who funds doctors' education

what a year of doctors' education costs, and who pays it

American doctors are required to keep learning to stay licensed and board-certified, and that education is a $3.9 billion industry. In 2025 the accredited continuing-education system reported $3.85B of income across 1,518 accredited providers — a record. Where it came from [1]:

• Registration fees — $2.08B, 54%. Learners and their institutions paying for their own education. This is, and has always been, the largest single source.
• Commercial support — $842M, 22%. Money from what the rules call “ineligible companies”: drug and device makers, pharmacy benefit managers, and the marketing firms that serve them.
• Advertising and exhibit income — $847M, 22%. Booths in the exhibit hall, adverts in the journal. Industry money too, but a different kind, and the accrediting body is emphatic that it must be counted differently.
• Government grants and private donations — about 1% each.

The definition, quoted rather than paraphrased. Commercial support is defined in the accreditation Standards as “financial or in-kind support from ineligible companies”, where an ineligible company is one “whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients” [3]. Note the term: it is ineligible company, not “commercial interest” — that older phrase was retired in 2020, and the body's stated reason was to make clear that eligibility “is not based on whether an organization is for-profit or nonprofit but is based on its primary mission and function” [4]. Advertising and exhibit income is a separate line, and ACCME warns it “should be interpreted differently from commercial support” because it is “reported as provider-level revenue and … not assigned to individual accredited activities” [1]. This page never silently adds the two together.

the share has fallen by half, and the page leads with that

The version of this story that circulates is that drug companies fund most of doctors' continuing education. Twenty years ago that was nearly true. In 2005 and 2006, commercial support was about 49% of all reported CME income, and in 2007 it peaked in cash terms at $1.25 billion [2]. It has fallen more or less continuously since. In the one population that can be tracked consistently across the whole period — providers accredited by ACCME or by a state medical society — it was 10.3% in 2025 [1][2].

Why the line is broken twice, and why that matters more than the slope. The accrediting body changed its own ruler in 2011. In its words: “Through 2010, ACCME-accredited and state-accredited providers reported the monetary value of in-kind commercial support they received, and included that amount in their total commercial support numbers. Beginning in 2011 … accredited providers no longer included the monetary value of in-kind support and reported only the dollar values for funds actually received” [2]. So part of the 2010-to-2011 fall is definitional, not behavioural, and reading the slope across that band would be reading an accounting change as a change in conduct. The 2014 gap is simpler: it is in neither document we retrieved, so nothing is drawn there.

The honest summary is that the industry share fell while the dollars roughly held. Total reported income grew about 56% between 2015 and 2025 while commercial support grew far more slowly, so industry money was diluted rather than withdrawn. It is still $842M a year.

it did not leave. it concentrated.

The falling average hides the more interesting fact. Split the system by who accredits the provider, and the two halves are moving in opposite directions. Among the hospitals, medical schools and state-accredited providers most people picture when they hear “CME”, commercial support has fallen to 10.3% of income. Among jointly accredited providers — a fast-growing group of 206 organisations, 14% of the system — commercial support is 47.5% of their income, and they now take 67% of every commercial-support dollar in the system [1].

229 for-profit publishing and education companies take $673.5 million — 80% of all commercial support in the system. Schools of medicine and health sciences take $65.5 million. Hospitals and health systems take $17.1 million [1]. Inside the jointly accredited segment the concentration is even starker: 63 publishing and education companies account for $516.9 million of that segment's $566.5 million in commercial support — 91% of it [1].

The correction this table forces. “Drug companies fund medical schools' teaching” is close to backwards. Medical schools take under 8% of commercial support, and it is 18% of their own CME income. The money is concentrated in commercial firms whose business is producing accredited education — and those firms draw roughly a third of their income from it. If you want to know where industry money and accredited education meet, that is the address.

Why 2018 is a break, not a jump. Jointly accredited providers only enter this accounting in 2018, and the accrediting body annotates the break on its own charts: “In 2018, the launch of the Joint Accreditation Program and Activity Reporting System (JA-PARS) enabled jointly accredited providers to report program and activity data … into a single, unified repository. Before 2018, jointly accredited providers reported data into multiple accreditors' data systems” [1]. They existed before 2018; they were not in the total. So the whole-system headline series changes who is counted at 2018, which is why the chart above uses the consistent population instead. We verified this by arithmetic rather than assumption: the report's sub-tables for ACCME-accredited and state-accredited providers sum to its headline exactly for 2015–2017, and only with the jointly accredited table added do they sum exactly from 2018 on.

the rules changed — and not only in one direction

In December 2020 the accrediting bodies replaced the Standards for Commercial Support — first adopted in 1992 and updated in 2004 — with the Standards for Integrity and Independence in Accredited Continuing Education. Providers were required to comply with new or changed requirements by 1 January 2022 [4]. Five standards: the first three apply to all accredited education, the fourth only where industry money is taken, the fifth only where marketing sits alongside teaching [3].

What genuinely tightened [4]: the disclosure lookback doubled from 12 to 24 months; providers must now collect all financial relationships and decide relevance themselves rather than letting individuals pre-filter; disclosure to learners must now include a statement that relevant relationships have been mitigated; faculty may not market or sell their own products during accredited education; providers must get learner consent before passing names or contact details to industry; and a 30-minute interval must separate accredited education from marketing in the same room. Research grants count as financial relationships even when the money goes to the institution rather than the individual.

And what loosened — printed here because a page that hid it would be propaganda. In the accrediting body's own words: “Effective immediately, accredited providers no longer need to: Collect disclosure information from individuals in control of content about the relevant financial relationships of their spouses or partners … Identify, mitigate, or disclose relevant financial relationships for nonclinical activities, activities where the learner group is in control of content, or self-directed activities” [4]. The stated reason for the first is privacy law. And Standard 4 — the standard governing the money itself — was not tightened. Its summary of changes reads, in full: “Simplified guidance about decision-making, documentation, accountability, and disclosure to learners. Clarifies that accredited providers can sign onto an existing commercial support agreement.” During drafting a proposed restriction was also dropped: “We removed the proposed requirement prohibiting joint providers from paying or reimbursing expenses to individuals such as faculty” [4].

The defensible sentence is therefore narrower than “the rules were tightened”: the rules on disclosure and on separating education from marketing were tightened and took effect in 2022; the rules on the money itself were simplified, and one proposed restriction was dropped before publication.

Whether any of it worked is unmeasured. The accrediting body said it expected “to begin measuring compliance after the transition phase” [4]. We searched the peer-reviewed literature two ways for a published evaluation of the Standards' effect and found none. Its chief executive published an account of the changes in JAMA in 2021, but that article is closed-access with no abstract, so this page cites its existence and quotes nothing from it. The rules changed; the effect of the change has not been published.

does the funding change what doctors prescribe?

This is the question the whole page exists to reach, and the honest answer is that the evidence is far thinner than the confidence with which it is usually asserted — in both directions. Three things are established, and they are not the same thing.

First: education changes practice at all. A Cochrane review of 215 studies covering more than 28,000 health professionals found that educational meetings “probably slightly improve compliance with desired practice” (adjusted risk difference 6.79%) and “probably slightly improve patient outcomes” (3.30%), at moderate certainty [6]. Note the verb — probably slightly — and note that this review says nothing about who paid. It matters because it closes the first link: if CME did not move practice, who funds it would be a much smaller question.

Second: contact with industry is associated with prescribing. A systematic review and meta-analysis of 19 studies found that 15 of them showed a consistent association between industry interactions promoting a medication and “inappropriately increased prescribing rates, lower prescribing quality, and/or increased prescribing costs”, with a pooled odds ratio of 2.52 (95% CI 1.82–3.50) and moderate-quality evidence [7]. Two qualifications are mandatory and both come from the paper itself: “None of the studies assessed clinical outcomes”, and the evidence was downgraded for risk of bias and inconsistency.

Third, and this is the finding: the CME-specific evidence is two studies. Inside that same review, the passage on continuing education reads: “Two studies assessed the effects of industry-funded continuing medical education on physician prescribing behaviors … Both studies found significant associations … The overall risk of bias was judged as high for one of them” [7]. The review's subgroup analysis found no difference by exposure type, meaning CME was pooled with detailing and free gifts rather than shown to be separately potent. And the two studies were published in 1988 [9] and 1992 [8]. That is the entire direct evidence base.

The 1992 study is worth reading closely, because of what it actually measured. It tracked pharmacy usage of two intravenous drugs for 22 months before and 17 months after symposia to which physicians were flown on “all-expenses-paid trips to popular sunbelt vacation sites”. Usage of one drug more than tripled and the other more than doubled, both diverging from national patterns. The physicians interviewed beforehand said such an enticement would not affect their prescribing [8].

And the practice it measured is now prohibited. Standard 4.1.c: “The accredited provider must not use commercial support to pay for travel, lodging, honoraria, or personal expenses for individual learners or groups of learners in accredited education.” Standard 4.1.a: “Ineligible companies must not pay directly for any of the expenses related to the education or the learners” [3]. So the strongest primary evidence that industry-funded medical education moves prescribing is thirty-four years old and describes conduct the current rules forbid. Anyone citing it as a description of CME today — including anyone citing this page — should say that too.

What the accrediting body's own review concluded. A 2014 literature review, commissioned and funded by ACCME and cited here as such, reached this: “We did not identify any data-based articles to support or refute the assertion that commercial support produces bias in accredited CME” — adding that physicians perceive very low levels of commercial bias (3–5% on average) and that the same level is reported for commercially supported and unsupported programs [10]. It also conceded the other half: earlier work found “limited evidence showing that CME activities funded by commercial interests can be effective in changing physicians' prescribing practices”, but “with no studies addressing the impact of these prescribing changes on patient care, they could not determine if the changes were or were not in the best interests of the patient” [10]. It called for rigorous studies to settle the question. Twelve years later we could not find them.

Two measurements, pointing different ways, both worth knowing. A study of 213 accredited programmes found a median 97% of attendees reported no commercial bias, and no association between the extent of commercial support and perceived bias — with the authors' own caveat that “further study is needed to determine whether commercial influence persisted in more subtle forms that were difficult for participants to detect” [11]. Meanwhile a survey of 770 clinicians found 88% believed commercial support introduces bias, with larger amounts posing greater risk — yet only 15% supported eliminating it and 42% would pay higher fees to reduce it [12]. Doctors believe the money biases the teaching, do not perceive bias in the sessions they personally attend, and mostly do not want the money removed. All three are measured facts about the same profession.

why none of this is in the federal transparency database

The United States runs a public database of drug- and device-company payments to clinicians. It is called Open Payments, and our page on pharma and the news uses it. It reported $3.92 billion in general payments for 2025 [15]. It contains almost none of the $842M above — and that is by regulatory design, not oversight.

The history is genuinely surprising. The original 2013 rule carried a bespoke exclusion for speaking at continuing-education programmes accredited by any of five named bodies. CMS deleted it in the 2015 physician fee schedule rule, effective for data collected from 1 January 2016, partly because naming five accreditors had been read as an endorsement [13]. But deleting it changed little, because a broader exclusion still applies. In CMS's own words:

“When an applicable manufacturer or applicable GPO provides funding to a continuing education provider, but does not either select or pay the covered recipient speaker directly, or provide the continuing education provider with a distinct, identifiable set of covered recipients to be considered as speakers … CMS will consider those payments to be excluded from reporting under Sec. 403.904(i)(1).” [13]

Now read that against Standard 4.1: “The accredited provider must make all decisions regarding the receipt and disbursement of the commercial support” [3]. The independence the accreditation rules require is exactly the condition that makes the money a non-reportable indirect payment. The rules that keep industry money at arm's length from the teaching are the same rules that keep it out of the federal database built to make industry money visible. Roughly $842M a year is disclosed — by the accreditor, not by the government, and only in aggregate. There is no public record of which company supported which course.

What Open Payments does show for education is worth its own look. In 2025, payments to clinicians for speaking at venues that are explicitly not continuing education came to $751.9 million across 249,154 records — promotional speaking. Payments for serving as faculty at a medical education program came to $34.1 million [15]. Promotional speaking outside accredited education is twenty-two times larger than speaking inside it.

And that $34.1 million category got less informative in 2021. The 2020 fee schedule rule merged two separate categories — accredited/certified continuing education and unaccredited/non-certified — into one. The objection is on the record in the rule itself: “One commenter disagreed with the consolidation … because they believe that the difference between accredited/certified and unaccredited/non-certified is significant in potential manufacturer influence.” CMS's answer: “By aligning to the terminology provided in the statute, we are streamlining data reporting. We do not believe that the change … will detract from the context of the data” [14]. Since 2021 it is not possible to tell from this dataset whether a speaking payment was for accredited education or not.

what about medical school and residency?

This page is weighted toward continuing education for a reason: it is the only stage of a doctor's training whose industry funding is publicly accounted for, year by year, by the body that accredits it. No federal agency publishes industry funding of medical schools or residency programmes, and no current peer-reviewed series exists. The best citable measurement is twenty years old.

A national survey of department chairs at all 125 accredited US allopathic medical schools and the 15 largest independent teaching hospitals, fielded in 2006 with a 67% response rate, found that among clinical departments 65% received industry support for continuing medical education and 37% received industry support for residency or fellowship training; 19% received unrestricted funds for department operations. Sixty percent of chairs had a personal financial relationship with industry [16].

The counter-finding from the same survey, and it is a familiar shape. More than two-thirds of chairs perceived that their own industry relationships had no effect on their professional activities — while 72% judged that a chair holding more than one industry role would have a negative impact on the department's ability to conduct independent unbiased research [16]. The risk was visible in colleagues and invisible in the mirror. That is the most consistent finding in this entire literature, and it is the reason disclosure rules exist at all.

These numbers describe 2006. We are printing them with the year attached and no suggestion that they describe today, because nothing published since would let us say.

the report that asked for a different system

In 2009 the Institute of Medicine published the most-cited assessment of conflicts of interest in American medicine. Its Recommendation 5.3 was unambiguous:

“A new system of funding accredited continuing medical education should be developed that is free of industry influence, enhances public trust in the integrity of the system, and provides high-quality education. A consensus development process … should be convened to propose within 24 months of the publication of this report a funding system that will meet these goals.” [5]

The committee published its own strongest objection alongside it. From the same chapter: “Most committee members believed that a near-term end to industry funding would be unacceptably disruptive for the major providers of accredited continuing medical education, including medical schools and professional societies, which together provide 68 percent of the total number of hours of this type of education. A SACME survey found that 77 percent of respondents said that immediate elimination of commercial support would substantially reduce the number of courses at their academic centers” [5]. A report calling for industry money to be replaced also recorded that removing it quickly would shrink the teaching. Both halves are the committee's.

The 24-month deadline was 2011. The replacement funding system was never built. The industry share fell anyway — from 49% in 2005–06 to about 26% by 2013 and 10.3% by 2025 in the comparable population [1][2]. This page does not claim the report caused that: the decline was already under way in 2008, before the report was published. The rules changed, the money shrank as a share, and the causal arrows between those two facts are not something we can source.

One more thing sits in that report, from an earlier congressional review of educational grants. It found that ACCME's own compliance record documented cases of undue influence over “supposedly independent educational programs” — in 2005 and 2006, 18 of 76 program providers were found out of compliance with at least one accreditation standard related to independence — and, in the same review, that most large manufacturers had by then established written grant policies, stopped sales representatives soliciting grant requests, and centralised grant administration [5]. The problem was documented and the conduct changed. Both are part of the record. We cite this at second hand, through the IOM report, because the congressional document itself could not be retrieved.