The need for an Institute of Continuing Health Education

In his March 25th editorial (1), Dr Paul Hebert laments the current state of Canadian continuing education and advocates a more effective and ethical approach. Many of his comments are salient indeed.

However, as a long-time medical writer who has worked in a variety of roles, I would like to point out that such an approach is already underway, at least for family physicians across Canada. Founded in 1992, the Foundation for Medical Practice Education (www.fmpe.org), affiliated with McMaster University, embodies the principles espoused by Dr Hebert, particularly through its flagship program, the practice-based small group learning program (PBSG). This program (2) gives physicians the opportunity to define and engage in learning activities that are self-directed and related to authentic practice problems. It is accredited to issue MAINPRO- C credits by The College of Family Physicians of Canada.

Dr Hebert outlines the criteria for continuing health education initiatives to achieve a “more principled approach” and “arrive in a healthier place.” The Foundation’s PBSG program meets these criteria in a variety of ways: a) It receives no pharmaceutical sponsorship, and is funded entirely through membership fees and partnerships with other non- profit healthcare organizations such as The College of Family Physicians of Canada, The Lung Association, The Heart & Stroke Foundation, etc; b) Gaps identified between current practice and best available evidence are the focus of all educational modules. These modules then provide practical strategies and tools to bridge the gaps, and help to improve both clinical practice and patient outcomes; c) The PBSG program actually works. A randomized controlled trial involving PBSG members found that involvement in the program had a positive effect on prescribing patterns for target medications (3); d) Finally, the PBSG program is affordable and accessible to all communities across Canada.

Currently, over 3,500 family physicians in Canada are PBSG members. In the midst of a “truly broken system” as described by Dr Hebert, this program demonstrates that continuing health education can be effective, ethical and enticing to a growing group of physicians. For these reasons, I began working with the Foundation over eight years ago. My respect and enthusiasm for it continues unabated.

References:

1. Hebert P. The need for an Institute of Continuing Health Education. CMAJ 2008;178(7):805-6.

2. Armson H, Kinzie S, Hawes D, Roder S, Wakefield J, Elmslie T. Translating learning into practice. Lessons from the practice-based small group learning program. Can Fam Phys 2007;53:1477-85.

3. Herbert CP, Wright JM, Maclure M, Wakefield J, Dormuth C, Brett- MacLean P, et al. Better Prescribing Project: a randomized controlled trial of the impact of case-based educational modules and personal prescribing feedback on prescribing for hypertension in primary care. Fam Pract 2004;21(5):575-81.

Conflict of Interest:

None declared

Dear Dr. Hebert:

Thank you for your editorial on The Need for an Institute of Continuing Health Education. We are pleased you included academic detailing as one of the underutilized CME strategies. Presently, academic detailing programs exist in six provinces. These programs have formed the Canadian Academic Detailing Collaboration to share expertise and resources and promote academic detailing nationally. The Collaboration works closely with local family physicians and COMPUS, the Canadian Optimal Medication Prescribing and Utilization Service.

The academic detailing programs demonstrate many of the elements you advocate: 1) interprofessional (most academic detailers are pharmacists and provide education to physicians, nurse practitioners, and other health care professionals); 2) provide accurate information free from real or perceived biases (academic detailing programs research and appraise evidence on clinical topics and present a balanced view of that evidence); and 3) make use of proven, effective adult learning techniques (systematic reviews have consistently found academic detailing effective in changing physician behaviour and improving health outcomes.)1,2

A recent report from the Health Council of Canada recommended that academic detailing be expanded in Canada.3 However, despite the high quality education the academic detailing programs provide, their resources comprise a small part of the overall CME picture. Programs in Saskatchewan and Nova Scotia are offered to all physicians. The program in British Columbia has been focused in North and West Vancouver, although the province has recently initiated plans to provide a Provincial Academic Detailing program. Programs in Alberta, Manitoba and Ontario are limited and provide academic detailing service to only small local areas.

Should the proposed Institute of Continuing Health Education be developed, the Canadian Academic Detailing Collaboration is willing to work with it and other agencies that are independent of external influences to promote evidence-based education for health care professionals.

Michael Allen MD, Dalhousie Academic Detailing Service, Nova Scotia

Shawn Bugden BSc(Hon) BSc(Pharm) MSc, Prescription Information Services of Manitoba

Anne Nguyen PharmD, Pharmaceutical Services Division, Ministry of Health, British Columbia

Debbie Bunka BSc(Pharm), Academic Detailing – Calgary Health Region, Alberta

Loren Regier BSc(Pharm), Rx Files Academic Detailing Program, Saskatchewan

Tupper Bean MBA MHSc, Centre for Effective Practice, Ontario

Margaret Jin BScPHM PharmD CGP, Personalized Academic Detailing Program for the Hamilton Family Health Teams, Ontario

1. O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard-Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, Freemantle N, Davis DA, Haynes RB, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000409. DOI: 10.1002/14651858.CD000409.pub2.

2. Grimshaw, J.M., Thomas, R.E., MacLennan, G., Fraser, C., Ramsay, C.R., Vale, L., Whitty, P., Eccles, M.P., Matowe, L., Shirran, L., Wensing, M., Dijkstra, R., Donaldson, C. (2004) Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment 8(6): 1-72.

3. Health Council of Canada. (2007). Safe and Sound: Optimizing Prescribing Behaviours — Summary of Main Themes and Insights (Report on a Policy Symposium). Toronto: Health Council. www.healthcouncilcanada.ca.

Conflict of Interest:

None declared

Dear Dr. Hebert,

The members of the Board of the CACHE (Canadian Association of Continuing Health Education) are writing this letter in response to your editorial published in the March 25, 2008 edition of CMAJ.

CACHE was born out of a need to share, promote and support Canadian continuing health education (CHE) initiatives. CACHE draws together a spectrum of educators, administrators, and representatives from health care, academia and industry -- all of whom contribute to the fabric of Canadian Continuing Health and Medical Education.

As a group we are open to new initiatives and ideas that promote and enhance the quality of continuing health education, that impact continuous performance enhancement of our health care system, clinical teams and health professionals, and ultimately benefit patients. For this and other reasons, we feel compelled to respond to your editorial.

We agree that continuing health education should provide accurate information free from real or perceived biases. We also agree that these initiatives should focus on themes and topics based on the needs of patients or health professionals; make greater use of a broad range of proven, effective adult learning techniques; include all health professionals; and be affordable, accessible and, where possible, integrated into clinical practice.

It is critical at this time to share the body of evidence that supports the statements in the editorial. More specifically evidence addressing the issue of bias from industry in education programs that are accredited by the governing bodies.

While there certainly may be merit in exploring the role and need for an Institute of Health Education, there is no published evidence to suggest that our current Continuing Professional Development programs require a major overhaul. As well, we question the perception that educational initiatives sponsored by industry distort topic selection or embellish positive elements while downplaying potential adverse effects.

In our extensive collective experience, we have numerous examples of accredited and unaccredited educational programs as well as publications in peer reviewed journals that would support the value and contribution of the collaborative education and research initiatives, sponsored by industry, that would verify our position.

More importantly, our Canadian health care education landscape is unique and engages many stakeholder groups in a collaborative model which supports improvements in our healthcare system and our patients’ health and wellness.

We would welcome the opportunity to provide further information as to the accreditation process and the education methods that are being used in Canada to ensure that education programs are fair, balanced, evidence based and provide information about both non-pharmacological and pharmacological options for disease prevention, health promotion and disease management. We wish to continue to develop, support, and promote interprofessional education opportunities in a collaborative manner to identify gaps, integrate education in the practice environment, and enhance life-long learning.

Respectfully,

Bernard A. Marlow, MD, CCFP, FCFP Director of CPD, CFPC

Isabelle Mongeau Director, CE and Development Pfizer Canada Inc.

Dr. Sol Stern, MD, CCFP Chairman of Palliative Care, Halton Healthcare Services Oakville, Ontario

Suzanne Murray President/Founder – AXDEV Group Int.

On behalf of the entire Board of the Canadian Association of CHE

Dr. R. Gary Sibbald, MD, FRCPC(Med)(Derm), Med Professor of Medicine and Public Health Sciences University of Toronto

Alex Szucs, BA, MSc Vice President: Medical Group Diversified Business Communications Canada

Mary Bell, MD, BScPT, MSc, FRCPC Continuing Education and Knowledge Translation & Exchange Department of Medicine, University of Toronto

Bob Chester, BSc Manager, CHE Ortho Biotech

Valerie James Coker, RN, BSN, MSc Medical Communications Consultant

Della Croteau BSc MEd Director Professional Development Ontario College of Pharmacists

Jill Donahue HBa, MAdEd President/Founder Excellerate Consulting

Gilles Hudon, M.D. FRCPC Directeur des Politiques de la santé et de l'Office de développement professionnel Fédération des médecins spécialistes du Québec

Louanne Keenan, BA, Med, PhD PhD Educator / Research Director University of Alberta

Fran Kirby, M.Ed. Director, Professional Development & Conferencing Services Calgary Health Region

Kathryn Raymond, RN, CCPE Director, HealthCare Education Purdue Pharma

Glenda Wong MHSA Business Manager, Continuing Medical Education University of Calgary

References:

Murray, S.1, Marlow, B.2, Nagpal, S.3, Sidel, J.4, Phaneuf, M.5, Chester, B.6, Key, R.7, Lyndsay, E.8, Aldoori, W.9, Salter, E.10, & Ashley, L.11 (2006, September). Innovation in collaboration: The paradigm for the future in research partnership between multiple public and private organizations. Workshop conducted at the meeting of the Canadian Association of Continuing Health Education, St-John's, Newfoundland & Labrador, Canada.

Murray, S.1, Silver, I.12, Patel, D.4, Dupuis, M.1, Hayes, S.1, & Davis, D.13 (in press). Community group practices in Canada: Are they ready to reform their practice? Journal of Continuing Education in the Health Professions.

I am writing in response to the March 25, 2008 editorial advocating for the creation of an Institute of Continuing Health Education for Canada (1). This recommendation was based on legitimate concerns of the impact of pharmaceutical company sponsorship of continuing medical education (CME); particularly the importance of ensuring the scientific integrity, objectivity and completeness of the evidence that informs the continuing education of physicians. These concerns have been consistently raised in the United States over the past several years, in part in response to the changing standards for commercial support proposed by the Accreditation Council of Continuing Medicine Education. More recently these discussions were included as part of a recent consensus conference sponsored by the Josiah Macy Jr. Foundation (2) and has been the focused of several commentaries earlier this month in JAMA (3).

However, the editorial presented an incomplete and inaccurate picture of continuing medical education in Canada. We have come a long way from the old continuing medical education paradigm where experts lectured to passive participants about the latest innovations in medicine at the local “Holiday Inn”. This model was based on the belief that knowledge transfer, through such methods would automatically inform and shape physician thinking and behaviour. This assumption has been the subject of an expanding and rigorous research agenda into the effectiveness of CME. The editorial implies that the majority of the CPD events or systems Canadian physicians use to enhance their knowledge, skills, and improve their practice are based on group learning events funded by pharmaceutical companies. This is incorrect!

The shift from CME to CPD has promoted learning linked to multiple dimensions of practice (clinical, administrative, research and education) and across multiple competencies. The editorial only makes passing reference to the myriad of practice based self-learning strategies, self- assessment options and practice assessment and improvement strategies embedded within the MAINPRO (CFPC) and MOC (RCPSC) programs. For example, between 2002 and 2007 the percent of credits earned by Fellows of the Royal College from participating in rounds, journal clubs or conferences (nationally or internationally) ranged from 35 to 42%.

The editorial fails to acknowledge the work and efforts by the CFPC, Royal College, and multiple other organizations in addressing the legitimate concerns on commercial sponsorship of CME. The Committee on Accreditation of CME, the National Committee on Continuing Medical Education (CFPC) and the Continuing Professional Development Committee (Royal College) have promoted increasingly rigorous standards that all accredited providers and programs must fulfill to be included as an accredited group learning event. If the only viable option promoted by the CMAJ is the complete elimination of the involvement of pharmaceutical companies through the formation of an arms length institute then the process of reviewing how programs must meet the ethical standards embedded within the CMA guidelines governing the physicians and the pharmaceutical industry, the requirement for full disclosure of all relationships by faculty speaking at CME conferences, the development and assessment of tools to assess and address bias, the auditing of content before and during the event will not matter.

You should be aware that the Royal College and the College of Family Physicians of Canada have demonstrated leadership in the development and implementation of standards for effective continuing professional education, promotion of lifelong learning, exploration of ways to integrate education into clinical practice, and more recently exploring inter-professional education in collaboration with multiple partners. We are engaged in an important dialogue with the national specialty societies and university offices of CME, and others on these issues. The proposal for creating a separate institute seemed to me to be premature and potentially redundant.

It is important and legitimate to promote debate and discussion. The Royal College is committed to and would welcome the opportunity to work within the health professions to develop a system of continuing professional development that promotes the highest standards expected of the profession, the health system and the public.

Craig Campbell MD FRCPC, Director, Professional Affairs, The Royal College of Physicians and Surgeons of Canada

References

1. Hebert P. The need for an Institute of Continuing Health Education, CMAJ 178:7

2. http://www.josiahmacyfoundation.org/index.php?section =home

3. Steinbrook R, JAMA, March 5, 2008 – Vol299, No 9

Conflict of Interest:

None declared

Your 25 March editorial states “…physicians believing that strong industry involvement is not only normal but also that they are entitled to receive the benefits. This culture of entitlement may be one of most difficult obstacles to overcome. To arrive in a healthier place, we need to disentitle physicians and adopt a more principled approach.”

Many physicians have long since recognized that neither we nor the industry benefit from continuing education that in any way resembles product marketing. To do otherwise would be insulting to our colleagues. Further, we recognize and approach continuing education with a strong focus on disease issues using effective adult learning techniques. Some of us even attempt to do work with our colleagues to enhance their own facilitation skills.

The tone of the editorial was disturbing, particularly given the clear “culture of entitlement” apparent on the part of the CMAJ and most journals reliant on the pharmaceutical industry for their journal’s existence (and staff salaries). Of the 174 available pages in the March 25 Journal, 79 pages are pharmaceutical advertising and 42 pages present current research or educational material. Perhaps it is time that the Journal recognize the necessity for “…a radical change in [their] approach to funding”. Would the journal “…argue for the need to completely ban all [advertising] funded by the pharmaceutical industry…to change that…culture of entitlement”?

Without that acknowledgement, by any other name, this represents a clear double standard on the part of the journal.

Conflict of Interest:

Dr Becker has served on advisory boards for most companies involved in asthma and allergy therapeutics over the years. He has received grant support from CIHR, AllerGen NCE, AstraZeneca, GlaxoSmithKline and Merck Frosst and contract research funds from Genentech, Novartis and Nycomed. He has developed a facilitator training program with educational support from Merck Frosst.

Dear Dr. Hebert:

I am writing on behalf of the CME/CPD offices at the seventeen (17) Canadian medical schools. We read your recent editorial, The Need for an Institute of Continuing Health Education, with great interest. As a group of academic CME/CPD providers, we have had these same concerns for many years and have worked diligently to provide high quality continuing education programs with minimal bias which are helpful to change practice and improve patient care. Furthermore, we are actively engaged in research to determine the most effective methods to provide CME/CPD and how to measure and minimize bias.

All medical schools in Canada have divisions of CME/CPD and can be regarded as leaders and innovators at a national and international level. Many of the effective programs outlined in your editorial such as academic detailing, small group workshops, and audit/feedback have been developed by us and currently part of our curriculum. In addition, we have developed programs in multi-source feedback and innovative approaches to increase access to educational programs such as video-conferencing, pod- casts and e-learning. All of the steps outlined in Box 1 as the mandate of the proposed Institute for Continuing Health Education are currently underway at CME offices at Canadian medical schools.

Each of the CME/CPD offices participate in a national accreditation system that is dedicated to ensuring we meet our social responsibilities and continuously enhance the quality of each of our offices. The standards to which we are mutually held reflect the issues you thoughtfully enunciate in your editorial.

In the last few years, most medical school CME offices have also begun to work in the area of interprofessional continuing education with local and national partners. This work is complex but very important. In Canada, funding from the pharmaceutical industry is currently part of our revenue stream, but it is strictly controlled and frankly is an ever decreasing percentage of the total.

Our conclusion on your proposal for an Institute for Continuing Health Education: we actually have such institutions already in place and call upon funders of the health care and education systems to regard continuing education funding with the same importance currently given to undergraduate and postgraduate health education.

Sincerely,

Douglas Sinclair MD CCFP[EM] FRCPC

Chair, Standing Committee on CME, The Association of Faculties of Medicine of Canada [AFMC]

Associate Dean, Continuing Medical Education Dalhousie University

:vw

It is commendable that Dr. Hebert and the CMAJ should encourage a continuing medical education that is "firmly in the hands of unbiased and qualified people" but the public and Canada's doctors may want to look at our current arrangement of care that extends far beyond just prescribing medications and continuing medical education to requiring physicians be fully funded in most provinces by government for medical services provided.

In a medical system under pressure from many sides and in which resources are strained and rationed, people in positions of authority within the medical system and who receive their paycheques from government, both physicians and non-physicians, are at risk of not engaging in a "thoughtful discussion" which Dr.Hebert points out is "the first step in fixing a truly broken system maintained by our culture of entitlement."

If physicians are paid and employed by government and educated by government and are even influenced in their ongoing medical education by government, then patient need is in danger of being replaced by government need which is often short term in nature.

We saw the results of this in the cutbacks of medical school enrollment in the early 1990s for which patients are paying the long term price now with inaccessible care in many instances and we see it today with varying access to cancer medications across the country.

Across Canada provincial governments are trying desperately to control their health care budgets without much success as costs spiral upwards. Just as much as we should be on guard against corporations whose "main concern is the bottom line", we should be very concerned that even more government involvement in educating physicians could have the unintended consequence of shifting the focus away from patients and towards satisfying government need. This would be perilous and unbalanced indeed with the bottom line of corporations being replaced with government's bottom line.

Conflict of Interest:

None declared

The response to Dr. Hebert's editorial by the doctor who denied that doctors get too much of their "education" from drug companies is ludicrous. How can anyone seriously say that doctors are not getting the bulk of their on-going education from pharmaceutical companies? Even medical school texts are produced by Merck and their ilk. While there are some independent ongoing education alternatives, how can anyone (much less a doctor) seriously oppose independent education?

Like almost no other group in our society, the medical establishment fights to preserve and protect its uniquely privileged and powerful position. Anyone who attempts to challenge the medical status quo (i.e. doctors), is met with hostility and swift, aggressive action. I've taken a special interest in the medical system largely because of the egregious actions of doctors that I've experienced myself, and of the truly astonishing number of friends and acquaintances who've had similarly disturbing experiences with their doctors. Dr. Hebert is akin to Copernicus or Galileo in being denounced by self-promoting group pressure exerted by the doctor industry.

I am not castigating all doctors, but there are far too many incidents of errors and egregious behaviour by doctors and by their various associations and organizations. In this country doctors are rarely questioned, much less punished in any way, except in rare occasions and usually after the lapses were well-known within "the system." Doctors operate with impunity, within their own protective bubble. Doctors squawk loudly and also invoke their incidious public relations machines (witness all the medical doctors who now are dispensing mild-mannered, nice guy advice on radio programs these days but in fact are merely there to convey a soft nice-guy image to the public).

However, people know what's happening in the real world. Remember, the "public" sees you one patient at a time, behind closed doors. We experience your arrogance, your ineptitude and, most of all your utter lack of compassion, first hand. You may be able to protect the myth of the doctor for a while longer, but that era is gone and the old doctor image is disintegrating now. It's time for doctors to stop living with their self-created myth and improve the way they do business. I say "business," because doctors have long ago dispensed with the Hippocratic oath. Today, doctors, as a group, are largely the protectors of, and dealers for, pharmaceutical companies as their ways and means of wealth.

If doctors as a group were wise, they would welcome fresh perspectives and genuine efforts to improve a rotting profession. Bravo Dr. Hebert! You deserve a medal but you'll probably have to wait a couple hundred years for that recognition.

Conflict of Interest:

None declared

Dr. Paul Hebert and his Editorial-Writing Team have identified an important issue concerning the current state of sponsorship for continuing medical education (CME) in Canada [1]. As they note, a large proportion of CME is funded by the pharmaceutical industry and physicians have become habituated to receiving such subsidized learning opportunities.

We recognize the many and varied challenges that physicians face as we strive to keep our knowledge and skills current, as is necessary in order to recommend and prescribe the best possible treatment for each individual patient.

The Canadian Medical Association has embedded the obligation of physicians to pursue life-long learning in its Code of Ethics and has articulated the standards of ethical behaviour expected of physicians in its Guidelines for Physicians in Interactions with Industry. These guidelines provide advice to Canadian physicians who find themselves in a possible situation of conflict of interest in dealing with drug companies, and also outline the requirements which must be met so that the CME sessions can be as independent as possible of industry influence.

In January of this year the Canadian Medical Association convened a meeting of national specialty societies and related medical organizations to discuss issues related to online CME. A prominent theme in the discussions was the desirability of diversifying sources of financial support for CME. An Ad hoc Working Group was charged by participants with exploring the formation of a National Alliance for Online CME, one objective for which would be the identification of new models of CME funding.

We welcome the discussion likely to be initiated by Dr. Hebert’s editorial and are confident Canadian physicians are capable of identifying innovative and sustainable approaches to meet the ongoing educational needs of the profession.

Sincerely

Susan King, MD, MCCP Chair, Council on Education and Workforce Canadian Medical Association

[1] Hebert P. The need for an Institute of Continuing Health Education. CMAJ 2008;178:805-06.

Conflict of Interest:

None declared

Dear Dr. Hebert and staff:

Congratulations on having the courage to take the stand you have, on this most important topic -- I cannot possibly agree more with everything you say, and especially with the need to "disentitle physicians and adopt a more principled approach." Entitlement is a serious and insidious disease that can easily erode one's integrity in this profession.

The additional logical step would be to eliminate all drug company advertising from the CMAJ -- I'm betting most members would support this if they gave the content of your editorial any thought. We should not mind paying a bit extra for a subscription to a more ethical, public- spirited journal; keep up the good work!

PJE

Conflict of Interest:

None declared

Dear Dr. Hebert, thank you for your courageous position statement. I think the problem of industry influence on physicians through so-called educational activites has been glossed over for too long. As physicians we are not stupid but we are human. Studies have demonstrated that the bias introduced by drug companies influences clinical decision making. The industry is very skilled at influencing physicians in subtle ways and spends millions of dollars on just that every year. I am a practicing family physician and I think drug company sponsored CME events are just plain wrong. It is time we reclaim the integrity of our profession. Sincerely, Stefanie Falz, MD CCFP Kimberley BC

Conflict of Interest:

None declared

Dear Dr. Hébert:

In response to your editorial “The need for an Institute of Continuing Health Education” March 25, 2008, published in the Canadian Medical Association’s journal, the CMAJ, the Canadian Agency for Drugs in Technologies in Health (CADTH) would like to bring your attention to its Canadian Optimal Medication Prescribing and Utilization Service (COMPUS). CADTH is an independent, not-for-profit agency funded by Canadian federal, provincial, and territorial governments to provide credible, impartial advice and evidence-based information about the effectiveness of drugs and other health technologies to Canadian health care decision makers.

COMPUS provides objective evidence-based information, recommendations and user-friendly tools to support the optimal prescribing and use of drugs. COMPUS is funded by Health Canada; there is no pharmaceutical industry sponsorship. While the total investment in our work is very small compared to pharmaceutical industry investment in continuing medical education, uptake of COMPUS information across Canada has been successful. The audience for COMPUS tools and services spans health care providers, decision makers and consumers.

A variety of ready-to-use products and tools, including accredited educational tools have been developed to assist in conveying the evidence- based messages on proton pump inhibitors (first COMPUS topic area) and are being used across Canada. Specific examples of how COMPUS work in proton pump inhibitors supports and informs health care providers, decision makers, and consumers include: provincial drug plan policy reviews and changes; five academic detailing programs across the country will be using COMPUS information by summer 2008; more than 17 presentations (including rounds) and several displays at various CME events. These tools are publicly available now on the CADTH web site.

COMPUS topics are chosen based on: large deviations from optimal utilization (over- or under- use); size of patient populations; impact on health outcomes and cost-effectiveness; benefit to multiple jurisdictions; measurable outcomes; the extent that evidence is available; and potential to effect change in prescribing and use. COMPUS’ current focus is the prescribing and use of insulin analogues in Type I and Type II diabetics. Recommendations, key messages and some tools in this area will be available later this spring.

For more information about COMPUS and CADTH, please visit our web site at www.cadth.ca.

Barb Shea Vice President, Canadian Agency for Drugs and Technologies in Health (CADTH) Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) Ottawa

Conflict of Interest:

None declared

Phew, another long hard week slogging thru the myriad of patient complaints, ever expanding circle of unsolvable problems, feeling like your work is undervalued, and now... The editor in chief of the CMAJ, Dr. Paul Hebert, an academic, in a university teaching centre, with lots of perks,(no doubt), now comes out and slams the CME provided by big pharma. I dont know where he is getting his info, but I have observed on numerous occasions over the past few years, that the blatant "in your face" promotion of a product has been toned way down. Sometimes, I have to search the presentation to figure out what it is. I find that the presenters go out of their way to avoid talking about the product for which the event was organized.

Once again this is a perfect example of those in the ivory towers, besmirching our profession in the public. Day by day, the perks get fewer and grimmer, and family practice becomes just a little less attractive.

Just a lowly Family Doc looking forward to that quick lunch on Wednesday at noon. Alas, probably soon to end.

David B. Bridgeo, MD CCFP Windsor, Ontario

Conflict of Interest:

None declared