Industry Payments to Surgeons Increased Despite Transparency Requirements
When the Physician Payments Sunshine Act was enacted, many assumed doctors would be reluctant to take industry payments they would need to disclose publicly. Yet industry payments to orthopedic trauma surgeons increased significantly between 2014 and 2019, according to a recent analysis.1
Payments for consulting fees, education, food and beverage, travel, and entertainment increased. Payments for royalties and grant funding decreased. Median annual payments were $460 in 2014, reaching $1,284 by 2019.
Despite the fact data on industry payments are publicly available, it does not appear to be causing patients to be suspicious of doctors’ integrity. “Even when physicians and researchers do reveal conflicts, it doesn’t seem to make patients or human subjects question it,” says Janet L. Dolgin, PhD, JD, co-director of the Hofstra University Bioethics Center and professor at Hofstra’s law and medical schools in Hempstead, NY.
Sometimes, the opposite is true. “The problem with rules that require reporting on conflicts of interest is that they tend to backfire,” Dolgin explains. “Often, people come away thinking, ‘What an honest, wonderful doctor or researcher because they revealed these conflicts.’ They get more credit than if they hadn’t had the conflicts in the first place.”
To many patients, the transparency over financial ties suggests the physician is straightforward and can be trusted. Patients generally do not focus on the potentially problematic implications of clinicians accepting payments from industry. “That is concerning. I don’t think that the revelation of information has proven effective. It’s a really terrible dilemma,” Dolgin says. “It seems to me it should be illegal for people to enter into at least some of the arrangements and agreements that directly impact patients and human subjects.”
Dolgin sees ties to the pharmaceutical industry as especially troubling. “It’s the idea that as a physician, you are working for a big industrial conglomerate rather than for your patients,” Dolgin argues. “There is something rotten at the core of a system where people who make a good living are taking money — sometimes even large sums — in a way that is very likely to shape their medical decisions.”
Aaron Mitchell, MD, MPH, has conducted research that found a strong correlation between industry payments and physician behavior.2 However, Mitchell still wondered if that correlation would hold up if multiple studies were analyzed. “This is a highly important area that physicians are grappling with right now. I felt that compiling and summarizing the full body of empiric literature on this subject would help to provide a common groundwork for this conversation,” says Mitchell, a medical oncologist and health sciences researcher in the department of epidemiology and biostatistics at Memorial Sloan Kettering Cancer Center.
Mitchell and colleagues analyzed 36 studies, finding payments from the drug industry were associated with physicians’ prescribing the paying company’s drug more often.3 The findings were consistent; all showed evidence of a correlation between industry money and physician prescribing. Notably, several studies revealed not just correlation but also a causal relationship between industry money and prescribing, all with a clear and consistent finding indicating receiving industry money leads physicians to prescribe that company’s drugs more often.
“I have heard numerous skeptics assert that ‘correlation is not causation’ and there is no proof that getting industry money affects how physicians treat patients. But this is simply no longer true,” Mitchell says.
Mitchell says the ethical implications are clear. “We as physicians, and all healthcare providers, need to seriously reconsider our current practice of accepting money and gifts from the drug industry.”
Especially concerning is the fact the prescribing changes resulting from receiving industry money are not always optimal for patients. “It is time for us to put our patients’ best interests over our desire to continue receiving free meals and speaker fees from the drug industry, and end this practice,” Mitchell argues.
Patients cannot be expected to figure out whether payments to doctors are ethically problematic. “I don’t think this can rest on patients, who are the vulnerable ones here. It has to rest on medical schools and medical associations to make really clear-cut rules on what providers are allowed to do,” Dolgin says.
This problem is long-standing. Decades ago, Dolgin was lecturing at a hospital, and an administrator announced lunch would be offered to everyone in attendance. As was common at the time, a pharmaceutical company paid for the catered meal. The administrator thought it was positive for residents to relax, eat, and leave with a free pen. “But the administrator failed to see what was really happening, that the residents would go away thinking that the drug produced by the company whose pen they were holding in their hand was the drug of choice,” Dolgin says.
Many physicians might be skeptical of the notion that a free sandwich and cheap pen could really affect their clinical decision-making. However, multiple studies have proven otherwise.4-6 Regardless, many clinicians cannot comprehend how a gift, regardless of its economic value, can affect their actions.
“But they clearly do influence healthcare decision-making,” Dolgin says. “They do it at the expense of patients who might have gotten a different set of decisions had their clinicians not been influenced by the connection to industry.”
- Frane N, Partan MJ, White PB, et al. Orthopaedic trauma surgeons’ financial relationships with industry: An analysis of the Sunshine Act Reporting of Physician Open Payments from 2014 to 2019. J Am Acad Orthop Surg Glob Res Rev 2021;5:e21.00251.
- Mitchell AP, Mishra AA, Dey P, et al. The association between drug industry payments and NCCN guideline panel membership. J Clin Oncol 2020;38:2068-2068.
- 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;174:353-361.
- Wood SF, Podrasky J, McMonagle MA, et al. Influence of pharmaceutical marketing on Medicare prescriptions in the District of Columbia. PLoS One 2017;12:e0186060.
- Hadland SE, Cerdá M, Li Y, et al. Association of pharmaceutical industry marketing of opioid products to physicians with subsequent opioid prescribing. JAMA Intern Med 2018;178:861-863.
- DeJong C, Aguilar T, Tseng C, et al. Pharmaceutical industry-sponsored meals and physician prescribing patterns for Medicare beneficiaries. JAMA Intern Med 2016;176:1114-1122.
Despite the fact data on industry payments are publicly available, it does not appear to be causing patients to be suspicious of doctors’ integrity. To many patients, the transparency over financial ties suggests the physician is straightforward and can be trusted. Patients generally do not focus on the potentially problematic implications of clinicians accepting payments from industry.
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