"I wish someone from industry could have come here to answer our questions about getting commercial support." So said attendees at the medical specialty societies provider section held during the Alliance for CME 25th annual meeting this past January. They discussed setting up such an exchange at next year's conference. Great idea--providers from all settings need more information about developing effective relations with industry.

But why wait? We wanted to get you answers as soon as possible. Frederic S. Wilson, director of professional relations at Procter & Gamble Pharmaceuticals in Mason, Ohio, agreed to answer the questions raised at the Alliance session. A 23-year CME veteran, Wilson served as chair of the Pharmaceutical Alliance for CME from 1996 to 1998. He was elected to the National Task Force on CME/Provider Industry Collaboration in 1998, and frequently serves as faculty at the annual meeting. Most recently, he was elected to the board of directors of the Global Alliance for Medical Education.

Q: Is it more effective for CME providers to solicit support through the local or national offices of pharmaceutical companies?

A: I can only speak from my experience, but I found that it depends on two variables. First, what is the geographic extent of the intended audience? If it's national, the home office should be approached. If it's regional, [approach the] local company representative.

Secondly, what level of financial support is the CME provider seeking? If [you are looking for] less than $10,000, I'd make the request of local individuals. Otherwise, go to the home office. Companies that have field educational people give them what they call local opportunity funds--discretionary spending. Some are empowered to use [those funds] to support small studies as well as smaller educational activities--dinner meetings, grand rounds, that type of thing.

Q: Is it more effective for physicians or medical society staff to solicit grants? Societies are concerned that physicians may not be as well-versed in Accreditation Council for CME regulations and may promise more than a society can give. On the other hand, they think it might be harder for a company to say no to a physician.

A: I think medical society staff should make the solicitations. They have the big picture. They will be responsible for honoring any commitments. It's not really harder to say no to a physician--with all due respect.

Q: What are the most effective ways for associations to contact supporters? Some societies are establishing centralized departments that apply for funding, so that they are not competing with themselves and approaching the same funder multiple times. Is that a good idea?

A: Yes, that's a great idea. If a society envisions a long-term collaborative relationship with a pharmaceutical company, the society should have a primary contact within each potential supporting company and meet with that contact as often as the two of them require. I enjoy a partnership relationship with a number of CME providers. I know for a fact it is a satisfying relationship on both sides, but it's because I'm the person here and I have a contact there, and the two of us keep our respective organizations straight.

Q: Would you prefer providers approach you with a whole year's requests at once? Or approach you to support individual activities?

A: Do both. Ask for all you need, but have needs prioritized so that the potential supporter can choose. I would prefer to understand up front an organization's annual plan for collaboration with industry partners. [The provider should] spell out its objectives and goals, and ask industry to suggest tactics to achieve those goals. Treat us like partners, as more valuable resources than just deep pockets. I expect that those organizations with whom we collaborated in the past will bring extraordinary opportunities to my attention on a first-come, first-serve basis.

It's particularly helpful if my fiscal year is ending within 90 days. A number of companies' fiscal years end midyear. The last quarter is when brand managers look at their budgets, and say, 'Wait a minute, we've got $100,000 we haven't spent yet.' Those companies that have money available, perhaps in the second quarter of the calendar year, [have to] spend it or lose it.

Q: How can providers build and maintain positive relations with supporters?

A: Those CME providers with whom we have positive relations collaborate with us to the fullest extent allowed by ACCME Standards for Commercial Support. Unfortunately, some CME providers don't recall that the ACCME feels, and I quote, "the purpose of these Standards is to describe appropriate behavior of accredited sponsors when planning, designing, implementing, and evaluating certified CME activities for which commercial support is received." In other words, CME providers should seek company support beyond the required funding. For example, supporting companies know the scientists within relevant therapeutic categories better than most, and understand which doctors can deliver effective educational interventions.

CME providers can use us as a technical resource as well as a marketing resource to build audiences. When a company rep can be involved in the planning of a CME activity, the rep can add value. The rep knows what company resources can be brought to bear. If you share the results of the needs assessment with the rep, the rep can say, "Let's see, sounds like you need slide development. Why not use our audiovisual department to develop those slides?" Or maybe the company could provide an audience response system to enrich the learning activity. If providers only look at the company as a source of funding, they give themselves short shrift.

Q: How can a provider demonstrate ROI without violating ACCME guidelines? Providers are concerned, for example, about giving supporters evidence of increased script-writing as a result of an activity.

A: [Element] 2.4. of the new ACCME system of accreditation defines exemplary compliance: "Educational activities are evaluated consistently for effectiveness in meeting identified educational needs, as measured by practice application." What is practice application? Sounds like prescriptions. If the CME provider shares the prescribing data and the supporting company uses [physician] names for internal market research only, and the purpose is for both the supporter and provider to measure the impact of the educational activity--then it is completely within ACCME guidelines.

[The data] should never leave the company. It doesn't go out to sales for direct mail follow-up. As long as I will sign a letter saying that participants' names are being released to me only for internal market research purposes, I've never had a CME provider turn me down. Nor have I violated that trust.

We usually look at a time period three months before and afterward and measure the difference. You really can't have terribly high expectations. One educational intervention is not likely to change a prescribing habit, but we have seen instances where a particular medication was being prescribed incorrectly, and after the educational intervention the product was prescribed more accurately. Patients get the relief of symptoms they expect and physicians are happy.

Q: Providers expect CME activities to generate revenue. Should they include their expected ROI in proposals to industry?

A: If the department of CME in an organization is [expected to] generate revenue, as their partner, I would like to know about it. I would like to be able to help in any way I can.

Q: What types of activities are the most attractive to supporters--live programs, online CME, multiday conventions?

A: A mistake often made, in my opinion, is providers forget that you can do enduring materials for almost any live activity. Enduring materials still have more appeal than the Internet. We're probably years away from online CME being as attractive as the traditional enduring material. Enduring materials can reach the majority who couldn't attend the live activity. That can expand the budget. The cost per attendee for a live symposium can be scary, but if the 25,000 specialists who didn't go to the annual meeting [buy the enduring material] you've lowered the cost per educational contact tremendously.

I see the CD-ROM medium growing. George Lundberg, MD [formerly the editor of the Journal of the American Medical Association, currently chief editor at Medscape] announced in the fall of '98 the CD-ROM was dead. I have seen it do nothing but grow since he said that.

Q: According to ACCME's 1999 data report [available at www.accme.org], about 18 percent of commercial support goes to communication companies, although they comprise only about two-and-one-half percent of ACCME accredited providers. Why is that?

A: Perhaps they're a little bit easier to work with, more respectful of the bottom-line mentality that any commercial enterprise has to have. Sometimes an academic CME provider views industry as being more philanthropic, but [the company] stockholders wouldn't want to learn that.

I would just try and put on the commercial supporter's hat for a day and try to understand what their agenda is. Everybody wants better patient care, but at the same time each company is going to support its therapeutic areas of interest. That only makes sense.

Q: What can nonprofits do to capture more support?

A: CME providers that are doing it right know which companies are working in which therapeutic areas, and they identify opportunities to involve those companies when a needs assessment dictates.

For example, if a provider is planning a women's health symposium, it should solicit funding from Eli Lilly and Company and Procter & Gamble, because we're big into women's health.

Q: What should providers NOT do when soliciting support?

A: Misspell the company's name or product name in a proposal. Half of the [proposals] we get spell Procter 'or' not 'er.'

Sometimes when I see an itemized budget that is submitted there will be a large administration fee or CME accreditation fee that's broken out as a line item. I believe, according to ACCME guidelines, you're not supposed to charge for CME coordination.

When you get through administration charges and the accreditation charges and the certificate fees, it's a significant percentage of the overall budget. Sometimes overhead charges have to be applied, especially with academic CME providers. That's another reason why commercial or for-profit CME providers are more attractive--they don't have those overhead charges.

Q: What are examples of best practices you've observed used by providers? What are examples of best practices you've observed used by providers?

A : I have to mention one unusual expe rience. An academic CME provider came back to me and said, "We didn't spend all the money and we've got 25 percent left. We suggest you do a spin-off activity or we'll refund it."

We left it in escrow with her for application to a future project yet to be determined. She's earning interest on the money.

I'll never forget that. I always give her more business when I can. It just showed incredible integrity, an incredible feeling for my situation. I have a limited amount of discretionary funding. I have to tell my management where it went. It was mind-blowing.

Providers Under the Influence? The common practice of allowing grantors to attend CME planning meetings can call into question the provider's independence in the minds of faculty and attendees. That's the assertion made by Mark H. Schaffer, executive director, CME, University of Medicine and Dentistry of New Jersey in Newark. In his article, "Commercial Support and the Quandary of CME," published in the Spring 2000 issue of The Journal of Continuing Education in the Health Professions, Schaffer calls on the Accreditation Council for CME to prohibit grantors from attending CME content development sessions.

Schaffer, who is founding chair of the MECCA, the Medical Education and Communications Company Alliance, has served in both the academic and private sectors of CME. In a phone interview, he explained he is making the recommendations based on how CME planning sessions are perceived.

"If you have a meeting with faculty and there are six or seven people in the room who everyone knows are with the grantor, I feel it may either curtail conversation or it may generate conversation specific to a product," he says.

During his tenure on the academic side of CME, he observed a focus group evaluating a slide presentation. More than half the physicians said they perceived commercial bias. In that case, it wasn't too late to change the materials, Schaffer says, but his point is that he thinks that part of the reason the materials were biased was because of the grantor's presence at planning sessions.

But Frederic S. Wilson, director of professional relations at Procter & Gamble Pharmaceuticals in Mason, Ohio, takes exception to Schaffer's recommendation. "The supporting company can enrich a curriculum," he counters, "since it has done its own needs assessment of a therapeutic category to justify commercialization of the product." Case-in-point: When applying to the Food & Drug Administration for a supplemental new drug application, P&G learned that at double the recommended dosage, the drug worked more than twice as well. Therefore, P&G knew that physicians needed to learn about the more effective dosage. Grantors can also suggest potential faculty. "If the provider is doing his or her job, perception makes no difference," Wilson says.

But, contends Schaffer, "There's a difference between a grantor making a recommendation and a grantor saying, 'You have got to use these people.' In some cases, there's a real fine line and a hidden message ."

What should a provider do if a commercial supporter tries to exert undue influence? "If I had to, I would continue with developing the activity," says Wilson. "But I wouldn't work with that commercial supporter again. That would be the end of that relationship."

To help protect CME from the perception of influence, Schaffer suggests that the ACCME mandate that providers make every effort to get multiple grantors for an activity.

"That's fine, as long as the overall subject matter is broad, like women's health," responds Wilson. "But, if it's a narrow therapeutic category--if he thinks that competing companies are going to provide support, he's got another thing coming. It's a very competitive industry. Jif and Skippy are not going to provide grants to the same peanut butter activity."