Whenever it feels like the sky is falling, the Pulse takes solace in one of grandma's favorite axioms on life: the truth always comes out in the wash. Nowhere is this more true today than in continuing medical education (CME). The trouble for all stakeholders is that CME, in terms of the "wash," is just entering the spin cycle. In just the past two months, we've seen the following cascade of activity and crises:

• The demise of a CME funding proposal from American Medical Association's Council on Ethical and Judicial Affairs. Why? The report on which the proposal was based lacked facts and confused certified CME with promotional activities.
• A literature review by the ACCME showing that no evidence confirms the alleged connection between commercial support of CME and alleged bias.
• An ACCME call for comment regarding enhanced monitoring and enforcement of policies and guidelines, as well as inquiries into what ACCME calls "high risk" organizations.
• A decision by Pfizer to limit certified CME grants to professional associations, academic centers, and hospitals.
• Inquiry letters from U.S. Sen. Charles Grassley (R-Iowa) to professional societies and pharmaceutical companies regarding close ties between individual physicians, industry, and societies.
• A New York Times article this week stating that 30 percent of the American Psychiatric Association's 2006 revenue came from industry support of journal advertising, exhibits, and the annual meeting.

  All of these proposals, investigations, and ideas originated with a simple truth. There have been and are examples where ties between pharmaceutical companies and others create conflicts of interest. The conflicts of interest need to be addressed tout suite. The trouble is that certified CME has a head start on dealing with conflicts, but it is still being confused with and tarnished by questionable practices in other areas. Since 2005, accredited providers have been required to identify and resolve conflicts of interest. But the U.S. Senate Finance Committee staff found enforcement of these rules lacking, according to the 2007 Senate Finance Committee staff report. Since then, there have been a mix of approaches - some based on getting at the truth and others at improving an organization's image, regardless of the truth. In an informal and unscientific polling of pharmaceutical, academic, professional society, med ed company, and accreditation board CME leaders, stakeholders classify recent actions as follows:

1. ACCME's move to monitor and enforce policies and standards? Truth-based.
2. ACCME's identification of some organizations as "high risk," in the absence of evidence to support this claim? Image-based.
3. Pfizer's decision to no longer provide grants directly to medical education companies, favoring societies and others? Image-based, especially given the fact that ACCME compliance data contradicts the decision and the recent NYT story shows there is no society or other "safe harbor" for grant dollars. Quality stems from an organization's integrity and deliverable, not its type or classification. "Pfizer's decision was not evidence-based," said a senior CME leader within big pharma.
4. Inquiry letters from the U.S. Senate? Evidence-based, mostly. The Senate is looking for the truth about ties between pharmaceutical manufacturers and any other organizations. But when it does not consider the progress and newer rules addressing conflict in certified CME, it may be looking for a scapegoat or throwing the baby out with the bathwater.

  One thing is for sure. The CME enterprise has been thrown into the wash with all other relationships between industry and the healthcare profession. It may take a few more cycles before we can remove the stains of the past and prove how clean we aim to be. The truth, however long it takes, will determine our future.