• Ethics

Dr McMahon, who directs the US Accreditation Council for Continuing Medical Education (ACCME), criticises1 our article on how continuing medical education (CME) was used to sell hypoactive sexual desire disorder,2 stating that we ‘provide no supporting evidence’ for our claims that CME courses are an important marketing tool. Perhaps he missed the references in our article, but additional studies support our points.3–9

Dr McMahon also claims that industry supported only 11% of CME activities.1 ,10 However, ACCME doesn't count two forms of industry funding as commercial support. In 2011, ACCME stopped requiring reporting of in-kind support, defined as ‘nonmonetary resources provided by a commercial interest in support of a CME activity’. Examples include ‘equipment, supplies, and facilities’.11 In other words, industry can pay for meeting space, hotel rooms, audiovisual costs, food and other costs related to a CME event—but as long as the money is paid directly to a hotel, caterer and the like, none of the money is reported as commercial support.

Also, advertising and exhibits income, which constituted 13.3% of total income in 2014, is not considered commercial support.11 Perhaps it is a coincidence, but since 2010, commercial funding of CME decreased 21% while advertising and exhibit income went up 23%. Industry is unlikely to purchase exhibition space at an event inconsistent with marketing goals.12

Dr McMahon also takes umbrage at our implication that the ACCME's Standards for Commercial Support: Standards to Ensure Independence in CME Activities are inadequate. How about entirely toothless?

According to ACCME's own materials, employees of drug and device companies are allowed to… control the content of accredited CME activities when the content of the CME activity is not related to the business lines or products of their employer [and]… can control the content of accredited CME activities … when the content of the accredited CME activity is limited to basic science research (e.g., pre-clinical research, drug discovery) or the processes/methodologies of research, themselves unrelated to a specific disease or compound/drug.13

These exceptions cover just about everything that industry needs from CME, which is important to marketing precisely because it never directly promotes products.3 ,6 ,14–18 Positioning invented diseases prior to product launch, convincing physicians of ‘unmet needs’, expanding populations eligible for treatment (pre-diabetes, pre-hypertension), exaggerating adverse effects of competing therapies, minimising concerns about targeted drugs and identifying ‘emerging’ (ie, unproven or disproven) uses of drugs are all classic ways by which CME is used for marketing. Basic science presentations create buzz about new mechanisms of action—especially important for marketing when a new drug has no actual clinical advantages. And ‘processes/methodologies of research’ talks can be used against evidence-based medicine.

CME activities with no commercial funding may still use speakers who are directly funded by industry. As an anonymous pharmaceutical executive stated:CME contributions are commercial decisions…Grants may also be made in support of programs including particular KOLs [key opinion leaders] whose opinions resonate with the promotional plan. … Similarly, those known for positions antithetical to the company's promotional plan are less likely to be supported … .5

Providers who are dependent on industry have a financial incentive to provide industry-friendly content.

ACCME's report also states that, in 2014, 41% of its 1908 CME providers have commercial support.11 That's true, as far as it goes, but the number of physician interactions that each provider has—the number of physicians multiplied by the number of CME activities—ranged from 0 to 1.5 million. About 178 providers reported less than 100 physician interactions.19

It would be fairer to examine the commercial funding of CME providers that served the most physicians. The top 500 ACCME-accredited providers accounted for 90% of physician interactions: almost three-quarters (72%) of the popular providers received commercial support.19 Publication/education companies, which have the most physician interactions, received 41.6% of their total income from commercial entities.11

In summary, the ACCME claims that its standards prevent industry influence on CME, but its annual report obscures the extent of that influence. In the interests of transparency, ACCME should

1. include in-kind funding as income, and disclose commercial support;

2. disclose the proportion of advertising and exhibits funded by industry; include industry-funded exhibits and advertising income as commercial support;

3. disclose the proportion of individual CME providers’ activities that receive commercial support;

4. disclose the titles and sponsors of individual CME activities and

5. disclose the conflicts of interest of individual presenters.

Avoidance of industry-sponsored CME is associated with more rational prescribing.4 We certainly agree with Dr McMahon that ‘promotion or marketing has no place in accredited CME’. So why isn't ACCME promoting objective continuing education rather than defending industry-funded CME?