Monday, 23 Jul 2018

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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 is the Executive Editor of RheumNow.com and Co-Editor of 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

I miss those old days also.I'm employed at a VA center.Attending a dinner meeting is discouraged but if one must go,"brown bag it"--no eating from the kitchen.As government intrudes more,things will only grow worse.
Agreed, but Im glad you're one of the growing number of "brown-bag" rheumatologists who still go to the good meetings!
Yes, I agree but there is more to it. The Dartmouth study hits it on the head. A big culprit is "electronic health records" and ends up causing the physician an extra 2 hours after work (for me it is more). Physicians do not have the time to go to a dinner meeting and then back to the office for 2 more hours. Another big problem is the result of government intrusion. As you note we are treated as untrustworthy without any evidence base. We are viewed as being naïve, having only 8+ years post college, we are ignorant and we will succumb to pharma pressure and implied dishonesty in their messages to us. Even the pharma reps who have only had a college education or more, can only discuss the package insert. They are certainly not capable of holding a scientific discussion! How dare they try that! They are allocated as “Stepford Drug Reps.” The government mentality is that I am not allowed to have a company pen – thus I am now at a loss as to what to write for a prescription. Thank goodness I do not use a pen for the worthless inept, non-scientific based, electronic health record I am required to use. I actually have a paper chart to care for patients and EHR for gov compliance.
Time is clearly a culprit here, as well as money. Physicians may not have the time (busy office/EMR work) nor the funds (time away from office) to go to meetings. But whats the solution. If they dont make the time or sacrifice then there's the loss of commaraderie, learning and advancement. Atlanta's MARS group was a leader in the effort to bring rheumatologists together for great interchange -- I hope MARS continues to lead and find ways to meet and bring people out!
Actually, we still do - now less CME, Less turnout, announce CME and pharma programs for those who wish to attend. The raping of healthcare by the regulatory mandates, PBMs, Insurance companies continues its inroads into care. I have my paper chart to care for patients and EHR to address the regulatory environment. I always ask do you want your physician to spend his or her time responding to regulatory nonsense or would you prefer they spend their time to review the literature and see what really might help our patients?
The rheumatologists of our region in the mountains of western North Carolina have met ~quarterly for dinner meetings for the last 17 years. I agree that it is an important forum both for education and perhaps more importantly to facilitate the relationships amongst the rheumatologists here. I do feel strongly that funding by the pharmaceutical industry can introduce bias, and though we appreciate greatly that pharma has brought us some amazing internationally recognized speakers over the years, we have progressively weaned ourselves off their funding without any reduction in the quality of the educational experience. We accomplished this firstly by paying for our own meals, and largely self educating, making use of the excellent talent we have here locally. And then starting a few years ago, our wonderful state society, the NC Rheumatology Association, began picking up the tab. I feel that the education and camaraderie generated by this journal club have been an invaluable contribution to my career as a physician and a rheumatologist.
I like the idea of searching for academic and educational support (as you have) to keep the ball rolling. Highly commendable - others should look to do the same! Thanks, JC