Cruise CME: The Gold Standard of CME? (Probably not…)

Last Friday there was a brief discussion amongst my CME colleagues on Twitter – under the #CMEreg hashtag – about what I like to call “Cruise CME”. Cruise CME is the general term I use to refer to CME activities that are bundled together with leisure activities like skiing, hunting, and, naturally, sailing on a cruise ship.

The general consensus from those participating in the Cruise CME discussion was that of “How and why are these types of CME activities still taking place?” I made the comment that, in theory, these types of activities should be considered the “gold standard”.

The gold standard? Really?

OK, maybe I was using a bit of hyperbole to make a point, but allow me to explain. I find this issue fascinating because I started out with one opinion on it, but once I did a little more digging, did a complete 180.

A couple years ago, I was approached by a travel agency interested in offering Cruise CME packages. Half to full days of education while the ship was sailing; free days when to ship was in port at various tourist destinations.

My first instinct when I read the emailed description was to say “Absolutely not!” and delete the email. There’s no way to make this a “legitimate” CME activity, I thought.

But here’s the part that made me start to reconsider: there was no commercial support involved. The entire activity was covered by registration fees. Participants paid a fee for the cruise and a fee to participate in the CME. That was it. No grantors, no exhibitors, no institutional funds. Only reg fees.

Yes, but…it takes place on a cruise ship that travels to exotic locales! There has to be some kind of regulations about that! I know I’ve read it somewhere.

Fair point. Let’s look at the ACCME’s Standards for Commercial Support…oh, wait…there’s no commercial support. Hmmm…I think I remember reading something in the PhRMA code…nope, that doesn’t apply either. As far as I can tell, there are no specific guidelines about the location of a CME activity when commercial support is not involved. If I am incorrect about this, I hope someone can point me in the right direction.

So, we have established that there is no commercial support involved and no guidelines or standards are being broken by the location of the activity. I, as the accredited provider, would have had complete control over the content. So I’ll repeat the question I posed on Twitter: in theory, isn’t this the “gold standard” of CME?

Maybe I should pose the question another way: if you are an advocate of the elimination of commercial support from CME, isn’t the “Cruise CME” model the ultimate goal? Participants pay for their own education; the potential of any industry bias from grant funding is absent; the CME provider controls the content. What else could you want? (Yes, I’m discounting the argument about the value of didactic-based CME. I don’t think it’s relevant to this particular issue.) Does it make a difference if the activity occurs on a cruise ship or in a hunting lodge?

My guess is that for a lot of people, the answer to that last question is “yes”. Cruise CME activities don’t pass the “smell test” and location is the big hang-up. We know something is wrong with these types of activities, but we just…can’t…quite…put a finger on what it is. Even after making all the arguments to myself that I laid out above, I still wasn’t totally convinced (side note: I corresponded with the travel agency mentioned previously, but nothing ever came of it. I’m not even sure if they ever did “Cruise CME” or not.)

The argument I make against it – and one I’ve heard from others – is whether or not the primary focus of the activity is on education or entertainment? But…why can’t it be both? If a physician wants to shell out $1500 to learn about…I dunno…Updates in Primary Care… and then use his free time to sip mojitos on the beach in Barbados, is that wrong? It’s a tough question, but the perception-

And…bingo. Perception.

Perception is king in CME, right now. No, there may not be any regulations that say a commercial support-free activity can’t be on a cruise ship, but the perception is that there is or there should be. The perception is that a “legitimate” CME activity cannot take be held while cruising around the Virgin Islands. The CME community is under constant scrutiny from the outside and these Cruise CME type activities make an easy target. Does that make them wrong or out-of-compliance? Not in my book, but it does make me a little leery of being associated with them.

I’m very curious to hear what others think of this issue. Am I missing anything with regards to compliance and location? Do I have the wrong read on the perception of these types of activities? I hope to make this a topic for an upcoming #CMEreg chat and continue the conversation.

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10 responses to “Cruise CME: The Gold Standard of CME? (Probably not…)

  1. As much as I love Derek, I must respectfully disagree with his statement that the Standards for Commercial Support don’t apply if commercial support isn’t accepted. This is a common misconception…and probably why Criterion 7 is the one that’s out of compliance the most.

    SCS 3.11 (under “Expenditures for learners”) states: “Social events or meals at CME activities cannot compete with or take precedence over the educational events.”

    Perception or not, if it’s a 7 day cruise with only 2 days of education, it will be out of compliance. If it’s a 5 day cruise with 5 days of education, probably not. Either way, it’s kind of tacky, even if you have a “captive” audience.

  2. Great feedback, thanks Pam!

    I based my assumption (I know, I know…never assume) that the SCS do not apply if commercial support isn’t accepted on the following points:

    1) I can’t find a statement in any of the ACCME’s materials that says the SCS DO apply even when commercial support is absent. You are obviously of the opinion that they do; do you have a reference for your opinion you can share as a resource?

    2) The “Ask ACCME” section on SCS 3.11 states the following:
    “How can meals or social events take precedence over educational events? (SCS 3.11) — Using commercial support to pay for modest meals and social events at CME activities has been allowed for years. However, providers must avoid making meals or social events longer or more important or more costly than the educational activity, for example.” (http://www.accme.org/index.cfm/fa/faq.detail/category_id/c14cc73e-22a9-4228-9943-93abd0e1f0b0.cfm)

    To me, this directly references using commercial support to pay for social events. It doesn’t cover when the money comes directly from reg fees.

    3) I felt the real kicker on this issue comes from the ACCME’s “Outline for the Self Study Report for ACCME Reaccreditation”, which can be found here http://www.accme.org/dir_docs/doc_upload/a966cccc-12a5-41e0-8547-85741293bb51_uploaddocument.pdf.

    On page 3, it states the following: “Describe the practices or procedures or policies you have implemented to ensure that social events, or meals, at commercially supported CME activities cannot compete with or take precedence over educational events. (C8 SCS 3.11) – or enter here, ‘We do not accept commercial support for any of our directly or jointly sponsored CME activities or enter here, “We do not provide social events or meals for any of our directly or jointly sponsored and commercially supported CME activities.’

    So if you accept commercial support, you need to include your policy about social events. If you don’t accept commercial support, you don’t need to include a policy about social events. This seems like a pretty strong indicator to me that SCS 3.11 doesn’t apply if you don’t accept commercial support. Am I drawing the wrong conclusion here?

    Perhaps I’m misinterpreting what the ACCME is saying (it wouldn’t be the first time.) If you can provide me with the references or resources I am missing, that would be great!

  3. Susan Yarbrough

    It still comes back to the sniff test. I still think it smells funny. That said, Your argument is pursuasive and I’m glad you did better due diligence than I about the background of CME activities. I still assert that it’s the competing priorties – education versus vacation. If the education is the driver, I have much less odor issues.

    I (half) jokingly say that I do my job with two little birds on my shoulders: one shoulder has Murray Kopelow perched, the other has a New York Times reporter perched on the other. When I plan a CME activity, how does it look to either of them?

    • Very good advice, Susan. No one wants to have an activity that ends up as a featured story in the NYT, WSJ, etc. (Sigh…because those stories are ALWAYS negative. Maybe someday someone will be able to say, “Hey! My activity was featured in the NYT!” and they’ll have a smile on their face…)

  4. Derek, good points!

    I think the most persuasive argument you presented was in the self-study, because I don’t think the ACCME FAQs are clear- they only mention meals or social events- regardless of whether or not they are paid for by commercial support. Like Susan said- it’s vacation vs. education.

    It might be that it has been beat into my head for years, but I know the SCS apply regardless of whether or not you accept CS for the activity…even if I can’t find that statement explicitly in writing.

    As of right now, the ACCME does not (and probably can’t) do a financial audits of an activity to see where the money came from. Providers have to give an “income and expense statement for the activity, including the receipt and expenditure of commercial support” in each activity file, but that’s self-created. Providers could, in reality, doctor (HA!) their books to move commercial support from one activity to another. (I should note that I am not in any way, shape or form advocating that practice, I’m just a cynic). I also think it’s unlikely that a surveyor or the ARC sit down with a calculator or look up hotel prices to see if what you presented as evidence for income and expenses is actually true.

    I think you could only reasonably skip that step in the self-study if you didn’t accept commercial support at all…although then I (if I was a surveyor) would still wonder where the money came from to pay for the cruise. Previous exhibit or advertising fees? Separate from commercial support…but still money from a commercial interest. That is another possibility- if you don’t accept commercial support for this cruise activity, do you allow for advertising? You don’t need advertising agreements, but that could generate a LOT of money and create bias.

    I guess nowhere does it say that the SCS are optional (although the ACCME makes it clear that if you want to be accredited, you have to follow ALL the rules). And frankly, if you can offer a cruise ship activity, money is probably coming from somewhere.

    My Friday funny-

    Cruise ship CME smells fishy.

  5. Pingback: Cruising for trouble? | Capsules

  6. I’m frequently very critical of commercially supported CME and other industry activities and I have no problem whatsoever with the concept of CME on cruise ships, or luxury hotels, or at ski resorts, as long as the doctors are paying their own way and there is no other industry support. In fact, I suppose this might serve as an excellent example of the type of creativity that might be unleashed if commercial support really would be removed from CME. Interesting thought…

    • Thanks for your feedback and perspective, Larry. I’m still a bit on the fence about the issue of Cruise CME, but the focus on entertainment over education does concern me. My preference would be for the bulk of the CME community’s “creative efforts” be geared towards learning formats and instructional design.

  7. I have not read the entire thread, but having just perused cruise cme websites, I found your discussions interesting. The first and only concern of a CME activity should be quality of content. I am fed up with talk of commercial bias. Underwriting of CME content is an apparently easy thing to do. I could care less. i do care if I pay $600 for a 2-3 day course that has lecturers who do not know their head from their arse, have poor or incorrect content, is in a dinky hotel charging $150 a night with a crappy breakfast and a view of the parking lot. This happens alot! As much and as hard as health proffessionals work, they should be allowed to learn any damn place they like. Novel and great ideas the cruise line’s are employing. Perhaps we could use them in our offices? 10 minute massage while you wait?

  8. Elizabeth Hebl, MD

    In today’s world of avoiding bias- one need only look at the funding of the course and the disclosures of the professors. The location only matters if someone is watching with their noses in the air. I have always only attended only hard core conferences sponsored by academic societies. But employed physicians only get a limited amount of vacation time- often vacation and CME time is lumped into one. So, why not allow your children and spouse enjoy the cruise ship while you study in an enclosed sea sickening conference room? Then in the evening you can join your family. Long gone are the days of endless allowable CME days off and endless funding for them. Now, we need to chose carefully- for content, expense, bias, and family friendliness. The cruise lines are willing to offer this- it seems like the watchers ought stay out. Maybe those doing a sniff test should open a course book, see what we are learning and realize that it is for the public’s benefit that their clinicians are both educated AND well rested.

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