July 19, 2009

Who Should Pay For Continuing Medical Education?

The money is in the C, not the E.

Dr. Nasrallah, editor of Current Psychiatry, has an editorial "The $1.2 billion CME crisis" asking the above question.

Everyone wanted Pharma out of it.  Now they're gone, leaving a large bill unpaid.  Oops.  Probably should have thought of that first.

(An aside: no one thinks twice about asking unemployed college kids or their parents to pony up $150k of after tax income for tuition alone for medical school, but asking employed doctors to put up hundreds of tax deductible dollars for CME is somehow drunken buffoonery.)

But the real question is, do we need CME at all?

Don't roll your eyes at me, Superfly, I'm serious. If we really need an artificial system to force doctors to stay current, does this do that?

Here's this month's CME post-test, worth 1/20th of the yearly state requirements:


What does this question teach you?  Nothing.

Time is not infinite-- whatever time and energy was spent learning this meant you didn't learn something else.  So I ask you again-- does this help me stay current and knowledgeable, or less so?

"Ok, some of it's trivial, but it's the best option we have."  Again, brainwashing: if something doesn't work, it doesn't matter that it's better than the other things that don't work.  Doing nothing is better than doing the wrong thing that costs money.

It isn't evident that this stuff leads you to be a better doctor.  There's a case to be made-- and I'm making it-- that this actually makes you a worse doctor.


Docs pay for CME because it absolves them of having to learn what appears to be an overwhelming amount of information on their own.  But then CME becomes the exportation of the particular biases of the isolated class of CME writers.  I have ten years of Depakote CMEs that were not funded by Abbott to prove it.  Do you have any Dilantin or Neurontin ones?  No?  "But those drugs don't work."  Do you know why you know that?  The Depakote guys told you.

You know these CME guys are called, without any irony, "thought leaders", right?

Imagine you paid money for a newspaper that selected and organized the information they thought was important, and trivialized/marginalized anything that didn't fit into the "accepted" paradigms-- for example, a third party candidate during an election.  Or, imagine you paid a bunch of guys you don't know $100k to select and organize what they think is important to your child's development, based solely on the reputation of the corporation that hired them.

Imagine that.


Here's why you've never questioned the need for "continuing education": it is designed to self-reinforce the impression of ignorance.  The focus is on continuing-- which means you're never done.  You must always be left with the feeling that you are actually quite ignorant about the "current" information. 

An example of this idea is Dr.Nasrallah's very editorial: the full title is "The $1.2B CME Crisis: Can eleemosynary replace industry support?"

Well, he got me on eleemosynary, I'll admit.  But then again, he probably got lots of people-- so why use the word? 

In that same way, Nasrallah uses eleemosynary in a post about continuing education to convey an impression of refinement and knowledge-- you're not as smart as him.  So it would never occur to you to question the need for further education; you're hooked into his musings  about who should pay the bill.


The argument about CME is structured similarly to the general healthcare debate: what ways can we make this affordable but free of bias and misuse?  But the focus on cost vs.  commercialism ensures no one notices that a lot of this stuff simply isn't necessary.  The number one branded drug in the U.S. is Lipitor and you don't need it.  But because CME is a $1.5B industry, no one will allow that question to be asked, not by conscious suppression but because of groupthink and brainwashing.  Go ahead, try.  You'll be dismissed with the "of course" fallacy ("of course, we need some system for continuing education,;of course, we need to keep doctors current; of course, we need a way to track it; of course, the system's not perfect but it's the best we have").

These are the responses given by those anchored in the system, in the Matrix.  They never question the premises.  Never question the textbook, the Introduction.

And they are the ones you will pay to have as your teachers and leaders.