CEJA Report on Industry Funding of CME Needs More Study, Say AMA Delegates

An AAFP-supported report aimed at guiding physician-learners and CME providers in managing their relationships with industry got as far as being recommended for adoption by the 2009 AMA House of Delegates here. But in the end, delegates referred the report for more study, citing concerns that it needed added clarity and further refinement.

The report, "Financial Relationships with Industry in Continuing Medical Education," was developed by the AMA Council on Ethical and Judicial Affairs, or CEJA, to provide "an ethical framework to guide professional practice with respect to financial relationships in the context of continuing medical education." AAFP member Regina Benjamin, M.D., of Bayou La Batre, Ala., chairs the council.

In testimony before an AMA reference committee on June 14, AAFP President Ted Epperly, M.D., of Boise, Idaho, praised the report and thanked CEJA for listening and responding to the Academy's concerns about an earlier draft of the document. He said the AAFP agrees that potential conflicts of interest stemming from commercial support of CME must be managed in a manner that

"It is essential that we demonstrate our commitment to uphold ethical values and to exercise professional judgment in our various roles as physician educators and lifelong learners," he said.

In his testimony, Epperly also complimented what he termed a "well-crafted" companion report from the AMA Council on Medical Education, saying that it should be "carefully considered by CEJA as a practical interpretation of the CEJA report and as a guide to its implementation."

The medical profession's "autonomy and authority to regulate itself depend on (the profession's) ability to ensure that physicians acquire, maintain and apply the values, knowledge, skills, and judgment essential for quality patient care," says the CEJA report. It recommends safeguarding the independence and integrity of CME activities by categorizing them as either "ethically preferable" or "ethically permissible."

For CME to be considered ethically preferable, according to the CEJA report, CME providers would accept funding only from sources that have no direct financial interest in physicians' clinical recommendations. In addition, those involved in CME would have no current, recent or potential financial interest in the educational subject matter and would not be currently or recently involved in a compensated relationship with a commercial entity that did have such an interest.

Ethically permissible CME, on the other hand, would allow CME providers to accept funding from industry sources if

Also ethically permissible, according to the report, would be involvement of individuals with "modest financial interests if the nature and magnitude of those interests are disclosed and steps are taken to eliminate or mitigate the potential influence of those interests."

"In rare circumstances," the report adds, "CME providers may permit involvement of a uniquely qualified expert who has a direct, substantial, unavoidable financial interest if the nature and magnitude of the specific interest are clearly disclosed; there is a demonstrated, compelling need for the specific CME activity in the professional community that cannot otherwise be met; and steps are taken to mitigate the potential influence of the unavoidable financial interest to the greatest extent possible."

Other speakers who addressed the reference committee joined Epperly in praising the reports as moving in the right direction, but a number of them expressed uncertainty about some of the terms used throughout the CEJA report.

Ralph Hale, M.D., EVP of the American College of Obstetricians and Gynecologists, or ACOG, said the reports represented an improvement compared with previous efforts to resolve the ethical issues surrounding industry support of CME, but he said he still had concerns about the distinctions between what the CEJA report termed "permissible" and what it called "preferable."

Troy Tippett, M.D., president-elect of the American Association of Neurological Surgeons, called the report "almost ready for prime time, but not quite," and joined those calling for the report to be sent back to CEJA for more fine-tuning.

At his association's annual meeting, Tippett testified, two-thirds of funding support comes from industry. Such support is sorely needed, he said, because otherwise, the cost to association members would be too great.

Internist Richard Frankenstein, M.D., a pulmonary medicine specialist who is the immediate past president of the California Medical Association, took up that very issue, testifying that physician-learners need to take more responsibility for their CME. He pointed out that although physicians' values often are rooted in altruism, industry is responsible to shareholders and, therefore, likely would not fund CME in the absence of a "pecuniary benefit."

"This is the beginning of the journey," Frankenstein said. "We need to pursue the resources to provide our own CME."

Dale Moquist, M.D., of Houston, chair of the AAFP delegation to the AMA, summarized the qualms that ultimately led the delegates to refer the CEJA report. "Many of the people testifying against adoption were very uncomfortable with the terms 'ethically preferable' and 'ethically permissible.' These were new terms that CEJA has never used before," he told AAFP News Now.

In particular, Moquist said, "Some of the members felt that using the term ethically permissible made those activities less ethical." The lesson here, he added, is that these terms likely should be avoided in the next iteration of the report.