AMA Delegates Vote on Range of Ethical, Advocacy Issues

It's official: The Academy now has specific ethical guidance on financial relationships with members of the pharmaceutical/biotechnology/medical device industry that support physician CME. This, after the AMA House of Delegates gave a final thumbs-up to a new ethical opinion from the AMA Council on Ethical and Judicial Affairs, or CEJA, during the 2011 interim meeting of the AMA house, Nov. 12-15 in New Orleans.

According to the AAFP Bylaws, any ethical guidance that becomes part of the AMA Principles of Medical Ethics also becomes the Academy's ethical stance on that issue unless countermanded by a two-thirds vote of the Congress of Delegates.

"Financial Relationships With Industry in Continuing Medical Education" (pp.14-15 of 31-page PDF; About PDFs) provides ethical guidance for physicians with respect to industry support for CME. The guidance aims to promote public trust by ensuring the independence and integrity of continuing professional education activities in which physicians engage.

The measure has followed a long, eventful path since its first iteration as a CEJA report in 2008. No fewer than five CEJA reports on this topic have been debated and voted on by AMA delegates, including the AAFP's delegation to the AMA.

During the interim meeting, AAFP Board Chair Roland Goertz, M.D., M.B.A., of Waco, Texas, expressed disappointment that the CEJA opinion retained specific wording to which the Academy had previously objected. The statement Goertz took issue with: "When possible, CME should be provided without (industry funding or in-kind) support or the participation of individuals who have financial interests in the educational subject matter."

Such language, he said, implies that industry support of properly accredited CME is categorically prejudicial, and he recommended that the AMA house ask the council to reconsider the CEJA opinion.

Given that the CME accreditation process includes meeting the Accreditation Council for Continuing Medical Education, or ACCME, Standards for Commercial Support, which impose well-defined restrictions on how industry interacts with the CME enterprise, as well as additional guidance adopted by the Council of Medical Specialties, or CMSS, "The AAFP does not believe that industry support of properly accredited CME is inherently bad as the opinion still implies," Goertz said in testimony before the AMA Reference Committee on Amendments to Constitution and Bylaws.

"We believe that with the ACCME and CMSS safeguards that clearly separate promotion (of industry products) from education (about these products), both the profession and the public are well served by this support."

Ultimately, however, delegates supported the CEJA opinion, voting that it be formally filed and added to the AMA Principles of Medical Ethics.

A second medical ethics measure AMA delegates considered involved physicians' dual role as both patient caregivers and stewards of health care resources. CEJA Report 1 (pp. 23-30 of 38-page PDF; About PDFs) aims to offer guidance to support physicians in making fair, prudent and cost-conscious health care decisions that meet the needs of individual patients while also helping to ensure availability of health care for others.

According to this report," Physicians' primary ethical obligation is to promote the well-being of individual patients." However, the report acknowledged, "Physicians also have long-recognized responsibilities to patients in general, to promote public health and access to care for all patients," responsibilities that require physicians to be prudent stewards of shared health care resources.

Testimony to the Reference Committee on Constitution and Bylaws reflected the complexity of balancing these two goals. Some recommendations contained in the report, such as ensuring that individual care decisions are based firmly on patients' medical needs and clearly articulated care goals and using scientifically grounded evidence to inform care decisions whenever possible, seemed straightforward and self-evident.

Others, however, such as ensuring physician education informs doctors about health care costs and how their behavior can affect overall health care spending, raised questions among those who testified on the issue. How much education would be needed to fulfill this obligation? At what point during the education continuum should it be provided? And who would be responsible for seeing that the condition was met?

Recognizing the need to resolve these and other sticking points, the reference committee recommended the report be referred for further consideration, and the delegates agreed.

The AMA house also took up a third ethical measure similar in scope to a resolution the 2011 AAFP Congress of Delegates considered in September.

In this case, AMA delegates called for (pp. 5-6 of 16-page PDF; About PDFs) "any entity offering crisis pregnancy services" to fully disclose the types of medical services (including contraceptive and pregnancy termination services) it offers or provides referrals for, as well as adoption-related services it offers or provides referrals for, "before any such services are provided." Furthermore, centers providing these types of services should be duly licensed to do so, should have appropriately qualified health care personnel on hand and should abide by federal health information privacy statutes.

AMA delegates also voted on two other topics the AAFP had previously tackled. The first of these items was a resolution directing the AMA to oppose any law restricting the right of physicians to discuss gun safety with their patients. In this case, AMA delegates adopted the measure (pp. 4-5 of 37-page PDF; About PDFs), mirroring actions taken by the Academy, which among other things, resulted in the adoption of a new policy decrying any interference in the free exchange of information between physician and patient and an outreach to the National Rifle Association.

Regarding the second item, AMA delegates diverged from the course taken by the Academy by calling for the AMA to "vigorously work to stop the implementation of ICD-10" (pp. 24-25 of 37-page PDF; About PDFs). According to Joseph Zebley III, M.D., of Baltimore, chair of the AAFP delegation to the AMA, "The AAFP was the lone voice in opposition at the reference committee; our argument was that the AMA should work to help physicians implement the new coding system in the most efficient and least costly way possible, but not engage in a futile attempt to stop it, as ICD-10 will be implemented in the near future."

The AAFP has, in fact, been addressing this issue since 2008. At that time, the Academy clearly outlined its opposition to adoption of the new ICD-10 codes sets, which would expand the number of codes from 14,000 to more than 69,000. Although CMS has since persisted in its plan to implement the new codes, the agency did bow to pressure to delay the rollout until October 2013.

Since then, the AAFP has focused on easing the transition by developing multiple resources to help Academy members make the switch.