Why hasn't academic detailing caught on?

Reading this editorial by Jerry Avorn in today's Boston Globe about academic detailing got me wondering why this hasn't really taken off. Avorn, the so-called "father of academic detailing," has been critical of the commercially supported CME model and has long proposed academic detailing as a superior educational tool. While I'm not agreeing with that, I do agree that it could and probably should have a place in the CME continuum.

I'm guessing it comes down to money, since it has to be expensive to train and disseminate experts to educate docs at their workplaces on best practices for specific disease states. Avorn seems to think the agricultural Cooperative Extension Service could be a good model to base it on, and in fact cites some similar medical public service programs that he says are successful.

Now that the funding for a pilot program that was included in the original Massachusetts healthcare reform legislation looks to be fading away, who's going to pay for it in my (and Dr. Avorn's) home state? He suggests insurers, which seems like an odd choice for someone concerned about undue influence on education—I'd say insurers have a pretty big stake in what's prescribed, wouldn't you? And that industry doesn't have all the safeguards and firewalls in place that we already have for pharma and device commercial support of HCP education, so if anything that would raise the risk of bias sneaking in.

So we still have to ask, if academic detailing is such a good idea, who should pay for it? Or is there something else that impedes this form of education from becoming more mainstream? Is the model itself flawed in some way that I'm not seeing? Maybe today's plethora of high-quality online educational activities (commercially supported or not) and reference resources are already bringing the information to the docs' offices so "un-salespeople" aren't really going to add much to the mix anymore?

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