Beginning next January, the University’s medical school will no longer accept commercial funding for its postgraduate education classes.
The decision — recommended by the Medical School’s Conflict of Interest Group — is part of a broader nationwide debate over whether pharmaceutical and device companies ought to have a hand in paying for medical education classes.
Continuing medical education, or CME, activities provide medical professionals an opportunity to learn about advances in medicine and health care. In many states, CME participation is required for doctors to maintain their licenses to practice medicine.
The Accreditation Council for Continuing Medical Education regulates CME across the United States and has strict policies in place to ensure that classes are free from commercial influence, including full disclosure and management of any conflicts of interest of an individual “who is in the position to control the content of an education activity.”
According to a 2008 report from the ACCME, about $1 billion — roughly half the total expenditure for CME classes — came from commercial funding nationwide.
Medical School Dean James Woolliscroft said leaders in the medical school community looked at literature detailing the psychological effects of commercially supported education and relationship-building in marketing, ultimately concluding that accepting CME funding from commercial industries simply “was not the right thing to do.”
“We were concerned that we don’t want there to be even a perception of bias in what is being communicated to physicians,” he said.
In an interview with The New York Times last month, Rafael Fonseca, who teaches 20 to 30 CME courses a year and is the deputy director of the Mayo Clinic Cancer Center in Scottsdale, Arizona, said CME classes keep doctors up to date in their fields and that bias is not an issue.
“We present what we think is the state-of-the-art of the management of the disease,” he said in the interview. “The accusation that there is bias is not substantiated.”
The January edition of the Journal of Academic Medicine published a study from the Cleveland Clinic Foundation, which reported that “prospective analysis found no evidence that commercial support results in perceived bias in CME activities.”
The study looked at evaluations from 95,429 participants in 346 CME activities at the Cleveland Clinic. The evaluations asked participants to rate how well the activities met the ACCME standards for commercial support and whether the activities were free from commercial bias.
Depending on the activity, only 1.0 to 6.8 percent of respondents gave a “fair” or “poor” rating on how well their activities met the ACCME standards, and 97.3 to 99.2 percent of participants said they felt the activities were free from commercial bias.
Of the activities under investigation, 56.9 percent were not commercially funded, but the study showed no statistically significant difference in perceived bias between the commercially funded activities and the others.
A similar study from the University of California, San Francisco, published in the same issue of the Journal of Academic Medicine, found that “rates of perceived bias were low for the vast majority of CME activities in the sample and did not differ by the degree of industry support or other event characteristics.”
The UCSF study reported that 95 to 99 percent of participants in 213 CME activities said they did not perceive commercial bias in the activities, and as in the Cleveland Clinic study, there was no correlation between level of commercial support and perceived commercial bias.
Both studies concluded that under the ACCME regulations, commercially funded CME activities can be free from bias. They both added, however, that the institutions under investigation, the Cleveland Clinic and UCSF, might have more rigorous screening processes for industry supporters than other accredited CME institutions and recommended further investigation at other institutions.
Both studies also suggested that a more subtle, undetectable form of bias could be present.
The UCSF study, for example, mentioned that speakers might subconsciously tailor their presentations for commercial benefit. Dean Woolliscroft said he agreed that such studies may not uncover certain biases because participants can’t perceive them.
“None of us feel that we can be influenced,” Woolliscroft said, “but yet all of us, if we step back, realize that the whole marketing industry clearly is successful.”
Woolliscroft added that whether the bias is real or not, doctors have a “social covenant” with their patients and owe it to them to not even allow the question of bias.
Tom Sullivan, president of Rockpointe Corporation, a medical education company based in Columbia, Maryland, criticized the University for making this decision without evidentiary support that commercially funded CMA classes are biased, especially when the Cleveland Clinic and UCSF have published extensive reports that suggest the contrary.
Sullivan said it’s not necessary to take commercial funding away from CME, and in fact, the University’s decision will ultimately hurt the CME courses offered at the medical school.
Funding from pharmaceutical and device companies, he said, allows CME providers to organize smaller class sizes that create a more personal environment where doctors can get direct instruction on new treatments and technologies.
“There’s a need for people to be able to discuss in forums practical applications,” Sullivan said. “You want your doctor educated on how something works … you don’t want him reading the book while he’s doing the operation.”
Sullivan warned that without commercial funding, such intimate atmospheres would “not be as readily available,” adding that he wouldn’t be surprised if the University changed its mind after two or three years.
Woolliscroft said, come January, class participants can expect a sudden disappearance of company representatives and advertisements, but the classes themselves will remain the same.
Woolliscroft also said in the long run, Sullivan’s concern about lecture quality will become obsolete because he and others in the medical school hope to entirely revolutionize the CME program by moving away from lecture-style classes and instead toward technology-aided education.
“It’s been recognized that lectures are not a very effective way to change care for patients, that physicians oftentimes do not incorporate into their practice patterns what they’ve learned,” he said.
The loss of personal interaction is a potential downside to technologically-driven education, Woolliscroft admitted, but by the same token, doctors will be able to have virtual conversations with colleagues not only throughout the U.S., but throughout the world.
“We’re in a time of change, so we haven’t migrated fully away from a lecture format to some new way of enhancing learning, so it’s going to be a time of transition when other revenue sources are also constrained,” he said. “It’s really actually a very exciting time, and we’re just in the beginning of a big change in education, not just in medicine.”
Recognizing the immediate need to compensate for lost funding, Woolliscroft said, the medical school will have to increase class registration fees and host classes in less expensive venues. Departments and divisions in the medical school have also offered to help compensate for the loss, he said.