Naomi
P. Alazraki,
MD
Careers for of Continuing
W
a Lifetime: Medical
I trained in radiology and nuclear medicine 20 years ago, I learned general radiology, special procedures (arteriography and venography), nuclear medicine (planar imaging with limited quantitation of static and sequential images), genitourinary radiography (intravenous urography, retrograde pyelography, and hysterosalpingography), gastrointestinal radiography (barium swallow and barium enema studies and salivary duct contrast studies), cardiac radiology (coronary arteriography and ventriculography), and neuroradiology (cerebral and vertebral arteriography, myelography, and pneumoencephalography). A genera! radiologist practicing today in a hospital may spend approximately 80% of his or her time working with technologies that did not exist 20 years ago. Some examples are computed tomography (CT), CT-guided biopsies, magnetic resonance (MR) imaging, MR angiography, ultrasound (US) for imaging and Doppler flow measurements, radionucide imaging with single photon emission CT (SPECT) and quantitative analysis for stress and rest quantitative myocardial perfusion imaging, expanded radionucide therapies, and US imaging of pregnancy including guided amniocenteses and fetal surgical procedures. The new field of interventional procedures for diagnosis and therapy, including angioplasty, vascular stent placements, laser therapies, intravascular occlusive therapies for bleeding from arteriovenous malformations and aneurysms in the brain and elsewhere, and other innovative approaches as alternatives to surgery are other examples. HEN
Index terms: Editorials ogy and radiologists Radiology
1992;
Education
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‘From the Department of of Nuclear Medicine, Emory of Medicine, 1364 Clifton Rd 30322; and VA Medical Center, ceived June 4, 1992; accepted reprint requests to the author. © RSNA, 1992
Radiology, Division University School NE, Atlanta, GA Atlanta. ReJune 5. Address
The Role Education’
Of all board-certified radiologists in practice in the United States today, about one-third are over the age of 52 years, and close to one-half are over 47 years (Krabbenhott K, American Board of Radiology Records, personal communication, 1992). Although not formally trained in most of these newer technologies and procedures, senior radiologists are performing these procedures as part of their practices. How did they learn to do what they are doing? Most likely, they learned these new radiologic technologies and skills from continuing medical education (CME) programs sponsored by academic radiology departments, professional societies, and commercial pharmaceutical and instrumentation companies. In some instances, they spent time (days to weeks) in a university radiology or nuclear medicine facility to be trained (or retrained). Most likely, they also learned from reading selected scientific or educational review articles published in scientific and professional journals, as well as specialized articles published by professional societies, university departments, or companies. According to book salespersons, radiologists are among their best customers. Thus, without doubt, radiologists have learned about these new technologies and procedures from regularly reading new books written by academic radiologists who are in the forefronts of these developing technologies and procedures. It is unlikely, however, that reading books is sufficient to sustain the depth of knowledge and experience necessary to enable even a trained radiologist to treat patients or participate in those new diagnostic procedures that have become central to radiology and nuclear medicine practice. Radiologists who trained 20 years ago have been able to continue working as competent radiologists in today’s medical practice world, in large part because of the relatively unrewarded efforts of academic radiologists dedicated to teaching the procedures that they and their colleagues have developed. Academicians creatively provide continuing medical education at scientific and educational meetings with the blessings and salaries provided by their university or institution. Without academic
institutional
support
CME
be limited,
would
for this
and
activity,
so would
continuing competence for a lifetime career in private-practice radiology. The major scientific and educational meetings such as that of the Radiological Society of North America would be crippled if not for the availability of the academic community to provide the materials of the meeting and financial support, in large part in the form of their university, Veterans Affairs, or other institutional paid time to prepare the educational materials and lectures, as well as to perform scientific studies that are the backbone of progress in the field. Unfortunately, there are many among us who trained 20-plus years ago but are not conscientious about retraining and learning those new technologies and advances that must be provided as part of an up-to-date and competitive radiology practice. These are the radio!ogists who do not bother to attend the
CME
courses
offered
or do not regularly
read the journals or new books published. Unfortunately, they leave themselves and their practices open for challenge from competing specialties. They jeopardize the quality of patient care, the reputation of radiology practice, and the turf of all radiologists.
THREATS
TO CME
In recent times, perhaps because of public concern over health care costs, congressional and government scrutiny of continuing medical education has called attention to involvement of industry in supporting and directing such programs. The central question has been, “Is this education or promotion?” Consumer Reports featured an article on the topic in its February 1992 issue (1). The authors described multiple mcidences of drug company-financed symposia, videos, and publications in which persuasive data and information about the company’s product or products were presented, while information about alternative products or therapies was omitted. In some cases, there was no disclosure of the company sponsorship of the symposia or publications. The article, entitled “Pushing Drugs to Doctors,” supported the contention that “over the past 15 years or so the $63-
603
billion-a-year
pharmaceutical
has made physicians the times willing, sometimes
industry
requirements
of CME ACCME policing
targets-someunwilling-of
sophisticated, subtle, and highly effeclive marketing techniques that permeate nearly every aspect of medical practice. Drug companies symposia that
promotional
are
organize actually
efforts
by professional institutions
ACCME
educational disguised
for their
products.”
mental agencies to regulate CME in the name of cost control. To minimize such intervention, the medical community respond
by vigorously
that
sponsorship
Furthermore, the mechanisms for strict compliance
societies and are authorized
academic by the
CME
to physi-
to give
credits
cians. The AMA, 2 years ago, issued guidelines for relationships with cornpanies, and the ACCME, on March 16, 1991, approved a new revision of guidelines for commercial support of continuing medical education.
This type of widely read material fuels public opinion and inspires govern-
must
for ACCME
organizations. is developing and enforcing
These response
assessing
ACCME actions are in direct to the draft concept paper re-
the problem and acting appropriately but reasonably to curtail objectionable practices and thus protect legitimate CME from excessive regulation. Unfortunately, the Consumer Reports article did not mention the efforts of the Amer-
leased last fall by the FDA about cornpany-supported CME and other forms of scientific exchange about products regulated by the FDA. The ACCME guidelines place responsibility with the
ican Medical Accreditation
and scientific integrity, sentation of a balanced
Association Council
accredited
(AMA) and for Continuing
school
or the
academic
of manufacturing
ing drugs, supplies
medical
training
or servicing
and/or health
are not different from other industries. They profit. While they may society and humanity help people in extending
care
and needs
companies in are out to make wish to serve positively and and enhanc-
a
ing quality of life, they cannot do all those good things unless they make a profit. For-profit companies must push their products, even when superior competing alternatives exist. The public and regulatory agencies have been sensitized to issues of fraud in advertising. The Food and Drug Administration (FDA) has become quite sophisticated in recognizing and discovering unproved, misleading, or unwarranted claims that companies make about their products. A high level of public awareness of these issues is being focused now on CME. In response, the AMA and the responsible organized medicine agency, the ACCME, have issued new, increasingly restrictive guidelines that are now
604
Radiology
#{149}
medical
education.
authority when it and policeman of
The
The
medical
community,
which
effectiveness of new drugs for uses scribed, recommended, or suggested the labeling (b) to assure adequate
prein di-
rections for use or uses of the drug and (c) to prevent dissemination of false or misleading labeling and advertising. Therein (item c) lies the FDA claim to regulate
drug
promotion,
or CME,
when it can be seen as promotion. The FDA position is that if the accredited sponsor demonstrates “independence” from a commercial funder, CME programs would be considered nonpromotional and not subject to FDA regulation. The FDA is revising its initial proposal in response to comments and welcomes additional comments when its next draft proposal, expected soon, is made public.
is today
being
The the
medical
position
ACADEMIC IN CME
community that
the
FDA
is unified oversteps
in
medito preof CME,
threatened.
We
financial
support
from
commercial
of careers
for a
SUMMARY (a) CME is largely responsible for providing pathways for radiologists and other physicians to remain current and credible as practitioners, despite the astounding changes in technology and medical practice. (b) The academic community is largely responsible for providing continuing medical education for the profession and deserves recognition and support for facilitating careers for a lifetime. (c) The importance of CME to medical practitioners interested in maintaining currency is critical and warrants our support and dedication to preserve the integrity of continuing medical education. Academic freedom of the CME process must be protected from overregulation or it will be disabled. Acknowledgment: William Casarella, ful review of the
I express appreciation MD, for his astute and manuscript.
to help-
References 1.
2.
PROTECTING FREEDOM
particularly
must reasonably satisfy questions raised about conflict of interest and legitimacy of CME programs sponsored by professional societies and academic institulions, and in part, directly or indirectly, companies. The issue lifetime is at stake.
Commis-
are po-
those in radiology and nuclear cine, should vigorously attend serving the academic freedom
with
Deputy
results
tentially destructive. CME organizers are concerned that open scientific discussion could be compromised and funds to support CME would be at risk for cutback. Therefore, the ACCME has strengthened its guidelines and requirements for documentation and monitoring of the CME process in an effort to preempt possible intervention by the FDA.
specify
sioner for Policy at the FDA, has stated that the question for the FDA is how to “foster the proper flow of information” about drugs (2). According to statute, the FDA has three information-related mandates: (a) to determine safety and
distribut-
instrumentation,
quality,
including preview of all op-
rightful as judge
lions
all participants. Michael Taylor,
environment, get information about new drugs, new technologies, and new practice standards. The companies that are in the business
for content,
in managing cases. They further that funds from a commercial source should be in the form of an educational grant, and commercial support must be acknowledged and disclosed to
Medical Education (ACCME) that are under way to correct some of the imbalance in educational programs for physicians. The article raised seemingly legitimate concerns about how practicing physicians, who are removed from the medical
sponsor
legitimate meddles
Pushing drugs to doctors. Consumer Reports 1992; 57(2):87-94. Taylor M. Drug regulation, off-label uses, and CME: reconciling competing values. Presented at the Update on Drug Advertising and Promotion, Food and Drug Law Institute, Arlington, Va, February 26, 1992.
its
September
1992