the kind of relationship doctors are supposed to have with pts. It's a diad with no one in between getting their needs met off the back of someone else. It hardly exists in medicine anymore outside of a pure cash practice. It is the most honorable of approaches. Two people who negotiate freely between each other. Each one free to walk away if they do not like what the other offers. Dr Carlat succeeds or fails based on the kind of newsletter he produces, not what pharma company he has whored up with.How could anyone be angry about that?

Dr Hassman I am sure works for free as he is so busy helping others he has no time to make it to the bank and if he does make an income it goes right back to the Little Sisters of The Poor. What sanctimonious crap. Are we to assume all those making an excellent income in the practice of medicine are robbing the weak and feeble minded? I cringe when anyone wants to come to my rescue or the rescue of others with the battle cry of "reasonable and fair" as if they are so damn superior they are the only ones who can figure that out. You don't like Dr Carlat and the idea he is making money don't buy his newsletter. Me I let my subscription lapse 2 months ago and was feeling a bit iffy about renewing. Not anymore.

I hope you make a million Dr Carlat. A GD $109 bucks at a time!

Joel Hassman, MD said...

What I do not understand is why the author of this blog has censored some of my submissions in the past as he has interpreted them as unfavorable to other commenters, or at times a bit harsh about some professional organizations like the APA. And yet, you read the drivel and insulting rhetoric directed to me from the usual suspects who are given space on these threads.

Hey Moviedoc, why not read the entire comment and not focus on just one sentence to take things out of context and attack someone who has been a supporter of this blog long before you started with your retorts.

And Dr John, why don't you ask what a commenter's backround is before you come to dismissive assumptions, and by the way, are you really an MD, as I thought I learned otherwise going to your link in the past. Sorry to blow you and your cohort away with the reality that some doctors work to help people, don't makes large income streams from the time spent doing clinical care, and watch others who start out with well intended agendas get dazzled and distracted with profit driven agendas, usually by non clinicians who use the physicians as a money making agenda.

My comment was just advising Dr Carlat, for whatever it is worth to him, to watch out for the usual attack defenses by those he is challenging when they read that $500 thou number. Sorry I did not write it out in so simple speech for you both to easily understand it!!!

I hope Dr Carlat reads the above comments by these two rude people and weighs in with his perspective.

By the way, I sign my submissions with my name, not some alias to be deflective and entertaining.

Daniel Carlat, M.D. said...

All right, let's try to keep things a little more civil everyone. I won't publish any more rude comments on this post.

At any rate, I essentially agree with Dr. John and Moviedoc on this one. Money per se is neither good nor bad, but we all make our personal decisions about how we choose to make it. If I could bring in a hundred million a year by selling non-industry supported CME, I would do so in a hearbeat and feel good about it.

I'd selfishly enjoy some of the proceeds for toys and vacations etc.... But I'd feel deeply good about being able to use all that money to hire great writers and editors who share my passion for honest medical education free of industry influence.

I deliberately chose not to seek nonprofit status because I want to prove that it's possible to run a profitable med ed operation without compromising one's principles. It ain't the easiest way to make money, but it's doable.

Alex Pirie said...

This is a tempest in the proverbial. A modest income from a much needed public service; no problem! What is missing here is that nobody is paying attention to what jumps out at me, a resident in a community where an epidemic of opioid overdose took 20+ plus lives in the early 2000's - "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.""

We've had three overdoses of either percocet or oxycodone in the last month and the area is awash in over prescribed and poorly administered and controlled pills in a rainbow of colors with a nightmare in consequences.

The cavalier attitude in this quote is something that needs to be addressed by the profession. These are readily available, over prescribed and potentially lethal drugs.

moviedoc said...

"Maybe I am out of line by that last sentence"

Dr. Hassman, sorry if I seemed rude in implying that I agree with your own statement. (Yes, you were out of line.) But your second statement does seem to implicitly ciriticize those of us, like Dr C, who might try to "profit" from medicine as well as those of us who choose to post anonymously. I offer this quotation:

"I swear by my life and my love of it that I will never live for the sake of another man, nor ask another man to live for mine" - Ayn Rand, Atlas Shrugged

I do my work because I choose to. If anyone ever holds a gun to my hand and order me to do psychiatry, they can pull the trigger.

If you find Dr Carlat to readily censors you, try one of my blogs. And if you don't like my anonymity, just think of me as a John Galt of psychiatry.

Anonymous said...

As one who is very familiar with QuantiaMD and knows people who work there it might surprise Dr. Carlat that physicians are NOT paid for these presentations! They receive 'points' that can be traded in for Amazon gift certificates-minimum token. And why would they do it, a cynic like Dr. C would ask? Because it gives them major visibility in their field; a single talk at a medical society can have 100in the audience; QuantiaMD is international; the audience is virtually unlimited. in addition, many of these MDs have their presentations already prepared from lecturing students, giving CME etc. If you worked hard on a presentation and someone would take it global wouldnt you agree? The thing that bothers me most is that Dr. Carlat took the time to find out about informed disclosure but he didnt take the time to obtain this simple information.
The truth is that there is great free CME out there and I as a physician have taken advantage of it since I was a resident. Even at my professional association mtgs, many of the talks have pharma input, but we are surely smart enough to look at the information--and the references --to decide for ourselves. I myself think the companies lose all their credibility when they are grossly biased. I can go pick up medical journals or go online to sites that offer me CME credit for reading articles and filling out tests. In short, in this day and age, no one has to pay for CME. though you are certainly free to offer it. it's a free market out there, --your bitterness is off-putting.