Hidden conflicts of interest in continuing medical education

TY - JOUR

T1 - Hidden conflicts of interest in continuing medical education

AU - Golestaneh, Ladan

AU - Cowan, Ethan

N1 - Funding Information: Ladan Golestaneh a lgolesta@montefiore.org Ethan Cowan b a Montefiore Medical Center/Albert Einstein College of Medicine, Department of Medicine/Renal Division, Bronx, NY 10467, USA Montefiore Medical Center/Albert Einstein College of Medicine Department of Medicine/Renal Division Bronx NY 10467 USA b Department of Emergency Medicine, Mount Sinai Beth Israel Medical Center, Icahn Mount Sinai School of Medicine, New York, NY, USA Department of Emergency Medicine Mount Sinai Beth Israel Medical Center Icahn Mount Sinai School of Medicine New York NY USA Continuing medical education (CME) is an integral part of postgraduate training for medical professionals in the USA and globally. CME enables physicians to maintain and gain knowledge and skills that ensure optimal medical care and outcomes for patients. For these reasons CME is a required component of licensure in the USA. 1,2 Since most physicians regularly complete CME hours, conflicts of interest that could introduce bias into CME must be avoided to prevent potentially detrimental downstream effects on patient care. However, joint provider activities, which can be undertaken between accredited providers of CME activities and medical education and communication companies (MECCs), raise serious concerns since they are a source of industry (such as pharmaceutical or device companies) influence on CME that circumvents regulatory oversight. 3 Mitigating the risks arising from joint provider activities is needed to preserve the integrity of the CME process. 3 We hope by bringing these new partnerships to light we can refocus attention on hidden conflicts of interest in CME activities. In the USA, physicians must present a certain number of American Medical Association Physician Recognition Award (AMA PRA) CME credits when they apply for renewal of state licences and hospital privileges, and for maintenance of certification with specialty boards. 1 Globally, CME requirements vary. 4–6 Canada has a maintenance of certification programme similar to the USA, whereas many European countries, Australia, and New Zealand focus on professional development that includes management and social skills training necessary to work in an interdisciplinary health-care system. 4 We focus here on CME activities in the USA and describe differences with other countries where relevant. Physicians in the USA earn AMA PRA credits by participating in educational activities sponsored by CME providers accredited by the Accreditation Council for Continuing Medical Education (ACCME), a non-governmental organisation funded by accredited CME providers and workshop registration fees. 1,2 ACCME accreditation requires that the CME provider commits to unbiased and scientifically relevant educational content and uses faculty speakers who do not have financial conflicts of interest with the presented material. 2 In some European countries, the funding of CME activities is provided by governmental departments of health but disseminated through medical societies and an emerging CME provider community, both of which are also partly funded by industry. 4,5 The European Accreditation Council for CME (EACCME) checks the integrity of the content, sets the standards for quality, and accredits content presented. 4,5 However, critics claim that the ACCME and EACCME are not stringent enough in their oversight, leaving room for influence on content by industry sponsors. 5,7–12 Since the early 1990s, US CME providers have partnered directly with the pharmaceutical or device industries to obtain financial support. 7,8 By 2006 concerns about bias and the promotion of off-label uses of some pharmaceuticals in CME were raised. 7–9 In 2009, after an AMA report of these unethical practices, more restrictive policies pertaining to CME content and the nature of partnership with industry were introduced by the ACCME, resulting in a reduction of direct industry funding of CME activities. 8,10 Unfortunately, this reduction was not offset by a corresponding increase of funding from other sources. 10,12 To fill the funding gap, CME providers in the USA entered into joint provider agreements with MECCs. 3,13 MECCs are independent, privately held, education companies, most of which are for-profit entities. 14,15 These companies are funded mainly by large US pharmaceutical and device manufacturers, 13–15 and MECCs tend to be part of larger public relations organisations for these manufacturers. 13,14 MECCs help CME providers design online and live conferences in addition to educational tools and printed material. 9,13 But payments by MECCs to accredited CME providers are not subject to transparency laws designed to combat industry influence on physician behaviour, including the 2013 Physician Payment Sunshine Act that mandated public reporting of all financial payments by industry to physicians and teaching hospitals. 15–17 Although MECC sponsor names are disclosed during educational activities, their relationship to industry is seldom transparent to audience members. Thus, educational grants from industry are given to MECCs, who, in turn, award it to CME providers in a joint provider activity. This mechanism ensures that industry indirectly stays involved in the educational activity but exempts the industry sponsor from reporting their role and any payments to the CME provider. Since CME providers are financially dependent on MECCs, their obligation towards maintaining the joint provider relationship raises the spectre of a conflict of interest that impugns the integrity of the CME content. Furthermore, even though CME content can influence the prescribing habits of physicians, physicians' practice groups, as recent as late 2016, were lobbying to increase exemptions to the Sunshine Act. 18 The risk of conflicts of interest presented by joint partnerships is not unique to the USA. A 2016 report of pharmaceutical payments to physicians in the UK revealed that up to a third of payments are made for consultancy and service fees, with a large portion going for payments related to educational events, including travel and admission fees to CME events. 19 A 25% increase in payments made to UK physicians in 2016 confirms an ongoing relationship between industry and physicians in the UK. 6 Strategies are needed to eliminate ethical concerns related to MECC financial contributions to joint provider activities in the USA and could be a model for the international CME landscape, especially with a burgeoning CME provider sector in Europe. 5 In our view, ethical considerations concerning joint provider activities should focus on the undue influence of industry involvement in CME content through joint provider arrangements with CME providers. The solutions proposed ( ) address three ethical concerns. First, joint provider activities are exempt from US transparency mandates and can result in a potential avenue for introducing industry bias in CME activities. Second, payments to CME faculty from MECCs could influence content and prescribing habits. Third, the ACCME has insufficient resources to evaluate the integrity of CME content, and relies mostly on CME providers themselves who are also engaged in joint provider activities. Only by implementing strategies, such as those outlined in the panel panel , can these ethical problems with CME be confronted. We thank Dr Ruth Macklin for her input in preparing this Comment. We declare no competing interests. The writing of this Comment was supported by National Institutes of Health (NIH)/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA grant number UL1TR001073.

PY - 2017/11/11

Y1 - 2017/11/11

UR - http://www.scopus.com/inward/record.url?scp=85032944030&partnerID=8YFLogxK

U2 - 10.1016/S0140-6736(17)32813-1

DO - 10.1016/S0140-6736(17)32813-1

M3 - Comment/debate

C2 - 29143744

AN - SCOPUS:85032944030

SN - 0140-6736

VL - 390

SP - 2128

EP - 2130

JO - The Lancet

JF - The Lancet

IS - 10108

ER -