What's wrong with CME?

Since January we've been including with CMAJ paid advertisements for a CME program (mdBriefCase) supported by “unrestricted educational grants” from pharmaceutical companies. After receiving complaints from readers, we learned that the CME packages contravene guidelines established by the Canadian Medical Association1 and the US Accreditation Council for Continuing Medical Education.2 For example, the CME company and sponsor, not the course organizer, choose the topics, design course content (which in some courses promotes use of the sponsor's drug) and select the course leader, while financial conflicts of interest are not disclosed. In future we will not include these CME inserts in our mailings of the print journal.

A large and growing proportion of CME (about 60% in the US3) is derived through commercial sponsorship, mainly by pharmaceutical companies. Responsibility for determining the legitimacy of commercially driven CME and its qualification for credits by the Canadian College of Family Physicians and the Royal College is delegated (by the 2 colleges) to the directors of CME at Canadian medical schools. The CME series in question were approved by the University of Calgary and then endorsed by the Canadian Medical Association and hosted on the CMA Web site.

Commercial financial support for CME is permitted by the CMA and the US accreditation agency as long as the “organizers are responsible for ensuring ... scientific validity, objectivity and completeness.”1 However, these criteria are open to interpretation, with the result that commercial sponsors become intimately involved. Unrestricted educational grants are easily restricted, twisted and manipulated.

But does the harm from allowing CME to be orchestrated by pharmaceutical companies outweigh the benefit of being able to offer it at a greatly subsidized cost, or free, to physicians? Those attending will learn about new guidelines and products — at least, those chosen by the sponsors. But this benefit is dwarfed by the harm of masquerading inadequate content as adequate and by the damage to the reputation of the profession and its governing bodies caused by deficient and ambivalent oversight. Playing second violin in the big-pharma orchestra is not leadership.

CME, although costly, is not a luxury. Rapid advances in medicine and its technologies make it a necessity. Unfortunately, the expenditures for organizers and instructors, handouts and teaching aids, advertising, meeting spaces, travel and lodging, together with the opportunity costs of absence from work, are not trivial. It is tempting to allow drug companies to foot the bill. Tempting, but compromising: whatever altruism they may possess, commercial sponsors are, in the final analysis, interested in raising the profile of their products. As tighter controls over sponsor influence make an impact on sales more difficult to achieve, corporate funding for CME will dwindle and disappear.

Medicine has accepted and welcomed the responsibility of self-regulation and of assuring the public of the continuing competence of physicians. But we have not found a way to pay for it. Working under an increasingly salaried system (often with fee-caps) most physicians have limited or no financial flexibility with which to pay for CME by increasing fees or working longer hours. If CME costs must be shifted away from commercial sponsors, the money will have to come out of the pockets of physicians.

This is not acceptable in a system of socialized medicine. In Canada, as elsewhere, we pay for our health care system out of general tax dollars, just as we pay for the education of physicians (although perhaps not as much as we should) and their postgraduate training. We need to recognize that CME is also part of the education of physicians and find a way to pay for it from the public purse, either through grants to medical schools or to individual physicians. If financing CME is left to the marketplace we'll find we have Continuing Product Education, not Continuing Medical Education. — CMAJ