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DECEMBER 5, 2008 10:49AM

The Secret Defense of CME

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While reading through the November 15th issue of American Family Physician, I happened across a peculiar advertisement. Neither a pharmaceutical nor a medical product ad, it had political overtones, and thus seemed oddly out of place. It stopped me because its subject was a topic of particular interest to me – civil rights in medicine. “Why are some members of Congress & Academia trying to censor medical communications,” it asks, almost plaintively.

Congress and academia censoring medicine? What was this all about? I knew of no political initiatives aimed at restictiing medical communication. And I had never heard of of any branch of academia, no matter how extreme, that was interested in doing so.

The ad copy was not very illuminating, and in fact raised my suspicion. “Information is part of quality care,” it says. “Yet government controls threaten to keep doctors in the dark about current medical advances.” At this point I smelled a rat. Big Brother talk often comes from interest groups with a partisan agenda. The second-to-last paragraph dropped a hint, but even it did not completely remove the veil: “We are concerned that some members of Congress and Academia are seeking to restrict the content of CME and other industry-sponsored communications [italics mine] without input from practicing physicians.”

I admire the way they insist on capitalizing Academia, by the way. It neatly sets off academics as a monolithic Organized Group, in apposition to Congress.

The article is signed by the Coalition for Healthcare Communication and it lists a website. To get to the bottom of this mystery, I went to the internet. There, the CHC identifies itself as an organization that “defends the right of health professionals and consumers to receive truthful information regarding pharmaceuticals and medical products, as safeguarded by the Constitution of the United States.” This means that the CHC is dedicated to ensuring that pharmaceutical companies can sponsor medical “education” opportunities for physicians without government or industry oversight.

So all this mess is about CME sponsorship.

To maintain a legal license to practice medicine, every physician in the U.S. must complete a certain number of hours of continuing medical education (CME) each year. CME programs are usually given by private groups for a fee, and every CME program has to be certified as educational by a national organization such as the American Medical Association. The required number of hours varies from state to state, but 30 hours is a typical number.

Long ago, drug companies found that offering free CME programs to doctors was a quick and easy way to market their products. Doctors have to get the hours anyway, so why not offer them information about hot new products and get the sessions certified as “educational”? Marketers could package the educational sessions with a nice lunch or dinner, free of charge. To pass muster with the AMA, the classes had to reasonably disguise their marketing intent, and employ professional speakers who could not endorse a particular product. Despite these limitations, CME must have some effect on sales, because free CME offers are everywhere. I get offers in the mail almost every day, and several times a day by email.

In the last few years, the federal government and various medical schools (i.e., “Academia”) have been trying to clamp down on the practice. Until about a decade ago, many CME programs were blatant bribes – a pharma company would offer a trip to Vail, all expenses paid and including lift tickets, in exchange for maybe 5 hours of CME. This was clearly excessive, and even the drug industry now acknowledges this.

Today, the process is much more subtle. A typical example is a booklet offering an online CME class or a 6 page newsletter which I can read through, answer a few questions about, and then claim as CME. No dinners or free goodies, just the education.

So what’s the matter with that? Some of the CME courses are quite good and I have learned much from the ones I have taken. They are scientifically oriented, written by practicing physicians, and appear unbiased. Most of them provide useful information in a concise format and help doctors learn about the latest therapies. Without them, it would be more difficult for doctors to sort through the latest information and would take much longer for them to find out about new products.

Think about it from your own point of view. How do you know what Tylenol is? How did you first learn about liposuction, or Lasik surgery? How do you know that aspirin helps heart disease, that there are pills for allergies that won’t make you sleepy, that heartburn is caused by acid reflux? Where did you first hear that a stroke is a “brain attack”? Chances are you heard it in an ad. Not everything advertisers tell you is wrong, and not everything they tell you is useless.

There are problems with sponsored CME, however. Sponsored CME may be medically accurate, but it often incorporates one of the most serious and insidious of biases – the selection bias. Selection bias refers to the error a study makes when it fails to choose its subjects properly. A medical study that enrolls 1000 patients at a psychiatric clinic to test an antidepressant, for example, may be biased because any patient that goes to see a psychiatrist is likely to have worse depression than the average person on the street. So, while a positive result in such a study might prove the drug works for patients who see a psychiatrist, it may not apply to the general population.

In the same way, sponsored CME has a selection bias towards prescription drugs. If I want to do CME in the area of cholesterol lowering drugs, or depression, or irritable bowel syndrome, no problem. I can take my pick. But if I want to do CME on the subject of alcohol addiction, forget it. There are no hot new drugs for alcohol addiction, and Budweiser certainly isn’t going to foot the bill to teach me how to get patients to stop buying their stuff. So if I want to do alcohol CME, I have to pay for it myself.

Doctors are like anyone else. They follow the path of least resistance. Suppose a doc needs 3 hours of CME. He has three offers on his desk – one for cholesterol, one for IBS, and one for the latest treatments for high blood pressure. All three are easy and free. They also just happen to cover areas in primary care where there are new, expensive, very profitable drugs available. It would take a special effort for this doctor to look past three free offers and choose to pay $100 out of pocket to learn about pneumonia, an area where there are not any hot new developments. Yet this doctor might benefit more from refreshing his memory on a bedrock topic like pneumonia than a sexy new one like IBS.

Commercial funding of CME gently leads medical professionals towards newer and more expensive treatments. Doctors prescribe medications they are comfortable with, and comfort comes from knowledge. I can give an example from my own experience. When I was a resident in internal medicine I received almost no training in migraine headaches. Migraines were the neurologists’ territory, and general IM residents simply didn’t get the exposure. About a year after I finished my training, in an effort to plug this knowledge deficit, I attended a one-day seminar on migraine treatment. The seminar was very useful, but instruction focused mainly on the newer migraine agents called tryptans. While tryptans are very useful in migraine management, the seminar avoided discussion about older and sometimes equally effective agents such as ergots, tricyclics, beta blockers, and sedatives. The CME seminary increased my knowledge about migraines but at the same time left me with a tendency to reach for the treatments I now knew best – the most expensive ones.

Nonetheless, I would be remiss if I didn’t point out the positive aspects of this seminar. Though clearly sponsored by one or more of the tryptan manufacturers, no individual products were endorsed, nor did the speakers express a preference. More importantly, if there had been no seminar, would my knowledge and comfort with migraine treatment be what it is today? Probably not.

This brings us back to our mysterious ad. Digging into the website, I found the information I was looking for:

The adage "there is strength in numbers" rings true for the Coalition. Its membership is made up of organizations and industry leaders that share common interests and goals. Thus, the Coalition's track record in making a positive difference has been excellent.

The members are:  American Association of Advertising Agencies , American Advertising Federation, American Business Media, American Medical Publishers Association, Association of Medical Publications, Association of National Advertisers, Healthcare Businesswomen’s Association, Healthcare Marketing and Communications Council, Medical Marketing Association, Midwest Healthcare Marketing Association.


All advertisers. Not to make too fine a point of it, but advertisers almost always represent money, and usually it is big money. Surely it is not simply ad companies behind this. Who trusts professional mouthpieces when they claim to be speaking for themselves? Most, if not all, of these ad groups do big business with the major pharmaceutical companies. Maybe Big Pharma has not specifically paid for this effort, but there can be no doubt that a bunch of advertisers would never launch such an effort without checking with their clients.

Unsurprisingly, this campaign underscores what is wrong with CME funding. You can’t tell where the money is coming from. This makes it difficult to interpret the message, or measure the bias. If Big Pharma and drug marketers can’t defend their CME practices without disguising them in cryptic constitutional arguments, it is hard to see them presenting CME in a way that would allow doctors to clearly evaluate bias.

This is not an ad for freedom of speech. It is an ad for secrecy. And secrecy in a scientific discipline is not a good thing.

Leave it to a group of marketers to make black seem white.

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Pretty fascinating deconstruction, Michael.
"Unsurprisingly, this campaign underscores what is wrong with CME funding. You can’t tell where the money is coming from."

I agree with almost everything you've said here, Michael, except your comment on identifying the bias in sponsored CME. EVERY program (if it adheres to ACCME guidelines, which it must to give CMe credit) identifies both the source of funding and any COI of the speaker. As such, learners always have the means to evaluate whether the progamming may be biased. As physicians..heck, as consumers, we all have our radar on for evidence of bias. Do we believe more strongly in a display ad from a device manufacturer, or a testimonial for their product by a trusted colleague ? If we attend a lecture on CGMs sponsored by Medtronic, we know to be cautious and check other sources for what is recommended.