The majority of cardiology fellows received a payment for a meal, travel, or consulting from a drug or device maker during their final year before graduation, reported investigators.
Pharmaceutical and medical device manufacturers paid cardiology fellows $13.3 million between 2014 and 2021, with the majority — $10.7 million — going to those in procedural intensive subspecialties such as interventional cardiology and clinical cardiac electrophysiology, according to the study published online in JAMA Internal Medicine.
In the year before fellowship graduation, 80% of proceduralists and 67% of nonprocedural cardiologists received a payment. The median for proceduralists was $1801, while the median was $198 for general cardiologists and for those who specialized in congenital heart disease, advanced heart failure, and transplant cardiology.
Sanket S. Dhruva, MD, MHS from the University of California, San Francisco School of Medicine, San Francisco, and his colleagues linked information from the Accreditation Council for Graduate Medical Education (ACGME) on trainees and recent graduates with the Centers for Medicare and Medicaid Services' Open Payments database.
Because the length of a fellowship varies across institutions, the authors focused on the final year of training, Dhruva told Medscape Medical News. As a result, "these payments are definitely an underestimate of the total amount that these cardiology fellows received during their training," said Dhruva.
The researchers also excluded research grants. Although those can introduce the potential for bias, "we do need relationships between physicians and the medical device industry and the pharmaceutical industry" to spur innovation, said Dhruva.
But "general payments" — for meals, travel, consulting and speaking — "are not intended to support the development of a new heart stent or a new drug to treat high cholesterol. These are promotion," he said.
The authors also found that physicians who accepted payment as fellows were more likely to receive industry payments within 2-5 years after graduation.
Three years after their fellowship, 96% of proceduralists and 81% of those in nonprocedural subspecialties received a payment, totaling $37 million over the 2014-2021 period. The median payment per physician per year was $1112 for interventionalists and electrophysiologists and $277 for the nonprocedural subspecialists.
Dhruva said this was not surprising. The physicians may have become conditioned to accept the payments, or they may have built relationships with manufacturers, he said.
Dhruva and his coauthors pointed out that the Association of American Medical Colleges recommends that physicians and trainees not accept industry gifts or payments and that the ACGME says that industry promotional activities can "seriously compromise" professional relationships. Given this guidance, "stronger policies may be needed to curtail payments from industry to trainees," they add.
Vinay Kini, MD, from Weill Cornell Medical College, New York, said that some of the general payments were likely reimbursement for travel to training sessions on new devices. But whether these present a conflict is nuanced, he said. When fellows attend these sessions, there is some concern that "you could introduce a bias," but there is a need to learn the new technologies and bring them to patients, he said.
Harlan Krumholz, MD, from Yale School of Medicine, New Haven, told Medscape Medical News that "the industry support of trainees raises questions about the intent and effect of these payments."
"There is certainly a need for transparency surrounding these payments — and efforts to ensure they are not part of a marketing strategy," he said. "Programs need to help trainees understand the ways that industry has used payments to promote their products and reward clinicians for their loyalty," said Krumholz.
The fact that industry payments continue — in spite of the existence of Open Payments — "probably shows that transparency alone isn't enough," said Kini.
"The onus is on the fellowship programs," he said. "If they allow their trainees to attend these kinds of events then they need to make sure that the trainees understand the risks and benefits of all the different kinds of devices and really understand the evidence behind using those devices on our individual patients," he said.