The study reported in JAMA Network Open examines data from the Open Payment Database (OPD), which requires pharmaceutical companies and medical device operators to list their payments to physicians each year. Those data correlated with the physicians’ gender information and the completion dates of their scholarship or residency training, so the researchers considered payments to physicians only during the first six years after their training.

They considered two surgical specialties, orthopedics and neurosurgery, and used one medical specialty, internal medicine, as their “control”. [1] Let me use this table to summarize their results:

Let’s start breaking down some of what hasn’t been said. The study took into consideration what the OPD calls “general payments”. This includes fifteen categories, but I’ll limit the undeclared data to the first few, food and drink: free lunch, fees, consulting fees, copyrights and licenses.

Tilt U

When it comes to averages, the basic assumption is that the distribution of values, its interval, is symmetrical: the “bell” curve. There are three values ​​you could use,

  • Average: what we consider the average
  • Median: the number in the middle of the range
  • Mode: the most common number

But this is not always the case and the relative asymmetry from the distribution of the bell shape is described as the slope of the distribution. As the skew increases, the mean, median and fashion become very different, which is the first problem with the values ​​expressed in this study.

The following examples are from the Open Payments 2019 dataset, a subset of the data used in the study. I suspect that while the numbers may change slightly, the relationships and relative amounts are stable over time. For transparency, you can find the dataset and my calculations here. (Click download in the upper left corner to view the spreadsheet)

Dramatic differences

There is another problem with an asymmetric distribution, outliers: values ​​that lie very far from most others and distort the mean, median and mode.

While we can all agree that royalty payments and licensing to doctors are indeed a financial deal, it’s hard to argue that this money influences prescription behavior. After all, if the doctor invented the device, they are already using it. Royalty and license fees drastically skew the amounts to the right, contributing 46% of all orthopedic payments, nearly 80% of all neurosurgical payments, and for internal medicine, a negligible 1%. What might mean, median and fashion look like if we removed those numbers?

There is little change in Internal Medicine numbers, but a dramatic change in average payouts for both neurosurgery and orthopedics. The choice of which categories to aggregate and which number to use to describe that aggregation (distribution) is important.

Finally, if we take a closer look at these general payments, the most common category is that of food and drink. Looking only at these payments, what do we find

Most of these new doctors, two-thirds of orthopedists, 80% of neurosurgeons and 91% of internists receive less than $ 50 in free food, not quite the terrible payola scandal and corruption of physician integrity suggested by the researchers.

The narrative – let’s get real.

“… Small gifts from the industry to doctors may seem irrelevant. However, research suggests that small gifts, even a single meal worth less than $ 20, may be associated with unconscious bias in the physician’s decision-making process (eg, in prescribing drugs). Therefore, we have considered that a physician who accepts the industry’s first payment of any amount develops a financial relationship with the industry that can potentially influence the physician’s behavior. “

The two groups they chose, orthopedists and neurosurgeons, are device-based specialties; there are few therapeutic options that these surgical specialties pursue. Devices, on the other hand, are a different story. But ask yourself, in the real world, what control do these newly minted specialists have over the devices they use? Short answer, very little.

Most doctors who have recently completed their training feel more comfortable using the devices they trained with. When they work in a new environment, they rarely decide which devices to use. Most of their senior partners have made choices and their practice or hospital is a “Medtronic” or “Boston Scientific” store. More importantly, senior doctors’ decisions are always in collaboration with the hospital, which seeks to limit the choice of devices so that their purchasing cooperatives give them the lowest prices. [3]

All those free meals and all those budding financial relationships; they mostly reflect the presence of sales staff in operating theaters. The sales staff aren’t there to guide the surgeons; they are there because they carry the range of inventory they might need and the equipment needed to implant their devices. Like any good guest, they don’t come with empty arms; they bring lunch for the staff in the rooms.

Now, due to the open payment rules, at least one doctor will be asked to sign that the meal has been provided. The signatures of residents and colleagues do not count, only the treating doctors do. So the reality is that residents and fellows have received free lunches throughout their careers. Their initial prescribing habits are dictated more by their training than by some independent thinking. And as for speaking fees, as with the copyrights mentioned earlier, you are not asked to speak as an incentive to use a device; you are asked to speak to induce others.

As I write this, a new target has arisen for conflict of interest observers, advanced clinical professionals (nurses, medical assistants, CRNA, etc.). According to a recent JAMA study, they too are “on the run”.

[1] Orthopedics encompasses several subspecialties, sports medicine, spine surgery, adult reconstructive surgery, hand surgery, trauma surgery, pediatric orthopedic surgery, and foot and ankle surgery. Likewise, internal medicine encompasses several subspecialties, including intensive care medicine or pulmonary medicine, heart or cardiovascular disease, oncology or hematology, gastroenterology, nephrology, rheumatology, endocrinology, and infectious diseases.

[2] Another point, orthopedists receive an average of $ 108,298 per talk, which is clearly an outlier. A deeper analysis of the data shows that only five events out of 641 intervention commitments account for 94% of that expenditure; I suspect an error in the data sent.

[3] The cost of the devices is not necessarily paid separately from the procedure itself. For example, nearly 50% of the payment received by hospitals for endovascular repair of an aortic aneurysm goes to pay for the implanted device.

Source: Trends in industry payments to doctors in the first 6 years after medical graduation JAMA Network Open DOI: 10.1001 / jamanetworkopen.2022.37574

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