Is continuing medical education a drug-promotion tool?

The College of Family Physicians of Canada (CFPC) has been accrediting continuing medical education (CME) programs for several decades. Since the inception of our Maintenance of Proficiency (Mainpro^®) accreditation system in 1998, our CME and continuing professional development (CPD) standards have undergone a steady and continuous process of rigorous upgrading, revision, and improvement.

For family physicians to obtain and maintain their designations with the College, they must comply with the very detailed and strict regulations governing the many components of Mainpro. Similarly, CME and CPD organizations, including pharmaceutical companies, must adhere to fastidious criteria in order to have their programs recognized and accredited by the College.

Accreditation

The CFPC accredits programs rather than providers. Granting of accreditation is restricted to the College (and its Chapters) and university CME offices. We do not have for-profit accredited CME and CPD providers in Canada.

Every CME and CPD program seeking accreditation from the College must have at least 1 CFPC member on its planning committee right from the initiation of the design of the program. The CFPC member is responsible for ensuring “quality control” of the program and maintaining the standards of the College. National programs must have CFPC representatives from each of our 5 national regions on their planning committees.

All CME and CPD program applications are subjected to a rigorous review by up to 3 experienced, CFPC-trained reviewers, who check programs specifically for balance, lack of bias, and lack of overt commercial support. There must be objective evidence confirming the need for the educational intervention, and budgets must be submitted for review. Conflicts of interest must be declared. The content of all commercially sponsored programs is submitted for peer review. In some cases, specialist content experts are also consulted.

After initial review and approval, each time a CME and CPD program is conducted, further details must be submitted for ethical review before the program is finally accredited. This review includes assessment of the appropriateness of venue, speakers, invitations, media releases, and honoraria.

Upon conclusion of all CME and CPD programs, attendees are asked to complete evaluations. These evaluations must include a question asking attendees whether they perceived any bias in the program. The CFPC is developing processes for auditing these responses. We are also developing a new tool to detect and measure bias that will be used in the accreditation review and program audit.

In addition, the College is in the process of developing a policy of cosponsorship wherein programs will no longer be submitted by individual companies, but rather by physician organizations. These organizations will be responsible for quality control as well as for payment of all expenses associated with CME and CPD programs. Many other new safeguards are also in development.

Not foolproof

While the CFPC has accredited CME programs for many decades, we know that our landscape has changed dramatically in the last 10 years. All CME and CPD programs accredited by the College are unquestionably balanced, free of bias, and not being used by pharmaceutical companies to market their products.

That is not to say that there are not companies who do, or try to, abuse or misuse our Mainpro process for their own ends. No system is completely foolproof so that those “in the know” cannot get around it. The College, however, prides itself on the experience and acumen of its reviewers and has confidence that they will “catch” those who try to misuse our system.

Additional measures

In addition to the measures put in place by the College, the Canadian Medical Association in 2001 established guidelines for “Physicians and the Pharmaceutical Industry.”¹ These guidelines clearly defined the distinction between CME or CPD activities and promotion and included guidelines related to sponsorship, advisory boards, samples, gifts, and relations with medical students and residents.

Industry itself, led by Canada’s Research-Based Pharmaceutical Companies, established a strict code of conduct.² The latest edition of this code of conduct became effective in July 2007 and features financial penalties and public censure for those who violate the code.

We believe these measures can and will prevent our accredited CME and CPD programs from being used for marketing³ in the manner described by Steinman.

CLOSING ARGUMENTS

• Industry practices in relation to continuing medical education and continuing professional development have changed dramatically in the last 10 years.

• Accrediting bodies, such as the College of Family Physicians of Canada, have introduced measures in their accreditation standards that prevent promotion in accredited educational activities.

• Physician organizations and industry leaders have established guidelines and codes that have been adopted widely and that clearly define the relationship between industry and physicians. These guidelines and codes ensure that accredited medical education and continuing professional development programs are balanced and unbiased.