Letters
RESEARCH LETTER Results | We examined 57 515 Twitter accounts to identify 642
HEALTH CARE REFORM
Financial Conflicts of Interest Among
Hematologist-Oncologists on Twitter
Twitter, the social media service that permits 140-character
posts or “tweets,” is undergoing rapid uptake by physicians.1
Twitter allows physicians to communicate, interpret, high-
light, and curate information as well as engage in discussion
or debate with other physi-
Related articles
cians, patients, patient advo-
cates, researchers, investors,
and industry employees. More than 60% of tweets authored
by medical professionals in the United States are health-
related, and approximately 14% mention commercial prod-
ucts or services.2 Yet, to our knowledge, there has been no in-
vestigation of the prevalence of financial conflict of interest
(FCOI) among these users.
Methods | We constructed a set of hematologist-oncologists who
are active on Twitter and have primary affiliations in the United
States. We then assessed their FCOIs occurring in 2014. This
data set was created in 2 steps. First, we selected 1 hematolo-
gist-oncologist (who does not have FCOI [V.P.]) and searched
all Twitter users who were followed by and was following that
physician; this set consisted of approximately 50 people. Sec-
ond, we used Google to identify hematologist-oncologists with
primary appointments in the United States. We took this set
of hematologist-oncologists and searched all of the Twitter us-
ers they followed using the same web search method; this set
consisted of approximately 600 people. Then, we combined
the sets.
Using FCOI data made public by the Open Payments pro-
vision of the Affordable Care Act,3 we determined the FCOIs
of the hematologist-oncologists we identified. Specifically, we
searched each name on ProPublica’s Dollars for Docs website
(https://projects.propublica.org/docdollars/) and then clicked
on the available link to view the individual’s 2014 Open
Payments page on the Centers for Medicare & Medicaid Services
Open Payments program website (https://www.cms.gov
/OpenPayments/Explore-the-Data/Explore-the-Data.html).
Two kinds of payments were received: (1) general payments,
defined as payments not associated with a research study,
which included consulting fees, travel, lodging, food, and
beverage, and (2) research payments, which included research
funding and associated payments as described by the Centers
for Medicare & Medicaid Services.3
Descriptive statistics are reported in the Results. Con-
ducted from June 1 to August 1, 2016, our study of publicly
available information did not require institutional review board
review and approval.
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US-based hematologist-oncologist Twitter users, of whom 8
(1.2%) are employees of the biopharmaceutical industry. Of the
634 hematologist-oncologists assessed for FCOI, 504 (79.5%)
were reported on the Open Payments website for having at least
1 FCOI (Table).
Hematologist-oncologists on Twitter received a median of
$1644.77 in general payments (interquartile range [IQR], $129-
$13 744) and a median of $11 064.21 in research payments (IQR,
$0-$175 164). Of the 634 hematologist-oncologists, 459 (72.4%)
received general payments, 397 (62.6%) received more than
$100, and 281 (44.3%) received more than $1000. Most gen-
eral payments were less than $10 000 (Figure).
General payments seemed consistent regardless of the ex-
tent of Twitter use, while research payments appeared great-
est among those who use Twitter the least (Table). One hun-
dred ninety-seven (31%) of 634 hematologist-oncologists
received only general payments, 45 (7.1%) received only re-
search payments, 262 (41%) received both general and re-
search payments, and 130 (20.5%) received no payments.
Discussion | Our results show that 504 (79.5%) of the 634 he-
matologist-oncologists in the United States who use Twitter,
including those who are most active users, have some FCOI,
ranging from an FCOI of more than $100 (received by 397
[62.6%] physicians) to an FCOI of more than $1000 (received
by 281 [44.3%] physicians). One limitation of this study is that
many hematologist-oncologists using Twitter have minimal
user activity. Physicians in the lower and middle tercile have
a median of only 10.5 and 138 tweets; yet, we did find the FCOI
is similar among physicians in the highest tercile. Some may
worry our data set is not representative of hematologist-
oncologists on Twitter as it began with a single user. How-
ever, we searched 2 levels out, involving more than 55 000
accounts, and identified more than 600 hematologist-
oncologists, which would mean that approximately 4% of all
practicing hematologist-oncologists in the United States are
using Twitter.4 Another limitation of this study is that we were
unable to examine use of Twitter over time, whether non–
hematologist-oncologists are active on Twitter and have con-
flicts, whether physician tweets are associated with FCOI, and
whether hematologist-oncologists are tweeting about prod-
ucts or companies about which they are conflicted. These limi-
tations may form the basis of future work.
Our results raise the question of how FCOIs should be dis-
closed and managed in an age in which information, interpre-
tation, and criticism associated with cancer products and prac-
tices are increasingly available on social media. As a minimum
standard, physicians who are active on Twitter should dis-
close FCOIs in their 5-line profile biography, possibly with a
link to a more complete disclosure. For tweets regarding spe-
(Reprinted) JAMA Internal Medicine Published online January 17, 2017 E1
 Letters

Table. Characteristics of United States–Based Hematologist-Oncologists on Twitter

Median (Range)a
Hematologist-Oncologists Lowest One-Third Middle One-Third Highest One-Third
on Twitter by Tweets by Tweets by Tweets
Characteristic (n = 634) (n = 212) (n = 211) (n = 211)
Tweets, No. (range) 138 (24-537) 10.5 (3-23) 138 (77-231) 1107 (543-2568.5)
Users followed by 108 (45-294) 33.5 (18-67) 131 (66.5-252) 373 (166-659.5)
hematologist-oncologist, No. (range)
No. of users following 166 (60-492.75) 38 (19-91.5) 158 (87-313) 684 (357.5-1579.5)
hematologist-oncologist, median (range)
Hematologist-oncologist receiving 504 (79.5) 173 (81.6) 171 (81.0) 160 (75.8)
any payment, No. (%)
General payments, No. (%), $
Receiving 459 (72.4) 158 (74.5) 155 (73.5) 146 (69.2)
Receiving>$100 397 (62.6) 134 (63.2) 127 (60.2) 136 (64.5)
Receiving>$1000 281 (44.3) 99 (47.0) 86 (40.8) 96 (45.5)
Per user, median (IQR), $ 1644.77 1963.39 1054.64 2374.66
(129.57-13 744.48) (108.40-11 863.55) (92.81-12 220.34) (239.91-19 024.86)
No. of companies paying 3 (1-6) 3 (1-5) 2 (1-5) 4 (2-6.25)
hematologist-oncologist, median (IQR)
Research payments, No. (%)
Receiving 307 (48.4) 118 (55.7) 96 (45.5) 93 (44.1)
Per user, median (IQR), $ 11 064.21 22 474.88 4834.46 3107.50
(0-175 164.46) (0-286 872.37) (0-148 609.57) (0-166 146.54)
No. of companies paying 1 (0-3) 1 (0-3) 1 (0-3) 1 (0-3)
hematologist-oncologist, median (IQR)
Most frequent institutional affiliations,
frequency (%)
No. 642 NR NR NR
MD Anderson 49 (7.63) NR NR NR
Mayo 38 (5.92) NR NR NR
Memorial Sloan Kettering 32 (4.98) NR NR NR
Dana Farber Cancer Institute 29 (4.52) NR NR NR
Cleveland Clinic 25 (3.89) NR NR NR
Massachusetts General Hospital 15 (2.34) NR NR NR

Abbreviations: IQR, interquartile range; NR, not reported.

a
Median is 25th to 75th percentile.

cific products that cause an FCOI, we advise users to include

Figure. Breakdown of Financial Conflict of Interest Among
the hashtag #FCOI. Policies beyond disclosure should also be
United States–Based Physician Users of Twitter
considered.
45

40 Derrick L. Tao, BS
Hematologist-Oncologists on Twitter

General payments

35 Research payments Aaron Boothby, BS

Receiving Payment, %

30
Joel McLouth, BS
Vinay Prasad, MD, MPH
25

20 Author Affiliations: School of Medicine, Oregon Health & Science University,

Portland (Tao, Boothby, McLouth); Division of Hematology Oncology, Knight
15
Cancer Institute, Oregon Health & Science University, Portland (Prasad);
10 Department of Public Health and Preventive Medicine, Oregon Health &
Science University, Portland (Prasad); Center for Health Care Ethics, Oregon
5
Health & Science University, Portland (Prasad).
0
0 >0-100 >100- >1000- >10 000- >50 000 Corresponding Author: Vinay Prasad, MD, MPH, Oregon Health & Science
1000 10 000 50 000 University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 (prasad@ohsu.edu).
Payment Amount, $ Published Online: January 17, 2017. doi:10.1001/jamainternmed.2016.8467
Author Contributions: Dr Prasad and Mr Tao had full access to all the data in
2014 Distribution of general and research payments to 504 hematologist-
the study and takes responsibility for the integrity of the data and the accuracy
oncologists on Twitter.
of the data analysis.

E2 JAMA Internal Medicine Published online January 17, 2017 (Reprinted) jamainternalmedicine.com

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 Letters

Study concept and design: Tao, Boothby, Prasad.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Tao, McLouth, Prasad.
Critical revision of the manuscript for important intellectual content: Tao,
Boothby, Prasad.
Statistical analysis: Tao.
Study supervision: Prasad.
Conflict of Interest Disclosures: None reported.
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4. Marshall DC, Moy B, Jackson ME, Mackey TK, Hattangadi-Gluth JA.
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