1 Boring Old Man

Medicine is not a static science. So medical training is just a launching pad for the process of life-long learning. I guess that’s why we call it "practice" [no one seems to question why we also call the people we see "patients"]. The main place where that ongoing learning takes place is in seeing patients in our practices. Since Medicine is way to vast for anyone to ever master, the idea is for a doctor to learn how to tell when [s]he doesn’t know what [s]he’s doing and how to look it up. My own favorite way to learn has been to teach. That may seem backwards, but the questions and challenges of students really keep us on our toes – so physicians donating their time to teach make up the bulk of medical education in medical schools – the "volunteer faculty."  In my own discipline, Psychoanalysis [which now includes other mental health professionals], it’s 100% donated didactic teaching time.

But for many physicians, particularly those in more rural areas, access to continuing medical education is harder to come by, and so for the last forty or fifty years, Continuing Medical Education credits have been required for ongoing licensure. In Georgia, the requirement is twenty hours yearly. Some CME credit is given for donated time like teaching or volunteering in a free clinic – up to 10 hours of this kind of CME per year. Traditionally, CME programs are provided by Professional Organizations and Medical Schools, but there are increasingly companies who put on CME programs for profit, so there are accrediting agencies to insure the quality of the educational experience. Obviously, CME means very different things for different specialties.

All of this sounds pretty good. Who wants a doctor who is running on ancient knowledge? But there’s another way to look at it. This system assumes that Physicians wouldn’t "keep up" on their own. All professions change over time, and any professional is expected to grow as the knowledge base expands. Lawyers need to know about new laws. Engineers need to know about new materials. All of us had to learn how to use computers and the Internet, etc. As a matter of fact, the Internet is becoming a powerful tool in ongoing learning for all of us. It’s kind of like the ancient library of Alexandria [except it’s fireproof].

In my specialty, I’m not so sure C.M.E. has been a good thing – at least it has its drawbacks. A lot of this business you’ve been seeing here about Dr. Nemeroff is simply the tip of an iceberg – the invasion of CME by the PHARMA Industry. In days of old, the pharmaceutical industry representatives were always around. When I started medical school, Eli Lilly handed out Doctor bags with a stethoscope, a reflex hammer, and a tuning fork. I didn’t buy a fancy stethoscope until I was an Internal Medicine Resident [I never bought a reflex hammer or a tuning fork]. Notepads, pens, little gadgets like plastic knee joints or rubber brains have always been abundant – duly labeled with the name of the company. I never gave it much thought – just like I don’t much think about cereal ads on television. They may get me to buy the first box, but after that – it’s the cereal that matters, not the ad.

So the problem with CME that’s being debated isn’t about advertising – that’s just the way business works. The problem is secret advertising – business interests disguised as science. And it’s worth billions of dollars in profits to pharmaceutical companies to invest millions of dollars into CME presentations to Psychiatrists. So the pharmaceutical industry [PHARMA] has poured money into research grants [drug trials], Speaker’s Bureaus, CME program donations, and have been a major force in the move of Psychiatry from an eclectic mixture of techniques into a pharmacology driven "pills for ills" specialty.

In spite of coming late to Psychiatry, I’ve been in the field for half my lifetime. When I look back on things and think about my own lifelong learning, most of what I’ve learned has come from the patients I’ve seen and treated [I thank them for their patience]. I would put as tied for second my colleagues/students and the psychiatric literature. How much has come from formal CME presentations? Almost none. I personally think the CME system as it is currently delivered with heavy funding from industry is, in fact, a detrimental force in Psychiatry. I’d rather have a few free pens, colorful notepads, and some rubber brains than a lecture from a paid drug shill like Dr. Nemeroff and his ilk. I know that those doo-dads are just that – tchotchkes. They’re much more useful than scientifically biased propaganda.