Debate – The Canadian Association of Gastroenterology should follow the Canadian Medical Association guidelines for maintenance of certification : Agree

Aregional gastroenterology group requests the accreditation of a meeting that will provide an update regarding diseases of the gastrointestinal tract. The topics were developed by a committee without industry input and were based on a needs assessment. The speakers were not picked by industry. The expenses of the attendees and their guests will be paid by industry. Families and partners, but not physicians, will be charged a registration fee. The meeting will be held at a well-known resort and the registration will cover part of the expenses.

A regional gastroenterology group requests the accreditation of a meeting that will provide an update regarding diseases of the gastrointestinal tract.The topics were developed by a committee without industry input and were based on a needs assessment.The speakers were not picked by industry.The expenses of the attendees and their guests will be paid by industry.Families and partners, but not physicians, will be charged a registration fee.The meeting will be held at a well-known resort and the registration will cover part of the expenses.
Under Canadian Association of Gastroenterology (CAG) guidelines, this meeting would not be accredited under the Royal College Maintenance of Certification Program (MOCERT).It can be argued convincingly that this format of meeting is no longer acceptable because it is unethical for physicians to accept gifts from industry.Receiving gifts from industry creates a conflict of interest, decreases the credibility of physicians as advocates for patient needs and creates an environment where industry sponsors may influence the educational agenda.It is important to note, however, that no one is saying the meeting cannot take place.Physicians are perfectly free to attend any function they wish.The decision to not accredit the meeting simply means that it will not have the Royal College and CAG seal of approval.
Additional background to this controversy may be useful.In 2001, the CAG applied to the Royal College to become the designated accreditor of gastroenterology educational events for the MOCERT program.MOCERT was established, in part, to demonstrate to the public and the provincial medical colleges that the profession is capable of meeting its own educational needs.The integrity of this process is critical.Because many educational events are funded by industry, it follows that some rules need to govern the interaction of industry with the education providers.The College did not write its own standards, but adopted those developed by the Canadian Medical Association (CMA).As part of the CAG application, the CAG agreed to adopt the CMA ethics guidelines.This proposal was unanimously adopted by the board of the CAG and accepted by the CAG membership at the last annual general meeting in Montreal.
The Code of Ethics of the CMA is available on the Internet at www.cma.ca(1).It consists of two sections; the code itself, which consists of 43 statements, and a second section made up of a number of specific CMA policy statements.
CAG has accredited numerous meetings without difficulty.One issue surfaces repeatedly, however, and has consumed more of the education committee's time than any other.In section 24 of the CMA's policy on Physicians and the Pharmaceutical industry there is the statement that reads, "… the industry sponsor should not pay for travel or lodging costs or for other personal expenses of physicians attending a CME/CPD event" (2).Therefore, the CAG education committee does not accredit a meeting if physician travel and expenses, other than that for speakers, are paid.
The majority of industry sponsors and physician groups have had no difficulty in complying with these new realities.Some industry and physician groups continue to chafe at these restrictions.It is useful to consider why.One explanation may be that some companies use education events as marketing tools (3).The payment of physicians and physicians' families expenses is a gift.Gift giving is a powerful social act that influences physician behavior.The prohibition of this particular form of gift giving presumably interferes with an effective marketing strategy.
Why would physicians object?There are the palpable pleasures of expense-free trips to some of the country's best resorts.Some physician groups erroneously regard the decision of the CAG to withhold accreditation as a slight on the educational value of the proposed meeting.In addition, if a regional organization is unable to stage an accredited meeting, it is likely that future attendance and industry funding will decrease.
What is the ethical issue?Central to this debate is the concept of conflict of interest.Conflict of interest has been defined as "a set of conditions in which professional judgment concerning a primary interest tends to be unduly influenced by a secondary interest" (4).The primary responsibility of the physician is to the patient.Accepting gifts from industry creates a secondary interest, an obligation to the sponsor and a conflict between the physician's responsibilities to the patient and the industry sponsor.
In addition to the potential damage to the physicianpatient relationship, the development of even an apparent conflict of interest can damage the credibility of physicians with both government and hospital administration.If a physician accepts gifts from the manufacturer of a new product, can the hospital pharmacy, for example, consider the physician's advice unbiased?How can government rely on physician input if we are under an obligation to industry?Perhaps the more serious effect on patient care is not that the physicians may prescribe one drug over another but that we will lose our standing as patient advocates because of our apparent, or even perceived, conflict of interest.
Ethics and the law are not always congruent, but they are in this case.Physicians, because of their position of power in their relationships with patients, have both ethical and legal obligations.Physicians have a fiduciary duty to patients (5).Fiduciary duties, from the Latin word meaning trust, are those where one party is entrusted to protect the rights of another, weaker, party.Conflict of interest rules are established in Ontario legal precedents.
The CAG, CMA, and Royal College position is similar to that of other national organizations, including that of the American College of Physicians.The American College of Physicians has proposed a number of questions that physicians might find useful in deciding whether they should accept gifts from industry (6,7)."What would my patients think about this arrangement?What would the public think?How would I feel if the relationship was disclosed through the media?What is the purpose of the industry offer?What would my colleagues think about this arrangement?What would I think if my own physician accepted this offer?" The CMA guidelines are not the problem, but rather the solution to the problem of how to ensure that interactions between physicians and industry are both appropriate and seen to be appropriate.Accordingly, they deserve our strong support.

Can J Gastroenterol Vol 17 No 4 April 2003 284
Editorial