Do you want an ophthalmologist using a piece of equipment to take out your cataracts after he or she has been to a conference supported by some company with a financial interest in people using its equipment? I don't," says Ruth M. Glotzer, MEd. Glotzer is director of the Office of Continuing Medical Education (CME) at Tufts University School of Medicine in Boston and member of the board of directors of Public Responsibility in Medicine and Research, a national nonprofit organization dedicated to educating the medical and legal professions, industry, and the public about the ethical, legal, and policy dimensions of appropriate and ethical research.
Glotzer and her colleagues at the Society of Academic CME (SACME) issued a White Paper last year (see MM September/October 1998, page 45) to SACME membership calling for an end to CME as offered by for-profit entities, even those accredited by the Accreditation Council for CME ().
The White Paper ignited a heated debate among CME providers about who was and who was not fit to offer Category 1 CME credit (credits which go toward the American Medical Association's Physician's Recognition Award, or PRA). At the time, the ACCME-accredited medical communications companies at whom the White Paper was aimed fought back by claiming that any decision to exclude them would amount to restraint of trade, since they were in fact accredited providers of CME.
On March 31 of this year, Glotzer and six other signatories from SACME circulated a new document, a resolution to be voted on at the SACME meeting in San Antonio in mid-April, this time saying that the awarding of Category 1 CME credit should be "reserved for the members of the seven parent organizations of the [ACCME]." (See "SACME Resolution," below.) The new resolution was not voted on at the San Antonio meeting because the SACME board wanted further discussion and a vote by the entire membership, not just those present at the meeting.
New Resolution, New Language The language of the new resolution is different from that of the original White Paper. Gone is the argument that for-profit providers have an inherent conflict of interest. Instead, the resolution argues that when the consequence of awarding CME credits is to give a physician new admitting privileges, or credentials, or relicensure, that such credits be awarded only by professional medical organizations.
"We're not looking to exclude anyone," says Glotzer. "It is simply that we think the professional aspects of CME--those parts concerning re-credentialing and relicensing--should remain the province and the responsibility of the medical profession."
While the resolution calls for SACME to consider the awarding of CME credit for the purpose of credentialing physicians by pharmaceutical companies, public relations firms, advertising agencies, and communication companies as inappropriate, it also allows for the possibility that organizations beyond the seven parent organizations might be extended the privilege of awarding CME on a case-by-case basis. "There may be other organizations we haven't identified that belong with this group," says Glotzer. "Our point is that when CME is to be used to recredential or relicense [physicians], the CME provider needs to go through a certain vetting process." While the resolution was not voted on at the San Antonio meeting, Glotzer expects it to be voted on by SACME membership later this year, so results can be announced at the annual meeting in October.
For the Defense While the new SACME resolution is a more tempered document than the original White Paper, it still challenges the legitimacy not only of medical communications companies, but of the very accreditation process. As was the case a year ago, Robert F. Orsetti, president of the for-profit Medical Education Collaborative, Mt. Laurel, N.J., has stepped forward in defense of the present accreditation system.
A l994 winner of the Alliance for CME President's Award "for significant contributions to the programs, services, and functions" of the ACME, Orsetti has many decades of experience in the CME community. His arguments in favor of the status quo boil down to these four:
* First, he notes that the ACCME makes no distinction among CME providers. For SACME to ask the ACCME to declare a distinction might be "viewed legally as purposeful restraint of trade without sufficient cause, with self-serving intent, and against legitimate businesses that are qualified and approved by the governing bodies, i.e., ACCME, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Osteopathic Association, and others." He adds that those providers denied the ability to provide Category 1 CME can be expected to take legal action.
* Second, he allows for the possibility that the pharmaceutical industry, which underwrites a lot of CME, will simply turn its back on the process and spend its money on direct-to-consumer advertising, promotional activities, and non-accredited education. "It is likely that if limitations are imposed, industry will be convinced that the CME community does not want a working partnership, but simply is seeking yet another way to keep industry in check while expecting 'blind' project funding," he says.
He points out also that medical schoolwhose research is supported by pharmaceutical industry grants also "can be expected to raise strong objection to the SACME policy with institutional administrators and with their professional societies."
* Orsetti's third point is that ACCME will face credibility problems if it suddenly reverses policy. "The ACCME and other CME-sanctioning bodies will be placed in embarrassing and largely untenable positions if forced to withdraw approval of certain accredited providers, and will lose the reputation and respect they now hold," he says.
* Finally, echoing CME providers who said this the last time this issue came up, Orsetti says CME doesn't need new restrictions, it needs better compliance with the rules it already has. "The SACME would better invest its time and effort by joining with the Alliance for CME and other groups to develop monitoring systems, training, and retraining programs to reduce CME guideline violations to a minimum, rather than to strike out generically against businesses that are guide- line-compliant," he says.
SACME Resolution Following is the text of the Society for Academic Con-tinuing Medical Education resolution, as presented to SACME members on March 31. The text of the original White Paper, "Thoughts and Comments Concerning Accreditation for CME Providers" can be found at our Web site at www.meetingsnet.com/mm/0798/white.htm.
We, the undersigned, hold that the authority to issue AMA/ PRA credit shall be reserved for the members of the seven parent organizations of the Accredi-tation Council for Con- tinuing Medical Educa-tion (ACCME), which are recognized and accepted as comprising organized medicine. Extending this privilege to additional organizations should be considered on a case-by-case basis.
The American Med-ical Association (AMA) credit system, the Physi-cian's Recognition Award (PRA), identifies the highest quality continuing medical education available to physicians. It is used by:
* State licensing authorities in the majority of U.S. states for relicensure of physicians,
* Medical institutions for documentation of "experience and/or competence in procedural skills" to guide the granting of "new or expanded clinical privileges," and
* Hospitals and medical centers to grant admitting privileges.
* American Medical Association Physician's Recognition Award. New Credit Designation Requirements for Sponsors of Continuing Medical Education for Physicians in New Procedures and Skills, Chicago, 1998.
In our professional judgment it is inappropriate that businesses such as pharmaceutical companies, public relation firms, advertising agencies, and communication companies are authorized to issue AMA/PRA credits which are then used to credential physicians in the practice of medicine. We wish to reaffirm that the granting of credits to physicians must remain the exclusive responsibility of the medical profession.
Marion C. Anderson, MD Medical University of South Carolina
Catherine D. DeAngelis, MD Johns Hopkins University School of Medicine
Ruth M. Glotzer, MEd Tufts University School of Medicine
Meryl H. Haber, MD Rush Medical College
David P. Heaphy, PhD Johns Hopkins University School of Medicine
Donald S. Kornfeld, MD Columbia University College of Physicians and Surgeons
Victor B. Marrow Albert Einstein College of Medicine