Top Harvard Neurologist: Macy Report is a "Stack of Cards"

Shortly after the Macy Foundation's report was released, I found myself in the Minot Room of Harvard Medical School's Countway Library, listening to one of the world's top neurologists trashing that report.

It wasn't exactly what I was expecting.

I was attending a medical ethics seminar hosted by Marcia Angell, author of the groundbreaking book The Truth About Drug Companies. In attendance were some of the harshest critics of excessive industry influence in medicine, including:
--Arnold Relman, former NEJM editor-in-chief and author of A Second Opinion: Rescuing America's Health Care
--Jerry Avorn, author of Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs
--Eric Campbell, the Mass General health policy guru who first-authored the recent NEJM study detailing the pervasive relationships between academic medicine and industry
--Jerome Greene, the physician and historian who wrote Prescribing by the Numbers: Drugs and the Definition of Disease
--A bunch of other wicked eminent people whom I didn't recognize

So you really have to hand it to Martin Samuels, the Neurologist-in-Chief at Brigham and Women's Hospital, for having the guts to defend industry sponsorship of CME. Although, in reality, Samuels was really defending only one particular MECC, Pri-med, for whom he directs the neurology CME course. He decried most other MECCs, calling for the abolition of industry-sponsored satellite symposia at major medical meetings.

At any rate, his most interesting comments related to the Macy Foundation report. Ironically, Samuels had been recruited to Pri-med by none other than Suzanne Fletcher, who chaired the Macy conference. And according to Samuels, one of the members of the conference's organizing committee was Denise Basow, a top executive of UpToDate. UpToDate is a multi-million dollar medical education company, but one that is not funded by industry. Instead, like my own Carlat Psychiatry Report, it is funded by subscribers.

So what? Samuels feels that the Macy Report's conclusions are neatly in line with the business goals of UpToDate--more emphasis on online practiced-based learning, and no further commercial sponsorship of medical education.

"This is an overt conflict of interest, and it should have been declared," said Samuels. "I find this report to be self-righteous and self-serving. It is so hypocritical that it will fall like a stack of cards."

In fact, Basow's affiliation was printed in the report, but I do agree that her involvement constituted a conflict of interest that should have been highlighted. But this doesn't besmirch the essence of the report--namely, that continuing medical education in the U.S. is critically ill, and needs emergency treatment.

Macy Foundation Bombshell: Industry-Funded CME Must End

The clock is ticking for industry-funded medical education. The latest body blow comes in the form of a report on medical education issued by the influential Josiah Macy, Jr. Foundation. Read it here. The report was the product of a conference attended by many of the brightest minds in medicine, including Catherine DeAngelis, editor-in-chief of JAMA, Harvey Fineberg, president of the Institute of Medicine, and David Leach, recent executive director of the Accreditation Council for Graduate Medical Education.

The Macy Foundation couldn't be clearer: commercial support of CME has got to go.

Here is the most powerful section of their report (you can find it on page 2 from the link above):

"Participants warned that the health professions, especially medicine, threaten the ethical underpinnings of professionalism by participating in a multi-billion dollar CE enterprise so heavily financed by commercial interests. This arrangement, which evolved over the years, distorts continuing education. It places physicians and nurses who teach CE activities in the untenable position of being paid, directly or indirectly, by the manufacturers of health care products about which they teach.

At the same time, commercial support of CE places learners in an obligatory position because they are often given free meals and small gifts. Independent judgment of how best to care for patients is compromised. Bias, either by appearance or reality, has become woven into the very fabric of continuing education.

The professions, themselves, must right this wrong. In a free-market system, commercial entities, such as drug and device manufacturers, have a clear responsibility to shareholders to gain market advantage and generate a profit, while health professionals have a moral responsibility to provide safe, high quality care for their patients, based on valid scientific findings. The two responsibilities are fundamentally incompatible.

Even if bias could be avoided, the potential, and the perception, are ever-present. Companies with billions of dollars at stake cannot be expected to be neutral or objective when assessing the benefits, harms and cost-effectiveness of their products, for they are in the legitimate business of gaining market advantage and want clinicians to use and prescribe their products. Yet, an objective and neutral assessment of clinical management options is precisely what is needed in continuing education.

Participants emphasized that, regardless of the financial impact on for profit companies, patient care must be based on scientific evidence and commercial interests should not determine the topics or content of CE. Because of these underlying ethical issues, participants concluded that the commercial entities that manufacture and sell health care products should not provide financial support for the continuing education of health professionals (emphasis added)."