Drug and device makers publicly report all gifts made to physicians and advanced practice providers, as required by the 2010 Physician Payments Sunshine Act. Residents and other trainees are excluded from this requirement — but that does not mean these providers are not receiving payments. Of the 124,715 residents in all training programs in 2020-2021, 12% received payments totaling $6.4 million, as recorded in the Open Payments Program database.1
“This study provides a window into how physician-industry relationships form,” says Sean O. Hogan, PhD, the study’s lead author and director of outcomes research and evaluation at the Accreditation Council for Graduate Medical Education (ACGME). Since reporting for payments made to residents is voluntary, the actual number is likely higher, assert the authors.
The researchers further analyzed of 65,992 residents in six specialties (orthopedics, urology, general surgery, OB/GYN, family medicine, and internal medicine). Some key findings:
- 13.4% of residents received at least one gift from a drug and device company. Most of the gifts were meals. The average resident who accepted a gift received the equivalent of about $65.
- Residents in orthopedics, urology, and OB/GYN had a higher probability of accepting industry payments than residents in internal medicine.
- Of orthopedic surgery residents, 39% took industry gifts with an average value of $526.
- For family medicine residents, the median value of a single gift was $17. In contrast, for an orthopedic surgery resident, the median value of a single gift was $112.
There is no evidence that payments were associated with compromised patient care, the study authors acknowledge. “At least in theory, important innovations can emerge from communication between practitioners and industry representatives,” says Hogan.
A 2009 report published by the Institute of Medicine discussed industry-physician trainee interactions and recommended that educators should prepare learners to navigate potential conflicts of interest.2 “Residents learn from observing what goes on in their learning environments. Efforts made by programs and faculty to model ethical conduct become part of the trainees’ formation,” says Hogan. The ACGME requires that institutions maintain a policy that addresses interactions between vendor representatives and residents/fellows. “While the ACGME does not stipulate the specifics of those policies, they need to be maintained,” says Hogan.
This study draws attention to an ethical concern that has been largely overlooked since the passage of the Sunshine Act, says Matthew Wynia, MD, MPH, FACP, director of the Center for Bioethics and Humanities at University of Colorado Anschutz Medical Campus. Wynia was lead author of a commentary on the study.3 “We don’t really know how many residents are getting so-called free lunches from industry. This recent study shows it might be pretty common, especially in certain specialties,” says Wynia.
Patients probably do not even consider the fact that a resident physician could have a financial conflict. “To be honest, my hunch is that many members of the public don’t know the difference between an intern, a resident, a fellow, or a physician who has completed training. In any event, I think they should expect us all to live up to the same ethical standards,” says Wynia.
For all types of providers, this means avoiding direct financial conflicts with drug companies as much as possible. Patients should be able to trust that providers are making decisions without incentives to use one drug or another, no matter what stage of career the healthcare provider is in. “Mistrust in medicine is such a huge issue these days. So much of it is driven by the concern that doctors might be in the pocket of drug companies. We really need to double down on our efforts to show that we are worthy of patient and public trust,” emphasizes Wynia.
Ethicists are well-positioned to call attention to the destructive impact of financial conflicts on patient and family trust, says Wynia. Wynia offers these examples of how ethicists can raise this issue:
• Ethicists can help to develop organizational policies on whether to allow drug reps onsite.
“Ethicists are probably more aware of the voluminous research on how incentives like small gifts actually work than are average clinicians or administrators at hospitals,” notes Wynia. Small gifts like a lunch are not likely to make doctors overtly biased. “Instead, they work through gift relationships, which are extremely subtle,” Wynia explains. “The person affected doesn’t even notice that their prescribing patterns have changed.” Multiple studies have shown that small gifts do, in fact, change doctors’ prescribing behaviors.4-6 “This has been proven over and over. Even though most clinicians sincerely believe they aren’t affected by small gifts, in the aggregate we know that they are,” says Wynia. “After all, if they didn’t work, drug companies wouldn’t spend so much money buying lunches for doctors.”
• Ethicists can share relevant comments made during consults.
“I’ll bet every clinical ethicist has examples of patients or family members implying that the doctor or hospital isn’t worthy of their trust because they’re allied with drug companies and motivated by profit,” says Wynia.
• Ethicists can ask organizations to decide how important is it for patients to trust that clinicians are not influenced by industry.
“If that’s a high priority — and I think it should be — then they should develop policies and practices to reinforce that priority,” asserts Wynia.
REFERENCES
- Hogan SO, Yamazaki K, Jing Y, et al. Industry payments received by residents during training. JAMA Netw Open 2023;6:e2337904.
- Lo B, Field MJ, eds. Conflict of Interest in Medical Research, Education, and Practice. The National Academies Press; 2009.
- Wynia MK, Baugh CM, Campbell EG. Next steps for addressing conflicts of interest in residency programs. JAMA Netw Open 2023;6:e2337828.
- 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.
- Katz D, Caplan AL, Merz JF. All gifts large and small: Toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth 2010;10:11-17.
- DeJong C, Aguilar T, Tseng CW, et al. Pharmaceutical industry–sponsored meals and physician prescribing patterns for Medicare beneficiaries. JAMA Intern Med 2016;176:1114-1122.
Drug and device makers publicly report all gifts made to physicians and advanced practice providers, as required by the 2010 Physician Payments Sunshine Act. Residents and other trainees are excluded from this requirement — but that does not mean these providers are not receiving payments.
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