1 Boring Old Man

Harvard’s Top Neurologist Just Says "No" to Commercial CME
Carlat Blog
September 14, 2010

^{In a piece of extraordinarily good news for those of us promoting industry-free CME, one of Harvard’s top neurologists, Martin Samuels, announced a new company, Lighthouse Learning, that will refuse any commercial funding for continuing medical education courses…}

For physicians, another option on education
^{Classes won’t take drug firms’ money}
The Boston Globe
By Liz Kowalczyk
September 14, 2010

^{But Samuels will not be attending. The class, he said, is not education, but subtle marketing by Teva Neuroscience, a pharmaceutical maker that sells a leading multiple sclerosis drug and, according to the fine print, is paying for the evening. It is just this type of program that led Samuels, a Harvard Medical School neurologist, to start a new company that he says will provide continuing medical education to doctors across the country — without funding from the pharmaceutical industry. "Doctors have lost confidence in [continuing medical education] and the public has lost confidence,’’ said Samuels, who sees patients at Brigham and Women’s Hospital, where he heads the neurology division. “The feeling is that everything is tainted. We simply must have a new way of doing this.’’ The company’s formation will be announced today.}

^{The venture is the latest development in an escalating national debate over the system for educating physicians. States require physicians to take continuing education courses to retain their medical licenses, but doctors often pay little or nothing for the instruction because many of the companies that offer it are partly funded by makers of drugs and medical devices. Samuels himself worked part time for such a company until last year, when he said he decided that commercial support created an unacceptable conflict. Critics say the reliance on industry funding allows drug and device companies to influence what is taught, potentially misleading physicians about the best treatments for patients and pushing up spending on prescription drugs. They note that many other professionals pay for their own continuing education…}

^{The Clinical Psychopharmacology Program at the Massachusetts Mental Health Center conducts several ongoing studies of new and the standard psychotropic drugs in a variety of clinical populations. Most of the research is focused directly on the use of antidepressants in selected populations, with special reference to the elderly and very elderly person. The program also studies anxiety disorders, antianxiety agents, dependence phenomena, and withdrawal. At present, several studies are focusing on the effects antipsychotics and other drugs in the treatment of psychosis, and agitation in the demented elderly nursing home resident.}

^{One particular focus of the research program within the Clinical Psychopharmacology Service of the Massachusetts Mental Health Center is a collaborative effort studying the diagnosis and treatment of depression and dysphoric states in the very elderly (over 80). Subjects for the study are residents of the Hebrew Rehabilitation Center for Aged, and the study is being conducted with Drs. Andrew Satlin, Adam Burrows, and Ken Nobel.}

^{A new project, just beginning within the Psychopharmacology Service, is the evaluation of interactive video for the diagnosis, management, and consultation of chronic and persistent mentally ill patients, and associated movement disorders. This project is being conducted in collaboration with Tewksbury State Hospital.}

^{Roberts is renowned for her work on ethical issues and public policy relating to both clinical care and research science, and her research has been praised as bringing valuable evidence to help resolve complex and controversial issues in health policy related to vulnerable populations. She has studied, for example, how best to obtain informed consent from people with severe illnesses, such as schizophrenia, cancer and AIDS, who are enrolled in clinical trials; and she has examined a wide range of health disparities, including the differences between rural and urban health care. A recent focus of her work has been identifying and developing the standards needed to support ethical practices in genetic research.}

^{The work will be paid for by the sale of the curriculum to hospitals, medical societies, insurance companies, and other organizations that provide professional education to doctors, said Samuels, who is Lighthouse’s director of medical education.}

^{The curriculum directors will not teach other courses funded by drug companies, to further insulate them from industry influence, he said. And, the company’s advisory board, which includes former Harvard Medical School dean Dr. Joseph Martin, will review the curriculum directors’ other relationships with industry. Consulting fees and other industry ties will not be prohibited for those writing curricula, but such payments would have to be limited and disclosed, Samuels said.}

^{But discomfort with the system has led some institutions, including Stanford University medical school and UMass Memorial Medical Center, to prohibit companies from funding specific courses in their continuing education programs, while a few, such as the University of Michigan, have banned commercial support altogether.}

^{But, Lighthouse executives say, most of those providers are small and don’t operate on a national scale. And, they said, the percentage is actually much lower if one counts money spent by industry on advertising and exhibits at educational conferences — money Lighthouse will not accept at its conferences.}

^{Eric Campbell, a researcher at Massachusetts General Hospital who specializes in conflict of interest in medicine, said, “It is unique to recognize that it’s inappropriate to pass on the cost of CME to patients in the form of higher drug prices’’ because of over-prescribing. “Doctors should pay for their own education.’’}

^{Nissen, who is directing the cardiology curriculum for Lighthouse, said it would be impossible to hire faculty who have no relationships to industry whatsoever. “The biggest name people, the people who have the most expertise and are going to draw an audience — they are people who work with industry,’’ Nissen said. But, he said, he will try to minimize potential conflicts by not hiring doctors who are paid speakers for companies that sell drugs and devices.}

• Diagnosis: Obviously, accurate diagnosis is the linchpin of Medicine. Psychoactive medications are not symptomatic balms. In part through the efforts of Pharmaceutical Companies, there are some conditions that are so over-diagnosed that seeing a real case is a cause for excitement – specifically I’m talking about "bipolar" illness. We don’t need CME presentations about how to treat it. We need CME on how to properly diagnose it. There are numerous other examples.
• Psychosocial Evaluation: As an Internist, I read an article that most people who saw Internists didn’t have physical illnesses. So I kept score in my military practice seeing only referrals: 70% problems of life. 20% illnesses I could treat [including minor illnesses]. 10% illnesses that were untreatable. While there’s nothing wrong with trying an antidepressant in a person with a bad relationship, or out of work, or personality disordered, it’s important to know about such things. Often, the patient doesn’t know or is denying that their dysphoria is a "life" thing. It’s pretty important to tell them [It’s easy once you get the hang of it]. "How to" CME would be a good thing, particularly for General Physicians. Way too many people get pills before any attempts is made to figure out what’s wrong.
• "Older" Medications: CME often focuses on "recent advances" or "breakthroughs." True "breakthroughs" in Medicine aren’t that frequent. But we know a lot more about the older drugs that have been around for a while. Nobody’s "pushing" them because the patents have expired, but they’re the ones I’d like to hear about – the "tried and true." What we’ve learned with time…
• What not to do: So much over-prescribing of psychoactive medication is for peculiar reasons. For example, the atypical anti-psychotic Seroquel is known as a "depression blockbuster" in the financial world [based on the dubious notion that it’s a second line drug in depression]. It’s used as a sleeping pill for PTSD at the VAH [second biggest drug expense there]. And most of the people I see on it were given it for anxiety. It’s an Atypical Antipsychotic for Schizophrenia being widely used as a non-specific "nerve pill" – and it can be a dangerous drug. There are plenty of What not to do topics that would make any number of useful CME presentations.
• Everydays Cases: Practitioners spend their days with worried people. They need to know about the everyday people who come to see them. I think it would be useful to have a lot more individual case presentations than statistical charts, graphs, and NIMH neuron slides in CME presentations. Somehow, the metaphor "evidence based medicine" has gotten way out of hand. It’s the business of experts to talk about practical ways that medical science applies to people.