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Posted by on Jun 23, 2008 in CME, Ethics, Pharma

A Response to Carlat the Magnificent

A Response to Carlat the Magnificent

I’ve deigned to think differently from Daniel Carlat. 

A fervent critic of all industry-supported CME and the host of The Carlat Psychiatry Blog, Dr. Carlat initially expressed cautious optimism last Thursday about the ACCME’s newly proposed guidelines (“ACCME Gets Serious With ‘New Paradigm’“) to monitor industry-supported CME. However, he showed serious disdain for the very same guidelines 48 hours later (“Using ACCME’s New Rules for Bias and Profit“), evidently in response to my criticism on Friday of the ACCME’s overblown and confusing verbiage in its document and the organization’s apparent failure to entertain the consequences of its proposed actions.

What’s somewhat perplexing, other than Dr. Carlat’s turnaround opinion, is his not-so-subtle castigationand even analysisof me. (So what do I owe you, doctor?) Of course, the absolute gorgeousness of having a blog (other than the fact that I can use words like “gorgeousness” without fear of editing) is that I can respond to Dr. Carlat’s post right here on my own little cyber-acre. So here I go.

Dr. Carlat began:

In bmartin’s pro-industry-CME blog Pathophilia, there is an interesting post about the newly proposed ACCME rules intended to stamp out commercial bias while still allowing commercial support.

I wouldn’t characterize my blog as “pro-industry-CME”; however, I’m not against industry-supported CME, particularly given the current guidelines for its production. Nor am I in favor of stifling the flow of information, whatever its source. It’s important to remember that industry-supported CME isn’t consumed in a vacuum, but that it exists in the context of commercially supported CME from various industry competitors, as well as a wealth of educational information from nonindustry sources. And doctors are a pretty independent bunch. They can and do decide, individually, what to believe and how to apply information in practice on the basis of a piece of information’s provenance and a whole host of other factors, like data reproducibility and clinical experience. Moreover, to my knowledge, there are absolutely no controlled studies demonstrating that participation in industry-supported CME leads to suboptimal medical care or poor patient outcomes. 

Bmartin parses out the wording of ACCME’s proposal in order to try to divine the organization’s actual intentions, and finds much to ridicule. 

I parsed the ACCME’s wording to express my opinion that the ACCME is in love with its own bombastic voice at the expense of meaning. 

You can detect a heavy dose of financial anxiety in this post. It’s an attempt to read the tea leaves in ACCME’s new policy in the hopes that it will not actually mean any significant changes in the current system. But bmartin ends on a decidedly pessimistic note, predicting that the regulations will lead to less industry funding, and ultimately, to the disappearance of ACCME itself.

Well, maybe Dr. Carlat detects financial anxiety. I thought I was just pissed off at the writing style and lack of forethought of yet another bureaucratic organization.

While I wish I could agree with bmartin, unfortunately I see this as very good news for industry support. Anybody who owns a CME company and has undergone accreditation and reaccreditation (as I have) knows that there is really nothing new in this “new” guidance. Any company will be able to demonstrate compliance with each of these and yet still produce promotional and biased CME. Let’s take each of these elements point by point and apply it to a recent promotional CME article produced by Medscape (see here for more details, and see Barnard Carroll’s excellent investigative journalism on Medscape here and here).

I’m not sure if Dr. Carlat’s implying that I don’t know what I’m talking about; however, for what it’s worth, I have experienced an ACCME reaccreditation process (which, BTW, generated a lot of printed paper). But more to the point, the ACCME’s newly proposed guidelines are different from the existing guidelines (other than the general guideline that content should be free of commercial bias). For instance, there is currently no mandate that educational needs must be identified by an organization that does not receive commercial supportwhich eliminates most (if not all) MECCs, professional organizations, and university-based CME offices. My main beef with the ACCME’s newly proposed guidelines is that they’re too vague in how they should or can be executed.

1. Needs assessment will have to be identified by a neutral organization. Not a problem! You want to keep the flow of money coming from Janssen to help it promote Invega? Many non-industry funded organizations will report that practitioners have a need to learn more about the appropriate use of antipsychotics. Bingoyou’ve just done your needs assessment.

Of course, those in the CME business know that a 1-sentence rationale from any organization is not a sufficient assessment of educational need. Needs assessments are typically multipage documents that include information from literature searches, clinician interviews, outcomes from prior CME programs, physician surveys, and other sources. 

2. Practice gaps will have to be identified by neutral organizations. Same non-issue as number one. Any reasonable organization will identify adequate treatment of schizophrenia as a “practice gap.” For example, the AHRQ produced this document which can be cited to support the need for education about how to use atypical antipsychotics. Medscape will argue that focusing an article on treating a schizophrenic patient with liver disease (which just happens to be the specialty of Invega, its sponsor’s medication) fills an identified “practice gap,” and ACCME won’t argue with them.

This point indicates that there are government sources to guide the treatment of conditions like schizophrenia, and that these sources can be used in an assessment of educational need. However, an educational activity that focuses on antipsychotic use and liver dysfunction could not rest (at least, in my experience) on the one generalitynamely, that there is a need for education on the use of atypical antipsychotics. But my question to the ACCME would be Must the authors of these government-dispensed treatment recommendations have no ties to industry?

3. The curriculum must be specified by a bona fide organization. This is a hard one…let me see…okay, how about psychiatry’s specialty board, the American Board of Psychiatry and Neurology, Inc., which publishes these “core competencies” in psychiatry. Go to the “Somatic treatment” section and you’ll find the following recommended curriculum for psychiatrists:

Again, my question to the ACCME would be Is a specialty board, or more specifically, are the drafters of a board’s core competencies sufficiently commercial-free? 

4. It must be verified as “free of commercial bias.”

This is a redundancy, since this is already a centerpiece of ACCME Standards for Commercial Support. The organization will never have the resources to monitor the thousands of industry-supported CME activities hatched yearly.

Maybe they will; maybe they won’t. In my scenario, I guess it’s possible that there could be a point of equilibrium, where the dwindling number of CME providers can be sufficiently managed by a beefed-up ACCMEuntil the organization collapses from lack of fees.

So don’t fret, bmartinin fact, I would argue that this is a cause for great joy. ACCME is handing you the perfect mechanism for a commercial CME whitewash. Use some of that industry money to celebrate.

Okay, it’s my turn for analysis…um, bilious sarcasm?

bmartin (1130 Posts)

A native East Tennessean, Barbara Martin is a formerly practicing, board-certified neurologist who received her BS (psychology, summa cum laude) and MD from Duke University before completing her postgraduate training (internship, residency, fellowship) at the Hospital of the University of Pennsylvania in Philadelphia. She has worked in academia, private practice, medical publishing, drug market research, and continuing medical education (CME). For the last 3 years, she has worked in a freelance capacity as a medical writer, analyst, and consultant. Follow Dr. Barbara Martin on and Twitter.