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CME
and the pharmaceutical industry:
The role of "big
pharma" in continuing medical education (CME) is undoubtedly one
of the major professional issues in medicine today. Let us approach it
from three different vantage points: that of the pharmaceutical industry,
of medical schools, and of physicians and their patients. "Big pharma"
involvement in CME is a mixed picture. On the one hand, the pharmaceutical
industry has its own interests - it's a business, after all - and there
are lots of examples of so-called educational events whose real objective
is to change prescribing behaviour.1,2 On the other hand, a code of marketing
practices does exist,3 many pharmaceutical companies are scrupulous about
distinguishing between CME and promotion, and - at the end of the day
- many discoveries that extend lives and reduce suffering are made in
the research departments of pharmaceutical Now for the involvement
of medical schools. The role of an ethical provider of CME such as "McRonto
University" is, to a greater extent than one might imagine, a mixed
picture of pharmaceutical and nonindustry funding. Although separate data
do not exist for Canadian schools, the biannual survey of the Society
for Academic Continuing Medical Education4 captures data from the United
States and Canada. This survey reflects a growing trend among medical-school
providers of CME: over the period 1993-2001, while medical schools reported
a modest 25% increase in the number of courses and a doubling of registration
fees, they disclosed a quintuplingof commercial support for CME. Does
this matter? Does increased industry funding necessarily lead to bias
in medical-school CME? Research indicates
that industry funding can skew CME content in various ways to match the
goals of industry.2,5,6 This skewing may be felt in the subtle influence
of industry on the selection of topics (do medical-school CME curricula
devote as much time to the diagnosisof hypertension as it does to its
treatment?) or, at a more general level, in what receives support and
what does not (courses on social pathologies are less common than those,
say, on diseases with specifically "medical" management). Given
that the primary driver of physicians' involvement in CME is an interest
in their patients' welfare, and that the main interest of industry is
to promote profitability,7,8 increased industry funding of CME raises
many questions, among them: What can we do about a possible skewing effect?
Need we do anything? Here we come to the third vantage point. In determining
the appropriate boundaries between the pharmaceutical industry and medical
schools and, by extrapolation, between industry and CME more globally,
we must not forget what CME is all about: physician-learners and their
patients. This vantage point must inform the steps we take to ensure that
physicians make informed decisions about CME. In that vein, let us take
the following steps: 1. Increase the decision-making
capacity of physicians. We need to assure ourselves that physicians have
adequate undergraduate, postgraduate and continuing training in critical
appraisal and ethical decision-making. This assurance implies both teaching
and testing. Let's do both. Let's do them better. 2. Broaden the definition
of "full disclosure."It may not be enough to ask the physician-speaker
to "disclose" industry connections at the beginning of a talk.
All CME providers, medical school and industry included, might 3. Level the playing
field. Some have called for greater government and professional support
for continuing professional development, to balance the influence of industry.10
Although support from these quarters also has the potential to introduce
bias, the diversification of funding sources has in fact begun: the support
of the Ontario Ministry of Health and Long-Term Care and of the Ontario
Medical Association for the Guidelines Advisory Committee11 is an example,
as is the federal government's Primary Health Care Transition Fund12 initiative
with the Association of Canadian Medical Colleges. This could be just
the beginning. 4. Organize dialogue,
develop guidelines, give the process legs and teeth. Who will continue
the dialogue, and how? Who will develop Canada-wide guidelines and see
to their application? Although guidelines do exist at the local level
(the University of Toronto's are arguably the most stringent in the country13)
and overall accreditation guidelines are in place,14 there is wide variability
in their application. Clearly, we need a national body to take on the
challenge of containing, examining and regulating the issues for all Canadian
health care such as the Committee on Accreditation for Continuing Medical
Education (a collaborative accreditation process of t the Canadian Medical
Association), the Association of Canadian Medical Colleges, the Royal
College of Physicians and Surgeons of Canada and the College of Family
Physicians of Canada, among other groups. Are there more steps to take
in the process? Of course. But if we want physicians to have the necessary
information, skills and confidence to make informed decisions (for example,
in choosing between course A and B), and thus to be better able to balance
learning needs and patient concerns, these four action items might be
a start. References |