Should doctors who are paid to promote pharma products be barred from teaching CME activities about the same topics?
55% of physicians say no.

“Absurd and insulting.”

That is one physician's opinion about the Accreditation Council for CME's proposed policy that would prohibit physicians who are paid by pharmaceutical companies to promoteproducts from developing or teaching continuing medical education activities about the same topics. With the debate about how to manage conflict of interest going strong in the CME and wider healthcare community, we decided to ask doctors for their perspectives in our 2008 Physicians' CME Preferences Survey.

We also asked physicians their opinions of the gift ban imposed by the newly revised Pharmaceutical Research and Manufacturers of America Code on Interactions with Healthcare Professionals, and how the economic crisis is affecting their CME travel plans, in addition to our annual questions about their CME choices.

Checks and Balances

Choosing 1, 2, or 3 on a 6-point scale in which 1 meant “strongly disagree” and 6 meant “strongly agree,” more than half — 55 percent — of physician respondents oppose the ACCME's proposal regarding faculty restrictions. Of those, 29 percent “strongly disagree” — more than twice the number of those (14 percent) who “strongly agree.” (For a more detailed breakdown of responses to this and other questions, see the charts on pages 21 and 25.)

Physicians who disagree with the proposal commented that as long as activities were peer-reviewed and faculty disclosed conflicts of interest, there should be no restrictions on teachers, with some pointing out that paid promotional speakers are usually the most qualified experts in a particular area. “I learn from physicians with a strong knowledge of product,” noted one. Some respondents acknowledged the potential for bias but still believe the prohibition unnecessary. “They know the product, but I maintain a healthy skepticism about their conclusions and I ask questions,” said one. Another commented, “None of the physicians I know makes major changes in their practice on the basis of a single presentation.”

“No professional bias? Great!” That doctor and other respondents who support the ACCME proposal said it would avoid the perception of impropriety and prevent bias. “If there is conflict of interest, [the presentation] is an ad,” said one doctor; another observed that “lectures have become completely biased in the last 10 years.” Patients end up paying for the price of promotional speakers, said another.

One respondent felt the proposed restrictions should cast a wider net: “These physicians should [also] be prevented from developing clinical guidelines.”

You Can't Buy Me

Physicians are even more vehemently opposed to the gift ban included in the updated PhRMA code than they are to the ACCME proposal. Sixty-three percent disagree; of those, 38 percent “strongly disagree,” compared to 14 percent who “strongly agree.” The revised code, which took effect January 1, 2009, prohibits companies from giving away any items unless they are primarily for the education of patients or healthcare professionals. Even stethoscopes or general fitness items for patients, such as pedometers, are ruled out.

Ludicrous, stupid, and ridiculous were some of the respondents' reactions. “I'm insulted that anyone thinks a pen/notepad/meal is going to buy me,” said one. Another said, “Data available on my drugs of choice informs my prescribing decisions, not a stack of sticky notes or a handful of pens.”

One felt the policy was a poor move, particularly in conjunction with a sinking economy and rising CME fees. Another physician reported increasing the number of patient appointments to earn more money, and therefore decreasing the time available to see reps, because “I now have to cover the overhead for pens, pads, table covers, clocks, pedometers, and calculators.”

Several said that the ban's inclusion of patient care items went too far. “Those are very important,” argued one doctor, “are frequently not covered by insurance, and patients don't purchase them.”

Injecting a bit of humor, one physician said: “I'd rather have pens than lunch… fewer calories.” Another felt the money would simply be redistributed. “Now the money the pharma companies save will go to TV [direct-to-consumer] advertising, making my life miserable.” Apparently thinking the code was imposed by the government, several respondents thought politicians should clean their own house before judging others. “It's OK for a politician to accept money from a lobbyist, but we cannot accept even a small trinket?” exclaimed one doctor. “Something's wrong here.”

Image Improvement

Those who agree with the ban believe that it will improve the public's perception of healthcare providers. “Patients are less likely to feel doctors are prescribing meds based on gifts,” said one. “The image of physicians is clouded by their apparent paid-off relationships with drug companies,” agreed another. “I trained in the Navy and was not permitted to receive items from reps. Any practice-related item could be seen as a bribe from the company,” wrote one.

Giveaways cause real, not just perceived, conflicts, others said. “Gifts [create] bias no matter what we like to think about our ability to remain objective.” Another stated, “There should be no inducements.”

Grounded!

In addition to seeking their opinion about regulatory developments, we asked physicians how the tumbling economy and higher cost of travel are affecting their plans to attend out-of-town meetings. To place these responses in context: Surveys were sent out beginning in mid-September as financial markets plummeted. Although oil prices and fuel costs dropped during the fall, airfares continued to be higher than in 2007.

Half of respondents said that they plan to attend fewer meetings requiring overnight travel during the coming year. Thirty-eight percent said they plan to attend more local meetings, while 50 percent said they plan to earn more of their CME credits via methods not requiring travel. However, 33 percent said they had no plans to change their travel patterns.

In a separate question, physicians were asked about their upcoming travel plans. Twenty-seven percent said they plan to attend no out-of-town meetings during the next 12 months — almost double the 15 percent of respondents who gave the same answer in last year's survey. Thirty-one percent of docs plan to attend one meeting, down from 39 percent last year. Twenty-five percent plan to attend two meetings, down from 28 percent last year.

Air Travel Decisions

For the first time, when asking doctors how they make their decisions to attend out-of-town CME meetings, we included choices about air travel expenses, availability, and hassles — and those factors ranked in the top 10. A meeting's “geographic location” tops the list, as usual, with a mean of 4.8 on a scale of 1 to 6, with 1 meaning not at all important and 6 meaning extremely important. Next up were “meeting length” (4.8) and “meeting dates” (4.7). The “greater expense of airfare” came in at 4.4, as did the “increased hassles surrounding air travel.” The “reduced availability of flights” ranked 4.2. These travel-related factors came in ahead of the “CME provider's reputation,” and “speaker reputation,” two choices that made the top 10 list last year. This year both scored 4.1.

Economic pressures may have affected doctors' travel during the 12 months prior to the survey, as well. Respondents earned 34 percent of their credits at out-of-town meetings, which is a dip from the 2007 survey result of 41 percent, but is still the most popular method for racking up credits. Out-of-town conferences were the most popular with the younger-than-45 docs, who garnered 46 percent of their credits at meetings, compared to 33 percent of the 45-to-55s, and 31 percent of the older-than-55s.

Local meetings came in second, with respondents acquiring 22 percent of their credits through those events, up from 19 percent in last year's survey.

Click Here for CME

E-CME was the third-most-popular method of obtaining credits, with docs acquiring 15 percent of their credits through online services, up from 11 percent in the 2007 survey, and more than double the number in the 2006 survey, when respondents said they earned 7 percent of their credits electronically.

This method is least popular with the younger-than-45 crowd, who earned 8 percent of their credits online, compared to 18 percent for the 45-to-55s, and 15 percent for the older than 55s.

For the third year we asked physicians what online CME formats they use. The most popular method among the 38 percent who answered is Internet point-of-care, as we've seen in previous years, accounting for 62 percent of respondents' online credits. The next most popular choice was enduring Internet activities; docs earned 20 percent of their credits through that medium, down from 25 percent last year. Live Internet activities such as webcasts came in next, with physicians accruing 10 percent of their credits via those services, up from 7 percent in last year's survey, and 5 percent in the 2006 survey. MP3/podcasts accounted for 5 percent of respondents' e-CME credits, a jump from last year when docs earned fewer than 1 percent of their online credits through that method; however, in the 2006 survey, physicians also obtained 5 percent of their credits via MP3/podcasts.

We asked all the respondents about their e-CME plans for the next year, and they aim to increase their participation. Forty-seven percent plan to use Internet point-of-care to obtain credits, up slightly from last year's 46 percent. Twenty-two percent plan to use performance improvement, an increase over last year's 17 percent; 13 percent said they plan to use MP3/podcasts next year, a big jump from the 2007 survey, when 8 percent intended to try that format.

Room for Improvement

Asked how effective CME activities are in meeting their needs, the largest percentage, 55 percent, answered “somewhat effective,” while 38 percent said “extremely effective,” and 5 percent responded “slightly effective.” Nobody answered that they were not at all effective. These answers roughly correlate to last year's.

As for why CME activities do not meet their needs, respondents' write-in answers indicate that CME providers are heading in the right direction with more individualized formats, such as point-of-care and performance improvement. Doctors said activities were not relevant or tailored enough to their clinical practice.“I attend activities for the hours, but rarely is the content specific to my needs,” said one doctor.

Another said, “It's hard to concentrate for a full day but [I] can't justify less when going to a meeting.” One lamented, “same old lectures and speakers.” Another complained that the locations are too “ritzy” and hotels cost too much. Two respondents observed that activities are too biased.

On the positive side, one in five physicians said they earned fewer credits than in previous years; that's an improvement over last year's survey, when one in four earned fewer credits than they had previously.

For those who tallied fewer credits than in past years, with respondents choosing all answers that applied, 21 percent said it was because CME activities did not meet their needs, a higher percentage than last year's 14 percent. The most prevalent reason was that they are too busy to take time away from their practice (61 percent). Economic pressures are also a factor, with 46 percent saying it is “too costly to take time away from my practice,” and 15 percent answering that “employer restrictions on attendance-reimbursement” resulted in their earning fewer credits than in past years.

More On/ Meetingsnet.com

  • Survey Snapshot

    This year's survey consisted of 23 questions. Responses to all of these were cross-tabulated by gender, age, and by number of out-of-town meetings respondents attended in the previous 12 months. To purchase the full report, visit The Research Store at meetingsnet.com.

AVERAGE AGE OF RESPONDENTS
52

AVERAGE NUMBER OF YEARS IN THE MEDICAL FIELD
23

71%
OF RESPONDENTS ARE MALE

2%
DID NOT RESPOND

Ban the Ban

27%
OF RESPONDENTS ARE FEMALE

What is your opinion about the updated PhRMA Code that bars pharma companies from giving physicians any items unless they are related to education?

Bribes or Benefits?

Respondents answered based on a 6-point scale in which 1 represented “strongly disagree” and 6 represented “strongly agree.”

Gift ban opinions

“We are moral and not stupid. I cannot be swayed by material stuff.”

Education or Infomercials?

“Physicians should not be billboards for pharmaceutical companies.”

Speaker restriction opinions

“As long as I am aware upfront about such conflicts it should not matter. We should not be denied access to [these experts'] information.”

No Gag Rules

“An unbiased presentation cannot be given from someone on the payroll of the product they are discussing.”

What is your opinion about the ACCME's proposed policy that would prohibit physicians who do paid pharmaceutical company product promotion from developing or teaching certified CME activities about the same product or content area?

Top 10 Travel Factors

Respondents answered based on a 6-point scale in which 1 represented “strongly disagree” and 6 represented “strongly agree.”

For the first time, we included choices about air travel expenses, availability, and hassles when asking physicians how they decide whether to attend an out-of-town meeting, and those factors drew high scores.

Meeting's geographical location 4.8
Meeting length (days away from home/work) 4.8
Meeting date(s) 4.7
Availability of education (no local equivalent) 4.5
Need/desire for CE credits 4.5
Meeting registration fee 4.4
Greater airfare expense 4.4
Increased hassles surrounding air trave l4.4
Miscellaneous costs (travel, food, lodging) 4.3
Reduced availability of flights 4.2

Grounded!

Respondents rated factors based on a 6-point scale where 1 represents “not at all important” and 6 represents “extremely important.”

How will the weakened economy and/or higher costs of travel affect your attendance at CME meetings during the next 12 months?

I plan to attend fewer out-of-town meetings. 50%
I plan to attend more local meetings. 38%
I plan to earn more of my CME via methods not requiring travel. 50%
I have no plans to change my travel plans. 33%

Point-of-Care Most Popular

Respondents chose all answers that apply.

Physicians earned
62%
of their online credits through Internet point-of-care activities.

Mostly Meetings

47%
plan to earn credits through point-of-care activities during the next 12 months.

Percentage of credits earned, by method

Attending out-of-town meeting 34%
Attending local meetings 22%
Online services 15%
Reading journals 12%
Audio CDs/tapes 5%
Other 4%
DVDs/CD-ROMs 3%
Audioconferences 3%
Performance improvement 2%

Credit Climb

Total does not add up to 100% due to rounding.

Respondents earned an average of 51 credits during the 12 months prior to the survey, up from the average of 48 credits reported in last year's survey.

Lecture Me!

38% find CME activities extremely effective in meeting their needs; an additional 55% find them somewhat effective.

When attending a CME meeting covering new clinical information, how effective are each of the following formats in motivating you to change your practice behavior?

Ratings are based on a 6-point scale where 6 represents “extremely effective” and 1 represents “not at all effective.”

Sidebar: Methodology

Lectures with Q&A session 4.8
Case-based learning 4.3
Hands-on, skill-building sessions 4.1
Consulting with colleagues 3.8
Small-group interactive sessions 3.6
Lectures with pre- and post- test 3.6
Lectures without Q&A session 3.4
Unstructured topic discussion 3.0

This is the 16th Annual Physician Preferences in CME Survey. It is the longest-running horizontal study of physician preferences and participation in CME. Penton Media mailed alert postcards on September 15, 2008, followed by cover letters and questionnaires sent on September 17 to 1,500 U.S.-based physicians selected on an nth number basis from an American Medical Association file provided by KM Lists, Marlton, N.J. A follow-up mailing was sent on September 30, 2008, to nonrespondents. Letters in the first mailing were affixed with first-class stamps to differentiate them from competing direct-mail pieces, and contained a one-dollar incentive and a postage-paid response envelope. We received 175 usable surveys, a response rate of 12 percent.

Related article:
Bias in the Hot Seat