Independent Continuing Medical Education (CME)/Continuing Professional Development (CPD) Must Deliver Unbiased Information

ABSTRACT

Physicians commit themselves always to act in the best interests of their patients, and this includes their approach to continuing medical education (CME) as well as continuing professional development (CPD). For many years professional codes, and in some countries also the civil law, have defined that CME/CPD must be independent of commercial interests. Over the last few decades, numerous bodies have introduced CME/CPD accreditation to ensure that the planning and conduct of CME/CPD follows a set of defined standards, with independence of commercial interests as one of the leading principles. Recently industry has proposed that it be accepted by accrediting bodies as a direct provider of accredited CME-CPD. Such a move would not only open the door to the introduction of an inevitable bias in CME/CPD but would jeopardise the professional standing of physicians. Accreditation of CME/CPD currently serves several different purposes, but its credibility depends on whether it can retain its ability to differentiate independent CME/CPD from the provision of commercially framed information.

KEYWORDS:

• Continuing medical education
• continuing professional development
• accreditation
• independence
• medical information

Physicians commit themselves always to act in the best interests of their patients [1], and this includes their approach to continuing medical education (CME) as well as continuing professional development (CPD) which are cornerstones for the maintenance of professional competence. For many years professional codes, and in some countries also legal statute, have defined that CME/CPD must be independent of commercial interests [1–7].

Over the last few decades, numerous national bodies have introduced CME/CPD accreditation to ensure that the planning and conduct of CME/CPD follow a set of defined standards, with independence of commercial interests as one of the leading principles [3,5,7–11].

In Europe, this is augmented by an additional type of accreditor, the European international accreditor. These accreditors include members of CME-EA, EACCME and other organisations and are devoted to accreditation of CME/CPD activities in Europe that have primarily international attendance [12–17].

Accreditation has little value in and of itself, and is almost entirely dependent on having clear and transparent definitions, rigorous application of appropriate principles and rules, and being in a position to enforce its own standards. This only applies to those few European national accreditation systems which are officially legitimated by national jurisdictions (e.g. Germany, Austria, Italy). This enables the accreditor to impose accreditation standards on all providers nationwide (but vice-versa also imposes legal liability on the accreditor). But still many accreditors in Europe (including all European international accreditors) are non-governmental institutions lacking official legitimation.

Despite its sometimes variable legal status, CME/CPD accreditation still serves as an important component of quality assurance in medicine. Accreditation safeguards the credibility of the medical profession in one of the most important areas in medicine, i.e. maintenance of intellectual decision-making informed by life-long learning. However, regardless of legal considerations, accreditors will only be able to convince the (medical) public of their legitimacy by comprehensible and rigorous application of transparent principles and rules.

All major European accreditation systems grant accreditation prior to the start of the CME/CPD activity. This implies that accreditation relies on professional honesty, and commitment of the medical professionals involved in delivery of CME/CPD, to align their presentations with the principles and rules as outlined by the accreditor.

There are several key principles in medical education to be followed by providers (which should also be used by participants to evaluate a given CME/CPD activity). Firstly, there must be independence both of the source of the information and of its interpretation in the appropriate clinical context. Other criteria like educational efficacy of a CME/CPD activity are of secondary importance compared to the fundamental bias introduced by the use of framed information in life-long learning.

Fully transparent and timely provision of data can obviously collide with the commercial interests of industry [18–20], as driven by the market economy’s framework set by governments in most developed countries. This limitation weighs even more because currently about 80% of all trial patients are in clinical trials sponsored by industry [21].

Since the development and provision of drugs and devices follow the fundamental principles of a market economy with its inbuilt difficulties of accessing information, the acceptance of industry as a provider of accredited CME/CPD, as recently proposed in this journal [22], would open the door to an inevitable bias in CME/CPD. It is for this reason that major accreditors have recently reiterated in a global consensus document that “the content, as well as persons and organizations in control of the content, of the accredited CME/CPD activity is developed/selected independently, with no influence, control or involvement from a commercial interest … ” [23].

Many accreditors go one step further by defining the details of communication to participants to avoid any misperceptions with regard to promotion [3,8,9,13,15–17,24], in particular in sponsored CME/CPD.

Accreditors are well aware that in CME/CPD there are further threats to independent alignment of evidence with current strategies in diagnosis and treatment of particular conditions (interpretation), and discussion on how to apply evidence in the individual patient (implementation):

• This includes a long list of (potential conflicts of) interests, including issues related to career development and/or welfare of individuals involved in planning and delivery of CME, but also institutional interests, e.g. of hospital owners, insurance companies, etc. Thus, fully transparent communication of interests to participants in CME/CPD as well as management of the conflicts of interest are indispensable supportive strategies in planning and delivery of independent CME/CPD. However, they can never overcome the negative effects of information compromised by commercial interests, which also negatively impacts on the work of institutions aiming to facilitate evidence-based decision-making in clinical practice [25,26]. Major accreditors recommend the systematic use of their tools in the provision of accredited CME/CPD [8]. However, the value of such tools also critically depends on timely and complete availability of data to obtain a realistic estimate of risk-benefit ratios of diagnostic and/or therapeutic interventions.

• CME/CPD should always be designed to help participants to close gaps in knowledge and/or professional performance. The underlying gap analysis as well as definition of “learning objectives” mark another area, in which the involvement of commercial interests should be forbidden in order to avoid direct agenda setting by industry, although accreditors are well aware that indirect agenda setting currently occurs by allocation of sponsoring. Evidence is available that CME with industry involvement has a narrower range of topics and more product-related content than CME without direct industry involvement even when funding is unrestricted [27].

The primary importance of independence in accreditation should not inhibit consideration of the role of different educational formats in the delivery of effective CME/CPD. Although overall educational quality may be considered as satisfactory [28,29], accreditors have always wanted to stimulate providers to improve their educational formats [8,14,17].

CME/CPD accreditation has been designed to demonstrate the difference between independent, evidence-based CME/CPD and interest-driven CME/CPD. If the need for independence is not actively prosecuted, accreditation will lose its potency and may be seen as no longer needed. In certain jurisdictions [30] commercially driven CME/CPD is already considered as providing inadequate independence in influencing opinion formation, and decision-making, thus highlighting the need to differentiate education from advertising.

Accreditation of CME/CPD currently serves several different purposes, but its credibility depends on whether it can retain its ability to differentiate independent CME/CPD from the provision of commercially framed information.

Disclosure statement

Declarations of interests can be found in the supplementary material section.