Industry payments to family medicine residents in Portugal: a descriptive analysis of the national transparency database

Abstract

Objective

To analyse payments made to family medicine residents by the pharmaceutical industry during their residency in Portugal, using mandatory disclosure data.

Design and participants

Cohort study of residents starting their family medicine training in 2015, using data collected from the public national transparency database (Plataforma de Comunicações Transparência e Publicidade). Payments were categorised into six groups, including scientific meetings, educational activities, travel allowances, fees, gifts and undetermined.

Main outcome measures

Number of payments and the total value received by family medicine residents during their training period; number of payments according to their nature (six categories); number of payments and total value by paying entity.

Results

We analysed data of 457 family medicine residents. A total of 2790 payments were made to 424 (92.8%) residents, amounting to €826 271.14. Thirty-three residents did not receive any payment. The median number of payments per resident was 5 and the median amount received per resident was €1309.51. Residents who ranked in the top 25%, according to value received, were subsidised more than €2500.90 over the course of their residency. This subset of residents received 59.1% of the total amount disbursed in payments. Payments were primarily for attending scientific meetings (80.9%) and educational activities (17.1%). The top 10 paying entities accounted for 69.2% of the total amount paid.

Conclusion

Pharmaceutical industry funding for family medicine residents was highly prevalent, raising concerns over industry influence on medical education, while payment distribution was heterogeneous.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Portugal’s mandatory disclosure policy allows for a comprehensive analysis of the industry’s role in funding family medicine residents’ education.

• We analysed the total amount of overall industry payments to a group of residents who began training in 2015, including each payment category and the top 10 pharmaceutical companies involved.

• Rather than limiting our analysis to the expected 4 years, we extended it until the actual completion of residency programme.

• One limitation is that the analysed payment reports provided limited information regarding the purpose of the funding.

• Our analysis is limited to payments exceeding €60, the threshold for mandatory disclosure, and may result in underestimating the industry’s funding of residents.

Introduction

Residency plays a critical role in a physician’s career by equipping them with the essential skills and knowledge required to attain professional autonomy. However, this period of intensive learning also imposes financial burdens on trainees, as they often participate in scientific meetings and medical education activities to stay current in the constantly evolving field of healthcare. In recent years, the cost of these activities has increasingly been borne by the pharmaceutical industry, as government and professional organisations do not typically cover these expenses.

Pharmaceutical industry sponsorship of medical education undermines the objectivity and impartiality of information, ultimately harming the quality of patient care and increasing costs in healthcare.^1–6 Exposure to drug promotion during earlier stages of professional development may influence subsequent behaviour, including receptiveness to pharmaceutical promotional messages.⁷

The 2009 Institute of Medicine report² has served as a foundational document in this field, proposing key recommendations. These include the implementation of policies that prohibit trainees from establishing relationships with the industry, the inclusion of curriculum content addressing the potential effects of drug promotion, and the establishment of alternative funding sources for medical education. Reflecting on the past decade since the release of this report,⁸there are indications of some positive effects,⁹ although concerns still persist.

Despite increasing apprehension, Europe remains heterogeneous in terms of transparency policies, with only a few countries implementing legislation on disclosure of payments made to healthcare professionals, while others adhere to a self-regulatory and industry-led approach, under the European Federation of Pharmaceutical Industries and Associations code.^{10 11}

In 2013, Portugal implemented a mandatory disclosure policy, with all data published in an online public database called the Plataforma de Comunicações Transparência e Publicidade (https://extranet.infarmed.pt/pmro/Publico/ListagemPublica.aspx). This database provides a comprehensive list of payments made by the pharmaceutical industry that exceed €60, including information such as donor, recipient, amount and purpose of payment. Family medicine (FM) is a 4-year postgraduate training programme that mainly takes place in primary care units under the public national healthcare system. Its structure and educational content are regulated by both state and national/regional committees for FM residency, without affiliation to academic institutions. The curriculum includes content ranging from general clinical areas to more specific rotations in paediatrics, gynaecology/obstetrics and psychiatry. The regional FM residency committee arranges both mandatory and optional medical education courses. Mandatory events take place usually once per year, while optional activities and courses are usually more frequent. However, due to high demand and limited availability, residents must participate in a lottery system to secure a spot for the optional events. This scarcity leads FM residents to seek supplementary medical education opportunities elsewhere, including industry-sponsored events. Currently, in Portugal, there are no national policies regarding interactions of medical students or residency trainees with pharmaceutical companies. The great majority of medical education activities, ranging from courses to conferences, have some degree of pharmaceutical sponsorship. Most of these activities lack formal accreditation or independent validation to ensure the absence of drug promotion in the educational content, unlike the US ACCME standards.¹²

FM residents are a crucial population for studying industry-sponsored educational events for several reasons. First, they represent the largest group of residents nationwide, accounting for approximately one-third of all annual residency placements. Their front-line position in healthcare and widespread distribution across the country make them an ideal focus for such studies. Additionally, the comprehensive nature of FM clinical practice, which encompasses prescribing a diverse range of medications, may render FM residents an appealing demographic for drug promotion initiatives.

The extent to which the pharmaceutical industry sponsors FM residents in Portugal is widely unexplored. The aim of this study is to characterise the nature, prevalence and magnitude of these financial ties between FM residents and the pharmaceutical industry using the national transparency database.

Methods

We conducted a secondary analysis of industry payments to FM residents who started training in 2015. Data were collected from March to July 2022.

The list of residents, which includes name, gender and region of placement, was obtained from the public lists of the Central Administration of the Health System (https://www.acss.min-saude.pt//2016/09/12/internato-medico/). FM residency typically lasts 4 years, but completion dates can vary due to factors such as parental or sick leaves. To address this, we compared our initial list to public records of residency completion between 2019 and the first half of 2022. Residents who switched specialties or did not complete their residency by June 2022 were excluded.

In certain instances, two residents shared the exact same first and last name (homonymy). Since the database lacked unique identifiers, we tried to mitigate this issue cross-checking the platform’s entries with information from the Portuguese Medical Board (https://ordemdosmedicos.pt/medicos-registados-na-ordem-dos-medicos/) and annual reports of primary care health units (BI-CSP, https://bicsp.min-saude.pt/pt/contratualizacao/planosdeacao/Paginas/default.aspx). Payments were excluded when it was impossible to unequivocally associate them with a specific individual.

To assess the financial contributions received by residents during their training period, we obtained the corresponding data from transparency database, which included information on the source, recipient, total amount and purpose of payment. In contrast to the US Open Payments database, where payments are categorised by nature (eg, consultancy fee, food and beverages), the Portuguese transparency database presents information as it is provided by a third party (usually the sponsor) as free text, without any predefined categorisation or distinction of the sponsorship content. For this reason, we had to develop a system to categorise the information for subsequent analysis. We used six categories, as described in table 1. The categorisation process was performed independently by two investigators. In case of doubt or disagreement, the nature of the event was categorised as undetermined.

Table 1.

Definition of the subcategories of payments disclosed

Category	Description
1—Scientific meeting	Conferences, seminars and industry symposia
2—Educational activities	Courses, workshops, masterclasses
3—Travel allowances	Travel and accommodation fees, food and beverages
4—Fees	Advisory boards, consultancy, speaker fees
5—Gifts	Books, journals or medical software subscriptions
0—Undetermined

Descriptive analysis was performed using Microsoft Excel. Cost variables were expressed in Euro.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

Our original sample comprised 496 residents; however, it was reduced to 457 after excluding 38 residents who did not complete their residency by June 2022 (figure 1), while one was excluded due to the risk of homonymy. Female residents were 327 (71.6%).

Figure 1.

Study population with included and excluded residents. FM, family medicine.

During the training period, residents received a total of 2790 payments, amounting to €826 271.14. Thirty-three residents (7.2%) did not receive any payment. The median number of payments per resident was 5, ranging from 0 to 31. The median amount received per resident was €1309.51, ranging from €0 to €10 040.04. The median amount per payment received was €210, ranging from €30.12 to €2684.49. The top 25% represents residents receiving more than €2500.90 during their residency. The total amount received by these residents is €487 921.37 (59.1%), with a median value of €3683.55 per resident and a maximum of €10 040.04 (table 2).

Table 2.

Analysis of payments made to FM residents during their residency, with sub-analysis of the top 25% of the residents by total amount received

Measure	Amount paid per payment (€)	No of payment per resident (N)		Total amount paid per resident (€)
		Total	Top 25%	Total	Top 25%
Range	30.12–2684.49	0–31	3–31	0–10 040.04	2500.09–10 040.04
Median (IQR)	210 (248.01)	5 (7)	12 (6)	1309.51 (1255.63)	3638.55 (2065.35)

FM, family medicine.

Additional information about the gender and geographical distribution of recipients can be found in online supplemental table 1.

Most of the payments made were for attendance of scientific meetings (80.9%), followed by educational activities (17.1%), with other categories representing less than 2% each as shown in table 3. Online supplemental table 2 presents payment details categorised by the year of residency for residents who finished their training within the expected 4-year period.

Table 3.

Payments to FM residents classified per category

Category of the payment	No of payments per category (N)	%	Total amount (€)	%
Scientific meetings	2258	80.93	681 505.33	82.48
Educational activities	477	17.09	123 521.63	14.95
Travel allowances	19	0.68	4313.70	0.52
Fees	1	0.04	800.00	0.10
Gifts	6	0.22	2389.31	0.29
Undetermined	29	1.04	13 741.17	1.66
Total	2790	100	826 271.14	100

FM, family medicine.

Payments were made by 59 entities, with the top 10 paying entities totalling over 69.2% of the total amount (table 4).

Table 4.

List of top 10 paying entities by number of payments

Paying entity (name)	No of payments (N)	% of all payments	Total amount paid (€)	% of total amount paid	Mean amount per payment (€) (SD)	Maximum amount of a single payment (€)	No of residents funded (N) (%)
BIAL—Portela & Cª, S.A.	310	11.1	101 778.76	12.3	328.32 (309.86)	2272.83	161 (35.23)
Merck Sharp & Dohme	304	10.9	62 674.68	7.6	206.17 (154.57)	1040.95	180 (39.39)
Menarini Portugal—Farmacêutica, S.A.	285	10.2	64 186.24	7.8	225.21 (193.60)	1079.09	162 (35.45)
Boehringer Ingelheim, Lda*	275	9.9	94 979.87	11.5	345.38 (279.34)	1995.74	158 (34.57)
Tecnimede—Sociedade Técnico-Medicinal, SA	168	6.0	77 262.23	9.4	459.94 (274.03)	2684.49	120 (26.26)
Novartis Farma—Produtos Farmacêuticos SA	133	4.8	42 230.50	5.1	317.52 (213.55)	829.00	90 (19.69)
Servier Portugal Especialidades Farmacêuticas, Lda.	106	3.8	26 614.12	3.2	251.08 (245.74)	1360.26	79 (17.29)
Grünenthal, SA	105	3.8	31 948.90	3.9	304.28 (285.94)	2392.74	70 (15.32)
Merck, S.A.	103	3.7	37 116.58	4.5	360.36 (225.08)	897.00	73 (15.97)
Laboratórios Pfizer, Lda†	101	3.6	33 396.22	4.0	330.66 (191.30)	827.00	76 (16.63)

*Includes payment by Boehringer Ingelheim Portugal, Lda.

†Includes payments by Pfizer Biofarmacêutica Sociedade Unipessoal Lda.

All available information about the top 10 highest payments can be found in online supplemental table 3.

Discussion

Our study reveals that the majority of FM residents (92.8%) received at least one payment by a pharmaceutical company during their residency programme. The total amount received ranged widely, with a median value of €1309.51 per resident. Payment distribution was heterogeneous with the top 25% of residents receiving over half of all funding (59.1%).

The FM residency programme requires extensive learning, so payments for educational activities would be expected. However, our analysis found a striking predominance of scientific meetings (80.9%) over educational activities (17.1%). We hypothesised two reasons for this. First, residents’ final evaluation is more positively influenced by the number of posters and oral communications presented in scientific meetings than educational activities,¹³ thus leading to increased participation in such events. Second, when presented with limited and ambiguous information about whether an event was an educational activity or a scientific meeting, we chose to classify it as the latter, potentially leading to an over-representation of scientific meetings in our analysis.

Travel and accommodation allowances accounted for less than 1% of payments. This could mean limited support for these costs or undercounting in our analysis, as they may already be included in educational activity and scientific attendance payments.

The top 10 of the 59 subsidising pharmaceutical companies accounted for over half of the total funding granted. This aligns with results from a previous UK study,¹⁴ where funding was also concentrated among a set of large companies. Possible explanations for this concentration include differing levels of acceptance of funding by healthcare organisations, varied marketing strategies, available resources for payments and a wider scope of drugs marketed by these companies, reflecting the generalist nature of FM clinical practice.

These results show that pharmaceutical industry plays an important role in sponsoring educational activities for FM residents. This arrangement appears to benefit both parties, as it reduces costs for physicians (and healthcare systems) while allowing companies to promote their products.¹⁵ Residents often believe themselves to be more immune to industry influence than their peers.¹⁶ The influence of the industry can introduce bias that steers clinicians towards pharmacological interventions, potentially causing them to overlook non-pharmacological or preventive care,^17–19 which are essential in the FM setting. In a study conducted over 4 years, primary care physicians were often targeted and encouraged to prescribe specific, often cost-ineffective treatments for certain conditions during industry-sponsored events.¹⁸

The observed payment concentration on a small group of residents, as illustrated in table 2, may heighten concerns about its impact on prescribing behaviour, as prior research indicates a link between funding levels and the likelihood of prescribing sponsored products.⁶ Costly expenses such as research, courses and conferences, which are necessary for career advancement, may encourage dependency on pharmaceutical industry funding. A survey of urology residents in Europe found that most Portuguese residents spent over €2000 on education in the past year, which exceeded their base salaries. The drug industry funded 86.2% of these expenses.¹⁵

Limitations

Portuguese transparency platform has several limitations¹¹ that hindered its use as an effective tool for evaluating the financial relationship between pharmaceutical industry and FM residents. The quality of the data extracted, therefore, affected the subsequent analysis.

First, the use of free text instead of unique identifiers for recipients, with several typographical errors and duplicated information. Data analysis was also unnecessarily time-consuming due to the risk of homonymy.

Second, the lack of categorisation of the nature of payment. This limitation, combined with the lack of comprehensive information regarding the nature of the event, posed a challenge in accurately categorising the events. This potentially led to an overestimation of the scientific meetings category and to 1.66% of payments being categorised as ‘undetermined’.

Lastly, previous studies have shown that physicians commonly accept gifts such as office stationery, dinner invitations and drug samples from industry representatives.²⁰ However, in our analysis, we could not estimate this interaction due to the €60 reporting limit.

Conclusion

Our study shows that industry funding is prevalent among FM residents. Despite increasing concerns about industry influence in medical education, analysis of the nature, extent and value of these interactions has been limited. To our knowledge, this is the first study to comprehensively assess pharmaceutical companies’ contributions to FM residents in a European country.

Despite Portugal being one of the few European countries with mandatory disclosure policy, the national disclosure database does not ensure adequate data quality and accessibility, thereby hindering its ability to promote open and transparent information.

Having access to medical education is essential for ensuring high-quality healthcare services. Therefore, it is crucial for entities with responsibility in this area to assess the available data and take steps to improve accessibility and affordability. This includes exploring options for cost-subsidised training programmes and encouraging the development of such initiatives.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Our study protocol was appraised by the Ethics Committee of Lisbon and Tagus Valley Regional Health Administration (ARSLVT) and exempted from formal approval due to the public nature of data (#016/CES/INV/2022).