“Financial Relationships with Industry in Continuing Medical Education,” the much anticipated follow-up report from the American Medical Association’s Council on Ethical and Judicial Affairs, has not yet reached the end of what is turning out to be a long and winding road to acceptance. At the AMA’s House of Delegates (HOD) meeting in Chicago in June, the association sent it back for more study instead of adopting it as it stood. As is often the case with issues involving pharmaceutical companies and financial involvement in CME, objectors believed that CEJA still needed to clarify and refine a few points before the AMA could consider adoption.

Released in early May, the latest report had backed off of some of the original recommendations, such as eliminating commercial support for CME altogether, which proved to be unacceptable to many in the medical education world. Instead, it allowed for the medical profession to have the “autonomy and authority to regulate itself depending on ability to ensure that physicians acquire, maintain, and apply the values, knowledge, skills, and judgment essential for quality patient care.” To ensure CME activities remain independent of pharma influence due to commercial support, the report recommends categorizing them as either “ethically preferable” or “ethically permissible.” (For more on what qualifies as ethically preferable or permissible, please see “CEJA Won’t Seek Funding Ban” in the June MM, page 13.)

Therein lies the rub, according to the Alliance for CME. In a letter to the chairpersons of CEJA and the AMA’s Reference Committee on Constitution and Bylaws sent shortly before the HOD meeting, Alliance President Jann Balmer, PhD, applauded the report for its goals of providing “ethical guidance for physicians and the profession with respect to industry support for continuing medical education” and agreed that “relationships with these companies must be transparent and managed in a manner that identifies and resolves potential conflicts to prevent bias.”

But Balmer noted that the division between ethically permissible and ethically preferable is a false one. As she said in the letter, these distinctions “can be subjective and confusing and will be interpreted differently by physicians and the public alike. We believe there is no value in suggesting shades of gray as to whether or not a practice is ethical. Both ‘ethically preferable’ and ‘ethically permissible’ are, in fact, ethical.” She further notes that it would place more stress on CME providers to eliminate commercial support, and emphasizes that sometimes, those who have ties to industry are in fact still “the best potential faculty for a CME activity.”

These issues were raised at the AMA HOD meeting, and appeared to be the main sticking points for most of the objectors. According to an article in American Academy of Family Physicians’ AAFP News Now, there were several people who sought further clarification of the “permissible” and “preferable” distinction before recommending the report for adoption, including Ralph Hale, MD, executive vice president of the American College of Obstetricians and Gynecologists.

Another term deemed in need of clarification was “overly reliant, ” as in the CME provider must not be overly reliant on funding from industry sources in order to qualify as “ethically permissible.”

CEJA will take the objections under consideration and present a revised version at the HOD meeting next summer.

Rebecca J. Patchin, MD, board chairwoman of the American Medical Association, told MM, “The AMA is committed to high ethical standards. We look forward to the revised report, which will provide detailed guidance on how to continue to provide physicians with high-quality continuing medical education and maintain ethically sound relationships with industry that benefit the practice of medicine and our patients.”