Who Sets The Standard of Medical Practice?

Commercial support of continuing medical education ("CME") is a widespread practice. Sometimes the sponsor links its name to the program or presenter. Sometimes, a calculated distance is maintained between the sponsor and the program by use of intermediaries or donation to a program "fund." In each case, the unspoken part is the commercial sponsor’s message, “we define the standard of care,” delivered by paid advocates through continuing medical education (CME).

"Sponsored education" is not restricted to physicians and other health care providers. The United States is unusual in that it permits direct advertising of pharmaceuticals (technically known as "dangerous drugs") to consumers. Like CME, consumer advertising implicitly dismisses physicians, who do not prescribe its product, as substandard and suggests that the consumer “find a better doctor.” Some CME speakers talk about the “efficiency” of prescribing the drug they are touting that day, but their real message (often couched as biased interpretations of flawed research) is that failure to prescribe or use the commercial supporter’s branded product means that the physician does not meet generally accepted standards of care and is inferior.

Defensive medicine is not limited to ordering unnecessary X-rays, tests and procedures. The subtle message of commercially sponsored CME, “meet the standard of care by prescribing our products,” keys into physicians’ fears of malpractice lawsuits, adverse peer review, and action by state medical boards. The results are defensive, unnecessary, costly and sometimes dangerous prescriptions and orders. The subtle message adds to our health care deficit.

Patients, the public, and our professions are paying a dear price for that free meal, lecture, slide show and hour of CME credit. Patients are taught to depend on pharmaceutical company advertising and to distrust their physicians and other health care providers. I believe it is time to terminate the destructive franchise we have given to commercial supporters of CME and direct consumer pharmaceutical advertising.

Dealing With Medically Underserved Areas

Medical education is already heavily subsidized (tuition does not cover the educational institutions' costs). Some young physicians choose their career paths primarily based on their assessments of how quickly their earnings will pay off their debts. There could be an alternative: provide financial incentives to medical students, interns, residents and fellow to choose the specialties which America needs, where the needs exist, and commit to providing them with free educations if they serve in designated medically underserved areas for a defined period following completion of their training. If the young physician's career objective is to be a Beverly Hills cosmetic plastic surgeon, he or she should receive no subsidy or income guarantee; if he or she will contract to practice plastic surgery in an inner city hospital for seven years, provide a generous subsidy which makes the medical training free and provide a reasonable and adequate income so that the physician can support his or her family. The decisions on need and location cannot be left to the medical profession alone, nor to hospitals, because the medical profession and health institutions will game the system for their advantage.