Within 24 months, all of the stakeholders involved in continuing medical
education (CME) should come up with proposals for reforming the system by
which CME is funded, according to the Institute of Medicine.
A new system for funding accredited CME should be developed that is"
free of industry influence, enhances public trust in the integrity of
the system, and provides high-quality education," the IOM stated in a
300-page report released in late April.
The recommendation was one of 16 addressing industry relationships in all
areas of medicine. Also included were recommendations that organizations
involved in the development of practice guidelines or diagnostic manuals be
free of industry influence and have policies in place for transparent
disclosure of potential conflicts.
The IOM report, "Conflicts of Interest in Medical Research,
Education, and Practice," is the latest in a succession of responses to
the tide of public and congressional interest in pharmaceutical and
device-manufacturing company influence over American medicine.
In April leaders of professional medical associations—including APA
Medical Director James H. Scully Jr., M.D.—issued recommendations for
elimination of industry influence in activities of such associations. Those
recommendations appeared in the April 1 Journal of the American Medical
Association (Psychiatric News, May 1).
The IOM is prestigious, and because it reports to Congress, its
recommendations can be especially consequential. "This is another
important step to developing a new paradigm in how medicine and the
pharmaceutical and medical-device industries will relate," Scully told
Psychiatric News. "It's very similar to the JAMA
article and other recommendations, but the IOM report relates to all of
medicine and is much more extensive."
Scully also emphasized that regarding the recommendations that most
directly affect APA, the Association is ahead of the game.
"The recommendation for associations to work with all the stakeholder
organizations in CME to revise standards within 24 months probably has the
greatest direct impact on APA, although less than other societies because of
actions we have already taken such as phasing out industry-sponsored symposia
at our annual meetings," he said.
The IOM recommends that Congress require pharmaceutical, biotechnology, and
device firms to report through a public Web site the payments made to doctors,
researchers, academic health centers, professional societies, patient advocacy
groups, and others involved in medicine. And it calls on researchers, medical
school faculty, and private-practice doctors to forgo gifts of any amount from
medical companies and to decline to publish or present material ghostwritten
or otherwise controlled by industry.
Consulting arrangements should be limited to legitimate expert services
spelled out in formal contracts and paid for at a fair market rate. Physicians
should limit their interactions with company sales representatives and use
free drug samples only for patients who cannot afford medications. (See
Collaborations Beneficial, but Limits Needed for summary of
"It is time to end a number of long-accepted practices that create
unacceptable conflicts of interest, threaten the integrity of the medical
profession, and erode public trust while providing no meaningful benefits to
patients or society," said Bernard Lo, M.D., chair of the committee that
wrote the report. He is a professor of medicine and director of the program in
medical ethics at the University of California, San Francisco. "We also
need more specific disclosure of the financial relationships that doctors and
researchers have with medical industries. This report spells out a strategy to
protect against financial conflicts while allowing productive relationships
between the medical community and industry that contribute to improved medical
knowledge and care."
In some ways, the IOM report is less stringent than the recommendations
spelled out in the JAMA report by medical association directors and
others. (Those directors, including Scully, were asked to sign on to the
recommendations as individuals, not as representatives of their
organizations.) For instance, the IOM does not recommend that organized
medicine aim for total elimination of industry support.
"In general, the IOM committee ... supports further restrictions on
and oversight of financial associations—but not 'a goal of $0
contributions from industry,' as was recently proposed for professional
medical associations," wrote Robert Steinbrook, M.D., in an editorial in
the April 29 New England Journal of Medicine. "Some of the IOM
recommendations involve prohibitions, such as bans on faculty participation in
companies' speakers bureaus and other promotional activities in which they
'present content directly controlled by industry' and bans on gifts of any
amount from medical companies. In some areas, such as research, the committee
recommends permitting structured involvement in exceptional cases of
physicians who have substantial financial interests in industry but also have
expertise that is deemed essential."
The issue of industry relationships with medicine continues to command the
attention of all sectors of medicine. In April both Harvard Medical School and
Johns Hopkins University School of Medicine issued reports clarifying existing
guidelines and adding new restrictions on how physicians, scientists, and
staff at those institutions may interact with industry.
The IOM report is posted at<www.iom.edu/CMS/3740/47464/65721.aspx>.
The NEJM editorial, "Controlling Conflict of
Interest—Proposals From the Institute of Medicine," is posted at<http://content.nejm.org/cgi/content/full/NEJMp0810200>.
The JAMA article, "Professional Medical Associations and Their
Relationships With Industry: A Proposal for Controlling Conflicts of
Interest," is posted at<http://jama.ama-assn.org/cgi/content/short/301/13/1367>.▪