Defending Professional Independence
Authors: Arnold S. Relman
Journal: JAMA (2003)

ON JANUARY 14 OF THIS YEAR, THE ACCREDITAtion Council on Continuing Medical Education (ACCME) released a draft of proposed new and stronger standards for the commercial support of continuing medical education (CME) and requested comments from the medical community. The following month, the Washington Legal Foundation (WLF), a legal think tank, issued a highly critical commentary, in which it recommended that the ACCME withdraw its proposals because they were unnecessary, counterproductive, and possibly even illegal. Both the proposed new ACCME standards and the WLF critique raise issues of the greatest importance to our profession with respect to the growing intrusion of the pharmaceutical companies into medical education. These issues need to be discussed and clearly understood before the ACCME issues its final guidelines. Two years ago I argued that our profession had made a serious mistake in the way it has allowed pharmaceutical companies to participate in CME. I pointed out that current guidelines for “unrestricted support” in fact permit companies to become much too involved in the selection of topics and speakers and in the actual content of presentations. I was particularly critical of the ACCME for accrediting “medical education and communication companies” (MECCs), which prepare CME programs under contract with pharmaceutical firms and select and pay the speakers. I urged the ACCME to strengthen its guidelines to ensure more separation between professional education and pharmaceutical marketing. Predictably, industry spokespersons defended the status quo. They said that without the financial help of the pharmaceutical companies, professional providers of CME would not be able to continue their programs. Their argument gains support from a recent Wall Street Journal article that states that industry contributed more than 60% of the total support for CME in 2001. The largesse from industry has helped persuade far too many in our profession to believe that medicine cannot afford to educate its own without partnering with pharmaceutical firms. But as industry’s involvement with professional CME has continued to grow, I suspect that leaders in medical education are becoming embarrassed by the spreading media coverage of the financial ties between pharmaceutical businesses and the profession, and they are uncomfortable when such connections generate conflicts of interest. As an example, consider a recent report in The New York Times, which was simultaneously featured in the PBS television program NOW With Bill Moyers. The article described how large advertising agencies that produce advertisements for drug companies have recently acquired MECCs, as well as businesses that conduct clinical trials under contract with these same drug companies. The chief executive officer of one of the largest of these advertising agencies is quoted as saying, “We provide services that go from the beginning of drug development all the way to the launch of your products.” These “services” include the creation of accredited CME programs that reinforce the agency’s advertising campaigns for its drug company clients. What clearer demonstration could there be of the commercial purposes of industrysupported CME and what more compelling argument could be made against accrediting MECCs or allowing industry involvement in the selection of CME content and speakers? Evidently concerned about these serious conflicts of interest, the ACCME decided to rewrite and strengthen its 1992 standards for commercial support of CME, and the announcement was prominently reported by the Wall Street Journal. While the proposed new standards do not prohibit any input by commercial interests into accredited CME programs (a prohibition that I advocate), they do state that MECCs, and CME teachers who are paid to serve as speakers or consultants for pharmaceutical companies, have a conflict of interest that cannot be managed simply by disclosure. Unfortunately, the current draft does not clearly explain how such conflicts should be handled. However, a reasonable interpretation of the intent of the guidelines is that, except for special circumstances (not yet defined), MECCs should not provide accredited CME programs that concern drug therapy, and teachers who are paid by drug companies as lecturers or consultants should not be allowed to participate in programs about drug products made by those companies. Whether that will be the final language of the proposed standards will depend on how they are modified after the ACCME receives comments from the CME community and other interested parties. Also unanswered is the question of whether, and how, the ACCME will enforce any strengthened standards.