The Journal of the American Medical Association today has commentaries by Marcia Angell and Arnold Relman calling, respectively, for an independent agency to run new drug trials and eliminating industry's role in funding continuing medical education. Unfortunately, both ideas have garnered less support than efforts to reduce industry gifts and payments to physician/teachers at academic medical centers, the subject of a third commentary in today's JAMA.

With industry now providing half of the $3 billion going into organized CME, Relman asks if there isn't some alternative option for paying for physician education. "Physicians attending CME programs ought to be willing and able to pay something for their continuing education."

Actually, physicians don't pay for CME. Consumers through their insurers pay for CME. When drug companies provide the upfront money, consumers pay through higher drug prices. If doctors start paying for CME, then consumers will pay through higher physician fees. Why not get rid of the middle man -- the drug companies -- since the only role they play in the process is skewing the content to suit their own purposes.

It's also important to remember that physicians do not have a choice about attending CME classes or taking online CME courses. They are a requirement of maintaining medical licenses in virtually every state. Given the regulatory imperative behind CME, it is perfectly legitimate for states to begin amending their CME requirements to forbid classes paid for by industry. As I pointed out above, this is a no-cost solution this problem. It merely changes the path through which consumers pay.

In repeating the call in her 2004 book, "The Truth About the Drug Companies," for an independent drug testing agency, Angell suggests housing it within the National Institutes of Health. Given the repeated failures of major academic centers to police conflicts of interest and the powerful incentives in the law (the Bayh-Dole act) to steer basic science research toward patenting and commercialization (not necessarily a bad thing, in my view, although it badly needs reform to limit patent thickets that arise from commercializing of basic science insights -- another story), I don't think that is the right place to put it.

It would make more sense to push for this reform in the context of setting up a comparative effectiveness agency, which has received support from both candidates for president. Companies would pay user fees to an independent agency to get their new drugs tested, but clinicians either at that independent agency or at academic medical centers would design the protocols. The user fee would only apply to the company's drug. But if the independent clinicians who designed the trials thought a new drug needed to be tested against others in its class or against other classes of medicine for the same condition, those fees could be supplemented by taxpayer funds to get the comparative information needed to properly inform clinical practice.

Finally, a few thoughts on David Rothman's and Susan Chimonas' article on "New Developments in Managing Physician-Industry Relationships." They note that "a substantial body of research indicated that gifts, stipends, and honoraria from drug companies influenced physicians' treatment decisions." They offer three footnoted citations to studies in the medical literature to prove this claim. I wish they had directly attacked (and referenced) Thomas Stossel's work, where he repeatedly claims, both in the medical literature and on the website of the libertarian Manhattan Institute, that there is no evidence that gifts, payments and the like adversely affect patient care.

What hampers the movement to eliminate industry influence from academic medicine is not just its failure to rebut its more strident critics. It is the absence of a unifying principle by which to judge whether particular practices are injurious to the training of new physicians and subsequent medical practice. In my testimony before the Institute of Medicine last March (you can read the full paper here), I suggested such a principle. Industry should be forbidden from having anything to do with the diffusion of new technology.

Medical practice should be informed by science and the clinical evidence of what works best. The first steps in getting there is having an independently funded and administered agency to determine what the state of the science is, and a physician education system that doesn't rely on industry funding.