Money in Medical Education Makes Me Sad
The Study of the Week describes industry payments to cardiology trainees. It helps explain one curious thing.
I call it therapeutic fashion. Practice patterns. Beliefs. Ways of doing things.
Examples: patients with new heart failure get coronary angiography; patients with chest pain without evidence of heart attack get stress tests; certain drugs and devices become favored over generics.
The curious thing about many therapeutic fashions is their lack of evidentiary support. The REVIVED-BCIS trial, for instance, found no benefit to revascularization of severe coronary disease in patients with heart failure and multi-vessel coronary disease. Yet the train to the cath lab for these patients is non-stop.
A recent study in JAMA-IM suggests (to me) that one reason for this curious imbalance between evidence and practice patterns is industry marketing.
I am not talking mere advertisements.
The study chronicled direct payments from industry to doctors. And not just any doctors. The most susceptible doctors—trainees.
Drs. Sanket Dhruva, Rita Redberg and colleagues used available databases to quantify payments to cardiology fellows in their last year of training.
Their study included more than 5000 cardiologists. Slightly less than half were in procedural intensive subspecialties.
The authors used data from the Open Payments database. They included only general payments—not research monies. Things like travel and meals.
Results
In the last year of training, 80% of fellows in procedural aspects of cardiology and 67% of those in nonprocedural fields received industry payments.
The median amount of money received per doctor was $1800 for procedural fields and $198 in nonprocedural areas.
About 1 in 5 procedural fellows received more than $5000 in their final year.
The authors then looked at the future likelihood of receiving industry money. Those who received general payments in the final year of fellowship were twofold more likely to receive payments after graduation. (HR 2.12 95% CI 1.89-2.37).
Comments
The practice of enriching (and influencing) trainees is not new. Industry had a prominent presence in the 1990s when I trained. I didn’t notice it. I don’t think anyone noticed it.
But I notice it now. Large swaths of education in my field of electrophysiology come directly from industry sources. Proponents of this model argue that much of what we do involves industry tools. Our arrhythmia mapping systems for instance are intricate and not totally interchangeable.
But. Education from such sources are nearly always full of bias. I went to one of these industry-sponsored session this year at the HRS meeting (No, I did not eat their free lunch). I went to listen to a friend speak about ongoing trials in the field. I stayed for the other lectures. Three key opinion leaders spoke in glowing terms about the sponsor’s products. It was eye-opening and depressing. I lost respect for these people.
This lunch symposium was only a small sample of industry-advertising.
Paying money directly to trainees surely has greater effects. Trainees are vulnerable. They have less of everything. Less money. Less experience. And less reputation. They will remember where that $1800 dollars came from in their last year.
What’s more, transferring money to trainees normalizes the process, as the authors found a strong likelihood (2x) that it would lead to receiving industry money in practice.
At the risk of finding cause when there is mere correlation, I think that the persistence of many dubious therapeutic fashions stem from industry relationships, forged early in training.
Why, for instance, has pulsed field ablation taken off among US electrophysiologists. I wrote recently that the empirical data reveals little difference from thermal ablation.
Trainees in cardiology cannot easily become a Top Person without having relationships with industry.
Once the Top People start doing something, like PFA, or left atrial appendage closure, the practice becomes a therapeutic fashion. It’s normalized. People forget or ignore the seminal data—which is often weak.
The JAMA-IM paper suggests that this process begins early.
The Answer
This is not a screed against industry nor the profit motive of innovation. Industry has advanced cardiology. We now have better drugs and devices because of profit motive.
The problem is having a strong enough wall between the practice of medicine and profit motive. There is essentially no wall now.
Another problem is that constrained thinkers in medicine have a disadvantage as the unconstrained thinkers hold all the important positions in Medicine—program directors, journal editors, and grant recipients. Receiving industry money surely does not favor constrained thinking.
That is why I commend Dr. Dhruva and colleagues for doing and publishing this sort of data. The first step in reforming the system is exposing the problem.
We at Sensible Medicine are working on another step: that is, cultivating a place where critical appraisal and constrained thinking can occur. It is the first inning.
We will work for a future where one can be a Top Person in a field without taking industry payments. It’s a long way off. But it’s a goal worth working towards.
As always, we at Sensible Medicine appreciate your support. We remain free of advertisements and industry influence because of your support. Thank you. JMM
Perhaps if the fellows were paid more by their educational institutions (and treated better), they wouldn't feel such a strong desire to accept the money from industry. I don't know how things are now, but I remember well how they were when I did my 'not cardiology' residency. We were treated terribly and paid less than minimal wage once one calculated the hours we worked. This should not be taken as a call to make residency a cushier, more benign experience. I just don't think it is fair to the fellows and the residencies to take away money from industry without talking about why they are so likely to accept that money in the first place. Perhaps an established doctor who earns hundreds of thousands of dollars a year (and gets to actually spend some time with family now and again) doesn't feel like 1800$ is enough money to tempt them. But if you dangled 1800$ in front of me when I was a resident, it would have looked like a true pot of gold. That money would have allowed me to pay some of the enormous debt I carried down. Including the credit card debt I used to purchase groceries for some months. Maybe luckily for my soul, no one ever did offer me money like that when I was a resident. I like to think I would have refused it. But I still remember balancing my checking account down to the pennies every month to make sure I didn't bounce a check.
There has been an interesting trend at our institution to welcome industry lunches back at our workplace. For a while, we were written up if we took a pen, now lavish lunches poured on staff/fellows as competition to retain overworked CV staff and maintain a “happy place” heats up. The productivity gerbil wheel works for everyone in healthcare delivery but the folks on the front line of patient care.
Burnout high? Feed them cake. We all know how that worked out in the long run.