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November 16, 2009

Continuing Medical Propaganda Education

A little known provision in the House health care bill would require the $1 billion continuing medical education (CME) industry to disclose more about what it's teaching the nation's doctors:

WASHINGTON—Health legislation moving through Congress would force drug makers to disclose how much they spend on continuing medical education classes for doctors, sparking some resistance from the industry.

For-profit continuing medical education companies have seen revenue fall by double digits in the last year, according to industry statistics, following congressional investigations into the influence of drug makers on medical research and course content. [WSJ]


I used to write CME modules on high blood pressure drugs, sleeping pills, anti-malaria medicines, anti-depressants, hepatitis vaccines, and other remedies. Keep in mind that I quit medical writing several years ago and the rules have changed a lot since I left.

Sometimes these CME modules were financed by drug companies. In which case, they'd often consist of PowerPoint slide decks summarizing industry-funded research, which had been presented by industry-funded experts at industry-funded conferences.

The drug companies would give these training modules away. Doctors could answer multiple choice questions to earn points towards renewing their medical licenses. Sometimes CME companies would commission CME modules to sell to doctors for a profit. Some CME is produced by non-profit corporations and/or independent academic or professional outlets.

The drug companies did hire real doctors and lawyers to make sure that non-doctors like me didn't accidentally recommend anything lethal or fictional. This was called "med/legal review." Med/legal sent stuff back to us all the time when creative excess got the better of us and we started making claims that were "too promotional." This was a necessary check because we answered to marketing executives.

Review was thorough because the company didn't want to get sued. But a CME module that will stand up in court isn't automatically a quality teaching tool for your doctor. The standard for a true claim was basically whether the statement had been accurately paraphrased from an approved source, typically a peer-reviewed study. Usually, the drug company would tell us which papers to use. More often than not these were write-ups of research sponsored by the company. 

It was obvious to me at the time that this was no way to go about educating the nation's doctors. It wasn't that the information was false, it was just profoundly biased in favor of whoever was selling the drug. The drugs with the most money got the most exposure. Doctors could learn about the latest blockbuster for free, but they'd have to pay out of pocket to learn about a less heavily marketed alternative. So, doctors being much busier versions of normal people, were more likely to learn about whatever the industry literally put in front of them.

The overriding goal was to familiarize doctors with the key sales points for that drug. The specific claims were backed up by research, but at the end of the day doctors were getting a heavily-footnoted sales pitch. The primary object of the exercise was to hype a product, not to disseminate scientific truth.

At a time when the future of health reform depends on cost control, it might not be such a good idea to let pitchmen educate doctors.

More transparency in the CME industry can only be a good thing. The public might not like what it sees.


So, doctors being much busier versions of normal people, were more likely to learn about whatever the industry literally put in front of them.

Why are doctors busier than normal people? Given the amount they earn per hour, I'd guess they could work many fewer hours per week and still live quite well. Why don't they?

It's important to distinguish actual CME from the "drug dinners" that are far more common in my experience. Non-CME drug dinners offer no educational credit and no compensation aside from the dinner itself (for the physician only--no plus ones). They're still pretty regulated, but they don't have to hide their bias.

Actual CME programs have to go a long way to clear themselves of bias in order to be accredited, and the handful I've attended have been reasonably balanced. Most of them rely on the idea that a rising tide lifts all boats--that is, if you teach doctors to treat COPD properly, they'll use more Advair, even if they also use more of their competitor Symbicort.

I'd still love to see the drug companies out of the CME game entirely, but it isn't high on my outrage list.

Why are doctors so busy? (I don't know if they're busier than your average NY investment banker or senior Hill staffer, but IME they are a very busy group.) Paperwork is a big culprit. Fee for service is a perennial incentive to do more. Call schedules. Emergencies that don't fit into banker's hours. For some people, trying to fit in clinical practice, research, and teaching.

I'm sure it's partly self-selection. Medical schools favor people with good grades and resumes full of extracurricular activities. If you crave a lot of unstructured time, you probably won't like pre-med or medical school very much.

I felt like a lot of the CME I did was a disservice to the doctors who studied it. I did a CME module for what was at the time the latest "non-addictive" double-layer sleeping pill. The company really wanted to sell it senior citizens. They gave me a whole pack of papers with the relevant charts circled. It became obvious to me as I read these papers that the real upshot was that this whole class of drugs was, on the whole, not very effective and pretty bad for old people.

Our drug had a lower rate of certain side effects than the leading brand, but rates at least as high for other side effects. We concentrated on the marginal differences between new drug X and other drugs in its class, and the studies that showed that X was objectively superior on measure Y. We just kind of glossed over the studies showed that X users were just as likely to break their hips as users of drug Y and that seniors in the drug group broke their hips a lot less than those in the placebo group.

Parse: doctors in hospitals work in shifts. In Israel, the standard way of running things is that you work 9-5 every day, and one day per week you work overnight, from 9 am to 5 pm of the next day. In the US I think it's the same, but the shifts are 12-hour unless you're really senior.

In general, professionals all work really long hours. They make a lot per hour, but that just gives them an incentive to work more. It's only when you get to the level of a CEO, or a full professor, or a hospital manager, that you have enough underlings that you can work less than 60+ hours a week.

Lindsay: my girlfriend's PI forwarded this article to everyone at the lab. Apparently, there are a lot of good, cheap drugs that cut your likelihood of getting cancer by half, but because of apathy nobody takes them. If CME tells doctors "Prescribe those drugs to your patient," no industry funding could make it bad...

Depends on the doctor. General practitioners or pediatricians (the lowest paid of all doctors, BTW) have to run lots of patients through their office in order to receive enough money from the insurance companies to stay in business. Many (including my GP) perform community service, work in free clinics, etc. Not all doctors are plastic surgeons sipping drinks by the pool in La La land.

And of course effective drugs that lack patent protection get little or no promotion since nobody stands to make gobs of money off them. Getting the drug companies under control and mitigating the bias towards expensive drugs would do a lot to bring down health care costs.

I think there should also being a law requiring both doctors and drug companies to disclose how much palm greasing goes on between them. I know doctors that literally never pay for their own lunch; one of a dozen drug reps in the region buys lunch for each of several doctors' offices every day of the week. That's only the tiniest example.

Can we trust doctors to do what's in our health's best interest when pleasing their benefactors in in their financial best interest?

When I was in practice, my hours, in theory, were not bad: six three hour office sessions, and one call/OR day. But then there is the other stuff. Returning phone calls. Rounding on patients. "Paperwork"--reviewing lab results, mammograms, ultrasounds, figuring out what they meant in the context of the patient's medical history, figuring out a management plan, and then and phoning or writing patients. Although I was scheduled to be in the office from 9 to 4, I was really there from 8 to 8 many days. My one evening clinic a week ran from 5 to 8 but, again, was more like 4 to 10.

And weekend call--as an obstetrician, I could and sometimes did spend the entire three days at the hospital. BTW, my weekly call day was a 24 hour day, and it could easily be spent at the hospital, too.

Then there are department meetings, committee meetings, and the weekly M&M (morbidity and mortality rounds) I had to attend. As I was part of a large hospital system, there the week or two a year I had to staff the resident GYN clinic, and the week or two I had to staff the resident-run Labor and delivery. Plus the one or two extra calls at the main hospital a month, on top of the call for my patients at the outlying hospital (above).

And I have to do 50 hours of continuing medical education a year to keep up my licensure (state), plus another 20-30 to keep up my board certification, plus all the paperwork this all requires.

Mind you, I never went to drug company dinners, nor took any gifts from them except drug samples (for my uninsured patients) or books (which I donated to hospitals in India and Ukraine that needed them).

I got tired of it all (mentally and physically), and now work as a hospitalist, with set hours and without all the extraneous responsibilities. But if all doctors did this, there would be no doctors' offices to go to.

I realize that some of us are grossly overpaid for what we do (dermatologists, plastic surgeons), but primary care docs are, generally, not. Well, at least the conscientious ones aren't.

iCME is an iPhone app that lets you track, sort, plan and email you CME activities directly from your iPhone!

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