CME in California

Last weekend I attended the annual one-day conference for providers of continuing medical education (CME) in California. Presented in Sacramento this year by the Institute for Medical Quality (IMQ), a division of the California Medical Association, there were talks on documentation requirements and updated accreditation criteria. There was praise and support for the majority of those attending, the office staff who organize much of the CME offered in the state.

I was there as chair of my hospital’s CME Committee, a position I’ve held since January. While my primary concern is commercial bias in CME, the conference highlighted two other areas of potential controversy I thought I’d share here as well.

Regarding industry bias, there is good news and bad news. The good is that overt bias is explicitly and increasingly monitored. There are regulations at both state and national levels to maintain a wall of separation between industry funding sources and the content of CME presentations. Physician audiences evaluate each CME offering and are asked whether any bias was present. Thanks to media attention and official pronouncements, the issue is now on everyone’s mind. At last it seems reasonable to hope that bald-faced marketing pitches in the guise of balanced CME are on their way out, at least in academic settings.

The bad news is that CME is not provided only in academic settings. “Medical education communication companies” (MECCs) are private entities that host about 40% of all CME accredited by ACCME, using funds mostly from drug companies. As described in the PharmaLive blog, “Most MECCs were simply spun off from advertising and marketing agencies doing business with pharmaceutical companies.” Psychiatrist-blogger Daniel Carlat calls this arrangement “money laundering”; the fairness of this characterization hinges on whether the MECC itself allows its funding to influence its message. While I imagine MECCs run the gamut from earnest educators to crass money launderers, I confess to some cynicism after having experienced first-hand a public relations firm showcasing a Wyeth drug pitch in the guise of a public education event.

More subtle biases continue to slip under the radar as well. New products are welcome topics for CME, while older products, perhaps equally effective, are not. Prescription medications heavily advertised to the public — all new, relatively expensive, and not available generically — require CME introductions, so that doctors have an intelligent response when patients obey the advertising pitch and “ask their doctor” about them. Since physicians themselves seek education about new products, truly unbiased CME at this level seems an ideal not easily reached in real life.

Another topic discussed at the IMQ conference was a 2006 California law that requires all CME in the state to include “cultural and linguistic competency” (CLC) as part of the presentation. This CLC requirement aims to incorporate information regarding “health disparities” in all ongoing medical education. The basic idea is that language, economic, and cultural barriers have health consequences, and that it ought to be part of every California doctor’s training to know about them, and how they apply in every clinical situation. I’m sure the legislation was well-intended, and I agree CLC warrants special focus in medical education.

The problem is force-fitting CLC into every CME presentation. Many CME speakers have an area of research or clinical expertise, which is why they were chosen to speak in the first place. Most are not experts on CLC issues, but in deference to state law they need to cover (or pay lip-service to) this anyway. Instead of making speakers talk about something they lack expertise in, a better alternative would be to require a certain number of CME hours specifically devoted to CLC for annual re-licensing. Then CLC could be presented by CLC experts, and be given the attention and focus it deserves.

Perhaps the most interesting thing I experienced at the IMQ conference was the way “improving patient care” constituted the unquestionable goal of CME. Certainly it is a hard rationale to argue with. After all, medical practice as a whole is aimed toward patient care. It also lends itself to empirical validation: Did physician practices change, and ideally did patient outcomes improve, as a result of a given educational experience? I do agree that the goal of the great majority of CME should be to improve patient care.

However, physicians are not mere technicians. I have attended CME talks on psychiatric practices in other countries. I would be hard pressed to say how this changes my care of patients here, but it still seems valuable for me to know. I have attended CME on standards of care in medical areas other than psychiatry, areas I will never practice myself. I can easily imagine valuable CME that reviews public perceptions of controversial area of medicine both psychiatric and non-psychiatric, cosmetic surgery for instance, that would have no effect on patient care per se. Each of these examples rounds out the education of physician-learners in important but intangible ways. Unless the profession and the public are content with medical “training” as opposed to education, the focus of CME should in my opinion span a somewhat wider domain.

Ironically, the IMQ conference itself awarded me 5.5 hours of CME credit for attending, and yet nothing presented will “improve patient care” in any direct sense. It was still valuable, and I am glad I attended.

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