Daniel Carlat, M.D. is a psychiatrist in private practice in Newburyport, Massachusetts. He graduated from a psychiatric residency at Massachusetts General Hospital in 1995, and is the founder and editor of The Carlat Psychiatry Report, a monthly CME newsletter. Dr. Carlat reports the following conflict of interest: He publishes an industry-free CME newsletter, so he would stand to benefit financially if drug companies were not allowed to fund his competitors. In 2007, Dr. Carlat started a blog entitled The Carlat Psychiatry Blog after having an influential op-ed piece published in The New York Times about industry-funded continuing medical education (CME).
John M. Grohol, Psy.D.: You started your blog just over a year ago after having an op ed piece published in the New York Times about the conflict of interest in industry funded, continuing medical education.
How has the continuing education industry changed since then in response to efforts such as yours?
Daniel Carlat, M.D.: The op ed did garner a fair amount of response, both positive and negative; negative response being mostly from medical education companies that stand to profit, from the CME business.
A number of things happened after that op ed was published. One of them was the Josiah Macy Foundation organized a meeting of prominent figures in medicine, and this group issued a report recommending that medical education no longer be funded by industry.
Soon afterwards, the American Medical Association came out with a report through its main Ethics Committee (CEJA, the council for ethical and judicial affairs). This report on medical education was about two years in the making and they also recommended that continuing medical education no longer be funded by the pharmaceutical industry, basically saying that the marketing aims of drug companies have become overly intertwined with continuing medical education.
These physician groups were both saying that have lost control of the content of their accredited medical education, and that we need to take that control back. I’m not talking about promotional talks here—I’m talking about accredited, Category One CME, which is the credit doctors need in order to maintain their medical licenses in most states. So this type of education is really is a big deal, and has implications for the wellbeing of out patients.
Aside from these two reports other things happened. The Senate Finance Committee, under the leadership of, Senator Charles Grassley, came out with a report, saying that after interviews with different stake holders, they felt that many of the CME programs had become promotion activities for pharmaceutical companies.
They sent a letter to that effect to the ACCME, (which is the overall regulatory body for all CME). And then that set in motion a number of activities in the ACCME
It seems that every couple of months now if you go onto the ACCME website they have come up with another set of proposed guidelines to make more impenetrable the firewall between medical education programs and industry sponsorship.
For example, they have redefined what a commercial entity is in order to limit the involvement of advertising companies in CME. In the past pharmaceutical marketing companies could actually also create CMEs.The ACCME looked at that and said, “No, guys. If you as a promotional marketing company want to create CMEs you will have to be very careful. From now on, you have to spin off the CME part of your business into a separate corporation. You can still be sister companies, but it has to be separated in some reasonable way.”
Most recently, ACCME has proposed that when any CME company comes up with a proposed topic for a course they have to do their needs assessment and their topic choice based on independent information sources. They listed a bunch of potential information sources, like medical organizations, and government-funded organizations that can suggest unbiased topic areas. The idea is that this would theoretically prevent a company from just deciding, for example, to create a course about injectable antipsychotics just because Janssen is funding that program (Janssen markets Risperdal Consta, an injectible antipsychotic)
So now, if they do decide to come up with a program on injectable antipsychotics and Janssen is funding it, they are going to have to demonstrate to the ACCME that they came up with that topic and they generated that topic in an independent way without any influence of the promotional needs of the company.
The most recent development is that Pfizer, one of the largest drug companies in the world, announced that they would no longer directly fund CME that was produced by independent medical education companies. That has caused an uproar in the medical education community, which is about a 1.2 billion dollar business,. However, one has to wonder, even with all these new developments, if there are ways for those companies to make end runs around the new regulations.
And I think in the case of Pfizer, it’s pretty clear that Pfizer is saying that, while they won’t directly fund medical ed companies anymore, they will fund education programs that are sponsored by medical societies or academic medical centers, even if those programs are run and produced by private med ed companies. So the money will now go to the medical society, and then from the medical society it will still go into the same coffers as before–the med ed companies!
Will there be a little bit more adequate oversight of the content? Hopefully there will be. But I think that ultimately the same education companies that are one hundred percent dependent on grants from pharmaceutical companies for their business, those companies will still be very much involved in producing the content of these educational activities.
Dr. Grohol: So it sounds like it almost becomes an increasing shell game of how many filters can we put the money through before it actually gets to the same people. And it begs the question, will we ever see real reform in the CME industry?
Dr. Carlat: Well, we will. But it is a very, very slow incremental process. This reminds me of, when the campaign manager for President McKinley was asked what were the most important things in politics. And he said, “There are two important things in politics. The first one is money, and I forget what the other one is.” It works very similarly in the pharmaceutical marketing industry, and it really is all about the money.
So if there is reform, the way that the reform will come about is that the drug companies themselves will realize that their profits and their bottom line are threatened by their continuing involvement in sham educational activities. And once they realize that their bottom line is affected, then they’ll pull out very, very quickly.
Right now it’s difficult because if a particularly ethical company, decides, “This really is very embarrassing and demeaning for us and doctors to be putting on these sham educational programs. We don’t really need to do it anymore, we have plenty of other outlets for advertising that are legitimate. Let’s just stop doing it.” Well, then their shareholders are going to be complaining that they’re taking away a valuable marketing tactic from their business and putting them at a competitive disadvantage to all the other companies that have not been so ethical. Companies are always looking behind their backs at what their competition is doing to make money.
Dr. Grohol: Sure.
Dr. Carlat: So, somebody is going to have to take a stand at some point, or regulatory bodies will do it for them. If companies, both the drug companies and the med ed companies don’t materially change their ways, aside from these shell games and these smoke and mirrors operations, then the Senate Finance Committee will begin to, not simply write letters asking questions and expressing displeasure, but they’ll start to ask Congress to change the laws so that this kind of thing can’t happen anymore.
Dr. Grohol: Recently you’ve had some pretty strong words for George Lundberg and Medscape on your blog about their CME efforts. In an ideal world what could Medscape and other companies like them do to reform their CME in the short term?
Dr. Carlat: Well, I think both George Lundberg and myself are very blunt and frank people. And it’s true that in a recent video editorial broadcast on Medscape, Dr. Lundberg really lashed out. In my opinion he lashed out at everybody who’s trying to bring more honesty into medical education.
Dr. Lundberg certainly isn’t a bad or unethical person, but he is a person who has cast his lot with a private, very profitable medical education company, Medscape, which is, again, almost one hundred percent dependent on pharmaceutical company funding for the production of their medical education. So, anything that threatens that spigot of money is going to threaten everybody that works in that company, and will certainly personally threaten Dr. Lundberg’s position as editor of their medical site.
One of the things that he said was that Medscape is “good, clean, and transparent.” And that bothered me because the real issue, and where the rubber meets the road in this entire debate, is when you look at the actual educational courses, are they biased, are they promotional, or aren’t they? I can give you a lot of rationales for why these things might become promotional, but if you look at them and they are just perfectly good unbiased education, then it really doesn’t matter who’s paying for it.
But when I looked at the psychiatry offerings after Dr. Lundberg published that editorial, I was astounded at how transparently and blatantly commercial and promotional all of the psychiatry CME courses that I reviewed were. It wasn’t as though the bias was even difficult. It was like shooting fish in a barrel.
You just look at anything on their site. I looked at one event, one course for ADHD medications, and the first 10 slides in the online program were essentially commercials for the latest Shire products in ADHD. In another example there was a course on a new antipsychotic called Invega, which is produced by Janssen. And this antipsychotic has only one little niche advantage in the very, very crowded and competitive field of antipsychotics, which is that it doesn’t get metabolized through the liver, and so it’s a good medication to prescribe for someone with liver disease
So, in the Janssen funded antipsychotic program the entire program is based around the case study of, wouldn’t you know it, a patient who had liver failure. The program took the audience by the hand and said, “Let’s look at this important case example of a patient with liver failure. Let’s look at what would be the best medication to treat this person with if he’s psychotic. Guess what? The best medication is Invega.”
And you keep going through the website, and it is so obvious that the money and commercial influence are infiltrating the CME programs, which is really why I ended up lambasting Dr. Lundberg in a couple of blog entries. I received a fair amount of flack from various people who felt I was a bit nasty. But there’s no question that passions do run high in this debate..
Dr. Grohol: So how do they change their business, though? If their business is dependent 100% on pharmaceutical companies to fund them, I mean Medscape would be out of business tomorrow.
Dr. Carlat: That’s ture, Medscape would be out of business, if they felt they needed to continue to produce accredited CME. However, the amount of money companies spend on accredited CME is 1.2 or so billion dollars a year. The amount of money companies spend on non accredited medical education, i.e., various forms of advertising, promotion, dinner talks, dinner programs, web based non CME programs is in the tens of billions of dollars. There’s plenty of money out there for a company like Medscape if they decide that they want to continue to depend on pharmaceutical money. They simply could no longer call their offering “accredited” CME.