Trends in Industry Payments to Physicians in the First 6 Years After Graduate Medical Training

Abstract

ImportanceFinancial incentives and conflicts of interest may influence physician decision-making. It is important to understand financial interactions between the pharmaceutical and medical device industries and newly independent physicians who have recently completed their graduate medical education using a national transparency program.ObjectiveTo identify trends in industry payments to recent graduates of Accreditation Council for Graduate Medical Education–accredited residency or fellowship programs in orthopedic surgery, neurosurgery, and internal medicine.Design, Setting, and ParticipantsThis retrospective cohort study analyzed Open Payments reports of industry payments made between July 1, 2015, and June 30, 2021, to newly independent physicians from residency or fellowship programs in neurosurgery, orthopedic surgery, and internal medicine who graduated between January 1, 2015, and December 31, 2019.ExposuresSpecialties (neurosurgery and orthopedic surgery, with internal medicine as a comparison group).Main Outcomes and MeasuresIndustry payments to newly independent physicians, including any general payments (noninvestment or nonresearch) and at least $5000 of general payments in aggregate value per year, which are considered significant financial conflicts of interest. The percentage of newly independent physicians accepting general payments during the first 6 years after graduation was analyzed by specialty and sex using cumulative incidence curves and hazard ratios (HRs) in univariable and multivariable analyses.ResultsThere were 45 745 recent graduates (28 137 men [62%]; median age at graduation, 33.0 [IQR, 31.0-35.0 years]) in neurosurgery (n = 595), orthopedic surgery (n = 3481), and internal medicine (n = 41 669). In the first 2 years of independent practice, 95% (n = 3297), 92% (n = 546), and 59% (n = 24 522) of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, respectively, accepted any general payments. A higher percentage of the newly independent physicians in orthopedic surgery and neurosurgery accepted any general payments (orthopedic surgery vs internal medicine: HR, 5.36 [95% CI, 4.42-6.51] for women and 7.01 [95% CI, 6.35-7.73] for men; neurosurgery vs internal medicine: HR, 3.25 [95% CI, 2.24-4.72] for women and 4.08 [95% CI, 3.37-4.94] for men; P = .03). A higher percentage of male physicians compared with female physicians accepted any general payments (orthopedic surgery, 2884 of 3026 [95%] vs 413 of 455 [91%]; P < .001; neurosurgery, 466 of 502 [93%] vs 80 of 93 [86%]; P = .01; and internal medicine, 15 462 of 24 609 [63%] vs 9043 of 17 034 [53%]; P < .001) and at least $5000 of general payments (orthopedic surgery, 763 of 3026 [25%] vs 71 of 455 [16%]; P < .001; neurosurgery, 87 of 502 [17%] vs 5 of 93 [5%%]; P < .001; and internal medicine, 882 of 24 609 [4%] vs 210 of 17 034 [1%]; P < .001).Conclusions and RelevanceIn this cohort study of newly independent physicians in orthopedic surgery, neurosurgery, and internal medicine, the financial relationship with potential conflicts of interest between newly independent physicians and industry began to develop soon after training programs and continued to expand in the early years of newly independent physician practice. Newly independent physicians in surgical specialties and male physicians accepted significantly higher industry payments. Further studies are needed to evaluate whether modifiable factors are associated with the future outcome of newly independent physicians accepting general payments.

Next Steps for Addressing Conflicts of Interest in Residency Programs

“…Elsewhere in JAMA Network Open , a team from the Accreditation Council for Graduate Medical Education (ACGME) and Johns Hopkins University School of Medicine examine these voluntary reports, and despite the apparent limitations of the data set—which doubtless undercounts actual payments, perhaps dramatically—their findings are compelling and support several specific policy changes.…”

“…One unexpected finding was a lesser association between program directors (PD) receiving gifts and their residents doing so. Prior research has suggested a strong role modeling effect—when a mentor accepts gifts, their mentees learn that doing so is acceptable—but in a multivariable model, Hogan et al found just a 1% increase in the relative risk that residents in a program would accept gifts for each gift taken by their PD. Still, the average PD who took gifts appears to have received about 10 of them in the year, raising the risk that their residents will also take gifts that year by about 10%.…”

“…In brief, Hogan et al find that among 65 376 residents in 6 major specialties, 13.4% received gifts from drug and device companies in the 2020 to 2021 academic year. Most of these gifts (approximately 60%) were in the form of meals, and the total value of the gifts was almost $4 million.…”

“…The rule could easily have been written otherwise, allowing both licensed physicians and those in accredited postgraduate clinical training programs to be recognized as physicians legally authorized to practice. But there was a second reason given for excluding residents: CMS believed it would be “difficult for us to accurately identify residents [and track gifts they receive] … because many of them do not have a NPI.” No data were cited for this assertion in 2013, but Hogan et al have shown it is clearly false today; ACGME records now include a valid NPI for 99.9% of residents.…”

A New Perspective on Conflicts of Interest Among Surgeons: They Start Early in Careers

“…In the new study, Misop Han, MD, and colleagues examined trends in industry payments to physicians over the six years after residency and other forms of graduate medical training in the United States. (See Han et al, 2009. )…”