COMMENTARY

Response to AMA's Council on Ethical and Judicial Affairs Draft Report on "Ethical Guidance for Physicians and the Profession With Respect to Industry Support for Professional Education in Medicine"

Thomas P. Stossel, MD

Disclosures

June 12, 2008

Commercial Support and Educational Content

The Report made the pretentious assertion that eliminating commercial support of CME is necessary to preserve the gains in medical education initiated by the Flexner Report of 1908 that revolutionized medical education. To compare the alleged risks for commercial educational subsidy in today's highly technical medicine, based increasingly on the use of products minutely vetted by the FDA, with the documented chaos of unscientific pre-Flexnerian medical apprenticeship, training is hardly in the Flexnerian tradition of demanding scientific rigor.

Similarly, both The Report and Brennan and colleagues misrepresented science in their indictments of bias. Conceding that freedom from bias is incompatible with human existence, The Report nonetheless, resonating with Brennan and colleagues' assertion that "absence of bias in medical decision making" defines professionalism,[2] set up as an ideal that "professional education in medicine is fundamentally grounded in the ideal of scientific objectivity -- in other words, education that is free of all bias," and concluded that eliminating commercial support of medical education is necessary to approach this ideal.[1] However, "scientific objectivity" is an oxymoron. Scientists passionately pursue their research driven by strong competing biases, but they subject their treasured ideas to rigorous tests designed to delineate their reproducibility and validity. From these tests a consensus may evolve, but in the end, except in mathematics, subjective interpretations come into play.[26,27] Ultimately the track record of the science, not the motives -- or the profits -- of the scientists, determines the durability and utility of the scientific claims. The misrepresentation of objectivity in science fuels sterile quibbling over whether information is "educational" or "promotional." Because nearly all information, including -- indeed especially -- the content of the Brennan paper and The Report, has promotional elements, the contrast is false. The important issue is the strength of the evidence on which the information is based. Brennan and colleagues and The Report concluded without rigorous documentation that commercial information is by definition inferior to nonproprietary information.

To believe that some repository of nonpromotional or otherwise unbiased information exists that is superior to what physicians obtain from the competing universe of proprietary, or in part commercially supporting educational, offerings -- or could exist in some utopia where we could afford to subject all medical interventions to randomized controlled trials and find "disinterested" experts to perform and analyze them -- is a conceit. We rely on transparency in medicine not to eliminate all bias or even fraud but to ensure competition and inquiry that over time reveal and eliminate them. Proponents of "academic," "unbiased" medical education brand their education products by promoting the alleged unreliability of commercial information.

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