Abstract
This study evaluates adherence to industry and professional standards among physicians endorsing drugs and devices on a social media platform.
Physicians commonly receive financial payments from industry, totaling $2.46 billion in 2022.1 These payments can represent scientific collaboration but may involve marketing efforts without scientific benefits, raising concerns regarding their influence on clinical decision-making.2
Pharmaceutical marketing frequently includes peer-to-peer promotion, often through speaking engagements. Per industry standards, speaking engagements should feature physicians with relevant knowledge and experience to educate other health care professionals about manufacturers’ products.3 However, whether industry selects true experts for peer-to-peer marketing is unknown. More recently, a new form of peer-to-peer promotion emerged: endorsements on social media. We characterized this phenomenon and evaluated adherence to industry and professional standards.
Methods
This cross-sectional study followed the STROBE reporting guideline. This study was deemed exempt by the Memorial Sloan Kettering institutional review board. We used X (previously Twitter)4 to identify instances during 2022 of physician endorsement of a drug or medical device, defined as active participation in a marketing campaign (eg, not solely expressing a favorable opinion about a product). The search strategy (detailed in the eMethods in Supplement 1) included a broad set of terms associated with pharmaceutical marketing and additional searches for the names of all drugs first approved in 2021 and 2022 (anticipating these would be the most likely marketing targets). We included posts from physician and industry accounts whether the promoted product was explicitly named or implied.
We identified unique, US-based physician endorsers, excluding industry employees. Endorsements were categorized as industry-sponsored testimonials, posts, white papers, or webinars. Each physician’s H-index (a measure of academic productivity, with an H-index ≥20 regarded as accomplished [from Scopus])5 was recorded. Authorship of pivotal phase 3 trials, any clinical investigation, or any peer-reviewed literature related to the endorsed product was determined by searching PubMed from inception through 2022. We manually linked each physician to Open Payments and measured 2022 research payments (connected to formal research protocols) and general payments (unconnected to research). We measured total payments from all companies, payments from manufacturers of endorsed products, and the subset of payments from manufacturers related to the specific endorsed product. For comparison, we calculated the specialty-weighted mean of industry payments received by all physicians in 2022. Analyses were performed using Excel, version 16.47.
Results
Of 28 physician endorsers in 2022, 21 (75%) specialized in urology, medical oncology, or radiation oncology. The median H-index was 15 (IQR, 3-33); 68% (19 of 28) had an H-index less than 20 (Table 1). Fourteen (50%) had no publications related to the endorsed drug or device. Seventeen promotions (61%) were sponsored physician testimonials, with 8 of these (47%) having no disclosure of compensation.
Table 1. Promotion and Physician Characteristics.
| Physician or promotion characteristic | Physicians or promotions, No. (%) (N = 28) |
|---|---|
| Physician specialty | |
| Urology | 9 (32) |
| Medical oncologya | 6 (21) |
| Radiation oncology | 6 (21) |
| Gynecologic oncology | 4 (14) |
| Internal medicine | 2 (7) |
| Pulmonary and critical care medicine | 1 (4) |
| H-indexb | |
| <10 | 11 (39) |
| 10-19 | 8 (29) |
| 20-49 | 8 (29) |
| ≥50 | 1 (4) |
| Mean (SD) | 17 (15) |
| Median (IQR) | 15 (3-33) |
| Research involvement | |
| None | 14 (50) |
| Any peer-reviewed publication | 14 (50) |
| Any clinical investigation | 6 (21) |
| Pivotal phase 3 | 2 (7) |
| Manufacturer of endorsed product | |
| Boston Scientific | 15 (54) |
| GlaxoSmithKline | 6 (21) |
| Eisai | 2 (7) |
| Exelixis | 2 (7) |
| AstraZeneca | 1 (4) |
| Novartis | 1 (4) |
| Pfizer | 1 (4) |
| Product identification | |
| Specified | 23 (82) |
| Implied | 5 (18) |
| Endorsed product | |
| Device | 15 (54) |
| Drug | 13 (46) |
| Endorsement type | |
| Sponsored physician testimonial | 17 (61) |
| Sponsored post | 8 (29) |
| Sponsored white paper | 2 (7) |
| Sponsored webinar | 1 (4) |
| Physician received payment related to endorsed product without disclosure | |
| Sponsored physician testimonial | 8/17 (47) |
| Sponsored post | 0 |
| Sponsored white paper | 1/2 (50) |
| Sponsored webinar | 0 |
Sum of hematology medical oncology, hematology oncology, and medical oncology.
H-index is defined as authorship of N publications that have each been cited N times or more.
All 28 physicians received at least 1 general payment (Table 2), totaling $1 448 083 (mean [SD], $51 717 [$43 183]). The specialty-weighted mean of general payments received in 2022 across all physicians was $4492. Twenty-six (93%) received payments from the endorsed product’s manufacturer (totaling $713 976; mean [SD], $27 461 [$27 354]), and 24 (86%) received payments related to the endorsed drug or device (totaling $492 098; mean [SD], $19 684 [$22 530]). Of these drug- and device-related payments, the greatest dollar value was for speaking ($376 935; 77% of total) or consulting ($76 906; 16% of total). Although 10 physicians (36%) received research payments, only 1 received research payments related to the endorsed product (totaling $224 577).
Table 2. Dollar Value of Payments Received by Endorsing Physicians During 2022.
| Payment type | Physicians who received any payment, No. (%) | Value, $ | ||
|---|---|---|---|---|
| Total (% of drug payment) | Mean (SD) | Median (range) | ||
| General payment | ||||
| Overalla | 28 (100) | 1 448 083 | 51 717 (43 183) | 51 237 (71-136 026) |
| Companyb | 26 (93) | 713 976 | 27 461 (27 354) | 17 373 (42-83 567) |
| Drugc | 24 (86) | 492 098 | 19 684 (22 530) | 8222 (83-83 567) |
| Nature of paymentd | ||||
| Food and beverage | 20 (71) | 6894 (1) | 345 (269) | 276 (68-978) |
| Speakinge | 18 (64) | 376 935 (77) | 19 839 (17 321) | 16 340 (800-56 400) |
| Consulting | 12 (43) | 76 906 (16) | 6409 (6088) | 5169 (894-20 613) |
| Travel and lodging | 12 (43) | 31 363 (6) | 2614 (2287) | 2172 (138-5984) |
| All other categories | 0 | 0 | NA | NA |
| Research payment | ||||
| Overall | 10 (36) | 3 712 849 | 371 285 (382 951) | 321 213 (660-1 249 632) |
| Company | 1 (4) | 224 577 | NA | NA |
| Drug | 1 (4) | 224 577 | NA | NA |
Abbreviation: NA, not applicable.
Dollar value of all payments within the indicated Open Payments category.
Payments from the drug or device manufacturer whose product the physician endorsed.
Payments related to the specific drug or device that the physician endorsed.
Analysis pertains only to the drug payment subcategory.
Compensation for serving as faculty or as a speaker for a nonaccredited and noncertified continuing education program.
Discussion
This study of social media–based drug and device endorsements found that most physicians participating in endorsements on the studied social media platform received general payments from the manufacturer related to the endorsed product. The conflict of interest between the manufacturer and endorsing physician may not be apparent to the general social media audience as these connections were not consistently disclosed in posts.
Most endorsement-related payments were for speaking, which is typically a marketing activity, as opposed to consulting, which may indicate scientific involvement. Physicians’ involvement in research was limited, raising doubts regarding whether physician selection was driven by scientific expertise in accordance with industry standards. Federal regulators view deviation from industry standards on physician engagement as potential evidence of violation of federal statute.6
Study limitations include small sample size, use of 1 social media platform, potential incomplete capture of endorsements, uncertainty regarding whether payments were specifically endorsement related, and a search strategy that included drugs but not devices.
Physicians’ participation in industry marketing raises questions regarding professionalism and their responsibilities as patient advocates. If the medical profession fails to self-regulate these arrangements, governmental intervention may become necessary to uphold standards.
Section Editors: Kristin Walter, MD, and Jody W. Zylke, MD, Deputy Editors; Karen Lasser, MD, MPH, Senior Editor.
eMethods.
Data Sharing Statement
References
- 1.Facts about Open Payments data: 2022. Centers for Medicare & Medicaid Services. Accessed March 13, 2024. https://openpaymentsdata.cms.gov/summary
- 2.Mitchell AP, Trivedi NU, Gennarelli RL, et al. Are financial payments from the pharmaceutical industry associated with physician prescribing? a systematic review. Ann Intern Med. 2021;174(3):353-361. doi: 10.7326/M20-5665 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Code on Interactions With Healthcare Professionals. Pharmaceutical Research and Manufacturers of America. 2009. Accessed April 10, 2024. https://natap.org/2008/HIV/PhRMAMarketingCode2008.pdf
- 4.Pershad Y, Hangge PT, Albadawi H, Oklu R. Social medicine: Twitter in healthcare. J Clin Med. 2018;7(6):121. doi: 10.3390/jcm7060121 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hirsch JE. An index to quantify an individual’s scientific research output. Proc Natl Acad Sci U S A. 2005;102(46):16569-16572. doi: 10.1073/pnas.0507655102 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Mitchell A, Sarpatwari A, Bach PB. Industry payments to physicians are kickbacks: how should stakeholders respond? J Health Polit Policy Law. 2022;47(6):815-833. doi: 10.1215/03616878-10041205 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
eMethods.
Data Sharing Statement
