Industry Support of Continuing Medical Education: Evidence and Arguments

This past summer, Pfizer, Inc., announced plans to dramatically cut back its financial support for continuing medical education. It will support programs run by academic institutions, teaching hospitals, and medical societies, but eliminate direct financial support for courses offered by for-profit medical education companies.¹ To date, Pfizer is the only pharmaceutical company to make this move, but many in medicine believe it will not and should not be the last. "Its decision indicates a sea change in sponsorship of continuing education in the United States," wrote Mark Gould in a set of essays in the British Medical Journal about corporate sponsorship of medical education.²

Physicians are required by law and by professional codes of ethics to participate in continuing medical education.³ Given CME's high cost, and given declining support for CME from public and academic institutions, it is not surprising that medical educators and physicians have sought financial support from private industry.⁴ This effort has been successful; the amount and proportion of funds provided by industry have increased despite reservations about the influence that industry can exert over content and mission.⁵ According to a national survey of physicians conducted in 2003 and 2004, more than one-third of physicians (35 percent) are reimbursed for costs associated with professional meetings or continuing medical education.⁶ Over half of financial support for CME comes from industry, and CME increasingly is provided by primarily for-profit medical education and communication companies (MECCs), which receive nearly all of their income from commercial sources.⁷

No one knows exactly how much industry support physicians receive, however, because it comes in many forms and types. Pharmaceutical firms and other health-related businesses sponsor speakers at conferences, organize and sponsor dinners with faculty presenters whom they select and pay, provide food at grand rounds or conferences, and sponsor educational events at a variety of other venues, with a variety of providers, and with varying input and control over content. Indeed, one could characterize three categories of CME: (1) CME that is accredited by the Accrediting Council on CME, (2) unaccredited CME that nonetheless includes learning objectives and methods, and (3) promotional activities purporting to be CME (also unaccredited). No clear agreement exists about what industrial activities go in the last two categories. Unaccredited CME can include industry sponsored dinners, satellite conferences, and speakers' bureaus. Although some of these activities doubtless mix education and marketing, accurately distinguishing between the two is very difficult. Nonetheless, most reasonable observers would include the distribution of trinkets-pens, notepads, and coffee mugs-sporting industrial logos, drug samples, food and beverages, and tickets to cultural or sporting events as pure promotion, not in any way educational. Since the latter two categories may not be readily distinguished on their face, accreditation has the potential to serve as the only way to reliably distinguish CME from promotions masquerading as CME. Accredited CME must comply with guidelines developed by the Accrediting Council for CME (ACCME), which include prohibitions about the sponsor's control over content.⁸

Perhaps the most compelling ethical argument for permitting industry funding of education rests on physicians' liberty interests. These liberty interests, however, are outweighed by the ethical obligations of physicians to place patient interests ahead of their own, and by the duty and privilege of a profession to control the education of its members. Claims that industry funding benefits patients by improving physician knowledge and competence have little empirical evidence to support them. In contrast, some evidence exists that physicians are inappropriately influenced by industry-funded CME, and that patients and the public view such activities negatively.

The Evidence

A number of positive effects of industry funding on CME have been proposed. By keeping the cost of attendance down or making participation more attractive (such as by providing meals), industry support may result in greater participation in CME. Certainly, physicians are more likely to attend continuing education events when refreshments are provided, and they regularly voice concerns about the cost of CME.⁹ Surveys of physicians indicate that some favor industry funding if...