Biological Clock
Blog topic: How we are ruining continuous medical education (CME)
Norbert Gleicher, MD
Maybe more than any other profession, medicine is dependent on life-long learning. Knowledge changes so rapidly, that only continuous efforts assure professional competence. A need for continuous medical education (CME) was recognized many decades ago, resulting in an evolving system, progressively moving from voluntary to mandatory accumulation of CME credits. Today, hospitals mandate CME credits to maintain staff privileges, and states to license physicians.
Such credits can be earned in different ways. Most popular are courses and medical conferences, because they allow for accumulation of relatively larger credit numbers within a comparatively short time period. Credits can, however, also be earned by reading medical articles, reviewing submitted papers for medical journals, writing papers, attending departmental lectures and other activities.
To award CME credits, an organization has to be accredited. The responsibility to accredit all institutions and organization was given to one private company , located in Chicago, called the Accreditation Council for Continuing Medical Education (ACCME). It, unchallenged, sets and enforces standards in physician education for the whole country and, therefore, represents an absolute monopoly.
ACCME has only seven constituent member organizations, all representing professional organizations or industry groups with strong political self-interests: the American Board of Medical Specialties, American Hospital Association, American Medical Association (AMA), Association of American Medical Colleges, Association for Hospital Medical Education, Council of Medical Specialty Societies and Federation of State Medical Boards of the U.S., Inc. Obviously lacking is participation of practicing physicians. AMA no longer represents a majority of practicing physicians.
The real power in ACCME, however, rests with its fulltime staff, led by the company's Canadian CEO, Dr. Murray Kopelow, who in testimony before the United States Senate's Special Committee on Aging on July 29, 2009 described standards set by ACCME as "quasi-regulatory," and as "often deferred to by government entities, including state medical licensing boards, the Food and Drug Administration and the Department of Health and Human Services Office of Inspector General." He in this testimony also noted his position as special advisor to the White House Office of National Drug Control Policy.
While a private company, ACCME, thus, quite obviously perceives itself as a quasi-extension of the federal government. It, therefore, should not surprise that it also follows the government's ideological drumbeat, including widely promoted efforts to minimize alleged improper influences of industry on physicians' prescribing patterns.
Such allegedly improper influences have recently been widely reported: Unfavorable pharma study outcomes were allegedly withheld; on other occasions data were only selectively reported or potentially adverse outcomes went unreported. Pharmaceutical companies were accused of bribing physicians with cash, free trips, golf outing and free meals. Under pressure, by January 2009 the pharmaceutical industry, voluntarily, put into effect 15 new rules, the so-called "Pharma Guidelines," restricting practically all prior services of even minimal value to physicians. This included gifts of coffee mugs and free pens.
A largely unintended and unanticipated consequence of these new rules was a decline in financial support for CME activities, because almost half of all CME funding in the U.S. used to come from pharmaceutical and medical device companies. One of the 15 new "Pharma Guidelines" specifically prohibited payment for meals outside of educational frameworks. In practical terms that, suddenly, meant that pharma companies no longer were permitted to sponsor cocktail parties or meals at medical conferences, even if such funding was fully disclosed and the events offered no opportunity of influencing participants. Lacking financial support, even major medical congresses in the U.S. have been shrinking in size, while European and Asian conferences, where such subsidies are permissible, are thriving more than ever.
ACCME, in parallel, has been tightening conflict of interest and disclosure rules for design of CME events and selection of speakers. Above noted Senate hearing was, only six months after implementation of the new "Pharma Guideline," one amongst many meant to investigate continuing inappropriate influences of industry on CME activities.
Kopelow was specifically asked to comment on the extent of industry support for CME activities and noted in his testimony that in 2008 the absolute amount of commercial support for the first time had declined by approximately $200 Million. By 2010, ACCME reported the first-ever shrinkage in the number of CME providers over the preceding 12 months.
Nobody can disagree that inappropriate influence on the CME process by industry or other interested parties has to be avoided. The questions, however, is how this can be best done without negatively affecting the whole CME system via unintended consequences. It at times appears almost comical to see members of Congress, surrounded by lobbyists, sitting in judgment over alleged undue industry influences on physicians.
Physicians, however, should, indeed, make medical decisions disincentivized from secondary financial gains. A regulatory framework to achieve this goal, however, has to make sense. Like much of government regulations, current CME rules don't, and are excessive and harmful.
Our center in December cancelled its ACCME accreditation. It was an excruciatingly difficult decision after approximately 20 years of uninterrupted accreditation. We simply were no longer able to shoulder the administrative burden and costs imposed by ACCME. By that point, we already had absorbed the complete loss of industry support, which until 2008 had covered 70 to 80 percent of our CME budget. We also had added additional administrative support in compliance with new ACCME regulations, mandating better documentation of effectiveness of CME activities. ACCME, however, nevertheless, placed our program on probation, making us recognize that there no longer was a place for small, private CME providers like us in the new world of institutionalized CME.
On first impression, our experience may appear unconnected to the discussion about Obamacare. It, however, foreshadows the likely fate of private medicine in general. By establishing accreditation criteria, specifically designed to serve the needs of large institutional organizations (representing ACCME's seven constituent member organizations), and mandating that all providers, independent of size, follow identical criteria, small CME providers are automatically eliminated. ACCME being a government-associated monopoly, we have no choice to turn elsewhere for CME accreditation.
The approximately 100 colleagues who for many years have been attending our oversubscribed monthly events will now have to face their own difficult choice, whether to continue attending the talks of our carefully selected and totally unconflicted speakers without receiving formal credits or seek CME elsewhere. Whatever their choice, CME has lost, and big government has one more time succeeded in its drive towards one unified government-run health care system.
Norbert Gleicher, MD is Founder and Medical Director of the Center for Human Reproduction in New York City, and a Visiting Professor at Yale University School of Medicine. CHR welcomes submissions of relevant opinions to this blog. Please contact the editor.
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