The Corpus Callosum

JAMA has an article on the history of continuing medical education
(CME).  Annoyingly, they did not make it one of the
open-access articles, so they don’t get a link.  However,
there are some telling excerpts and some good commentary over at href="http://carlatpsychiatry.blogspot.com/2008/08/new-jama-history-of-cme-when-will-we.html">The
Carlat Psychiatry Blog
.

There was a time when families used to sit, all together, at the dinner
table, and eat dinner together.  I grew up in those days.
 Dad, an MD, would sit at the head of the table.  My
little sisters would sit next to him.  The idea was that he
would be more able to contain their behavior.  Not that it was
that bad, really, but that was the idea.

The other idea was that whatever was said at the head of the table,
during dinner, was The Truth.  Dad did not trouble us with The
Truth very often.  When he did, we all listened.  I
still remember those Truths.

One of the Truths, for example, was that veterans should get better
benefits.  I still believe that.  Another was that
physician advertising is bad.  I still believe that, sort of.
 A small notice of a new practice is OK, or of a new service
that was not previously available in the community.  But
generally, it is unseemly for physicians to advertise.

Another Truth is that drug companies are too aggressive in their
advertising.  


Drug companies used to send — unsolicited — samples directly to the
doctor’s home.  That’s nuts.  They stopped doing it
in the late 60’s, when those little sample boxes started mysteriously
disappearing.  Imagine sending boxes of barbiturates through
the mail, unregistered, no signature required.  Nuts.

For a while my Dad kept some of them.  One day he decided it
was
nuts, and flushed them all.  I got to help, for some reason
that was not bestowed upon us at the table.  Maybe it was an
oblique way of teaching me, that free stuff is not entirely good.
 At least, not always.

The main point of the JAMA article is that drug company marketing has
been controversial for a long time.

Perhaps the most controversial has been the co-opting of CME.
 Drug companies sponsor a lot of CME. Much of it is free.  I don’t have
statistics handy, but it seems as though the majority of CME is at
least partly sponsored by pharmaceutical companies.  

In
1961, for example, Charles D. May, the editor of the journal Pediatrics,
wrote the article, “Selling drugs by educating
physicians,” in which he
bemoaned the body-snatching of medical education by the pharmaceutical
industry:

A
vicious cycle is created by a mad scramble for a share of the market:
the doctor is made to feel he needs more
“education” because of the
prolific outpouring of strange brands but not really new drugs,
produced for profit rather than to fill an essential purpose; and then
the promoter offers to rescue him from confusion by a corresponding
brand of “education.”

Now, nearly 50 years later, Dr. May’s quote still captures
the essential damage done to medical practice by industry funding of
CME.

Dr. Carlat points out that legislative efforts, in the 50’s, 60’s, and
in the 90’s, have not had a huge effect.  They have reduced
some of the more blatant abuses, and have made the whole process more
subtle.  But in doing so, they have added an air of legitimacy
to the business.  Companies can point out that they are
following the rules, as if that makes everything fine.

In some ways, the more subtle influences may be more dangerous than the
blatant ones.  I can’t prove that, but I suspect it is true.

BTW I made up the word “co-optization.”  Or I thought I had.
 Google gives five hits for it, but it never would have been
acceptable at the dinner table.  

I agree with Dr. Carlat that something needs to be done, and that
physicians are the only ones who can do it.  But organized
medicine doesn’t seem to be dong anything other than talking about it.
 

Perhaps local medical societies could start organizing free CME
conferences.  But CME conferences have to be accredited, and
that usually is done via affiliation with institutes of higher
learning.  Which make money from CME.  Why would they
promote something that cuts into their profit?  

It takes a lot of time to put together a good educational program.
 The problem for physicians trying to do it on their own is
that the time would not be compensated.  Plus, then you would
have problems with people trying to co-opt the new system, perhaps to
advertise their own services.  Arg!