Report from the Alliance for CME annual conference

The continuing medical education community suffered another blow to its credibility when, in January, just several weeks before the Alliance for CME annual conference, the Josiah Macy Jr. Foundation released a scathing report. Stating that the field was “in disarray,” the report criticized everything from CME's overuse of lecture formats to its failure to promote teamwork among healthcare professionals.

Macy's most controversial conclusion was that commercial support creates an unavoidable conflict of interest that cannot be eliminated by strengthening firewalls between pharmaceutical/device companies' marketing and education divisions. CME providers received about $1.2 billion in pharma industry grants, representing about 50 percent of their total income in 2006, according to the Accreditation Council for CME data report. The Macy solution: phase out commercial support over a five-year period. The report also recommends that accreditation should be restricted to academic institutions and medical societies, as well as a few other groups.

The report is the result of a conference the foundation held in November 2007 in Bermuda, which brought together 36 leaders from the academic healthcare education community to discuss their concerns. The document that was released in January, “Continuing Education in the Health Profession: Improving Healthcare through Lifelong Learning,” is actually only an executive summary. The full report, complete with background papers supporting its findings, is due out later this year. Before the report, many CME professionals had never heard of the New York-based foundation, which was founded in 1930 to improve healthcare education.

Coming less than a year after the April 2007 U.S. Senate Finance Report on CME, which also concluded that pharmaceutical industry funding compromises CME's independence, the Macy paper generated great anxiety among CME professionals. It became the talk of the Alliance for Continuing Medical Education's annual conference, held January 19 to 22 in Orlando, right up until a heated session on the last day.

The Macy View

While attendees thought the report raised important issues, they criticized it for providing no data to support its conclusions and no practical solutions for how to implement its recommendations. It also failed to acknowledge recent improvements in the CME system, such as the Accreditation Council for CME's updated accreditation criteria and new commercial support policies. And, they faulted the process, pointing out that only academic professionals were invited to the conference, and that other sectors, such as medical education and communication companies, were excluded.

The highly anticipated hot-topics session on the closing day of the conference gave attendees a chance to hear from CME professionals who had participated in the Macy forum and to respond.

Although some Alliance attendees had expressed disbelief that their colleagues who participated in the Macy conference really agreed with its conclusions, Macy representative Ellen Cosgrove, MD, senior associate dean, education, University of New Mexico School of Medicine, Albuquerque, explained that the report's findings were reached by consensus during the November conference. “We all stand behind the report,” she said.

Refuting comments that the Macy conference was convened in reaction to the Senate Finance Committee report, Cosgrove explained that the conference took 18 months to plan and therefore was not a response to the SFC.

Speaking to the commercial-support issue, Cosgrove said that while industry has done a good job of strengthening firewalls, too much time and too many resources go into proving a negative — that CME is not biased — when the focus should be solely on education. “We share the concerns about what it will mean to fundamentally change the structure of how CME is funded,” she said. “That is a question that is as scary for [the Macy participants] as it is for many of you.” The five-year time frame proposed by Macy, she said, is intended to give the profession the time necessary to alter the funding model.

Acknowledging that some in the community felt hurt by the report, Macy representative David A. Davis, MD, vice president, continuing healthcare education improvement, Association of American Medical Colleges, Washington, D.C., said that the proposed ban on pharma funding should not be construed as an attack on CME professionals for not doing their jobs. In fact, he said, it's a criticism of the healthcare profession for not supporting CME as it should. Macy calls on academic health centers, healthcare organizations, group practices, and other stakeholders to step up and foot the bill. “It's not so much about demonizing [the pharmaceutical] industry as it is a call to action to the healthcare community for the professional development of CME,” said Davis.

Catalyst for Change

CME leaders on the panel as well as attendees then presented their perspectives. Panelist Marcia Jackson, PhD, president, CME By Design, Santee, S.C., took exception to some of the language in the Macy report. She thought statements such as “CME is in disarray,” “Bias is woven into the fabric” of CME, and “The accreditation process is laborious” were inflammatory and overstated. Jackson also said that choosing Bermuda as a site could give the impression that the meeting was a junket, a perception that the CME enterprise has been trying to combat.

However, like other speakers and many attendees, she said that the report included sound recommendations, raised valid issues, and should be used as a catalyst for discussion.

Mike Saxton, Med, senior director, team leader, medical education group, Pfizer, New York, agreed, adding, “We must guard against letting emotionally fraught issues like commercial support distract us from the more important findings.”

On the question of commercial support, Saxton said, “Industry's role has always been — and remains — to support the CME profession in its efforts to improve healthcare quality. Period.” His comments sparked audience applause. Then he added, “If after deliberation, the profession reaches the conclusion that it is best served by ending commercial support, industry should follow that lead. Industry is prepared to do that.”

There are pros and cons that would result from banning commercial support, Jackson said. Among the positives, curriculum would not be tied as closely to therapeutics, provider competition would be decreased, the burden of compliance would be lessened, and CME would have more of a local focus. On the downside, physicians would have less access to CME and providers would have fewer dollars for incorporating cutting-edge techniques.

But commercial support is only one factor contributing to bias, Jackson said. Speakers and faculty also have ties to industry and bring their own bias. Nancy Davis, PhD, founder, National Institute for Quality Improvement and Education, Homestead, Pa., concurred. “Taking commercial support out of CME will not eliminate commercial bias,” she said, adding that research and studies are another source of commercial influence.

Obvious commercial bias is one thing, but human or personal bias is another, said Robert Addleton, EdD, executive vice president, Medical Association of Georgia, Atlanta. It's impossible to eliminate the latter, he said, because it's human to have preferences. Without instructor perspective, education would lose its zing. “Bias-free CME is like decaffeinated coffee,” he said.

There are many alternative models for commercial support, Saxton said, including a balanced funding initiative — one that encourages CME providers to get funding from a variety of sources, both public and private (including industry). “We all agree balanced funding is a good idea,” said Saxton. “Let's have that discussion and not wait for outside groups to have that conversation for us.” The CME community needs to establish standards for commercial support, he said, such as limits on allowable amounts of funding. “Most commercial supporters would like to see those standards established, instead of each company adopting different thresholds or different mechanisms. Additionally, there are many conflict-of-interest issues in the profession that are not addressed in our current accreditation requirements,” he said. “Let's set an action agenda for addressing those issues today — not tomorrow.”

Action Agenda

The Alliance responded to the call for action. While it refuses to endorse or reject the Macy report until supporting data is provided, “there are issues here that need to be studied in a collaborative way,” said Alliance President Sue Ann Capizzi, MBA, associate director, division of CPPD, American Medical Association, Chicago. Toward that end, the Alliance has created an advocacy committee, chaired by Damon Marquis, director of education and member services at the Society of Thoracic Surgeons, Chicago, to establish positions on key issues, such as those raised by the Macy Foundation, said Capizzi. The committee, which had not yet convened at press time, will also help the Alliance communicate these positions throughout the medical community as well as to the government. “The committee is going to embrace a more active advocacy agenda for the Alliance in the coming year,” she said.

Additionally, the Alliance has appointed a task force to define the standards of the CME profession. The task force, which also had not yet convened at press time, is chaired by Kathy Johnson, EdM, manager, accreditation of educational institutes, American College of Surgeons, Chicago.

Drive for Data

The need for advocacy was a theme that was discussed at numerous sessions throughout the conference. In order to improve the perception of CME and successfully refute accusations that CME is commercially biased, the community needs data, CME leaders said.

Toward that end, the North American Association of Medical Education and Communications Cos. announced that it will initiate what may be the first national audit of certified CME activities to determine the prevalence of bias. NAAMECC committed $20,000 to the study and called on other CME stakeholder organizations to contribute additional funding.

In the first quarter of 2008, an independent auditor will be tapped, via a request for proposals, to conduct random audits of CME activities across multiple provider types, said NAAMECC President Michael Lemon, president, Postgraduate Institute for Medicine, Englewood, Colo. The data will be aggregated, with the identities of individual providers remaining anonymous. The audits will conclude in August and then NAAMECC will publish the results.

The Accreditation Council for CME is ramping up its data-collection process, said Murray Kopelow, MD, chief executive, Accreditation Council for CME. A new information-management system, scheduled to launch this year, will allow providers to upload detailed data on their activities to a Web site instead of submitting spreadsheets. This will enable the ACCME to aggregate comprehensive information about CME activities, including topics, outcomes measurements, and commercial support. “We couldn't even tell the Senate Finance Committee what proportion of activities were commercially supported,” said Kopelow. The new system will collect that data. “The data isn't there to say if we're successful or not [in preventing commercial bias],” said Kopelow. “We need to change that; we need that information.”

And it's the collection of such data — gathered through patient outcomes, performance improvement measures, etc. — that is the key to creating effective advocacy initiatives, said John Kamp, executive director, Coalition for Healthcare Communication, New York; and attorney with Wiley Rein LLP, speaking at the Pharmaceutical Alliance for CME section meeting. Data will demonstrate CME's value in improving patient care everywhere from Capitol Hill to Main Street to executive boardrooms, he said.

Spread the Word

Those opposed to commercial support in CME are organized and effective in communicating their message, Kamp said, citing the National Legislative Association on Prescription Drug Prices, the Prescription Project, and the Physicians Alliance as examples. If industry doesn't tell its story “half as well as the opposition — we're cooked,” said Kamp. “We've got to be prepared to stand up and defend ourselves.”

He called on attendees to get involved with influential organizations, whether it's NAAMECC, the National Task Force on CME Provider/Industry Collaboration, the Alliance for CME, or an organization he is forming called the Inside the Beltway Ad Hoc Coalition. He has invited a broad list of organizations, including AdvaMed, the Association of American Medical Colleges, the American Academy of Family Physicians, and the Biotechnology Industry Organization, to participate in the initial meeting — a “Call for Stakeholders meeting” — which will be scheduled in the near future. The coalition will work to advocate on behalf of CME with federal and state lawmakers.

Also, he asked attendees to make connections with legislators, politicians, and public policy groups, informing them about data or research that shows the value of CME. “Policymakers must hear that CME is about patient care,” said Kamp.

Another advocacy initiative has been started by the National Task Force on CME Provider/Industry Collaboration. A public-affairs committee aims to protect CME's reputation, analyze the risk from negative attacks, and develop comprehensive, rapid-response strategies.

As a first step, committee members are creating six fact sheets, each of which will address one topic, such as conflict of interest and the value of independent CME, in language that the lay public can understand. The committee plans to have two to four fact sheets ready within the year.

“There's so much misinformation out there in the lay press, in the government, and even, frankly, in the CME community itself, that we felt that a good place to start would be to get the facts out there, said Maureen Doyle-Scharff, committee chair; and director, medical education group, U.S. external medical affairs, Pfizer, N.Y., in an interview before the Alliance conference.“We're working on a number of different initiatives to educate the press and the public about the value of CME and its relationship to the improvement of physician performance and patient care.”

Kopelow also made a call for advocacy, urging Alliance conference attendees to promote CME's value to the leadership of healthcare organizations. “It's time for us as a system to let those around us know about CME,” he said. “Our CEOs and our healthcare systems need to say, ‘We're talking about changing physician practice — why isn't CME at the table?’ There is urgency because people are dying. There is urgency because people aren't getting medication. Don't say someone else has to do something. Each of us needs to address these things. You are the people who can carry this message forward.”

Wanted: Best Practices

Is CME professionalism incompatible with commercial support? That was one of the issues discussed at the Alliance for CME annual conference opening plenary session, Professionalism and CME: Taking the High Road, with speakers David Rothman, PhD, and Susan Chimonas, PhD, Columbia University Institute for Medicine as a Profession, New York.

IMAP is an organization funded by billionaire George Soros, who believes that professions should respond to professional imperatives and values, not the marketplace, said Rothman.

Unlike the Josiah Macy Jr. Foundation, the speakers don't think the road to professionalism necessarily excludes commercial support. “We're not rushing to judgment on that,” Chimonas said. “We're looking into what works, and a model that includes commercial funding could work.”

One of the barriers to change is that people don't know how to create a CME system that is free of commercial bias, the speakers said. IMAP hopes to change that by studying the best CME programs and publishing their findings in a report.

The models they plan to study include Kaiser Permanente, which accepts no commercial support; the University of Wisconsin School of Medicine, which does accept commercial funding but has rigorous policies to protect against commercial bias; and the University of Massachusetts at Worcester, which accepts commercial support through a central repository, meaning funding cannot be targeted to a particular topic.

IMAP is looking for more case studies. To participate or recommend candidates, contact Rothman at djr5@columbia.edu or Chimonas at sc2254@columbia.edu.

Of MECCs and Macy

The Josiah Macy Jr. Foundation's vision of CME in the future appears to exclude medical education and communication companies as accredited providers. According to its report, released in January, organizations authorized to provide CE should include only nationally accredited professional schools, not-for-profit professional societies, and organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations, as well as professional journals, multidisciplinary practice groups, and point-of-care resources.

Responding immediately to this latest attack, MECCA, the medical education and communication companies member section of the Alliance for CME, brought in Murray Kopelow, MD, chief executive, Accreditation Council for CME, to give his perspective. MECCS were particularly concerned because Kopelow had distributed the Macy report to all accredited providers. Did that mean the ACCME agreed with its conclusions? Absolutely not, said Kopelow.

“We didn't get invited [to the Macy conference]; we didn't participate; we didn't contribute. That's not our position,” Kopelow assured the group. “It isn't on [the ACCME's] agenda to talk about any of our provider types no longer being acceptable.”

Preparing for the Storm

During a panel presentation at the MECCA section meeting, speakers and attendees discussed how to best respond to the report. By releasing the summary report before the full report, Macy gave the CME community the opportunity to prepare for the potential storm, said one participant.

“This is a time for us to step up, to share our data with one another, to share our best practices, said Karen Overstreet, EdD, president, Indicia Medical Education LLC, North Wales, Pa. She also cautioned against giving too much attention to the report. “Raise your hand if you had heard of the Macy Foundation before the report came out,” she said. (A few people raised their hands.) “Not very many. We're all riled up about this; we're passionate about it because our livelihoods could be affected, but we have to remember this is not a well-known group in the CME space. Let's not overreact.”

But it's critical to advocate on behalf of CME and MECCs, most agreed. “I do think it is a major mistake to remain silent,” said one attendee. “Macy's argument is the one that's being popularized. If we do not do something to counteract that, we will ultimately damage ourselves. We have to stand up.”

Macy's Key Points

The Josiah Macy Jr. Foundation report, “Continuing Education in the Health Profession: Improving Healthcare through Lifelong Learning,” contends that the CME/CE industry needs a major overhaul. Among its recommendations, it proposes that the CME profession should:

  • Move from lecture-based to practice-based education
  • Train faculty in practice-based learning
  • Phase out commercial support over a five-year period
  • Disallow academic health center faculty from serving on pharmaceutical companies' speakers bureaus or as paid industry spokespersons, and from publishing articles ghost-written by industry employees
  • Create a single accreditation organization for nursing and medicine
  • Restrict accreditation to academic medical institutions, not-for-profit medical societies, and a few other groups
  • Create a national continuing education research center

For the complete executive summary, visit www.josiahmacyfoundation.org.