most Dentists, keeping our license current means that we must have
a minimum number of hours of CE (Continuing Education) credit on
file with the licensing body. CE is also a way of trying to stay
current in a rapidly expanding and evolving profession. With the
explosion in technology has come a myriad of products and techniques
- many unfamiliar to us until they are released to the marketplace
- for our purchase. Dental product sales are big business and worth
hundreds of millions of dollars in sales per year. For example,
whereas 50 years ago we had a limited number of choices when restoring
teeth, we now have 6th and 7th generation composites that are being
touted as the next greatest material. Implants, once thought of
as exotic treatment are now being placed routinely. Prosthetic and
Aesthetic materials have undergone a revolution. In my specialty,
Endodontic treatment now involves the use of Rotary Ni-Ti instruments
of differing designs and possible new obturation materials. Endodontic
irrigation solutions have now come under heavy study and marketing
and are being investigated to maximize their bacteriocidal, tissue
digesting and lubricating properties. It seems that every 6 months
there is a new material, device or technique that someone is willing
to sell you to make your treatments faster, easier and better. And
that is the problem.
fellow Endodontist, Dr. Terry Pannkuk, recently sent me an article
that had been written by Dr. Christian B. Sager about this very
subject. The title of the piece was "Commercial Conflict of
Interest and Continuing Education". Dr. Sager is the CEO
of the L.D. Pankey Dental Foundation and the Executive Director
of the Pankey Institute, where he leads discussion on ethical and
behavioral aspects of patient care. Sager recently became aware
of changes that had been adopted by the US Accreditation Council
for Continuing Medical Education (ACCME) as a result of a Sept.
29, 2004 article that he had read in the Wall Street Journal. In
the article Dr. Sager said that the AACME found that "No longer
was it enough for a clinician/lecturer to simply disclose his or
her financial relationship with a pharmaceutical company before
providing the audience with anecdotal information about a drug.
Now, the presenter is required to not only disclose the relationship
but also results of clinical trials and a review of the journal
must include any negative as well as positive studies". (Editor: This policy was probably partly the result of the fallout
from the recent drug fiasco involving Vioxx and other Cox2 inhibitors.) "Drug manufacturers and other commercial providers of health care
products and services proactively influence continuing education
to sell their products and services." The seven member organizations
of the AACME (including that American Medical Association) "endorse
keeping continuing medical education separate from product promotion."
And "they believe the practice of commercial organizations
influencing continuing education is not in the public's best interest".
Dr. Sager then asks the question: "To what extent are commercial
inroads biasing your practice of dentistry?" He then went on to
paraphrase some of the ACCME's revised standards. While these may
not directly apply to dentistry, it interesting to contemplate how
they would cause dramatic changes in Dental CE as we know it, should
we consider adopting similar changes. They included (my paraphrasing):
1. The goal
of the CE program, the educational objective, content selection
and presentation, as well as those in a position to control them
- must be "free of the control of commercial interest".
a CE provider has a commercial interest, or is aligned with others
who have a commercial interest, there is an inherent conflict
of interest. Those in control of the CE must be free of conflict
in order to act in the best interest of the patient.
3. Non Profit organizations, government organizations and non-health
care related companies are permitted to participate in these decisions
but commercial organizations producing goods or services not free
of commercial interest cannot partner in these decisions.
4. The CE provider (or in our case the body that oversees
the issuance of CE credits) should have a mechanism to determine
whether those in control of the CE have a conflict of interest. In that case, they should choose someone else who does not have
this conflict of interest. (Editor: Should the credit for these
CE hours be withheld - if the CE is merely a glorified "infomercial"
for a product? Who decides this?")
5. Presenters must disclose any financial conflict of interest
before speaking. Disclosure of the relationship (to include
company name) is allowed but mention of the trade name is NOT.
6. The CE provider must make all decisions regarding the use of
financial support from commercial organizations. This means that the supporter cannot require that the CE provider accept
advice, services, teachers and course content OR restrict discussion
to THEIR products.
7. The provider is NOT permitted to use commercial funding to
pay for travel, lodging, honoraria or personal expenses of the
CE learners. Commercial funding may be used for the provider's
employees, joint sponsors, and educational partners such as teachers
8. All educational content must be separate from promotional activities,
materials and messages. Product specific advertisements cannot
be part of educational slides, abstracts, handouts, or visible
as pop ups or ads on web sites. A commercial entity's promotional
materials cannot be displayed in the educational space before,
during or after the CE activity.
9. CE contents must promote improvements in quality of healthcare
and NOT a specific commercial business interest. "Presentations
must be balanced and if "trade names" are used - several companies
should be used. A balanced view of therapeutic options also means
that "No single product or service is over-represented in the
educational activity when other equal but competing products or
services are available for inclusion".
Dr Sager's article
concludes with these questions:
1. What can dentistry learn from the AACME recommendations?
2. Should Dentistry expand its disclosure requirements in a similar
3. Can we abide these recommendations and still hope to maintain
financial support from existing partnerships that we have in place
questions are difficult ones to answer. The AACME recommendations
seem to apply more to drugs and drug companies than they do to Dental
CE. But, as CE moves away from Educational Institutions to the popular
"Weekend Sponsored Seminar" or online CE format - How unbiased is
it? Is it really CE or is it sales? Dental CE has,
of late, come under the influence of the "Dental Guru" and big business.
It is easy for Dental manufacturer/suppliers to contract the "Hot
Clinician of the Year" to speak on their behalf. Some clinicians
receive a % of sales through patents or design fees. Others have
been lured by speaking contracts, or "consultant fees". It is even
more disquieting when you find a Dentist moving from company to
company (i.e./ product to product) in search of more money…all the
while claiming that the product they are NOW representing is an
improvement on the last one that they were touting only months before.
It makes one cynical, indeed.
the next time you see a speaker at your local CE program or online
(INCLUDING ME !!) , consider these questions in the back of your
mind as you listen to or read the information:
the speaker make a full disclosure before he starts speaking? IE/ Does he explain his bias before the presentation in order
to be totally honest with the audience? What's he selling?
the speaker have a patent on the material or instrument that they
are discussing? Is he a paid consultant? i.e. / is he
personally benefiting financially from a sale to you today? Caveat
he is a "clinician", how much clinical practice is he currently
doing? Or are the consultant fees/royalties so high that
shilling the product is equally, or more lucrative than private
practice. What does THAT tell you?
the speaker recognize your demographics and practice situation? (E.g./ How practical is it for YOU to toss $55 or $60 worth of
Ni-Ti files after one usage when he gets his files for free!!)
the speaker "Jumped Ships" recently? And why is that?
Did they pay him more?
6. Does he
compare his product with competitors and mention the competitor's
strengths vs. that of the product he is discussing? Does he mention
any problems with the product he is recommending or is it the
much research has been done with the product that has NOT been
funded by the manufacturer or inventor? Is this product
so new that HE is the only one with data that supports it conclusively?
Is the product "ready for prime time"? You don't want to find
out that it isn't - 5 years later!
DMD or DDS is not simply a degree that allows you to work in patient's
mouths. It also confers upon you certain responsibilities
that don't end when you finish school. Don't just rely on
the speaker, suppliers and free journals. Keeping current means
reading, researching and having a certain level of healthy skepticism
when you attend CE. Remember, having a broad knowledge base is your
best defense against those who want nothing better tan to sell you
their latest "wunderproduct". BTW, when putting together the web site
www.endoexperience.com, I made a conscious decision NOT to take
advertisement or money from manufacturers. In that way, I can provide
you with opinions untainted by commercial influence.