Wednesday, 20 Mar 2019

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Best of 2018: Death of the Dinner Meeting

Many years ago, rheumatologists would assemble with lunar regularity to discuss cases, journal articles or listen to a great visiting speaker or leader in rheumatology. While many of these meetings occurred at a local eatery, they were more about the meeting than the eating.

These dinner meetings were common in big cities and smaller hamlets. For many, these were either “can’t miss” events or a last minute decision based on the speaker’s resume, topic or the learning vs. life challenge.  

Dinner meetings were the rheumatologist’s version of guys-night-out or the monthly book club.  Convivial gatherings designed to stay abreast, yet these meetings renewed the fellowship that made rheumatology a tight knit, community of positive, like-minded practitioners.  

Not all could attend the annual big conventions and thus these local programs were their only dose of bread and butter education.  In smaller venues, the regular prescriber could hear from the masters and rub elbows with researchers who were leading the field.

Initially it was easy for a community leader to request financial support from any drug company to bring in a well-known educator to talk on any subject and the cost of the venue, meals, speaker travel and honorarium would be managed by societies or medical education companies.  

With time, pharmaceutical company representatives played a greater role organizing and promoting dinner meetings for the communal (and possibly company) welfare. But still these programs rolled on.

But the dinner meeting disappeared, and I think it’s a shame.

Sometime between the Kodachrome slide and PowerPoint laptops eras, the dinner meeting went face down, never to be seen again.  Some speculate it’s been buried in red-tape or under Morton’s steakhouse or that Lefty the Lawyer got to her. 

For some time I’ve been wanting to write about the “death of the dinner meeting” with the cheeky idea of turning it into a “who dunnit” murder-mystery tale, as in who killed “Dinah Meeten”?

However, such treatment of the evolution was neither clever, nor humorous; and lacked what should have been lessons learned. 

So, who’s to blame?  Blame is called for when you don’t like the outcome. It’s also the game played when politics go bad or some say it’s the lazy way of dealing with chaos.

Politics and chaos played leading roles in the reforms that led to the governance of physician-pharmaceutical relationships. Beginning in 1998, numerous entities and powers began to define the physician’s moral-ethical high ground. Many were motivated to protect physicians from themselves and their entitlement issues as they dealt with pharma and education. 

Was the industry educational (dinner) meeting an oxymoron (as are military intelligence, congressional ethics or airline food)?  Many worried as funding increased for dinner meetings, so did the risk of commercial bias in the topics, speakers, nominal tchotchkes being thrown about. What once was a benefit was now viewed as detriment to the education of a community.  

Even though local docs affirmed their control over the content and speakers deterred any effort by a sponsor to tip the marketing balance in their favor, the dinner meeting concerns led to a change in regulation and focus. 

Blame? I’m pretty sure it wasn’t the waiter, rheumatologist or sales rep that killed the dinner meeting. The pharma sales reps (PSRs) were once major advocates for quality local education. But the new rules limit their practices and interactions with prescribers. 

There was a sequence of political, ethical and fiscal evolutions that contributed to the chaos and later, demise of the dinner meeting. 

  • In 1998 the AMA published its guidelines for physician-pharmaceutical company relationships.
  • The Inspector General became concerned that promotional practices by pharmaceutical companies would result in more than inappropriate or unlawful product promotion.  Issues of healthcare fraud and abuse put the corporate practices under the microscope in a search for unethical or unlawful corporate conduct.
  • In 2003 the Department of Health and Human Services released a Compliance Program Guidance for Pharmaceutical Manufacturers ("CPG") in an effort to govern corporate behaviors and promotional policies. (Basically, the worry was that industry was paying off doctors to prescribe their drugs)
  • The US Sunshine act went into effect in 2014, requiring US pharmaceutical and medical device companies to fully disclose payments made to or on behalf of physicians for research, travel, meals, consulting fees and honoraria, etc.  This regulatory standard of transparency appears to keep the public and watchdogs informed, deter industry indiscretions and shame or deter physicians from greedful behaviors with companies.  Unfortunately, it has also sinisterized some physicians from participating in educational meetings or engaging in company sponsored research

This has lead to the current era of “buy your own pens, while I cater your office lasagna lunch and only offer dinner promotional (AKA package insert) talks”. There are “product theaters” or “innovation theaters” at regional or national meetings that are designed to educate and appease the company lawyers whose job it is to regulate content delivery and insure that physician interchange is minimized.

Is there a solution going forward?  If the goal is to promote physician fellowship, interchange and education, I believe there are several options and models that meet this need.

  1. CME accredited meetings:  a best option for many, plus it ensures a high level of education that is unbiased by companies or individuals. The problem is the task of applying for CME accreditation and funding is ardous to the point of being a deterrant to the local city or regional meetings.  Most CME today is delivered regionally by academic centers, medical education companies or annual conference organizers.
  2. Promotional programming: The content is organized, legalized and delivered by sponsor selected speakers (who usually have to undergo company directed training). Topic can be on their drug of disease state of commercial interest or can be “nonpromotional” general issues somewhat related to the company’s marketing plan. With these efforts and “slide decks”, all the content is reviewed by regulatory and legal folk whose sole job is to protect the brand and avoid misconception, uncontrolled discussion, and off-label discussion or case discussion. I’m not a big fan of promotional lectures. While they always contain meritorious, evidence based, scientific content, they are lacking in the free exchange of ideas and information. 
  3. Non-CME Educational Series: these are usually self-funded by educationally goal-driven physicians or can be supported by unrestricted educational grants from pharma, who do so as a corporate responsibility (to foster education) with no expected return on investment.
  4. ACR efforts: the ACR had been promoting local and regional meetings through their ASM programs.  Such programs are often focused on advocacy and advocacy issues for rheumatologists. 
  5. Internet and Social Media Learning groups: this would include twitter based “Rheumatology Journal Club” (#RheumJC) and the ACR’s listserv where a good discussion of a paper or issue can be had by like-minded practitioners. 
  6. Local Society Meetings: There are several successful local societies that are entirely self-funded.  This is primarily by dues, but may also be supported by external grants.  Such groups enjoy the freedom of creating an educational forum and format that most meets the needs of the constituency.

The disappearance of the dinner meeting has unfortunately created a void – in local education and fellowship. 

What have you done to meet this need where you practice?

 

Dr. Cush is the Director of Clinical Rheumatology at the Baylor Research Institute and a Professor of Medicine and Rheumatology at Baylor University Medical Center in Dallas, TX. He a Professor of Clinical Medicine at the University of Texas Southwestern Medical School.
 
Dr. Cush is the Executive Editor of RheumNow.com and also Co-Edits the online textbook RheumaKnowledgy.com. 
 
Dr. Cush's research and interests include novel drug development, rheumatoid arthritis, spondyloarthritis, drug safety, pregnancy and Still's disease/autoinflammatory syndromes. He has published over 140 articles and 2 books in rheumatology.
He can be followed on twitter: @RheumNow.

Rheumatologists' Comments

Besides being fun to attend for all the reasons you discuss, we and our spouses could socialize with many colleagues outside our specialty. We are all so isolated now as we communicate via the EHR. The requirement to stick to the slide deck also puts a damper on enthusiasm.
Besides being fun to attend for all the reasons you discuss, we and our spouses could socialize with many colleagues outside our specialty. We are all so isolated now as we communicate via the EHR. The requirement to stick to the slide deck also puts a damper on enthusiasm.
We have only to look at the allocation of physician time. The Dartmouth Study - We don't have time in the evening due to bureaucratic overregulation. The article in the December 6, 2016 Annals of Internal Medicine - Allocation of Physician "Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties" points this out. It concluded: During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.
The study concluded that: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. Therefore no time to be able to go to Dinner meetings, thus the "Death of the Dinner Meetings"
Ah....it wasnt the butler, lawyer or the Feds....it was the EMR that killed the dinner meeting! This is an important study that more people should know about. Thansk John!