Bias in CME: Your Perception Is Not My Reality

So I kind of missed out on the whole “OMG!-Doctors-think-commercially-supported-CME-activities-might-be-biased-but-would-rather-have-a-free-cup-of-$8-coffee-than-pay-for-it-themselves-what-a-bunch-of-jerks” (I’m paraphrasing) outrage that came up a few weeks ago, since I was on my little social media vacation during its peak, but I do have a theory about it that I’d like to try out (timely as ever, Derek. Nice work…)

If you’re unfamiliar with the study about the potential for bias in commercially supported CME printed in the Archives of Internal Medicine in May, you can read a little summary of it here.

I’m not interested in getting into the “perceived potential bias” vs “actual bias” argument – which is a good one and one Tom Sullivan wrote about extensively here – but would rather take a look at two commonly held beliefs which were supported by data from this AIM study and then postulate my own theory.

Here are the two beliefs supported by the study:
1) A CME activity with multiple funders has less potential to be biased than a CME activity with a single funder. Both of these have more potential to be biased than an activity with no funding from industry.
2) The greater the percentage of an activity’s overall costs covered by a single commercial supporter, the more potential it has to be biased.

And here is my theory: the number of commercial supporters and amount or percentage of commercial support has little impact on the potential for bias.

I got myself into a little hot water awhile back for using the phrase “I’m going to let you in on a little secret.” Throwing caution to the wind…I’m going to let you in on a little secret: CME providers don’t talk to commercial supporters about content. We don’t talk to them about speakers. We write our own needs assessments. We write our own learning objectives. We develop the content ourselves and pick our own speakers. There could be one commercial supporter or twenty commercial supporters; the content is still going to be the same.

Why? The ACCME. Scoff all you want, but it’s true. Any financial gain that might be earned by slanting a CME activity to appeal to a single funder is not worth the risk of losing your organization’s ACCME accreditation. That seems to be a point that gets lost whenever discussions of CME and the inadequacy of the ACCME are brought up. No, there are not a lot of organizations that have lost their accreditation status, but there doesn’t have to be. Just having one is enough to put the fear of God (or Murray Kopelow) into the hearts of any accredited organization.

Look, there certainly are challenges involved in putting together a balanced, unbiased CME program, and there are elements involved that could increase the potential for bias. Working with 3rd party organizations or faculty unfamiliar with the ACCME’s Standards for Commercial Support is one example. I have worked on programs in the past that were primarily funded by participant registration fees and were much more challenging in terms of bias and balance than programs entirely funded by commercial support. But then, that’s why people like me have a job: to teach those who don’t understand the standards involved in producing CME and assure its balance and validity.

My main point is this: the potential for bias in CME due to the presence of commercial support is vastly overrated by those not intimately involved in the production of CME on a day-to-day basis. The perceptions revealed by this study are not congruent with my reality as a CME Director.

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6 responses to “Bias in CME: Your Perception Is Not My Reality

  1. Pingback: Best response yet to the study about docs and bias | Capsules

  2. Nice post but there’s one major hole in your argument: the CME providers don’t need to talk to the supporters to do their bidding. As long as they know who’s paying the bills they will do everything they can to continue getting support. It’s a basic evolutionary principle.

    How about this modest proposal: perhaps the CME industry will agree to produce CME content by providers who are completely blinded to the source of funding?

    • Thanks for your comments, Larry. As I mentioned above, the scenario you present in your first paragraph is not the reality of the environment in which I work. We do not do “the bidding” of commercial supporters as you suggest; we can’t. We would get roasted by the ACCME if this was how we did business. Yes, we have evolved to survive, but differently than you may think. We have evolved to produce needs assessments based on gaps in performance and patient care, rather than submitting two references from a lit search and saying “good enough”. We are evolving to produce outcomes that show how CME is impacting knowledge, competence, performance, and patient care (still a work in progress.) We are NOT evolving by attempting to produce more and more materials slanted toward a particular company.

  3. I do not doubt your sincerity but I think you are fooling yourself. And if you really think industry support does not have an impact on content then you would accept my proposition to keep all content providers blinded to the source of support.

    ACCME, alas, is a paper tiger and a tool of industry. They require you (the CME providers) to jump through a whole lot of hoops to provide the appearance of independence, but ignore the 800 lb gorilla in the room, which is that industry spends a billion dollars a year to support CME in order to sell their products.

    It is preposterous to propose that only the tiniest proportion of CME providers and programs are problematic. Every year the ACCME disciplines only a handful of providers, and yet I can walk the halls of any large hotel during a major medical meeting, or go online, and find dozens of examples of programs that serve as obvious examples of commercially-influenced education.

    • Hey, we agree on one point; the ACCME certainly does make their providers jump through a lot of hoops!

      As for your proposal about being blinded to the funders, I don’t think I fully understand your concept, but…sure. Most providers just want an equal opportunity to get their programs funded. You obviously don’t believe this, but the needs assessments, objectives, faculty, content, etc that we as providers create for certified CME activities are not dependent on who is funding it. Being blind to the funders wouldn’t make much difference. Sorry, but that is my experience working in this field on a daily basis. We’ll just have to agree to disagree on this one.

  4. Yes, we’ll have to agree to disagree, but I’ll make just one more point: if the funding doesn’t matter and has no impact on the content, how come doctors and other observers familiar with a field can nearly instantly identify the sponsor of a CME program based on only a cursory look at the program? See my story on this topic a few years ago: http://cardiobrief.org/2009/11/08/play-the-cme-game-at-home-or-at-the-aha/

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