February 28, 2001
Number of members commenting: 4
The key issues were identified as:
The journal's editorial control of the material
Potential financial conflicts of interest for the journal
Extending the journal's "imprimatur" to the CME company
Whether this is advertising or something else (marketing)
The text of the original referral (verbatim from the requesting editor)
"A major medical journal has the opportunity to work with a company that offers online medical education. The online education company has proposed that they would develop an educational module to pair with each of 12 review articles the journal publishes. Each article would be accompanied by a sidebar, or box, that describes the online module and tells the reader how to access it. If the development of the module is supported by an educational grant from a pharmaceutical company (and all might be), the grantor would be identified. The educational module would be reviewed by the editors of the journal, and it would carry the brand of the journal and of the online company. The reader could work through the educational module online for free, but he or she would have to pay $10 to submit it for CME credit. More, with each module he visits online, the reader would be informed that the online company also has other modules unrelated to the journal—modules that are available on a subscription basis. The journal's parent organization would share in the subscription revenues.
In providing the sidebars directing readers to the online module, then, the journal would be helping readers enhance the value of the article and directing them to a source of CME. At the same time, though, it would be helping to promote the online company's subscription service and generate at least some income for the journal's parent organization. Should the journal agree to publish the sidebars? Do they constitute advertising? (If so, they would violate the journal's policy of not publishing advertisements within articles that deal with topics related to the advertisements.)"
The referring editor has confirmed they have complete control over the modules related to their articles, but not over the other materials on the CME site.
Synopsis of opinions:
Overall, committee members thought this plan had considerable potential for ethical problems and should not be implemented without further modification.
All were agreed that the journal should not be implementing this practice unless it has complete editorial control over the CME. If the journal has editorial control over the CME related to the review articles, but not to other materials on the Web site, that distinction needs to be made clear and probably should lead the journal to refuse to extend its "imprimatur" to materials it cannot control (since this inevitably will be construed as some form of endorsement).
If the journal has complete editorial control over only some of the materials on the Web site, this creates an opportunity for problems in that the CME company (or sponsoring pharmaceutical companies) may be willing to pay for only those pieces that serve their purposes or agree with their goals. The journal will need to have an explicit policy on what materials it approves, and why, and what the standards are.
All were also agreed that this situation provided ample opportunities for conflict of interest. The separation between journal content (and "endorsed" content) and the CME modules needs to be made very clear and the relationships between the parties openly and clearly disclosed.
Further (partial) individual comments from members
We need more data, but given what we do know, I don't favor this plan as it stands. At minimum, editorial control and conflict of interest issues need to be clarified, procedures for quality made transparent, and as clear a separation made as possible between the journal's content and these CME modules. Perhaps a sidebar is simply too close; have other, more "distanced" ways of linking the two been considered? I'm sure the CME company will argue that this defeats their purpose....Perhaps the bottom line here is an examination of the journal's policies to make sure this effort doesn't violate them, accompanied by clear and open disclosure of the relationships between the involved parties.
I think the key issue is whether the online company is going to derive monetary and "status" benefits by associating with the major medical journal. In effect, it seems that they will. The online company would benefit directly by letting more people be aware of their product(s), some of which may have nothing to do with the journal—this would constitute advertising and would lead to increased revenue. It is not clear whether the other online modules to which the reader may be directed have anything to do with the journal or its parent organization. In my opinion this practice would be a breach of the journal's policy of not advertising products which relate to the topic of the article.
The editors of the journal do seem to have editorial control over the content of the educational modules, but that isn't entirely clear. Announcing the modules in the sidebars makes the modules a direct extension of the journal. If there isn't an ironclad guarantee that the editors have total control, then announcing the modules in the journal shouldn't be permitted, and money shouldn't be accepted. If the editors do control that content, that's reassuring, and the money paid should be used to hire the additional editorial help needed to review and approve the educational content. This would, however, leave some other issues unresolved (see below).
Linkage to the journal gives the CME the journal's "imprimatur," which is obviously of value to the CME company and the potential pharmaceutical sponsors, since they're willing to pay for it. Money changing hands increases the potential for conflict of interest, and the possibility of content becoming slanted to serve the interests of the payor. (For example, a pharmaceutical company is likely to support only the CME pieces that favor its product(s). This is one reason many journals have a policy that doesn't allow them to publish supplements or any other material with a single commercial sponsor.) Both the image and the reality of direct support of a derivative product from the journal's articles are thus called into question by this particular direct financial arrangement. It contrasts with the usual advertising policy, in which advertising is totally separated from editorial decisions.
The proposal looks like marketing to me. Marketing is not the same as advertising: "Marketing 101" says that marketing includes product (what is it you're selling?), position (where does it fit into the market?), price (what will you charge for it?) and promotion (which includes advertising, but many other ways to "get out the message"). Just because the proposal doesn't include page ("display") ads doesn't mean it isn't marketing. If the journal's "advertising" policy is really a "marketing" policy (as it seems to me it should be), then the proposal is not consistent with its policy.