Does the C in CME stand for “Continuing” or “Commercial”?

The commentaries on commercial sponsorship of continuing medical education (CME) by David Davis1 and Bernard Marlow2 contain good recommendations, but both are hampered by an incomplete analysis.

Davis refers positively to the Code of Marketing Practices of Rx&D (Canada's Research-Based Pharmaceutical Companies), the brand-name industry association.3 In discussing industry sponsorship of CME, the code states that “member companies will: support, where possible, the principles and practices of CHE [continuing health education] programs established by practitioner bodies.” When it is possible and not possible to do so, the code doesn't say. Complaints, rather than active surveillance, are the means of monitoring compliance with the code.3 According to reports of the Marketing Practices Review Committee (which appear on the Rx&D Web site, at www.canadapharma.org/Industry_Publications/Code/), most of the complaints come not from doctors but from other companies, which suggests that the code's primary purpose is to level the playing field for companies rather than to enforce any ethical principles.

Marlow is opposed to restrictive actions that might choke off commercial support for high-quality educational offerings and restrict physicians' attendance at these meetings, but at least one recent commentary noted that “damage to the reputation of the profession” is a very serious concern if governing bodies don't provide proper oversight of CME activities.4 What is the evidence about the effects of company sponsorship on the quality of CME and prescribing behaviour? There is precious little, but the two studies that Marlow cites both show potentially negative outcomes.5^,6

Both authors cite the landmark analysis by Wanzana,7 but neither seems to understand the subtitle of that article. The people who run pharmaceutical companies don't give gifts; rather, they make investments, on which they expect a return. In the case of CME, the total “gift” in the United States is in the range of US$700 million annually.8 Gifts such as direct or indirect financial assistance to attend CME are part of the culture of reciprocity so important in physician–industry relations, and such gifts can create unconscious obligations in physicians that industry knows will be repaid in one way or another.9

Let's be clear about industry money and CME. There is a great deal of difference between selling space for booths at medical meetings and direct industry sponsorship in financing CME. The former is equivalent to selling advertising in medical journals, a practice that journal editors vigorously assert does not compromise editorial standards.10 The latter is more like pharmaceutical companies underwriting journal supplements that are used for their promotional attributes.11

If drug companies' primary motivation for contributing to CME is to advance physicians' knowledge, then they should heartily embrace a system whereby they place their money into a blind trust from which independent parties organizing CME events would be able to draw.