Why your doctor thinks what he/she thinks
When it comes to the source of your doctor’s upgraded medical knowledge, follow the money. I thought that phrase was from Jerry Maguire but apparently it’s not. Whether from the mouth of a sports agent, an investigative journalist, a movie script writer, or just someone who knows what he’s talking about, when it comes to your doctor, chances are it’s right on. Once your doctor finishes his training, he is on his own for further education (the editorial “he”; I’m not going to say “he/she” every time, regardless of PC, and regardless that we will soon have more female doctors than male; that’s another post). All US state medical boards now require doctors to show evidence of Continuing Medical Education (CME) in order to retain their licenses to practice. Talking over a problem in the doctor’s lounge, or calling the old professor to see what’s new, does not qualify as CME. Neither does reading the new edition of a comprehensive textbook (which, by the way, is already years out of date by the time it’s published). So how is CME accomplished? Commonly, there are four ways:
- Reading designated articles in current medical journals, then submitting the answers to an attached test (so-called “open book”). The “designated” articles are typically written by specialty “thought leaders”. The journals are usually sponsored by a recognized specialty board.
- Attending medical conventions/meetings, where more-or-less the same information as found in the journals is presented live by more-or-less the same thought leaders. Modern off-shoots include video-conferencing and pod-casts. Official conventions are usually sponsored by a recognized specialty board.
- Attending hands-on “mini-residencies” sponsored by a specialty board (or sometimes by a hospital).
- Attending meetings or studying materials provided by a “learning initiative” group. One such group in my field is CIEF: .
Each of these activities will provide a certain number of accredited CME hours, and each state has its hour-requirements for retaining medical licenses.
Sounds pretty good, right? When I was young, there were no requirements for modernization whatever. So what’s the problem with this system? In a word, money. Like power, money corrupts, and lots of money corrupts completely.
Of course, options 1 and 2 have clear drawbacks for the policing agencies. A nurse or PA can easily “cherry-pick” the answers from the CME journals for their doctors, and they do. Meetings have no way to ensure that the signed-in participant is not out playing golf, which he is. So long as he pays the fee and signs the registration, go for it.
The real problem boils down to “thought leaders” (also known as “opinion leaders” or sometimes simply as “whores”)and their relationships with industry. At one time, academic medical professors were mostly salaried doctors who earned far less than their colleagues in private practice, but who may have enjoyed teaching and the prestige of being a published thought leader. Today, it is almost impossible to find a “thought leader” who is not a consultant for the healthcare industry. More commonly than not, they will consult for several such companies. They have the highest earnings among practitioners in the USA. Within a given specialty, they all know each other, and at medical conferences, they give the colleagues on a different payroll wide latitude in professional opinion, and receive the same in return. The notorious “dogfights” of the intelligentsia of the past now dwell with the dinosaurs. In this fashion, they may represent juxtaposed positions, yet the audience comes away without any idea of the “correct” position, if there is one at all. My board organization advises its convention attendees and journal readers to consider the speaker/author’s commercial relationship disclosures as the information is distilled; in other words, “let the buyer beware.” Why would our board leadership do this? Why, silly, they’re on the team, too! When I read a study, or a journal article, or hear a presentation, I have no idea whether it is true. If it conflicts with my personal experience, I’m screwed. Oh, I neglected to mention: these same “thought leaders” come out with treatment guidelines for various maladies, which are endorsed by the board. Consequently, If I don’t follow the guidelines, attorneys can easily prove that I “breached the standard in patient care.” On the other hand, the “thought leaders” are the standard, so their treatment problems are defensible. So much for CME methods 1-3.
What about #4, the learning initiative? This is the most nefarious option of all. The FDA prevents pharmaceutical and device manufacturers from speaking to doctors about products that have not been approved; once approved, they can speak to doctors (when I write “doctor”, you should read “customer”) only about FDA-approved indications (uses). The exception to this is the doctor who is actually doing research studies for the products. That doctor can wear two hats: the hat of a researcher when he gets all the FDA non-approved info, and the hat of an independent practitioner when he speaks to his “fellow independent doctors” about the non-approved issues. By this approach, industry is able to by-pass FDA regulatory intent. In my field, all the educational initiatives, and the doctors who run them, are funded by companies who have a blockbuster product in that specialty. It is so cleverly done that the sponsor company seems like a good Samaritan, giving out grants to help humanity. AND, it qualifies as CME credit, which all doctors must acquire.
Do you suppose that even your well-meaning, I’m-just-trying-to-stay-current personal doctor may be misinformed?
In my next post, I’ll talk about the real leaders in doctor “education”; they weren’t included in this one because it’s not official CME. I’ll also throw in some first-hand, saw-it-with-my-own-eyes anecdotes.
In the meantime, don’t get sick.