Friday, June 24, 2011

Apres le Deluge: The CEJA Spin Cycle Begins

When the AMA adopted the 5th version of the CEJA report on industry-funded CME, it seemed clear that this was an ominous and very bad sign for the future of industry-funded CME. I already posted my take on the report here (short version: say goodbye to most industry CME). Now we are beginning to see how industry supporters are responding. Basically, they are saying, or maybe just desperately hoping, "Feh! It's no big deal."
They were singing a different tune before the vote. As was true for the prior CEJA CME reports, MECCs (medical education communication companies) and their supporters maligned the document. The Alliance for CME, the main trade organization for MECCs, had released this statement recommending that many sentences in the recommendations be stricken—essentially any sentence that challenged the status quo.  

ACRE, a relatively new organization composed of physicians who  vigorously defend financial relationships with drug companies issued what amounted to a white paper calling for the rejection of the report. ACRE found so many things wrong with CEJA 5.0 that its critique ran three pages longer than the report itself.

A couple of weeks before the vote, Medical Meetings magazine published an editorial by columnist and MECC owner Stephen Lewis angrily attacking CEJA as being an “oxymoron” because it “seems to have forgotten the critical link that exists between ethics and evidence.”

And five days before the vote, Thomas Sullivan, the owner of the MECC Rockpointe, who writes the influential pro-industy blog Policy and Medicine, reviewed and agreed with the Alliance for CME’s position that the CEJA report be canned.

So much for the run up. Now that the report has been adopted, industry advocates appear to be quickly distancing themselves from these prior alarmist views about CEJA.

Two days after the vote, Thomas Sullivan was almost celebrating. Headlined “AMA CEJA 2011: AMA House of Delegates Approves Report – Now Emphasis on Value of CME in Patient Care,” his post was nonchalant. Far from seeing this as a threat to industry funding, Sullivan now argued that the report “merely reflects an alignment of AMA policies on CME with the ACCME, HHS OIG, and the PhRMA and AdvaMed Code of Ethics.  Commercial support of CME will still remain a valuable resource for CME providers to help keep physicians up to date on the latest breakthroughs and treatments.”

Medical Marketing & Media, a publication financially dependent on pro-industry stakeholders, published an article that appeared to be journalistic coverage of the decision but which was essentially an editorial saying "don't worry, be happy." The article emphasized that CEJA 5.0 does not call for an “all out ban” on industry funding, but instead “places the moral onus on physician presenters to disclose to learners their financial interests in the topic they are speaking about.”

Derek Warnick, an industry CME director and blogger, responded with an entertaining and thoughtful post in which he concludes that “If I had to guess (OK, I don’t HAVE to guess, but I’m going to anyway), I would say that CME providers may be asked to provide a little more documentation about faculty selection and conflict resolution processes, but I don’t anticipate any major shake-ups.” 

Meanwhile, the only person whose opinion anyone cares about has remained silent. That would be Murray Kopelow, the director of ACCME. If you email ACCME for his response (as I did) you will receive the following official statement: “We are currently reviewing the CEJA Recommendations and the Board of Directors will be deciding on any next steps.” The next board meeting is July 21 in Chicago, so we will probably not get any response until they publish their Executive Summary of that meeting, probably a month or so after it occurs. 

Meanwhile--into the void--let the spinning continue. 

Tuesday, June 21, 2011

AMA Votes to Discourage Commercial Support of CME

Something huge happened yesterday at the American Medical Association House of Delegates meeting in Chicago. Although the meaning of what happened will be spun throughout the blogosphere, twittersphere, and schmuckosphere, the bottom line is that the AMA just voted most commercial funding of CME out of existence.

Specifically, the delegates voted to approve a report of the AMA ethics committee that calls for a near elimination of industry support for CME. The report is entitled "Financial Relationships with Industry in Continuing Medical Education," and can be read in its entirely here.

It is a 12 page report, and CME geeks like me will want to pore over every word, but the essence is found on page 8 under "Recommendations." The third paragraph makes the intent of the AMA explicit:

"CME that is independent of funding or in-kind support from sources that have financial interests in physicians‘ recommendations promotes confidence in the independence and  integrity of professional education, as does CME in which organizers, teachers, and others  involved in educating physicians do not have financial relationships with industry that could influence their participation. When possible, CME should be provided without such support or the participation of individuals who have financial interests in the educational subject matter." (emphasis added)

What this means is that the AMA now expects that most CME courses will meet two criteria:

1. No commercial support for the activity.

2. Faculty teaching the CME should have no financial relationships (such as being on speakers' bureaus) with drug or device companies.

The report does allow for some exceptions to these criteria: "At times it may be impossible to avoid a financial interest or extraordinarily difficult or even  impossible to mitigate its potential impact on an educational activity." They cite examples such as courses involving the use of very expensive material, such as cadavers or sophisticated equipment. Also, they allow that in some remote parts of the country it may be acceptable to take industry money to fly out experts to teach doctors. However, in that same "exception section," they reiterate that: "For the most part, accepting support from a company or permitting participation by an individual when there is an irreducible financial interest would not be ethically acceptable."

What happens next? Since the AMA literally defines "AMA PRA Category 1 Credit" for the ACCME, any company that deviates from the recommendations of this report will be non-compliant with ACCME's criteria for CME. ACCME itself will have to revise its Standards for Commercial Support to clarify that in most cases, commercial support is no longer allowed.

None of this will happen overnight, of course. But you can bet that medical societies and medical education companies that are dependent on commercial support are, even as you read this, holding emergency conference calls with their attorneys to figure out what they need to do next. 

We have finally entered the era of post-deception medical education. Congratulations to the AMA.

Unhinged in The New York Review of Books

The July 14, 2011 issue of The New York Review of Books includes the second of a two-part review of several new books on the topic of psychiatry, including my book Unhinged. Review author Marcia Angell, Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine, calls Unhinged “absorbing” in her article “The Illusions of Psychiatry,” where she also explores Irving Kirsch’s The Emperor’s New Drugs, Robert Whitaker’s Anatomy of an Epidemic, and the DSM-5.
Read the review here: