In a previous article,1 a broad theoretical concept was presented that suggested that physician participation in continuing medical education (CME) programs was diminishing and would continue to diminish. The reasons suggested for this were:
Growing dependence on pharmaceutical companies for financial support of CME programs
Increasing pressure for regulatory oversight of educational programs sponsored by pharmaceutical companies
Increasing and negative imposition of “ethical standards” for physician behavior by pharmaceutical companies in CME interactions
Despite regulatory oversight, growing pharmaceutical company control of the development and marketing of physician “experts” for CME, whether promotional or accredited
With increased regulatory oversight, a decline in the degree of creativity and level of sophistication of such programs, converting many CME or promotional programs into “infomercials.”
According to unofficial but authoritative sources in various pharmaceutical companies, these influences have resulted in a substantial decline in physician participation in CME programs. Despite these trends, there is no evidence that the current directions will be altered in the near future. Altering these characteristics would be very desirable in diabetes care.
The Need for CME in Diabetes Care
Multiple studies have confirmed that the prevalent level of care for diabetic patients is demonstrably deviant from recommended guidelines and procedures.2-7 This has been documented in various care settings, including primary care,family practice, and large urban managed care organizations.
Despite vigorous efforts on the part of the American Diabetes Association(ADA) and other organizations to remedy these deviations, there is no compelling evidence that such efforts have substantially improved these gaps in care. A study on the impact of the Canadian Diabetes Association's clinical practice guidelines for postpartum screening of pregnant women with gestational diabetes for type 2 diabetes demonstrated that the guidelines had no significant effect.8 The failure of such educational efforts in diabetes reflects a widespread failure of CME efforts to improve clinical practice.9 Part of this problem relates to the relevance and complexity of guidelines or clinical practice recommendations and the ease with which these changes in care patterns fit into existing practice.10
These issues emphasize areas of concern in professional education in diabetes care. They underscore how important postgraduate physician education in diabetes care is and how concerned we all should be about declines in physician interest in such opportunities. They document how important it is for educational efforts to be driven by physician need and interest rather than by the self-interested agendas of outside organizations or corporations. And they suggest that the imposition of new obstacles to physician participation, such as unpopular “ethical guidelines,” must be modified to remove their barrier effect.
Barrier 1: Application of “Ethical Guidelines” on Postgraduate Physician Education
As most health professionals know, major pharmaceutical companies, through their professional organization Pharmaceutical Research and Manufacturers of America (PhRMA), recently issued the PhRMA Code on Interaction with Health Professionals.”11 This extensive, 56-page document covers a number of important issues regarding the ethical interaction of companies with health professionals, including interactions in the conduct of company-sponsored CME programs. This year, the Advanced Medical Technology Association adopted a similar code of conduct.12
The implementation of these guidelines has included certain key changes in how physicians could participate in corporate-sponsored educational programs. First, physicians' spouses or other guests who are not health professionals or who have work responsibilities not clearly relevant to the educational program cannot attend. This restriction is enforced by most companies even if the attendees are willing to pay for whatever food or beverages are provided to their guests at the program. Second, companies cannot spend more than a“modest” amount of money on the food or beverages at these programs. Third, health professionals can attend out-of-town programs only if they are willing to accept “reasonable” travel arrangements. Finally, guests may accompany health professionals to out-of-town programs only if the professionals or guests pay for whatever travel, food, and beverages are provided.
While these changes sound highly ethical and appropriate, it is one of the most open secrets in the health care industry that, when implemented, they have had an extremely negative effect on physician participation in educational programs and physician attitudes toward the process. Although many recognize pressure from the federal government (specifically the Office of the Inspector General [OIG]) on vendor companies to follow such guidelines, the manner in which they are implemented may appear high-handed to many health professionals. Regardless of cause, large PhRMA companies are imposing a code of conduct on their health professional customers. But the hole in their stance is that no other groups of customers or influential members of the community are subjected to the same code of conduct.13,14 This includes managers or executives of large managed care organizations,pharmacy benefits executives, congressional staff, and elected officials.
Perhaps the most controversial part of the codes, as they affect health professionals, is their requirement that spouses or guests be excluded from attendance, even if the health professionals pay for their guests' meals. Informal but broad feedback from pharmaceutical representatives of various companies indicates that this one stipulation has been the most influential in discouraging physician participation at educational programs. Whether this restriction is well-founded or not, it is perhaps the single most important obstacle to health professional attendance at educational programs.
There should also be concern about the application of rules regarding attendance at out-of-town meetings. A previous article15 noted that the engagement of third-party vendors by pharmaceutical companies may lead to abuses. The potential for abuse, by which these vendors may increase their profits, should be monitored carefully. In their zeal to demonstrate forcefully that they are adhering to ethical guidelines, PhRMA companies are allowing third-party vendors to charge attendees exorbitant amounts for food and transportation to and from airports for their spouses or other guests. At one recent educational conference, the organizing vendor charged attendees more than $800 for two airport transports and three meals for their spouses/guests. The same services purchased directly would have cost only$280!
Another issue is whether travel restrictions imposed on conference participants under the guise of these guidelines are truly required by PhRMA guidelines. There is a fine line between ethical behavior and poor treatment of health professionals.
A solution for these problems is clearly needed to improve enthusiasm for educational conferences while adhering to the ethical requirements of the OIG. Corporate advocacy of ethical conduct for health professionals should be presented in a positive and cooperative fashion, not in the high-handed directive fashion in which it is presently offered. PhRMA companies should reconsider whether, under ethical codes, health professionals may be permitted to bring spouses or other guests to such programs. Each vendor may individually decide whether providers should pay the food and beverage costs for their guests. Third-party vendors of educational conferences should be required to provide transportation, food, and beverages to attendees' guests at their cost, not at an inflated estimation of what health professionals should be charged. Making these changes should have a positive effect on health professionals' willingness to participate in corporate-sponsored programs.
This would benefit all concerned about diabetes care. Given the large number of existing medical products and the number of new products that will become available during the next 5 years, encouraging provider access to educational programs should be a priority.
Barrier 2: Increasing Restrictions on Accredited Programs
On 28 September 2004, the Accreditation Council for Continuing Medical Education (ACCME), under pressure from the OIG, announced strict new guidelines regarding speaker involvement with vendor companies.16 All parties involved in ACCME-approved programs have until May 2005 to become compliant with these guidelines. Under these guidelines, any individual who has any demonstrable financial relationship with a corporate sponsor cannot help plan a program or speak on a subject relevant to the products of that sponsor at an ACCME-accredited program. Knowledgeable experts on CME programs believe that these changes will alter professional education substantially.
One worry is that these efforts of the ACCME will exclude many recognized experts from speaking about areas relevant to their expertise. Pharmaceutical companies have had substantial influence in developing and marketing experts on new therapies or devices. Also, pharmaceutical companies are an important source of funding for ACCME programs. Obviously, these new guidelines will encourage ACCME-accredited programs and pharmaceutical companies to develop new relationships for funding such programs and for developing credible experts.
These changes are so new that no answers are yet apparent regarding how diabetes CME will be affected. However, these changes may strengthen the role of professional organizations, such as the ADA, in developing experts. Such a development would clearly confer more independence in professional education and emphasize the benefits of having ethical organizations assume a greater role.
Summary
Current trends in both objective restrictions and subjective attitudes may be decreasing, rather than encouraging, provider participation in educational programs. Amelioration of these trends may substantially reduce these adverse effects. The introduction of new guidelines for participation in planning or speaking at educational meetings will have a profound effect on professional education. These changes may work to strengthen the independence and objectivity of continuing education in the long run.
Steven B. Leichter, MD, FACP, FACE, is co-director of the Columbus Research Foundation and president of Endocrine Consultants, PC, in Columbus,Ga. He is a professor of medicine at Mercer University School of Medicine in Macon, Ga.
