The backlash against commercial support has also led many prominent medical centers to ban faculty from receiving significant amounts of industry dollars for teaching and consulting. But these professors are often the top experts in their field, the ones at the research helm. Promotional talks given by drug reps—who are company employees, not doctors—are monitored by the FDA, and any discussion of off-label use is strictly prohibited. That's for good reason; the only people telling doctors how to use a drug should be doctors who know how to use the drug. But if these doctors are prohibited from giving talks, then how is that going to happen?
Continuing medical education programs are another option. The pharmaceutical industry spends more than $1 billion a year on educational programs that are also CME-certified (see Table 6 here)—that is, doctors attending them can earn the credit hours they need in order to keep their medical licenses. These programs do permit off-label discussion of drugs. However, CME guidelines are strict. Programs must present a balanced view of all treatment options for a given disease, and pharmaceutical companies may not influence the program.
Fair enough. Companies shouldn't be able to determine the content of any educational program, especially one that qualifies for CME credit. But as this wall has thickened, pharma has pulled away from funding CME programs, which means fewer free educational opportunities for doctors. Unsponsored, in-person CME programs can cost hundreds to thousands of dollars, which starts to pinch the wallet, even for doctors, who aren't all loaded. The reluctance stems not only from the lack of opportunity to influence doctors but also fear of being seen as promoting a drug. Many companies have decided it's just not worth the risk or trouble. Besides, some universities are already pushing industry out of CME programs, too.
Without programs being brought to their door, most doctors will get their necessary credits in one fell swoop at their specialty's annual conference, which offer CME sessions. But an hour-long talk in a giant lecture hall is hardly the intimate atmosphere truly needed to learn about a new drug. More than 30,000 people attended the recent annual meeting of the American Society of Clinical Oncology, the largest meeting for cancer health care professionals. Presenting new drug data to an audience of thousands precludes the pertinent dialogue that's possible in a smaller setting. And waiting until the annual meeting rolls around doesn't seem like the best way to stay on top of the latest developments. Furthermore, the balanced nature of CME programs often leads to a very watered-down presentation of cutting-edge advances. A seminar may present several speakers discussing multiple treatments for a disease without honing in on the specifics of using one essential new tool. The content, the size, and the impersonal nature of these talks don't deliver the level of detail that doctors must know as they inject a new foreign substance into a living, breathing human.
The same goes for the plethora of online videos and other materials produced without commercial support. There is no substitute for a small group of people listening to a doctor talk about how to treat a disease. And there is no substitute for the commercial support required to run such programs.
In a recent study, academic researchers were paid a modest honorarium to travel around the country teaching more than 14,000 doctors about new treatment guidelines for high blood pressure. Each researcher met with small groups of doctors to educate them about the latest advances. In counties where the most sessions took place, adherence to the guidelines rose by more than 8 percent. In counties with the fewest such sessions, adherence decreased by 2 percent. The approach that the pharmaceutical industry has been taking for years is actually an effective way to educate doctors.
The concern about industry's influence over medical care is obviously well-founded. There are plenty of cases in which doctors have promoted unproven off-label use or have become unduly biased toward prescribing a drug that they learned about through a pharma-paid program. And it's doubtful that companies would shell out so much money if their bottom lines didn't stand to benefit.
But the entanglement caused by for-profit drug development can't be undone by eliminating the free lunch. As one physician suggested, perhaps pharmaceutical companies should be required to pay for medical education. After all, if companies are going to unleash new drugs into the world, shouldn't they be responsible for teaching people how to use it? Ousting commercial support is creating a huge chasm in medical education, leaving doctors not only hungry but also starved for knowledge.
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