Medscape Presents: The Brintellix Show

As I wrote in part one of my Medscape review, the website gets high marks for up-to-the-minute coverage of psychiatric news, and it deserves kudos for posting a ton of textbook-like content on disorders and drugs. I wasn’t so thrilled with its "un-privacy" policy, which results in your personal info and browsing history being sold to third parties. 

Today we get into the dark side of Medscape Psychiatry, which is their industry-funded CME. 

Medscape Psychiatry CME Overview

Medscape offers four different categories of CME on its “CME and Education” page.  "Clinical Briefs" and "Journal Articles" are mostly not industry funded, whereas "Patient Cases" and "Knowledge and Practice" are generally industry products.  

Brintellix (vortioxetine) Background

To give you a little context, Brintellix is the latest antidepressant to be FDA approved. It is being marketed as a "multimodal" antidepressant because it has effects on several different receptor sites. The company has produced some interesting data showing that Brintellix may cause fewer sexual side effects than other antidepressants, and that it may help improve the slowed-down thinking that is common with depression. But it is not FDA approved for either of these potential advantages, because thus far, the data are far from definitive.

Medscape and Takeda/Lundbeck

Medscape is the largest single recipient of pharmaceutical CME grants among all U.S. medical communications companies. According to an article in JAMA, it received $20,315,730 in 2010, the last year for which such data were aggregated. I don't know how much the company is receiving from Takeda/Lundbeck for producing CME programs, but it's probably a lot. If you click through Medscape's most technologically sophisticated online courses, a high proportion are funded by this duo.

Here are some of the titles of the courses:

• Strategies for Effective Communication With Patients With Major Depression
• Strategies for Improving Symptoms in Patients With Major Depression 
• Engaging Patients as Partners in Care: The National Quality Strategy in Practice
• Cognition in Major Depressive Disorder: Improving Quality of Life
• Updates and Perspectives in Major Depressive Disorder: Highlights From 2014 
• The Pharmacology of MDD Treatment: Building a Foundation With a Focus on 5-HT

Commercial Bias in One of the Courses

All of the courses listed above are likely biased in favor of Brintellix--there wouldn't be much point in paying Medscape to produce them otherwise. Since blogging is not my day job, I chose only one of them to watch: The Pharmacology of MDD Treatment: Building a Foundation With a Focus on 5-HT.

This course begins with four multiple choice questions, which are supposed to test your knowledge before you learn. Here's one of them:

Which of the following antidepressants manipulates the most serotonin receptors at once?

vilazodone

selegiline

quetiapine

vortioxetine

The correct answer? Vortioxetine. 

This is a clever way to prime the pump, to get the audience thinking about the promoted drug.

Next, we get a slide purporting to give an overview of the history of antidepressant drug development.

The big red bubble labeled MMD refers to "multimodal drug", ie., vortioxetine. That's the latest one. The implication is that it's the most technically advanced. 

Later in the program, there are a few slides highlighting "new antidepressants." Only one antidepressant gets prominently featured on two slides:

The more crucial question is not "how many ways can one drug manipulate 5-HT" (even the manufacturer states the "clinical relevance" of the drug's many serotonin actions is "unknown") but rather "how many ways can one communication company manipulate doctors's prescribing practices?"

To make their point crystal clear, one of the experts in the video glowingly endorses Brintellix, saying that its multimodal mechanism is like packing a bunch of great medicines into one:

"Vortioxetine is a great example of this multimodal thing we were talking about. It is a serotonin reuptake inhibitor, but it also is a very strong agonist at 5-HT_1A, which we said you want to have an agonist there. It also is a powerful antagonist at 5-HT₃ which and a powerful antagonist at 5-HT₇. On paper, here is a drug that has some of these qualities we have been talking about that could make it possibly a multimodal agent almost like a built in augmentation strategy in 1 pill, which certainly would be, just practically, a little easier for patients than having to take more than 1 medicine, which we often have to do.^[3-6]"

A bit later, he goes even further, implying that Brintellix uniquely targets three common symptoms of depression:

"Again, right now, the data clearly show the 3 most common residual symptoms, even with people who have a response to an antidepressant are insomnia, cognitive impairment, and fatigue. I think those are things that are not well addressed by an SSRI alone. Thinking more sophisticated, multimodal actions whether it is 1 pill that has that built in augmentation. I think that is where the field is going."

Summing up Medscape

Since the last time I reviewed a psychiatric website, I assigned a letter grade, I'll give Medscape one as well: a B-. 

Why? It gets an A for delivering bite-sized psychiatric news clips on its non-CME page, an A- for providing free but dry drug and disorders info, and an F for failing to comply with Standard 5 of ACCME's Standards for Commercial Support in its CME courses. Among other things, Standard 5 forbids a CME program from promoting a "specific proprietatry business interest of a commercial interest", and it requires that presentations "must give a balanced view of therapeutic options." 

I'm surprised that Medscape is still resorting to these shenanigans, but I guess that's what butters their bread. 

On Stephen Colbert, Super PACs, and Industry-Supported CME

The current New York Times Magazine carries a fascinating and quite hilarious profile of Stephen Colbert, of the Colbert Report. Colbert is well known for his parody of a know-nothing rabidly conservative Republican commentator—but according to the article he has taken his comedy into the real world, involving himself directly in those shady instruments of electioneering known as “super PACs.”

For those who haven’t followed super PACs, they are the political equivalent of the CME industry’s Medical Education Communication Companies (MECCs). Super PACs can take unlimited amounts of money from corporations, then turn around and use the money to promote candidates of their choosing—with the stipulation that they are not directly “coordinating” with their favorite candidates, whatever that means.  Analogously, MECCs can take unlimited amounts of money from drug companies, then turn around and use the money to pay doctors to promote the company’s products—with the stipulation that they cannot coordinate their CME courses directly with drug companies, again, whatever that means.

In both examples, a third party is being used by corporations to circumvent an inconvenient regulation. In the case of super PACs, companies can circumvent Federal  Election Commission (FEC) rules that limit campaign contributions to a maximum of $2500 per individual (super PACs can accept millions from individuals). In the case of MECCs, drug companies circumvent ACCME Standards for Commercial Support forbidding direct payments to doctors for CME, by laundering the money in the form of  educational grants to third party CME companies.

Colbert, in an effort to expose how corrupt super PACs are, has actually started his own super PAC, entitled "Americans for a Better Tomorrow, Tomorrow."  As quoted in the Times article, Colbert facetiously defends his and other super PACs by pointing out that they are “100 percent legal and at least 10 percent ethical.”

I’ve never heard a better characterization of industry-supported CME.  Let’s hope that Colbert continues his unorthodox lessons in the ways of money, corporations, and corruption.  For his next project, I suggest he start his own MECC, named, perhaps, “The Institute for Healthcare Education and Prescription Promotion.” 

"Medical Education Forum"? Or a Dying Industry's Last Gasp?

I just received the email below because I'm a member of a CME industry group, most of whose members depend on industry funding for their existence.  It's an invitation  to a meeting in Philadelphia where stakeholders in commercial CME will try to figure out how to stem the hemorrhage of money out of their ethically sketchy industry.

You've got to love the carefully scrubbed title of the conference: "Medical Education Forum: Improve Outcomes Through Collaboration to Maximize the Quality of Patient Care." Sounds like it should be a meeting of doctors and other health care professionals. But at a two day conference price tag of $2095.00 (not including travel or hotel), you can get a sense of who the attendees are likely to be and what their real incentives are.

January 5, 2011

Dear Colleague,

The state of medical education is ever changing and evolving. The pharmaceutical industry is continuously scrutinized for supporting CME. Recent reports on the Sunshine Act regarding payments to physicians, as well as other negative attention and public confusion about the purpose of medical education, are leading to a decrease in perceived value. With limited budgets and declining internal support, it is critical for industry grantors and CME providers to do everything, within regulations, to ensure the most appropriate and effective educational designs and outcomes. 

For providers, the expectations of industry grantors can be overwhelming without the appropriate staff and financial support. Providers struggle to execute and fulfill outcome assessments that demonstrate, at a minimum, a knowledge or competence change for learners that will positively affect patient care. 

For industry grantors and CME providers, the need for a common understanding of best practices in educational design is essential to ensure CME programs demonstrate positive outcomes that improve the quality of patient care. That is why CBI's Medical Education Forum is indispensable to medical education professionals. Hear about regulatory updates, innovative information channels, strategies to measure change in HCP behavior and methods for improved reporting and communication of meaningful outcomes. This forum provides a platform for the exchange of information and open dialogue surrounding the challenges and opportunities in medical education. 

Please join us March 21-22, 2011 in Philadelphia to learn from and interact with thought leaders in medical education. The seasoned speaking faculty includes perspectives from Abbott, Acorda Therapeutics, Celgene, CE Outcomes, Cephalon, Covidien, DIME, Endo Pharmaceuticals, Genentech, John Hopkins School of Medicine, Med-IQ, MedscapeCME, Medtronic, Merck & Co, National Foundation for Infectious Disease, New Jersey Academy of Family Physicians, Omnia Education, Pfizer, Prova Education, Rockpointe and the University of Pennsylvania School of Medicine. 

I look forward to seeing you there.

Sincerely,

Beth Brillinger CCMEP
Vice President, Educational Strategy and Development,
Discovery Institute of Medical Education

P.S. Don't miss concurrent breakout sessions addressing challenges specific to industry and providers!

Adriane Fugh-Berman's Article and Upcoming Conference

In the same issue of the Boston Review as Marcia Angell's great article (profiled in my last post) you can read a fantastic article about commercially-funded CME called "Selling Diseases," written by the irrepressible Adriane Fugh-Berman of Georgetown Medical School.

For those who understand the inherently corrupt process of industry-funded CME, the article covers familiar ground, but is nonetheless great reading. For those who are not aware of how self-deluding many of our top physicians have become, the article is an eye-opener and a call to action.

My favorite quote is:

"Industry-paid speakers frequently deny espousing marketing messages. I’ve heard many physicians justify their pharma-funded speaking gigs by saying, “I never emphasize their product” or, triumphantly, “I don’t even mention their drug!” But these comments only highlight their sales skills. Pharma doesn’t hire doctors to sell drugs; that’s a drug rep’s job. Pharma hires physicians to sell diseases."

I have always been amazed at my colleagues' capacity for rationalizing behavior when it suits their pocketbooks, and Dr. Fugh-Berman nails the issue here perfectly.

By the way, Dr. Fugh-Berman's non-profit organization, PharmedOut, has organized a CME conference called "Prescription for Conflict: Should Industry Fund Continuing Medical Education? It wil be held on June 25 of this year in Washington DC, and includes a start-studded line-up of speakers, including Deputy FDA Commissioner Joshua Sharfstein, the author and bioethicist Carl Elliott, senior investigator for Senator Grassley Paul Thacker, the director of Pfizer's CME programs Maureen Doyle-Scharff, among others. (There are also a few almost famous wannabees on the program, like me!) Here is a link to the agenda and the speakers, along with registration information. I hope to see you there!

Tom Sullivan, of ACRE Fame, Is Swimming in Drug Company Cash

Wherever there is a vocal battalion of defenders of drug industry funded medical education, you are certain to find Tom Sullivan leading the charge. Sullivan writes the most prolific pro-industry CME website, Policy and Medicine. He is a founding member of ACRE, and managed all the logistics for ACRE's first embarrassing meeting, held at Brigham and Women's Hospital. He collaborates closely with John Kamp, director of the pro-commercial CME front group, Coalition for Healthcare Communication.

Simply put, Tom Sullivan loves pharma funding of medical education, and he simply can't get enough of it. Why? If you ask Sullivan, he'll wax idealistic, as he did in one of his recent posts:

"Industry CME funding improves quality, because it helps support the development of an accreditation system for compliance and professional accredited providers that thrive by demonstrating quality and developing innovative education that improves professional practice."

It would be nice to believe that his passion stems from such an altruistic vision of industry/physician collaboration. But it's not true.

Sullivan's incentive, like most of his colleagues, is money. He is the president of Rockpointe, a medical education communication company. And while I always figured he made a good chunk of cash from drug companies, I had no idea just how much, until now. The Drug Industry Document Archive (DIDA) at UCSF just released a number of documents obtained from congressional sources, one of which is this list of drug company payments to Sullivan's company.

Here’s how much industry "educational grant" money Rockpointe has made over the last three and a half years:

2006: $4,209,685

2007: $8,701,080

2008: $7,298,064

2009 (first half only): $3,237,027

Sullivan is awash in cash from all the major drug companies. In 2008, he made over $400,000 each from AstraZeneca, Bristol-Myers Squibb, Daiichi Sanyo, Eli Lilly, Medimmune, Merck, and Novartis.

He specializes in crafting web programs and meeting symposia that are infomercials for specific drugs. For example, Novartis paid Sullivan $98,998.00 to create a two hour breakfast lecture which took place at the annual meeting of the American Society for Hypertension on May 17, 2008. The Symposium was entitled “Blocking the Renin Angiotensin System: Which Way is Best?”

Here's which way is best: the Novartis way. Novartis markets Diovan, an angiotensin receptor blocker. Furthermore, the FDA recently approved Novartis’ Valturna, a single pill combination of Diovan and Tekturna/Rasilez, another direct renin inhibitor. This symposium was chaired by Matthew Weir, M.D., who, yes, is a consultant for Novartis and who has frequently boosted Novartis products (see here, for example.)

By the way, the president of the American Society for Hypertension is none other than Henry Black, M.D., who, along with his pal Tom Sullivan, is on the steering committee of ACRE, and is also a consultant for Novartis.

My, there are a lot of dots to connect when it comes to Tom Sullivan, Rockpointe, ACRE, and the many physicians who have decided that helping drug companies market their products is the ethical way.

GlaxoSmithKline Will Fund MECCs Under the Table

Yesterday, I reported on GlaxoSmithKline's announcement that they would no longer fund commercial MECCs (Medical Education Communication Companies) to produce CME programs. The big question was whether the company would allow academic centers and medical societies to subcontract course production out to MECCs, an arrangement more genteelly known as "co-sponsorship."

I just received the answer directly from Mary Anne Rhyne, GSK's GlaxoSmithKline Corporate Communications Director. Rejoice, all ye MECCs, your loophole is intact!

In this earlier op-ed piece in the New York Times, I had referred to industry-funded CME as a money laundering operation, in which drug companies do not directly pay doctors to give lectures, but instead pay a MECC to hire and pay the doctors. This provides the illusion that the drug company is not involved in the program, when of course the program wouldn't happen without company funding.

With this new brand of CME "reform," both Pfizer and GSK are simply adding another layer to this laundering operation. Now the money will go from the drug company to the academic medical center to the MECC to the doctor.

Over the years, MECCs have become experts at creating a series of dog and pony shows called CME. They have the process down to a science. They know how to make the flashiest slides, hire and manage the best key opinion leaders, rent out the nicest conference rooms, and serve the tastiest food. They make the process so seamless and effortless that academic medical centers are only too happy to hire them to do the dirty work of actually putting on the courses. Under GSK's new policy, I predict that universities will get the big grants and will pass on a chunk to the MECCs, keeping a healthy slice for their own highly profitable CME departments.

Unfortunately, the actual medical education will continue to be slanted in favor of the most expensive drugs and medical devices.

By the way, I also asked for a list of the 20 favored academic centers. The GSK spokeswoman said that this will be posted soon on www.partnersinknowledge.com, their website for grant applicants.

GlaxoSmithKline Stops CME Grants to MECCs

In another piece of good news for patient care, GlaxoSmithKline has announced that they are clamping down on funding continuing medical education programs. According to their press release, "GSK will no longer fund CME by commercial providers including medical education and communication companies (MECCs)." The new policy takes effect immediately.

The company says that it will cut down drastically on the number of organizations receiving CME grants, to only about 20 academic centers that meet their criteria of having a "track record of developing and delivering high quality medical education programs that have a measurable impact on improved patient health." I asked GSK for a list of the favored 20, as well as exactly what their criteria for CME excellence are, but I have not yet heard back.

GSK posts their educational and charitable grants on the web. You can read the grants from the first and second quarter of 2009 here. I went through the Q2 grants and found that it's pretty hard to tell which are CME grants and which are patient advocacy or charitable grants. But I estimated that in the 2nd quarter of 2009, GSK made CME grants to about 90 organizations, and about 20 (22%) of these are MECCs. While this implies that cutting out MECCs is not a big deal, in fact the MECCs are the big money hogs of the bunch. MECCs received by far the largest grants, including Pri-Med Institute ($658,000), Research to Practice ($540,000), Discovery Communications LLC ($420,000), and Physician Education Resource Group LP ($363,000). MECCs are great at sponging up lots of cash from drug companies, because they have no other business plan. Some of the money goes to physicians who give lectures, but much more is sheer profit, padding the pockets of MECC executives.

Thus, cutting out MECCs will presumably save GSK a lot of money and save doctors from getting pounded over the head with the redundant marketing messages MECC-produced CME excels at.

Some of you may recall that Pfizer announced a similar policy change over a year ago. You can read coverage of Pfizer's decision in this Medical Meetings article and in my blog post. While I applauded Pfizer's decision I also noted that their policy left the door open for eligible providers to co-sponsor programs with MECCs, a rather giant loophole that lead to problems with a huge $12.3 million anti-smoking initiative the company funded. Pfizer funded University of Wisconsin to coordinate the project, but allowed UW to work jointly with a few MECCs, including CME Enterprises. The result was that the CME program was biased in favor of Pfizer's Chantix, as detailed in this article in the Milwaukee Journal Sentinel.

Nobody knows whether GSK will allow a similar loophole. Let's hope not.

A MECC that BLISSfully keeps Promotion in Medical Education

Recently, medical writers from across the country have been forwarding me blatant examples of how medical education companies are currupting the basic tenets of continuing medical education. Although I've become jaded, this particular company astonished even me with their willingness to do away with the pretense that industry-funded medical education is anything other than advertising.

The company is called Brand(x) and they are based in the United Kingdom. They are mainly an advertising firm but they have a robust medical education department. Here is a screen shot from their website in which they explain their conception of "medical education."


If you can't quite make out the small print, you can reach this page by going to the home page, clicking "enter" then "services" then "med ed." Here is the definition of CME, Brand(x)-style:

In today's business environment clients increasingly recognize that to get the best results, medical education must be led by a clear understanding of what the brand stands for and be closely integrated with the promotional strategy. At Brand(x), we are uniquely placed to provide the exceptional skills, which will help shape your educational strategy and implementation so that your brand's business objectives are met.

The company has developed its own process for making sure CME promotes a drug company's brand. It's called "BLISS," an acronym for "Brand Led Integrated Support Service." Here's a screenshot showing how they make CME more BLISSful:

Recently, Dr. Murray Kopelow assured the Senate Special Committee on Aging that his organization, the ACCME, has everything under control. In fact, here is what ACCME's standards for commercial support has to say about the content of CME:

The content or format of a CME activity or its
related materials must promote improvements
or quality in healthcare and not a specific
proprietary business interest of a commercial
interest.

But here is what Brand (x) has to say about CME:

BLISS ensures that your medical education programmes and strategies are synergistic with your brand's promotional strategy and execution.

I guess ACCME will need to hire a few more compliance officers.

Senate CME Hearing: Impressions, More Links

There's no question that the recent Senate hearing on CME was stacked against industry funding of CME, but that's because from the standpoint of the American public and Congress, the practice is slimy and wrong.

Senator Mel Martinez, a republican from Florida, summed up the mood best with his perplexed question (I'm paraphrasing here): "Wouldn't it just be better if doctors paid for their own continuing medical education?" As a lawyer, he said, he always paid for his own CLE (continuing legal education) and he was never paid to give CLE lectures.

To those of us who have lived and breathed this issue for years, his question came across as innocent, but in fact it hit the obvious point, and surely summarized the view of most Americans.

Tom Stossel, to his credit, came out swinging in a ring where he was badly outnumbered, but as he often does, he conflated two issues: the remarkable advances in medicine over the past few decades and industry funding of CME. The two are not related. We've had advances in medicine because of great science and appropriate interactions between doctors and industry--bona fide relationships based on developing products and conducting clinical trials. None of these relationships would be threatened in any way by the Physician Payments Sunshine Act or by the IOM's proposal to greatly scale back industry funding of CME.

My favorite moment of the hearing was when Senator Al Franken directly confronted Stossel, saying (again, I'm paraphrasing): "You seem to draw a lot of conclusions from anecdotes of people who have benefited from modern medicine. Medicine is a lot better now than when we were kids, but that doesn't mean that industry should fund CME."

Dr. Kopelow's comments were disappointing in the extreme. He repeated a single refrain, saying, in essence: "There is no problem with bias in CME. We are doing our job well. ACCME is the firewall between promotion and education." C'mon Murray! You know what's going on. You've seen the many, many letters of complaint reporting biased programs. In fact, you reprimanded one company for bias within the last few months--I know, because the reprimand was based on my letter. It only took you about two years to issue your decision. I won't mention the specifics in this blog because I promised you I wouldn't.

I liked Lew Morris's comments. He's the General Counsel, U.S. Department of Health and Human Services, Office of the Inspector General, and so he's pretty influential. He wants to set up "independent CME grant organizations" that would pool industry funds and divvy them out in ways that don't promote specific treatments or lucrative disease categories. Good luck to him. He admits that drug companies have shown zero interest in parking any of their so-called "unrestricted educational grants" in such organizations. He alluded to one that was set up by a surgical association. Its current budget: $0.00. Clearly, companies will only fund CME if they see a promotional advantage.

LINKS:

The Senate Aging Committee website has now posted links to all the written testimony, including my testimony (I am erroneously identified as being from the Cleveland Clinic--apparently they mixed me up with Steve Nissen and I am flattered!), as well as testimony from Pharmed Out (Dr. Adrian Fugh-Berman), and from a series of organizations that have vested interests in keeping things as they are, including the University of Wisconsin, PhRMA, AdvaMed, and Merck.

Senator Kohl Targets Commercial CME in Hearing Tomorrow

It was only a matter of time before the U.S. Senate decided to shine a national spotlight on one of the more corrupt sectors of the nation's economy: industry-sponsored continuing medical education (CME).

Senator Herb Kohl (D-Wis) has just issued this press release announcing a hearing entitled "Medical Research and Education: Higher Learning or Higher Earning?" It will take place Wednesday, July 29, at 2 p.m., at 562 Dirksen Senate Office Building in Washington DC. You can view it live on the web by going to the Special Committee on Aging's website.

To view the all-star line up of those providing testimony, see the press release link above. I think it is safe to say that there will be some very strong testimony about the plethora of sham "educational" programs that are in reality marketing exercises for the drug companies.

While I will not be there in person, I was invited to provide written testimony, which I will post after the hearing itself.

I encourage all of you to take some time out of your schedules tomorrow to watch the webcast (hey, it's summer--just cut out of work early). I anticipate that this will be a historic event in the world of medical education.

New ACCME Report: Commercial CME Support Enters Free Fall

Once a year, the ACCME (Accreditation Council of Continuing Medical Education) releases its Annual Report detailing the state of the health of the CME enterprise. It reports various things, like how many CME courses have been offered, how many physicians have taken part, etc.... But the meat of the report is always on page 8, Table 7: "Income and Expense by Organization Type".

This year, the big news (though not that newsy to those who have been following the issue) is that for the first time since financial records were reported in 1998, the size of the CME industry has contracted. In 1998, the total income for all CME activities was $888 million, and over the years, it steadily increased to a high of $2,539 million in 2007. Well, last year, the total dipped to $2,365 million, a "loss" of $174 million.

Why do I put the word loss in quotes? Because virtually this entire shortfall was accounted for by a decrease in commercial support for CME. Commercial support dropped from roughly $1.2 billion in 2007 to $1 billion in 2008. This is actually good news, because drug companies support CME in order to encourage doctors to prescribe the newest and most expensive drugs, even when these drugs have no advantages and, as often happens, have more severe side effects than older agents.

But the news is even better than this. Drug companies are wisely electing to pull their money out of the most corrupt and biased of all CME-providing entities--the for-profit Medical Education and Communication Companies. As you can see in this chart put together by my assistant who painstakingly entered years worth of ACCME numbers into an Excel spreadsheet (note to ACCME--shouldn't this data crunching be your job?), commercial support for MECCs has entered free fall mode. In 2007, drug companies forked over $594 million to MECCs in order to promote their newest and most expensive products; last year, they reduced the spigot to $463 million--a decrease of $131 million, or a 22% drop.

And believe me folks, the 2009 report will look even worse for MECCs. Pfizer has announced that it will no longer fund them. The American Psychiatric Association is ending industry sponsored symposia, all of which are administered by MECCs. The AMA, in its latest CEJA report, said that commercial funding should be allowed only if the CME provider is deemed "not overly reliant on funding from industry sources." Translation: for-profit MECCs will no longer be kosher. (I realize this second CEJA report has been sent back to committee to tweak language such as "ethically permissible" but the language regarding MECCs will likely survive). Finally, the Institute of Medicine has called for a drastic reduction in commercial support of CME.

So goodbye MECCs. Your Christmas and Hannukah lasted a long time, but it's finally winding down.