Is There a Role for Industry Sponsored Education?

Yes of course there is.  And here is a critique of a recently published commentary against commercial support of education from Jerry Avorn, MD (self proclaimed father of Academic Detailing) who’s goal is to use government funds to promote generic drugs to physicians and who's JAMA paper from 1983 is regularly referenced by politicians as current science.


His recent commentary, co-authored with his colleague Niteesh K Choudhry, "Is there a role for industry-sponsored education in cardiology?" was published in Circulation (volume 121, pages 2228-2234, 2010). The first paragraph uncritically invokes the authority of “behavioral economics” to build the frame that “unconscious biases and emotional factors” dominate educational messaging.


The second  paragraph concedes that industry makes “important” contributions to products that reduce morbidity and mortality (but doesn’t say how important). A book by the first author (Avorn) is then referenced to make the claim, “there is growing concern that educational activities should not be supported or influenced by companies whose profitability and very existence depend on the sales volume of the products they make.” Other than the book reference, no information quantifies the magnitude or source of “the concern.”


The third paragraph returns to behavioral economics to celebrate the policy of certain medical journals that preclude authorship of articles and editorials by individuals with ties to makers of products in order to avoid “unconscious bias.” It calls for extending the same policy to eliminating commercial support of education in cardiology. As a result, individuals with “minimal commercial interest in the topic being presented” transfer medical knowledge “most efficiently and with the least distortion.”


The next section of the paper outlines the types current levels of industry support of CME. It is particularly critical of salespeople, referred to as “detailers,” who “may have limited scientific training and are paid on a commission basis, depending on how much of their company’s products are prescribed by the clinicians they target.”


This section also alludes to large legal settlements paid by companies because of off-label marketing allegations. It does not mention the fact that these settlements are responsive to debarment threats (i.e., loss of government business including Medicaid and Medicare) or that indicted individuals who did not settle have won acquittal.

The article then states: “These developments demonstrate that the lure of multi-billion dollar sales from blockbuster drugs and devices can distort the accuracy of information provided by manufacturers to physicians, even when no laws are broken.” Is this emotion-laden conclusion not an example of “biases and emotional factors” influencing “educational messaging?”


In this section of the paper, the authors rehearse high-profile examples in which marketing allegedly contributed harm. In their reference to relative rather than absolute risk (Vioxx “doubled the risk of myocardial infarction and stroke”) to describe the harm and their invocation of one-sided accounts (including news media articles) of controversial but unresolved allegations, they again exhibit the “biases and emotional factors” they purport to want to eliminate.


The paper then summarizes “opinions from the leaders of medicine,” including policy recommendations by the AAMC, The Macy Foundation, the IOM, individual academic health centers and a widely cited article published in JAMA. It does not mention any dissent to these opinions, such as written objections raised by industry participants in the AAMC deliberations. It erroneously refers to “heated rebuttals” to the JAMA article, but, in fact, the reference cited is not a “rebuttal,” rather a call for eliminating industry support of CME. Is this “efficient” knowledge transfer “without distortion?”


The ensuing section of the paper explores the question of who should fund CME following elimination of commercial support. It prominently presents a glowing advertisement for the first author’s commerce-free “academic detailing” program based on “rigorous review of evidence.” Does behavioral economics not apply to this celebration of the author’s academic status and livelihood? Would the adoption of more academic detailing not be equivalent to paying commissions to a commercial sales representative? Neither author is a cardiologist; do concerns about “limited scientific training” not apply?


The paper ends with authoritative declarations that the march to suppress conflict of interest is akin to the introduction of statistics and human subjects protection to clinical trials. It ends on the note that we must eliminate bias, because it “can so easily be introduced unintentionally.” Continuing with their one-side account, the authors fail to cite four studies published in the past year documenting almost no perception of bias by participants in commercially sponsored CME activities. 


Having concluded that bias “is difficult to detect and prevent,” the paper sets as a standard the need to prove the nonexistence of nothing. It certainly isn’t hard to detect bias in this paper!