Within the past 2–3 years, numerous editorials and commentaries have highlighted ongoing problems of postgraduate medical education. Educators are concerned that the content of meetings, symposia, and print material has become too promotional and less scientific.
GRAND ROUNDS AND INDUSTRY SYMPOSIA
For many years, weekly grand rounds at community, regional, and university hospitals were an important component of the medical education of practicing physicians, wherein a local physician was usually invited to discuss a topic. He/she was honored to have been selected to participate and eagerly prepared a presentation. There was pride in being an educator—a sense of responsibility to communicate knowledge. This is now an unusual occurrence. Other than in university medical centers, it has become difficult to get a busy physician to take the time and make the effort to present a case or a subject; grand rounds, which were once a compulsory activity in most institutions, are poorly attended or have been discontinued in many community hospitals. Hospitals that still present weekly rounds are more frequently inviting speakers who are suggested by sponsors; in many cases, these are pharmaceutical companies and the topics are often prespecified. Pressures of the market place have allowed this to happen. The role of product managers has become important in the choice of speakers and topics.
One cause of the change in the approach to postgraduate education is the change in the system of reimbursement. Physicians were once required to work and teach in a clinic or make rounds as part of their “appointment to a hospital staff” requirement. As reimbursement formulae changed, the system changed. Rounds are no longer required except in university centers. Even patient education, certainly a responsibility of a physician, has been relegated to a “reimbursable item” in many areas. Somehow pride and an unbiased and less commercial approach to the dissemination of knowledge must be rekindled; that can be accomplished with some modifications of the present system.
POSSIBLE SOLUTIONS
A preferred approach for future face‐to‐face educational efforts would be that physicians would volunteer their time and expertise; however, this is no longer a reality in most instances. Some source of funding is usually necessary. If funding for outof‐state or out‐of‐city speakers and for symposia as well as lectures at major medical schools is necessary, it should come from sources other than industry—foundations, charitable organizations, or hospitals themselves. Speakers and topics should be chosen by the institution, not the sponsor. We should strive to achieve this approach. Another approach that is less than ideal but perhaps more realistic would be to encourage industry to sponsor educational programs with truly unrestricted, unconditional grants. Some might argue that industry should not be involved at all, but the fact is that this is where funding is available. Continuing medical education (CME) should be structured so that funding has no quid pro quo. Unfortunately, too often a grant is received, the sponsor suggests several speakers, all of whom may be well known and experts in the field; they may also suggest the topics. The director of education then approves the program, which is an easy way to plan the year's activities. Outlines of presentations and slides may even be provided to a local speaker if he/she is chosen. This common practice is not ideal; it is more about subtle or not‐so‐subtle promotion.
How often have you attended grand rounds, heard an excellent update on the treatment of hypertension, and then spent the last 10–15 minutes of the lecture listening to a commercial about a new study highlighting the benefits of drug A over drug B or the benefits of utilizing a new test or procedure that just so happens to be the product of the sponsor? How often is the speaker truly unbiased?
The proliferation of literally thousands of sponsored dinner meetings throughout the country has also changed the face of postgraduate medical education. Small groups of physicians and their wives, husbands, or friends attend a dinner and listen to a 30‐minute talk about a subject (hypertension is a favorite topic). The speaker is usually an out‐oftown expert who often uses a select “slide collection” since it is easier to do this than to spend the time and effort to prepare a balanced presentation. One must place some of the blame for this on the speaker, not on the sponsor. Obviously, industry believes that these relatively expensive meetings for a few physicians are worth the investment.
There are some ongoing programs that have attempted and succeeded in fostering a more ideal industry/physician education relationship. For the past 7 years, a consortium of pharmaceutical companies have been funding a series of hypertension symposia that have been held six or seven times a year in various cities throughout the United States. For 6 years, these programs were sponsored by the National High Blood Pressure Education Program (NHBPEP) and the Hypertension Education Foundation (HEF). Within the past year and a half they have been sponsored by the American Society of Hypertension (ASH) in cooperation with HEF and The Journal of Clinical Hypertension. There has been no input from the sponsors in the choice of place, speakers, or topics. Some product managers have not been happy because specific trials or studies relating to their specific drugs may not have been mentioned as often as they would have liked in the more than 40 symposia held to date. But these symposia represent a win‐win situation for everyone—adequate sponsorship, excellent speakers, and no commercials. CME credits are awarded by ASH, and nonbiased presentations have been acknowledged by participants. Physicians leave the meeting with new knowledge about how to treat hypertension and cardiovascular diseases more effectively. If one of the sponsors happens to market an effective drug for treatment, they will benefit; if more people are treated and more are treated adequately, more medications will be used—“a rising tide will lift all boats.” The pooling of resources from interested parties may be one answer to the short‐of‐ideal funding from foundations, hospitals, etc., for medical education.
Unfortunately, because of limitations by the FDA, fear of litigation, and perhaps reluctance on the part of various companies to commit to funding for a presentation where direct benefit is not apparent, pooling of funds has been less well accepted. Some companies are concerned that if they sponsor meetings and speakers discuss an unapproved use of a product, they will be censored by the FDA. This is just one more factor in the changing climate of postgraduate medical education.
There is a different problem with regard to sponsored symposia at major medical meetings. Physicians who come to a sponsored meeting expect to hear some type of favorable data about the sponsor's product. This is different from attending grand rounds or different types of programs where unbiased material is expected. Oftentimes, good science is presented at these single‐sponsored symposia and the product message is muted but, on some occasions, the speakers tend to say what they believe the sponsors would like to hear.
Perhaps industry has been blamed unfairly for some of these problems. They are expected to present their product, whether it is a medication, diagnostic tool, or instrument, in a favorable light. The responsibility of the scientist/educator is to put the data into perspective, not to act as a salesman. Perhaps too many physician speakers have forgotten this.
Additional issues regarding ongoing education relate to the type of journal articles that physicians are now reading (a subject of another editorial). Increasingly, these papers are being written by science writers employed by an agency for a specific company and not by a physician or group that did the research. Articles are well‐written, with extensive referencing, but the nuances of an experienced researcher are missing.
The bottom line is that all of us must make an ongoing and greater effort to change the face of postgraduate medical education before it becomes one large promotional show.