Pharmaceutical corporations providing illegal inducements to physicians to use their medications inappropriately off-label. National Institutes of Health researchers securing lucrative consulting contracts, inciting congressional furor. Journals publishing biased articles sponsored by proprietary entities. These headlines have underscored the challenges of commercial sponsorship in medicine.
New, tighter rules for commercial support of continuing medical education (CME) have been promulgated by the Accreditation Council for Continuing Medical Education (ACCME), but their effectiveness in safeguarding the public trust continues to engender debate. Many esteemed educators suggest that any commercial role in academe promotes subtle if not outright bias. They say objectivity and fair balance are impossible when a proprietary entity is involved, even at arm’s length. Authors or speakers may present data incompletely (if at all), frame data in a biased fashion, or inadequately consider competing interventions. Because studies are open to interpretation, primary data may be difficult to access, and reviews may therefore be limited. Uncovering such bias is often difficult.
On the other side, thoughtful individuals argue that commercial support brings to market significant discoveries, fuels the engine of innovative programming, and provides the capital needed to disseminate important information. At a time when the nation is struggling to provide basic health care, proponents of commercial backing say such support is essential.
Of course, there are noteworthy examples of CME programs sponsored by specialty societies, such as the American Academy of Family Physicians. Programs such as Home Study and Core Content are paid for through subscriptions, as are the Evidence-Based Practicenewsletter and The National Family Medicine Review Course sponsored by the publisher of The Journal of Family Practice(the latter in conjunction with Michigan State University). Still, many endeavors are often cross-funded by profitable commercial partnerships. ACCME data for 2003 indicates that 55% of funding for all certified CME programs—whether live courses, in print, or on the Internet—came from the pharmaceutical industry, a higher percentage than in previous years. Without such support, membership dues and fees would not sustain the range of current activities in family medicine. What are the alternatives?
Two suggestions, not entirely new, come to mind. First, we need the equivalent of the Strength of Recommendation Taxonomy (SORT) for rating the role of commercial support in educational products—a Degree of Commercial Support (DOCS) system. Was the article or lecture written by the author/speaker, a ghost-writer, or a third party? Was an honorarium paid to the author or speaker directly or indirectly by a pharmaceutical company, and how much? Who prepared ancillary materials? Products without commercial support could get a label analogous to EB-CME designation, indicating independent creation of educational materials.
Second, we could create a National Trust for Continuing Medical Education. Any corporation selling medical products in the US would be required to contribute to the Trust. ACCME reports that in 2003, $1.7 million was spent on certified CME programs, almost $1 billion coming from industry. Instead of millions of dollars going primarily to support therapeutic categories in which the supporting company has an interest, resources contributed to the Trust could support primary care research, dissemination of best evidence, and development of innovative educational programs. A national committee on CME could plan educational interventions in a coordinated way, emphasizing matters of widespread importance to a healthy population, and not the latest lifestyle enhancement, like erectile dysfunction, or “me-too” medication. Though product-related education might still exist, why shouldn’t we also have a totally unbiased source of funding with no connection to proprietary businesses?
Of course, I know these suggestions are akin to Don Quixote tilting at windmills. Who in the educational medical establishment will want to jeopardize cozy relationships, our gravy train of dollars? Why would our Academy want to turn down explicit funding received for commercial products? What corporation would risk making the first contribution to this Trust?
A number of you have given thought to these issues. What are your suggestions?
