The Death of CME as We Know It?

A variety of ills would ensue if industry support for meetings dried up

	Barry T. Katzen is course director of The International Symposium on Endovascular Therapy (ISET), and founder and medical director of Baptist Cardiac & Vascular Institute, Miami, Fla.

No one disputes the good of maintaining a healthy distance between the commercial interests of pharmaceutical and device companies and the continuing medical education (CME) needs of physicians. While the two remain inextricably intertwined, all of us clearly understand the potential danger in unchecked promotion masquerading as science. A medical professional’s decision about how to treat a patient should not depend upon how much money any given company has spent on marketing. Rather, our knowledge should be based on the collective intelligence of physicians who are willing to share with one another what works and does not work as gleaned from research, trials and experience. From this ideal comes the CME meeting.

Keeping CME meetings viable, however, very much involves the same companies that we must otherwise deal with at arm’s length. Without question, grants from companies that manufacture drugs and devices make most CME meetings possible. At the International Symposium on Endovascular Therapy (ISET), for example, such funding covers the expensive, but highly effective, teaching tool known as the live-case demonstration, an educational method I pioneered some two decades ago (see image above).

For practicing physicians, the opportunity to view in real-time procedures performed by experts at leading medical institutions and transmitted to, for example, a hotel ballroom that can seat hundreds, provides the best alternative to actually standing in the procedure room or going back to the classroom. Industry grants also defray the cost of bringing together recognized authorities from around the world to serve as faculty who comment on the live cases and deliver lectures. Other enhancements, such as instant polling that engages attendees and provides important feedback, likewise require the support of industry.

What would we give up?

Without industry support, ISET and similar meetings would otherwise have to charge physicians thousands of dollars in registration fees, a scenario that would lead to a variety of ills.

First, most doctors would have to rethink how often they attend national CME meetings. Many would certainly look at less-expensive online, journal-based and locally produced activities. Each of these has its place and contributes something to the overall goal of deepening a physician’s knowledge. As a main source of information, however, these options are limited—in the first two cases, by a lack of interactivity and, in the third, a potential lack of diversity in the views and experiences of the faculty.

Second, a decline in both grant support and attendance would force many well-regarded meetings to severely scale back or simply close up shop. The available choices for national CME would dwindle to a precious few, and the paramount goal of physician education for the good of the patient—the raison d’être of CME—would be compromised.

Third, and perhaps most disturbing, the very conflict of interest that the current and forthcoming guidelines governing industry/physician relations seek to minimize would grow tenfold. Monies that manufacturers today dedicate to the support of accredited meetings—those that can be called CME because they adhere to the rules set forth by the Accreditation Council for Continuing Medical Education (ACCME)—would simply go toward marketing. Ironically, this creates a situation similar to the one that prompted the formation of the ACCME in the first place: Industry invites physicians to its own (non-accredited) meetings, to be wined and dined and learn only about a specific company product.

This scenario of precipitously reduced industry support of CME is not hypothetical; it is already reality. Current and forthcoming guidelines set by the ACCME, trade industry groups that lobby for the pharmaceutical and device industries, and companies themselves (through formal regulatory/compliance departments), as well as, potentially, the government, have and will continue to exert a dampening effect on funding. Many of these responses are prompted by government actions against perceived abuses, many of which have nothing to do with CME but, rather, with marketing-driven activities.

Beyond the negative impact on funding, however, changes enacted by the ACCME to guard against conflict of interest are affecting the quality of meetings. Course directors, in preparing programs for meetings, for example, are no longer allowed to discuss content with industry. On its face, this seems like a valid way to thwart undue bias. In reality, however, such conversations have until now provided an opportunity to learn about the latest promising research and to invite physicians involved in early trials to speak on their findings.

And more changes are on the horizon, potentially forced by any of the entities mentioned above, all of whom fear the worst (in this age of desire for healthcare reform) and so insist on the most conservative route. One suggestion that has been made would prohibit doctors involved in trials from presenting results at meetings because of concerns that they may have been swayed to a positive opinion by payments made in exchange for their participation. In simplest terms, the very individuals who know the most about a new drug or device could be prohibited from sharing their expertise with colleagues in a formal, live capacity. Who, then, should we expect to talk about the findings, and how late in the game will we in the field hear about developments if those working on them must stay mum?

What is our responsibility?

As the course director for ISET, I take very seriously the role of managing potential conflicts of interest, an active process that requires good judgment and a shot of skepticism. I believe strongly that placing outside limits on who speaks at CME meetings can only compromise our ability as professionals to make decisions for ourselves. While not always perfect, national CME meetings provide an opportunity for broad exposure where debate flourishes, an occasion to dig beneath the perfect veneer that manufacturers might otherwise put forward. Without question, testing a speaker in front of hundreds of doctors in an open forum offers the best chance we have to hear the unadulterated truth. For years a standard practice at CME meetings, speakers must disclose their relevant financial relationships in writing. From there, it is up to the scientific community in attendance, both individually and as a group, to judge the talks and weigh the presented information against any disclosed potential bias.

We in the field have already experienced the downside of some of the over-regulation that has driven much of the device innovation outside of the U.S. The death of CME as we know it would only further erode our ability to acquire knowledge and, ultimately, to treat our patients.

A town hall meeting on the subject of CME funding and regulation will take place as part of the upcoming ISET meeting, scheduled for January 18-22, 2009, in Hollywood, Fla. The 21-year-old ISET meeting is a gathering for specialists working in vascular and cardiac intervention. To learn more, go to ISET.org.