Teaching Doctors—or Selling to Them?

Drugmakers worried about conflicts of interest back away from their sponsorship of continuing education

By Arlene Weintraub

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Illustration by Istvan Banyai

Trying to steer clear of potential conflicts of interest, two medical industry giants are distancing themselves from a little-known breed of marketing specialists. The recent steps by the drugmaker Pfizer (PFE) and Zimmer Holdings (ZMH), a medical device manufacturer, illuminate subtle promotional tactics other companies continue to aim at doctors, despite mounting concern on the part of some physicians and ethicists.

At the center of this controversy are medical communications firms paid by pharmaceutical and device companies to produce physician-education courses. Critics say the manufacturers hire the marketing firms as intermediaries to help them influence doctors' prescriptions and procedures.

In July, Pfizer announced it would no longer pay communications companies to arrange continuing medical education (CME) courses, which doctors must take to maintain their licenses. Pfizer said it would support medical education only when it's put on by hospitals and professional medical associations. Zimmer, which manufactures hip, knee, and elbow implants, has suspended funding of all CME activity. The company says it will restrict the way it funds courses in the future by identifying an independent third party, such as a professional society, to organize educational programs.

"We understand that even the appearance of conflicts in CME is damaging, and we are determined to take actions that are in the best interests of patients and physicians," Dr. Joseph M. Feczko, Pfizer's chief medical officer, said in a press release.

These moves are a blow to the marketing firms but by no means the end of their lucrative, multifaceted role. There are hundreds of such firms in the U.S. that design ad campaigns, hire doctors to educate colleagues about devices and medications, and produce conferences. Over the past decade, CME has become one of their most profitable businesses, as manufacturers have increasingly paid for the courses.

Industry support for CME has quadrupled since 1998, to $1.2 billion a year, according to the Accreditation Council for Continuing Medical Education (ACCME), an organization in Chicago that approves CME providers. More than half of that is funneled to marketers, with the rest going to hospitals, medical associations, and other nonprofit entities.

As industry money for continuing education proliferates, so do worries that many of the courses have become at least partly aimed at promoting products. The industry and its outside marketers say they ensure that the courses remain free of commercial influence. But some medical experts argue that when employees of communications firms are beholden to pharmaceutical and device companies, they will produce CME courses that are slanted in favor of their sponsors, even if they don't realize what they are doing. "There's not only a perception of bias, there's a reality," says Dave Davis, a vice-president of the Association of American Medical Colleges.

In some cases, the favoritism seems blatant, doctors say. In June, psychiatrist Daniel Carlat logged on to Medscape, one of the largest providers of online CME. As the Newburyport (Mass.) physician clicked through a series of multiple-choice questions, he says he was surprised to discover that the correct answer to one item about how to treat a patient with schizophrenia and alcoholism was to prescribe paliperidone. Better known by its brand name, Invega, the medication is made by Johnson & Johnson (JNJ) subsidiary Janssen Pharmaceutical. It's a relatively new product intended to replace lost sales from J&J's multibillion-dollar antipsychotic medication Risperdal, which recently lost its patent protection. J&J, it turns out, sponsored the CME course.

Carlat, an outspoken critic of potential medical conflicts of interest, reprinted the Medscape material on his blog.