commercial support for CME is pretty much dead. and that’s a good thing.

Seriously. And it’s a change that’s been needed for a long time.

Having worked in the continuing medical education industry for several years, I used to get asked all the time for my opinion as to where CME is going. And my answer always was that within a few years, there would no longer be any significant commercial support for medical education, meaning that like nurses and lawyers, we physicians would have to pay our own way for continuing education. You see, a good deal of CME, especially online CME, is delivered free of charge to physicians largely through pharmaceutical company grant support. While such support has certainly provided a great deal of educational opportunities for physicians like myself, there’s a glaring problem with this type of financial support. And that would be conflict of interest. Whenever a drug company funds an educational program, it’s generally not out of altruism. Rather, it is done to fulfill specific business objectives. Drug companies are not in the education business; they’re in the drug business, and their revenues are dependent on doctors and hospitals dispensing their products. As a result, a drug company is not going to sponsor an educational program about a disease state for which it doesn’t provide a therapeutic product. And they aren’t likely to fund a program that involves content that may tout the benefits of competing treatments while mentioning the downsides of the grantor’s own products. From a business perspective, they shouldn’t. But from an educational perspective, a potential conflict of interest with regard to physician education can have significant effects. Medical treatment should be based upon objective evidence and, when appropriate, clinical judgment and experience. Treatment should not be a function of which drug company happened to sponsor a successful educational program that ultimately lauded that company’s drugs.

Granted, there are certainly major regulations that guide the development of commercial CME, and these guidelines promote fair balance and objectivity. CME developers are not technically required to adhere to grantor suggestions for expert speakers and content developers. But let’s face it, if a small medical education company receives a grant from a drug giant, are they likely to object vigorously if that grantor suggests particular speakers for the program they’re funding? To say no, while laudable, is potential suicide, as that small company is not likely to be receiving any further grant support from that drug company. This is one area where the current guidelines from the ACCME (Accreditation Council on Continuing Medical Education) fall short. While no medical education company is required to accede to grantor requests regarding content, they aren’t forbidden from exercising their own judgment and complying with such requests.

That doesn’t mean all industry-supported CME programs are commercial in nature and of no educational value. Many such programs do indeed provide objective, evidence-based education. But the problem is that some, and perhaps a large number, are indeed tainted. Having drug companies fund medical education is like having the fast food industry support studies on their products’ nutrition. Would anyone really trust the results of a McDonalds-sponsored study of Big Mac consumption on serum cholesterol levels?

Another problem with commercial support is that we tend to have a ton of CME programs on disease states for which there are blockbuster drugs. I can’t count how many CME programs I’ve seen about cardiovascular disease and diabetes. By the same token, I’m still waiting to find commercially-sponsored programs that deal with pediatric depression, malaria and other disorders for which major drug companies just don’t make products in the US. 

In the past, when I would tell people that the day was coming when drug companies would stop funding most CME programs, they would usually look at me as if I had two heads. Well, recent trends suggest that the day when commercial support for CME goes away is very close. Indeed, Pfizer no longer will support CME programs except those developed by academic medical centers, on the theory that universities are less likely to be tainted with their money than independent medical education companies. I hate to break it to them, but the universities could be just as bad if not worse, but time will tell. And many academic medical centers, most recently Stanford, are now refusing commercial support for specific CME programs; the grant money has to go into a general pool, so that the university gets to decide what educational programs are needed.

I think this is a good trend. And it’s happening faster than I had predicted. Ultimately, CME needs to be individualized. The truth is, no one has ever shown that CME leads to better clinical care and outcomes. While one would think that taking CME would end up benefiting patient outcomes, that doesn’t appear to be the case. And if you think about it, how likely is a single educational program to really change physician behavior? I think it’s extremely unlikely. We’re a stubborn bunch and don’t change our practices that readily until there is a consistent volume of data supporting such a change. And even then, some physicians will not change what they do.

But none of this has kept the CME grantors from demanding ”outcomes analyses“ as a requisite part of any CME program. Sure, if a company is going to fund a CME program, it makes sense that they should be able to receive proof that the program is making a difference to physician behavior and clinical outcomes. The problem is that actually proving this is very difficult unless one is dealing with a closed medical system or can demonstrate clinical practice changes through a chart review. Using survey-based tools to assess changes in physician behavior is ridiculous. Ask any of my colleagues if he/she is doing the right thing after taking a CME program. What do you think the response will be? Truth is, we all tend to overestimate our clinical acumen. That’s the nature of human beings, and the last time I checked, most doctors were human, sometimes too human.

So where is this all going? I think we’re getting to a point where most CME companies will be gone or else have switched into a different area, most likely promotional education. CME will be provided in the interim largely by academic medical centers under drug company support (such support remains the majority source of CME funding), but eventually commercial support will essentially disappear since it makes little business sense to continue funding CME. Aside from being able to air off-label uses of their products and establish goodwill, there is little upside to a pharmaceutical firm from funding CME. And when commercial support goes down the tubes, doctors will largely have to pay for their CME. Medical societies might step in to some degree, but the cost will get passed on to their membership in the form of dues increases. But at least then, we might have untainted CME for a change, and that would be a good thing.

On the other hand, innovative education, such as Web 2.0-based collaborative CME, probably won’t happen under this model. But in my experience, it wasn’t going to happen under a commercial grantor-supported model, either, since trying to convince these large corporations to fund something really novel is like getting water from a stone.