After the American Medical Association declined to adopt two previous reports addressing CME, the AMA's Council on Ethical and Judicial Affairs recently issued a third draft report that encourages funders, CME providers, and physicians to implement additional practices related to medical industry funding. At its early November Interim meeting, the AMA House of Delegates once again referred thereport back to committee.
The bulk of the report's recommendations address “conditions” that should be met when industry funding is necessary “to ensure that physicians have access to appropriate, high-quality” CME. Unfortunately, most of these conditions already are required and addressed by Accreditation Council for CME Standards and policies. Any new conditions recommended in the document are focused more on blaming funding for our problems rather than eliminating the unethical users of CME funds.
The CEJA report paraphrases previous accusations and printed statements regarding industry-supported CME without citing evidence to back them up. The report makes the bold claim that “industry-supported CME programs … focus more on drug therapies and give more favorable treatment to company products.” The problem? These footnoted accusations are based on articles published in 2002 and 1986, respectively. The report ignores the 2003 Office of Inspector General compliance guidance as well as substantial updates tostandards and policies in 2004, 2006, and 2009 that specifically prohibit questionable past practices.
Not So Subtle After All
The report enters more dangerous logical territory when it states, “We must be clear: Our concern is not with egregious lapses of judgment or with corruption, but with the subtle bias that financial ties create.”
Two logical problems arise with this statement. First, it should be noted that virtually all news media reports, Congressional inquiries, and the summary of examples in the 2009 Institute of Medicine report regarding poor CME quality specifically hinge on “egregious lapses of judgment.”
All evidence to date that indicts CME stems from unethical practices, not from evidence of subtle bias. In the entire section of the 2009 Institute of Medicine report addressing CME conflicts of interest, only three specific examples regarding poor CME quality were cited. All three examples stemmed from federal cases alleging illegal marketing practices of the drugs Neurontin, Vioxx, and Xyrem between 2002 and 2005.
Regarding CME, these cases cited in the IOM report focused on physicians accepting payment from accredited education partners to allegedly promote drugs and off-label uses in their presentations. It should be noted that these practices are specifically prohibited by ACCME standards and policies for independence and conflict-of-interest resolution. Appropriate scrutiny of CME problems grew from the seed of rare but inappropriate physician and accredited-provider behavior — specifically, unethical conduct. The CEJA report ignores the root problem of addressing “egregious lapses of judgment” in favor of the poorly referenced concept that industry funding of CME somehow creates “subtle bias.”
If we are truly seeking to raise the bar for quality CME, we need to stop parroting well-worn but discredited accusations and focus on the real issue identified in 2007 by the U.S. Senate: rigorous enforcement of updated policies demanding transparency and independence.
Perhaps the third rejection is an indication that AMA leadership may finally be following the Senate's lead. Maybe now we can focus on evidence-based CME instead of the unproductive game of blame.
Stephen M. Lewis, MA, CCMEP, is president of Littleton, Colo.—based Global Education Group, and president of the North American Association of Medical Education and Communication Cos. Reach him at email@example.com.