AMA Adopts Measure Guiding Physicians on Industry Support of CME

The fifth time's the charm. At least, it was at this year's annual meeting of the AMA House of Delegates, June 18-22 here, when delegates finally adopted recommendations contained in an AMA Council on Ethical and Judicial Affairs, or CEJA, report that provides ethical guidance for physicians regarding pharmaceutical/medical device industry support of CME activities.

Testimony before the AMA's Reference Committee on Amendments to Constitution and Bylaws on June 19 clearly reflected the divide that has continued to dog this CEJA report (pp. 91-104 of 158-page PDF; About PDFs) since its first iteration in 2008.

AAFP President Roland Goertz, M.D., M.B.A., of Waco, Texas, was among the first to speak in favor of adopting the latest version of the report, which one delegate jokingly dubbed "CEJA 5.0." In his comments, Goertz noted that the AAFP both provides and accredits CME and, therefore, strictly adheres to the Accreditation Council for Continuing Medical Education, or ACCME, Standards for Commercial Support (3-page PDF; About PDFs), which seek to ensure the independence of CME activities for which industry support is accepted.

"The current iteration of the CEJA report has largely addressed the concerns of our delegation by dealing with the relationship between industry and individual physicians rather than the relationship between industry and organizations that provide CME," said Goertz.

"We have long endorsed the guidelines promulgated by CEJA that describe what is proper and improper in relationships between individual physicians and industry. These relationships do need CEJA guidance because there is no organization that is accountable, as there is in the case of the CME provider organizations that comply with the ACCME Standards."

Goertz noted, however, "The AAFP does not believe that industry support of properly accredited CME is as inherently bad as the report still implies in a few instances." He suggested that phrases, such as "When possible, CME should be provided without such support," be removed from the report should it be codified as a "CEJA Opinion" and become part of the AMA's Principles of Medical Ethics. (According to the AAFP Bylaws, the AMA's medical ethics principles become the medical ethics principles of the Academy, absent action by the AAFP Congress of Delegates.)

The phrases Goertz was referring to appear in the report's recommendations, which say "CME that is independent of funding or in-kind support from sources that have financial interests in physicians' recommendations promotes confidence in the independence and integrity of professional education, as does CME in which organizers, teachers, and others involved in educating physicians do not have financial relationships with industry that could influence their participation.

"When possible, CME should be provided without such support or the participation of individuals who have financial interests in the educational subject matter."

The implication that industry support of CME is innately prejudicial also drove the Council of Medical Specialty Societies, or CMSS, to oppose adoption of the measure. CMSS EVP and CEO Norman Kahn, M.D., testified that his organization could not support the persistent CEJA position that commercial support of CME is unethical and should be avoided.

The AAFP-endorsed CMSS Code for Interactions with Companies (29-page PDF; About PDFs) considers commercial influence unacceptable, said Kahn. But it is important that medical professionals and other health care entities work together to improve patient care. That is why the CMSS Code lays out guidelines for maintaining appropriate relationships between the two. "Industry influence of CME is unethical," said Kahn during his testimony. "Industry support is not."

In answer to calls for referral of the report for further CEJA consideration, however, William Holt, M.D., a delegate from the American Academy of Orthopaedic Surgeons, noted that his delegation felt council members had, by and large, listened and responded to previous concerns about the report, although some minor issues remained. But, he added, "We do not feel it's going to get better if it goes back (to CEJA), and therefore, we support it."

Internist David Downs, M.D., an alternate delegate from the Colorado Medical Society, also testified in support of adopting the measure, advising his colleagues to not let the perfect be the enemy of the good.

In its report (page 12 of 18-page PDF; About PDFs), however, the reference committee agreed with those calling for referral of the report and its recommendations, prompting yet more discussion of the measure on the floor of the AMA house on June 20.

AAFP Board Chair Lori Heim, M.D., of Vass, N.C., spoke for the Academy at that point, urging delegates to adopt the report's recommendations. "It's time for the AMA to have policy on this issue," she said.

Ultimately, the reference committee's recommendation to refer was rejected, and, as others joined the push for adoption, delegates finally put the matter to rest in a 285-191 vote to adopt the measure.