To the Editor,

In his article, "Separating Continuing Medical Education from Pharmaceutical Marketing" (Relman, AS: JAMA. 2001; 285: 2009-2012), Dr. Arnold Relman has allowed his anger and frustration over what he perceives as the commercialism of Medicine to overwhelm his perspective, causing him to chastise the ACCME and demonize the pharmaceutical industry. It is tantamount to calling for the creation of an academic monopoly that probably is illegal, and certainly is ill advised.

To bolster his case, with little evidence to support his claims, Dr. Relman attacks the widely accepted national standards for continuing medical education (CME) that have been applied even-handedly for years by the ACCME through its professional reviewers and surveyors to for-profit and non-profit organizations alike.

He also applauds the efforts of a dissident group of academic CME directors who submitted a resolution to their organization that would result in the creation of an academic monopoly on accredited CME by denying accreditation to for-profit providers. That resolution has yet to be accepted by their board who have selected a wiser and fairer course of determining the facts and not basing decisions on emotions.

Dr. Relman's exclusion of commercial involvement would be based, not on the creation of inferior medical content, since the same medical experts create content for both non-profit providers and for-profit providers. Rather it is based simply on the grounds that they (i.e. the for-profit providers) are them, and not us -- the long-discredited gown vs. town argument raised anew.

Antitrust issues aside, which Dr. Relman naively seems to believe the courts would ignore or decide in favor of his chosen providers, the conflicts of interest issues alone should put all interested parties on notice as to the true underlying motives of the academic activists - follow the money!

In a recent article analyzing US CME expenditures for 1999 (Dougherty, MJ and Sweeney, Jr. HA, Medical Marketing & Media. 2000; 35: 88-96) the latest figures available, the authors pointed out that of the more than $1.1 billion being spent on CME in the US annually, about two-thirds of the money already flows to "non-profit" medical institutions and associations that, nevertheless, produce a "surplus" that is the equivalent of a forty percent pretax corporate profit. Not bad for so-called "non-profit" institutions.

Dr. Relman also laments "the intrusion of for-profit businesses into the affairs of not-for-profit professional institutions." In this instance, Dr. Relman lacks historical perspective. Traditionally, CME was considered unworthy of the attention of the faculty of many academic institutions, and it was left up to the medical associations and industry to provide it.

However, as the competition for research grants increased, and Medicare, Medicaid, and managed care reimbursements decreased, academic institutions began to feel the pressure to develop new income streams. While alert CME offices were already on to this trend, many others suddenly woke up and found that many new competitive sources of medical information had left them standing in their tracks.

Viewed in this light, the monopoly grab by dissident CME directors might be seen as just a slam-dunk attempt to catch up or improve their market share. Since the same physicians are faculty for both for-profit and non-profit providers, and since the standards for accreditation are identical, what's left for critics to carp about, except who gets to act as transfer agents for the pharmaceutical industry's money?

"Industry has legitimate research interests and research capacity," Dr. Relman concedes, but he doubts the legitimacy of industry's right to communicate about its research. The right to communicate about the industry's research, Dr. Relman suggests, "ought to be the exclusive preserve of medical and educational institutions." Why, one might ask...simply to tip the economic scales towards the academic institutions?

It is particularly unfortunate that Dr. Relman also has seen fit to adopt the fuzzy logic of the hopelessly biased Public Citizens group, the same people who believe that pharmaceutical advertising is the cause of drug abuse in this country. Since the ultimate objective of a commercial enterprise is profits, the simplistic theory goes, any activity by that enterprise, including participation in something as important as CME, must be biased.

We have more respect for the women and men of medicine who conduct and receive CME in this fashion to accept that premise. Indeed, it is only appropriate that Dr. Relman's evidence for such a conclusion be put forward for examination. The focus and debate here should be on the excellence or shoddiness of the CME programs themselves, and not on the arbitrary political correctness of their sponsors or producers.

The most advanced developers of CME programs today are engaged actively, not only in creating better and better learning experiences for practicing physicians, but also in creating outcomes measurements that can be used to refine such programs, on-the-fly, to produce content improvement and, ultimately, to improve patient care. Such producers may be found in both the academic and commercial setting.

Effective collaboration and communication between and among government, academic and industry researchers since World War II is what has led us to this most productive era in medical discovery. A physician of the stature and experience of Dr. Relman must surely recognize that destruction of that cooperative relationship cannot be good for our economically challenged healthcare system and more importantly, patients.

Jack E. Angel
Executive Director
Coalition for Healthcare Communication