Marketing or research — what are doctors and nurses learning?

The commercial sponsorship of continuing medical education (CME) for our nation’s doctors, nurses and other medical professionals has caught the attention of mainstream media. Business Week reports that two medical industry giants, concerned about the appearance of conflicts of interest, have announced they would no longer fund CME courses or pay communication companies to produce CME courses. Well, sort of...

Pfizer Pharmaceutical said it would support continuing education only through hospitals or professional medical associations, and Zimmer Holdings stated it would fund courses only through independent third parties, such as a professional societies. It’s unclear how that actually changes much, as it’s no secret that commercial entities support professional societies, as well as the CMEs hosted by these trade groups. The author appeared equally skeptical that this was going to have a significant impact, as the article continued:

These moves are a blow to the marketing firms but by no means the end of their lucrative, multifaceted role. There are hundreds of such firms in the U.S. that design ad campaigns, hire doctors to educate colleagues about devices and medications, and produce conferences. Over the past decade, CME has become one of their most profitable businesses, as manufacturers have increasingly paid for the courses. Industry support for CME has quadrupled since 1998, to $1.2 billion a year, according to the Accreditation Council for Continuing Medical Education (ACCME), an organization in Chicago that approves CME providers. More than half of that is funneled to marketers, with the rest going to hospitals, medical associations, and other nonprofit entities...

The industry and its outside marketers say they ensure that the courses remain free of commercial influence. But some medical experts argue that when employees of communications firms are beholden to pharmaceutical and device companies, they will produce CME courses that are slanted in favor of their sponsors, even if they don't realize what they are doing. "There's not only a perception of bias, there's a reality," says Dave Davis, a vice-president of the Association of American Medical Colleges. In some cases, the favoritism seems blatant, doctors say.

Marketing permeating CME and the loopholes in ACCME oversight was recently reviewed here. ACCME admitted it’s had little enforcement power other than to mandate audits and self-analysis by providers or, in extreme cases, it can revoke accreditation or bar presenters from future appearances for failure to disclose conflicts or for presenting biased information; but that seldom happens.

Business Week went on to describe Dr. Daniel Carlat, M.D., a psychiatrist who logged onto to Medscape, one of the largest providers of online CME. As he clicked through a series of multiple-choice questions, he found that the “correct” answer on how to treat a patient with schizophrenia and alcoholism was to prescribe paliperidone. This new drug made by Johnson & Johnson, he says, is relatively new and “intended to replace lost sales from J&J's multibillion-dollar antipsychotic medication Risperdal, which recently lost its patent protection. J&J, it turns out, sponsored the CME course.”

It is difficult to imagine many medical professionals are unaware of the leanings in its editorial content, industry-written clinical guidelines and health policy coverage, even ignoring the sponsored marketing emails dropped into our mailboxes each week. While not all of the content is unvaluable, it does call for diligence on the part of the reader. JFS compared the editorial content and the research in several examples last year, noting inaccuracies and omissions, but after that miracle thigh cream study, personally endorsed by the medical Editor-in-Chief, further quality reviews seemed superfluous. But here are a few examples of the content in the Continuing Education credits provided nurses that I have recently encountered from Medscape. To get the questions right and receive a passing grade, often meant answering questions wrong:

· Course — Highlights of the 14th Annual Symposium of the Preventive Cardiovascular Nurses Association: The Framingham Risk Calculator was unquestionably promoted, and nurses were told to instruct patients that to prevent high blood pressure, losing weight would lower BP 5-20 mmHg, low-salt diet by 2-8 mmHg, exercise 4-9 mmHg, and cutting down alcohol 2-4 mmHg.

· Course — Obesity Epidemic in Children Fuels Need for New Recommendations in Lipid Screening and Cardiovascular Health: In this course, nurses learned that low-fat diets should be recommended for all children by age 2; all fat children should be screened for cholesterol from age 2; and statins should be considered for those 8 years and older.

· Course — Exercise Protects Against Premenopausal Breast Cancer: This class told nurses that exercise and weight loss was associated with a 23% lower risk of breast cancer.

· Course — Pandemic Influenza: Framing the Threat: This course needs no further description.

· Course — Rethinking Glucose Control and the Prevention of Cardiovascular Disease in Type 2 Diabetes: In this course, nurses learned: “There are ample data to show that modification of risk factors, especially blood pressure, along with other pharmacologic interventions such as statin and antiplatelet therapy, substantially reduces CVD risk.”

· Course — Child and Adolescent ADHD: An Update on Pharmacotherapy: This course highlighted that “Medication management was significantly better than behavioral treatment” among school-aged children; and methylphenidate in preschoolers “led to significantly greater improvements in ADHD symptoms than placebo...”

Business Week goes on to describe the problems with commercially-funded CME, as well as the fact that in medical journals, doctors and authors currently aren’t required to reveal payments from marketing firms, such as Vox Medica or Medscape, and the various changes being proposed to address these concerns. The ACCME says that it’s ramping up staff to better police CME providers.

The psychiatrist interviewed by Business Week had reprinted the CME courses he found at Medscape on his blog and got a flurry of other doctors “saying they, too, are fed up with what they see as the commercial taint of many CME courses.” But Business Week went on to report:

Medscape, a unit of publicly held WebMD Health, says it has been refining its CME courses to comply with new standards instituted by the accreditation group, ACCME. "We have a rigorous editorial process in place to make sure the content we develop is independent," says Dr. Steven Zatz, Medscape's executive vice-president of professional services. He adds that in polls, 99% of Medscape users say they perceive no bias in the company's online courses....

He’s likely referring to the evaluation questions that follow each CME/CE course asking about objectivity of the content. I suppose it’s possible, perhaps, that there are only 1% of us who perceive bias. Although, that’s an unsettling thought.

It’s even more disconcerting to contemplate that medical professionals are relying on interpretations of studies provided through an online marketing service for medical information, rather than going directly to the medical literature. After all, medical journals are all online today and can be read with a couple mouse clicks. As long as doctors and nurses take advantage of the free credits and don’t worry about what they’re learning with CME/CE hours, the concept of continuing education as improving medical expertise and skills will be debatable.