“IF YOU THINK ABOUT A TYPICAL HOSPITAL OR MEDICAL school or medical society that's looking at this panoply of communication companies, they don't really know what they do, they don't really trust them, they think they came right out of the pharmaceutical industry, and they try to stay away from them. But that's just too simplistic a view.”
So says Joseph Green, PhD, associate dean, continuing medical education, Duke University School of Medicine, Durham, N.C. Green ought to know. As a past president of the Alliance for Continuing Medical Education, a consultant who helped many medical education and communication companies (MECCs) become accredited providers, and an innovative voice in the MECC/accredited provider relationship, Green has long been on the front line of the MECC business.
Here are the reasons why “traditional” CME providers need to develop an informed and proactive approach to working with MECCs — and vice versa.
CME providers who have no contact with MECCs are likely to become a rarity soon. Consider this: In 1999, there were 39 organizations classified as MECCs by the ACCME that were accredited providers. By the end of 2001, there were 88 such companies. When non-accredited MECCs are included, the total rises to 182 companies. That's the number identified in a 2001 study conducted by staff at Meniscus Educational Institute, West Conshohocken, Pa.; and Discovery International, Deerfield, Ill.
“The reality is, they [MECCs] have the ear of the grantor,” says Gordon F. West, PhD, education specialist at the Annenberg Center for Health Sciences, in Rancho Mirage, Calif. “That's because they've probably worked with the grantor on a variety of projects, not all of them accredited.” The ACCME's annual report of income and expenses by organization type bears this out: In 2000, the latest year for which numbers are available, the average MECC received $3.64 million in income from commercial support. By contrast, the average medical professional society received $466,000; the average hospital $222,000.
“They've got the connections at the pharmaceutical companies,” says Sandra Pizzoferrato, associate director with the American Epilepsy Society, West Hartford, Conn. “Specialty societies have connections too, but the [MECCs] have salespeople who go out and call on the pharmaceutical companies.”
Money isn't the only thing MECCs bring to the table. “They have the staff, the connections, the expertise,” continues Pizzoferrato. “They tend to bring a very good understanding of the topic,” adds Annenberg's West. “They are aware of who is well-published and well-thought-of in the field — although we are, too — and tend to act on that information.”
MECCs may seem to have the lion's share of unrestricted grants, but it is hardly the case that they want to keep all those funds to themselves. Quite the contrary, according to Green. In the case of medical schools, he believes MECCs — accredited or not — are eager these days to partner. In other words, MECCs need you, too.
“This has to do with the legal environment they're operating in,” he says. “Their (the pharmaceutical companies') legal departments often want to have an academic partner involved to protect them [against charges of being overly promotional]. I think in the last six to eight months, especially, the pharmaceutical companies are becoming much more concerned, appropriately, about not trying to unduly influence the education process, letting the accredited providers do what they need to do, and keeping arm's length from all that.”
MECCs — even the accredited ones — also often seek both the prestige of an academic or professional society connection and the unique access such organizations have to their members. “If they don't have the stature, or can't reach the audience they want to reach, they'll come to a medical society to gain that substantive weight,” says Pizzoferrato.
While MECCs may have a lot of funding, they're more than ready to share it with CME providers that bring additional credibility to the table. And that's a good thing, says Green, given the underfunding and understaffing that is a chronic condition of so many CME departments. “Either you live with [lack of resources] and learn to keep people away from your office, because you can't deal with the demand, or you figure out how to bring in additional revenue on your own from outside the institution in order to survive, thrive, and do the things that CME departments ought to do,” he says.
Of course, not everyone shares Green's enthusiasm for collaboration. “Our position is that if it enhances the quality of the CME activity, then yes, we'll work with an accredited [MECC],” says Johnnie White, CMP, manager of CME services for The Endocrine Society, Bethesda, Md. “If not, we won't. So far, only one accredited communications company has come to us asking us to co-sponsor an educational activity because they wanted the association with our name; we felt there was no enhancement involved, because they weren't offering anything new.”
But, sometimes, there really isn't any choice — a communications company has already established a relationship with a pharmaceutical firm, and it will start looking for an appropriate CME provider. “We'll receive proposals for ancillary programs from commercial supporters, and they come in with a communications company that they already have a contract with,” says White.
The most common scenario for an accredited provider/MECC relationship begins with a single project. Martha Silling, PhD, director of CME at Northeastern Ohio Universities College of Medicine (NOUCOM), an educational consortium of three universities based in Rootsville, Ohio, gives an example of the organic nature of relationship-building. A MECC came to her attention through a faculty member. “He came to me, said he was working on a project, and would I be willing to work with them as a CME provider?” she says. “I did one activity with them, and it went very well. Then I did one more activity with them, and it went very well. Then I did something with them through another faculty member, and it went pretty well. Then they were interested in having a year-long agreement where we'd be one of their preferred providers. I went to visit them, at their invitation, at their headquarters in Princeton [N.J.]. They asked me to provide a day of training for their staff. We talked about ethics and walking that line. We talked about some of the programs they've turned down or backed away from because they felt there wasn't an intent on the part of the company to educate. Now I'm working with them on a number of projects, and I've been pleased, because having trained them, I know they know what they're doing.”
At the Annenberg Center, Gordon West doesn't have a form for MECC collaboration candidates to fill out, but he does have his own qualification strategy. “One of the things we do up front with communication companies is find out how everybody feels about the process of education,” he says. “We don't talk so much about what their clients are looking for; we talk about the varieties of education and what works best in terms of educating physicians. If their first concern is ‘How do we do this well?’ that's a good sign.”
At The Endocrine Society, the door for MECCs is wide open — but a wrong move can have drastic consequences. As White says, “We'll work with anybody — until they burn us. If they push the envelope, we will not work with them again. The same commercial supporter may come back to us with another program, but that communications company cannot be involved.”
Sometimes, though, even when a good relationship has been built between a MECC and CME provider, unsettling situations can arise — like when a pharmaceutical firm pulls out of a relationship with one MECC and replaces it with another in mid-development of a program. Martha Silling relates one such episode: “We gave approval for a program that we are sponsoring at the American Association of Osteopathic Surgeons conference, in which we'd been working with a communication company called Design Write (the same one she'd visited and trained). I got a phone call saying that they will no longer be working with the commercial supporter, Wyeth-Ayerst. We developed the program; we're using faculty who are national experts. But suddenly Design Write, which was doing a lot of the logistical planning — the handouts, the registration on site — has pulled out, and Wyeth has hired another company in their place. Scared the pants off me. I'm in the middle, having already given credit for this program, which I'm responsible for, and all of a sudden there's another company that I have no knowledge of whatsoever.”
In this case, it turned out to be Discovery International, which has a six-year accreditation with the ACCME. “At least I feel like I can trust them, because they know CME,” says Silling. But, as she cautions, “It could have turned out another way.”
As Green and others point out, there are good reasons for CME providers to work with MECCs, whether or not they are accredited. They have access to funding and they can provide expertise. “Quite honestly, they can do some things that we can't,” says Green. “They have more staff. They have some skill sets that we will never have in a school of medicine. We'll never be able to afford it.”
For example, Duke University School of Medicine sometimes works with a MECC called MediSpin Inc., based in New York City. “Duke has personnel who can create basic Web sites, but we bring a higher level of expertise,” says Brian Shanahan, MediSpin's CEO. “We specialize in things like Web-delivery systems.” Shanahan's company is so specialized, in fact, that he even does work with other MECCs. “It's because of the products we offer — they look to us as an extension of their services,” he says.
In the end, though, a good reason for CME providers to work with MECCs is simply their ability to provide people power, according to Green.
But he does have a caveat: “We're very careful when we work with the companies as to how we delegate what,” he says. “There are some things we don't ever delegate away, and those are the things we feel we have to do to maintain control over, such as faculty selection and content. But what we can delegate, we often do. In any given activity, they're in a much better position to help us both because of the numbers of people they have, and the skill sets they bring.”
When Green talks about medical schools, hospitals, and medical societies fearing any kind of association with MECCs, what he's really talking about is their fear of losing control of a program, and of an educational activity being corrupted by promotional messages.
Working with an accredited MECC should ease some of that fear. “As an accredited provider, we have to ensure that there is appropriate segregation of promotion and education,” says Fred Perner, senior vice president of Healthstream's Pharmaceutical and Medical Device Business Unit, Denver, Colo.
“It's funny — when you really explain the process of why you need that segregation, the commercial supporters are behind it 100 percent. At least with the large companies. It's always a challenge when you're dealing with new companies, because they want to promote, and you can't blame them, but that's an instance where we have to educate the commercial supporter first, before we can educate the physician.”
At the Annenberg Center, the CME department has actually done some modest research indicating that too much mention of a commercial supporter's product actually causes physicians to take the presentation less seriously. “So we can say to [MECCs], ‘Here are some things we know.…If you look at the results you'll see that you should tell the grantor that if they expect you to push the product big-time, they'll lose credibility in the long run,” says West.
Will MECCs listen to this kind of advice? In the end, it really does come down to relationships.
“We know there is the temptation to try to unduly influence,” says Green. “We are constantly vigilant to make sure that it never happens, although I don't think anyone's come up with a foolproof way to assure this. All I can say is we spend an awful lot of time worrying and trying to make sure that things go right. It's a complicated world; there aren't really any simple answers as to how to do it. I really think it has a lot to do with relationships and the trust you build up.”
The number of MECCs who have achieved the Accreditation Council for CME's seal of approval has more than doubled since 1999-now there are 88 — so it seems obvious that the companies themselves see accreditation as important.
“I find that those companies [that are accredited] understand the rules much better than those that do not have a CME arm,” says Johnnie White, CMP, manager of CME services for The Endocrine Society, Bethesda, Md.
Yet while many CME providers find it easier to work with such partners, accreditation is not a must-have. “I prefer to work with organizations that are accredited,” says Sandra Pizzoferrato, associate director, American Epilepsy Society, West Hartford, Conn. “They tend to be familiar with the steps that have to be taken to create a really strong educational program that everyone will want to attend. But I've also worked with organizations that were not accredited, and had no problems with them following my guidelines. They all know there's a line separating promotional and educational activities.”
“The communication companies that are accredited for the most part certainly understand the ACCME essentials, the FDA requirements, because they've been through that,” says Joseph Green, PhD, associate dean, continuing medical education, Duke University School of Medicine, Durham, N.C. “If they're not, it doesn't necessarily mean they don't understand it. I have worked with some that are not accredited, and have no desire to be accredited, yet they have gone out of their way to send their people to the ACCME workshops to understand the reality within which they're working.”
MediSpin Inc., a New York City-based MECC, is an example of what Green is talking about.“All our editorial staff has been through the ACCME workshops,” says Brian Shanahan, CEO of MediSpin. “We're well aware of the guidelines and how things should be positioned.” He adds that attending the workshop brought benefits beyond what the instructors had to say. “There were medical education companies and industry representatives there, and it was interesting to hear the conversations that came up on various issues,” he says. “AMA representatives were there, too, so I heard their views.”
So long as the MECC is current on ACCME practices, it seems it doesn't have to be accredited. Yet there are also circumstances like the one Martha Silling, PhD, director of CME at Northeastern Ohio Universities College of Medicine, Rootsville, Ohio, found herself in when the commercial supporter suddenly switched companies. (See main story.) She was a lot more comfortable knowing the new company was accredited. Actually, comfortable may not be the right word. “I admit to being a little intimidated by Discovery International, with its six-year accreditation status,” says Silling. [The ACCME normally gives four-year accreditation; outstanding providers attain six-year accreditation.] “That says a lot for them. I want to know what I can learn from them.”
When he first came to the Duke University School of Medicine, Joseph Green, PhD, associate dean, continuing medical education, found that the CME department had very few relationships with medical and educational communication companies (MECCs). Historically, the school had rarely reached out to work with MECCs, and consequently few had come to Duke's CME office looking to establish relationships. So Green and his staff had to figure out a way to get relationships built. What he came up with is a practice called “A Day at Duke.”
“We have been inviting communication companies in, one at a time. If we get the feeling they have something unique to offer, and/or that they're very good at what they do, we invite their top executives to spend a day with our staff,” he says.
“This idea came out of an Accreditation Council for CME workshop where I brought people together who were in hospitals, medical schools, and specialty societies on one side of the table, and on the other side were people from communications companies. And it was just so cold at the beginning! They had no idea about each other; they wouldn't speak to each other. But by the end of the session they were sharing business cards, because they realized they're all in the same game — although they come at it from different points of view — so they could probably help each other.
“Based on that premise, we've been bringing these companies to Duke, and it's been really interesting. They all have a unique approach, based on who their leadership is: Some are led by clinicians, some by marketing people, some are business people, some are educators. They're all very different. And depending on the type of leadership they have, they approach the world of communication companies very differently. Even though they kind of all look alike, they are not.”
The Duke CME office is setting up a database of MECCs, organized by the characteristics specific to each. “We have a lot of hands-on experience with these companies; having the database is very helpful when we're trying to pick the best partner to do whatever we're trying to do,” he says. “They appreciate it, too. We're not looking for exclusive relationships and neither are they — nor should they — but we are looking for good partners. We may have a meeting with one of them, and six months or a year later say, ‘Ah, remember that group?’ And we'll call them.
“The more you reach out, the more you understand what people bring to the table, the better off you'll be when you figure out who will be helpful in accomplishing your goals, not solely their goals.”