Abstract
This cohort study evaluates marketing payments from pharmaceutical and medical device manufacturers to physician trainees before and after fellowship graduation.
Industry marketing payments to physicians may compromise the objectivity and integrity of clinical decision-making, playing a role in nonrecommended care, higher health care costs, and reduced patient trust. Payments to trainees merit scrutiny because these payments may be formative on future practice. The Association of American Medical Colleges (AAMC) recommends policies “that prohibit the acceptance of any gifts from industry by physicians…and trainees.”1 The Accreditation Council for Graduate Medical Education (ACGME) states “promotional activities by industry can seriously compromise the professional relationships that form the substance of medicine.”2 The National Academy of Medicine (NAM) also argues financial relationships do not benefit the educational mission in ways that offset the risks created.3 We quantified industry payments to cardiology fellows and the association of these payments with payments received after training.
Methods
We linked the ACGME database, containing information on cardiology trainees and recent graduates, with the Open Payments database, containing information on financial payments from drug and medical device manufacturers to physicians, including fellows (eMethods in Supplement 1). We included only general payments, defined as “transfers of value made that are not in connection with a research agreement or research protocol”4 (eg, meals and travel compensation), received between July 1, 2014, and June 30, 2021. Fellows were classified as having procedural intensive (interventional cardiology and clinical cardiac electrophysiology) or nonprocedural intensive (general cardiology, adult congenital heart disease, and advanced heart failure and transplant cardiology) subspecialties. The Johns Hopkins University Institutional Review Board deemed this cohort study exempt from review and informed consent because deidentified data were used. We followed the STROBE reporting guideline.
Primary outcome was the number, type, and value of general payments during the final year of training. We also examined the proportion of fellows receiving $5000 per year or more, considered a “significant” financial conflict of interest by the US Department of Health and Human Services. We evaluated these variables during available follow-up and used a multivariable Cox proportional hazards regression model to ascertain the association of subspecialty with receipt of general payments in independent practice, adjusting for physician sex, age, and payments before graduation. Analyses were conducted between April 2023 and March 2024 using SAS 9.4 (SAS Institute Inc). Two-sided P < .05 indicated statistical significance.
Results
Overall, 5533 cardiologists were included (median [IQR] age at graduation, 35 [33-37] years; 1178 females [21%], 4343 males [78%]). Of these physicians, 2478 (45%) were in procedural intensive subspecialties (Table 1).
Table 1. Demographics of Physicians Receiving Payments During and After Cardiovascular Disease Fellowship Training .
| Characteristic | Physicians, No. (%) | ||
|---|---|---|---|
| Total (N = 5533) | Nonprocedural intensive subspecialty (n = 3055)a | Procedural intensive subspecialty (n = 2478)b | |
| Age at graduation, median (IQR), y | 35 (33-37) | 34 (33-36) | 35 (34-37) |
| Sexc | |||
| Female | 1178 (21) | 916 (30) | 262 (11) |
| Male | 4343 (78) | 2135 (70) | 2208 (89) |
| Payments accepted from industry during year before fellowship graduation | |||
| Any general payment | 4050 (73) | 2057 (67) | 1993 (80) |
| Total payments, median (IQR) | 8 (1-25) | 3 (0-13) | 17 (4-38) |
| General payments totaling ≥$5000 | 630 (11) | 88 (3) | 542 (22) |
| Median (IQR) payment value per physician, $ | 531 (17-2314) | 198 (0-893) | 1801 (282-4445) |
| Total general payments value, $ | 13 381 599 | 2 623 466 | 10 758 133 |
| Total payments accepted from industry during median 3-y follow-up after fellowship graduation | |||
| Any general payment | 4868 (88) | 2483 (81) | 2385 (96) |
| Cumulative total payments, median (IQR) | 25.0 (5.0-84.0) | 10.0 (2.0-37.5) | 59.0 (19.0-142.5) |
| General payments totaling ≥$5000 | 839 (15) | 247 (8) | 592 (24) |
| Median (IQR) payment value per physician per y, $ | 591 (172-1879) | 277 (95-838) | 1112 (372-2870) |
| Total general payments value, $ | 37 213 358 | 10 113 596 | 27 099 763 |
| Time to receive any payment, median (IQR), y | 1 (1-1) | 1 (1-1) | 1 (1-1) |
| Time to receive at least $5000 in 1 y, median (IQR), y | 3 (1-4) | 3 (1-4) | 2 (1-4) |
Nonprocedural intensive specialties include cardiovascular disease (general cardiology), advanced heart failure and transplant cardiology, and adult congenital heart disease.
Procedural intensive specialties include interventional cardiology and clinical cardiac electrophysiology.
Data on sex were unavailable for 12 physicians.
During the year before fellowship graduation, 1993 fellows (80%) in procedural intensive subspecialties and 2057 of 3055 (67%) in nonprocedural intensive subspecialties received industry payments. Median (IQR) payment amount per physician in procedural intensive subspecialties was $1801 ($282-$4445; median [IQR] payments, 17 [4-38]). In nonprocedural intensive subspecialties, median (IQR) payment amount received per physician was $198 ($0-$893; median [IQR] payments, 3 [0-13]).
A median (IQR) of 3 (2-5) years after fellowship, 2385 physicians (96%) in procedural intensive subspecialties and 2483 (81%) in nonprocedural intensive subspecialties received industry payments. Median (IQR) payment amount per physician per year was $1112 ($372-$2870) and $277 ($95-$838), respectively. Physicians who received general payments in the year before fellowship graduation were more likely to receive payments after graduation (hazard ratio, 2.12; 95% CI, 1.89-2.37) (Table 2).
Table 2. Factors Associated With Receiving General Payments in Independent Practice.
| Factor | HR (95% CI) | |
|---|---|---|
| Receiving any general payments | Receiving at least $5000 in general payments | |
| Cardiology subspecialty: procedural intensive vs nonprocedural intensive | 2.24 (2.01-2.49) | 3.31 (2.82-3.88) |
| Sex: male vs female | 1.12 (0.99-1.27) | 1.43 (1.15-1.77) |
| Age at graduation, per 5 y | 0.95 (0.89-1.03) | 0.86 (0.76-0.96) |
| Received any general payments during the year before fellowship graduation | 2.12 (1.89-2.37) | 0.98 (0.83-1.15) |
Abbreviation: HR, hazard ratio.
Discussion
Most cardiology fellows in this study received general payments from pharmaceutical and medical device manufacturers during their final year of training, with higher rates among those in procedural intensive subspecialties. These findings extend a smaller single-year study of 354 cardiology fellows5 and a study reporting at least 9% of internal medicine residents received industry payments.6 There are consequences for patients because industry payments to physicians are associated with less evidence-based practice.
Study limitations include incorrect attribution of payments to physicians, possibly underestimating or overestimating the amounts. However, physicians can review and contest reported payments before posting. Given clear guidance from AAMC and expressed concern from ACGME and NAM,1,2,3 stronger policies may be needed to curtail payments from industry to trainees.
eMethods.
Data Sharing Statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eMethods.
Data Sharing Statement
