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Wednesday, June 24, 2009

Equity and Balance in CE Funding

In another post, I suggested that those of us in the field of continuing professional development might do well to look at five other kinds of bias and not just the bias that can be introduced as a consequence of commercial support for a CE activity. In this post I want to suggest a broader perspective on the funding of CME.

I don't think it is necessary to limit the debate about CME funding to the two extreme options most frequently advanced of late: either accepting or not accepting commercial support. I think there are certainly other, more reasonable and more equitable formulas and systems for funding CME/CPD activities that we could, in good conscience, work to bring about?

Equity - For one thing, I think it is time that we consider supporting a more “equitable" fee structure for those participating in formal continuing professional development activities in the field of healthcare. At the moment, physicians are asked to pay lower fees (or no fees) for most of their continuing education activities when compared with the fees other healthcare professionals are asked to pay for activities of similar duration. This in spite of the fact that physicians are much better compensated than others in healthcare. It is universally understood that this is a direct consequence of the high level of resources made available by commercial firms for activities provided to those wielding the "prescribing pen."

Wouldn't it be fairer and create some much needed leverage of a sort useful in beginning to alter the funding mix for healthcare continuing professional development activities, generally, if physicians were asked to pay at least as much as their colleagues for comparable activities. Physicians should expect to pay a reasonable fee that relates realistically to the total costs incurred by the sponsoring organization to provide the activity. To the extent that commercial funds and/or other funds are made available to support continuing professional development activities, these should be pooled and expended in such a way as to subsidize and thus lower the fees charged for all such activities in a given geographical region or organizational setting.

Better Balance - I have a second suggestion to be combined with the first. It would further reduce the impact of commercial support on CPD activities. And it would keep the cost of continuing education modest (thereby preventing cost from becoming a barrier to participation by any group of healthcare providers).

I propose we seriously consider recommending that support for all such activities would come from three approximately equal sources: 1/3 from participating healthcare professionals, 1/3 from public and/or non-profit sources and 1/3 from pharmaceutical and/or device manufacturing sources. We should explicitly limiting commercial support to something like one-third of total activity costs. This type of limitation would ideally be applied on a program-by-program basis. Less desirable would be applying it to the programmatic portion of a CE provider’s entire annual budget.

Asking both physicians and the government to pay their fair share of the cost of healthcare CE, right along side commercial entities, seems like an especially appropriate suggestion at this particular moment, when we are doing our best to piece together a major package of healthcare reforms here in the USA.

Saturday, June 6, 2009

6 Kinds of Bias in CME/CPD

This post is one of a series of posts adapted
from an article published in the newsletter of the
Association for
Hospital Medical Education, Summer, 2006.

Three years ago, there was a discussion concerning “CME
Plus” on the listserve of the Society for Academic CME.
What was being proposed was a special designation for
CME activities put together without any commercial
support. Since then there has been a good deal of heated
discussion about commercial support and whether or
not medical schools, among others, should accept any
commercial support whatsoever for the continuing
medical education activities they sponsor.

That discussion left me thinking that there is a good
deal more we should be talking about besides
commercial support if those of us involved in supporting
the continuing professional development of
healthcare professionals truly wish to reinvent our

What I talked about when this piece was first published
seems more relevant than ever, today. So what follows
is an example of how I think we might broaden and
deepen such discussions, and question some long held

There are five additional, potential sources of bias that
need to be monitored by CPD professionals and
accrediting bodies if we intend to get serious about
reducing bias in continuing medical education /
continuing professional development activities.

[In future posts I'll get into a couple of CME/CPD funding
issues (equity and better balance), point out the need
to better distinguish the difference between practice
improvement initiatives and clinical research
(attempts to help providers meet or exceed
the current standard of care vs. initiatives that
attempt to alter the current standard of care), and
say something about the problem with trying to
move gradually from time-based credit to a system
of performance-based assessment.]

Let's take a closer look at concern about bias. What I
would very much like to know is this: Why is the
potential influence of commercial support the only kind
of bias we seem to care about and monitor? Isn't it obvious
that we are ignoring several other important potential
sources of bias?

• Clinical bias is the tendency of some instructional
faculty to make certain recommendations out of
habit more than anything else. This is less work than
wading through conflicting studies that attempt to
assess new approaches which may or may not prove
to be better than “what we’ve always done.”

• Researcher bias is the tendency of some
instructional faculty to see their area of research
expertise under every rock.

• Treatment bias is reflected, for example, in the
disproportionate emphasis on medication-based
modalities in CME/CPD activities, generally. Many
would argue that this is an appropriate focus.
But shouldn’t we find a way to support more
balanced representation of pharm and non-pharm
approaches to clinical care when the prevailing
standard of care encourages application of
multifaceted (often multidisciplinary) treatment
strategies for so very many conditions, and when
new evidence strongly suggests that consideration
be given to effective nonpharmaceutical and/or
complementary approaches to treating patients
with given conditions? If this is so, we
should begin to regularly ask instructional faculty if
they have adequately considered and included nonpharm
modalities and not just medications, devices and/or
surgical procedures.

• Reimbursement bias is catering, implicitly, to
prevailing patterns of reimbursement when they are
at variance with evidence-based best practices and/
or powerful cost-benefit considerations.

• Research methodological bias (possibly better
termed ‘disciplinary norm bias’) might be inherent,
for example, in the widespread practice of basing
clinical recommendations on short term trials
wherein a new medication is only compared with
a placebo and not also required to go head to
head with existing, well established alternatives.
Should we consider encouraging a much higher
evidence rating for therapeutic approaches when
the evidence of their effectiveness is based both
on comparisons with placebo and on comparisons
with competing alternatives, when these exist?
Aren’t we uncomfortable with the idea that so many
decisions at the moment, are made at every level of
the healthcare system (from PCP to the FDA), on
the basis that something new is apparently better, if
only marginally yet statistically better, than nothing?

Well that's it. What about all these other kinds of bias?
What do you think?

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