Medical Communication Companies and Continuing Medical Education: Clouding the Sunshine?

It’s always intriguing toopene-mail in themorningand lookat thelatestcropofcontinuingmedicaleducation(CME)invitations. Anddream.Whowouldn’twanttogotoMauitodiscusscommon issues in primary care? Or traveltoCancuntolearnabout using laboratory and clinical parameters to assess cardiovascular risk.Butgettingtimeoffcanbedifficultandtravel is increasinglyexpensive.Fortunately,abundantCMEopportunities areavailableonline.Physicianscanmeet licensurerequirements without leaving home andoften cando so for free. Wheredoall theseCMEinvitationscomefrom?Manycome frommedical communicationcompanies, largely for-profit entities that create, organize, promote, and run CME activities. Instead of CME, however, some medical communication companiesfocusonpromotionalservices,suchasrecruitingand trainingforthepharmaceuticalcompany’sspeakersbureausand preparing their slidedecks; assistingwithpublicationplanning formedical journalarticles,orevenwriting them.Somecompanies engage in both promotion and education. But that can be problematic.Educationshouldbeevidencebasedandunbiased: gettingcliniciansthefacts.Promotion is,well,promotional:persuadingclinicianstouseaparticularproduct.Companiesthatdo bothpromotion andeducation are required tomaintain a strict “firewall” between these activities—no contact between teams working in the sameclinical arena.Theobvious concern is conflictof interest.Withoutastrict firewallbetweenpromotionand education, promotional interestsmay bias educational efforts. Medicalcommunicationcompaniesmustbecertifiedbythe AccreditationCouncilforContinuingMedicalEducation(ACCME) for their CME to count toward licensing requirements. Accreditationstandards includeestablishing that industry clientswere not involved in the creationof theeducational activity and that presentations are balanced andunbiased. TheACCMEcertifiesCME for abroadarrayof clinicians including trainees. Most CME participants are physicians, but nonphysicians (eg, nurse practitioners, physician assistants) are catching up. From2003 to 2012, the number of physicians participating inCME-accreditedactivities increased133%from about 6million to 14millionparticipants. (Participants canbe countedmore than once depending on the type of CME activity.) Fornonphysicians, participation increasedby233%, from about 3million to 10million.1,2Medical communication companies account for only 7% of all accredited CME organizations, yet they account for 30% of physician and 43% of nonphysician participation in CME activities.1 Whodothemedicalcommunicationcompaniesworkfor?Industry accounts forhalf of the revenueofmedical communicationscompanies.3However,detailsaboutactualfinancialarrangementsaresparse.InthisissueofJAMA,Rothmanetal,4shedsome light intothis largelyunexploredworld. In2010,asaresultofvoluntaryandDepartmentofJusticerequiredactions,14drug-device manufacturerspostedgrant registriesontheirwebsites.According to the analysis of these registries by Rothman et al,4 the 14 companies issuedmorethan$650millioninnonresearchgrants. Almostone-thirdof thegrantmoneywent tomedicaleducation companies,morethananyothercategoryofrecipient:academic medical centerswereaclosesecondanddisease-targetedadvocacy groups were close behind. Medical communication companies were the leading grant recipients for 10 of the 14manufacturers (or 8 of 11, if the analysis was restricted to largest manufacturers—top20 forUSpharmaceutical sales).According to the report byRothmanet al,Medscape/WebMDreceived the most support by capturing 12%of the grantmoney. Medical communication companies' reliance on industry fundinghighlights the importanceofkeepingpromotionseparate fromeducation.All companieswill feel unconscious (and perhaps explicit) pressure to present their clients’ products in the best light. Bias can easily occur in the selection and training of speakers, in their presentations, on the websites, and even in test questions. Industry's adherence with regulation is concerning, particularly for thepromotionof off-label uses. In 2007, for example, the US Senate Finance Committee held hearings on industry conflicts of interest and noted that