Abstract Title: Financial Conflicts of Interest of Physicians Followed by Leading Medical Journals on X (Twitter) Background Social media platforms like X (Twitter) have become important for disseminating medical research. However, financial conflicts of interest (FCOIs) among physicians on these platforms may influence content. This study aimed to assess FCOIs among physicians followed by top medical journals on X.

Methods We identified US physicians followed on X by The New England Journal of Medicine, The Lancet, and JAMA. Using the Open Payments database, we analyzed general payments, research payments, and ownership interests received by these physicians from 2014-2021. We also examined payments to editorial board members and analyzed a subset of posts from physicians with FCOIs. We analyzed the posts using named-entity-recognition, topic modeling, and sentiment analysis.

Results Of 253 US physicians followed, 54.9% received general payments totaling $19.2 million. Specialists received significantly higher median payments than primary care physicians ($540 vs $0, p=0.0003). Among editorial board members with X accounts followed by their journals, 73.3% received general payments.When compared to general payments, only 9.5% of physicians received research payments. Analysis of physicians’ X activity showed those with FCOIs had significantly more followers than those without (64,490 vs 17,724, p=0.044). Topic modeling of Posts from physicians with FCOIs revealed frequent discussion of industry-related topics. Physicians with declared financial conflicts of interest tend to include academic links in their tweets slightly more often (20.93%) compared to those without FCOI (19.07%). Subspecialities of internal medicine and surgery tended to share more academic sources. Physicians with FCOIs tend to discuss more specific medical topics (e.g medical education, FDA and regulations, vaccines) compared to those without FCOIs, who often have "other" as their most common topic.The average sentiment scores vary between -0.037 and 0.576, with most scores being positive.

Conclusion A majority of physicians followed by top medical journals on X have FCOIs, with some receiving substantial payments. This raises concerns about potential bias in social media content from these influential voices. Greater transparency is needed regarding FCOIs on social media platforms used for medical information dissemination. Medical journals should consider implementing policies for disclosing FCOIs when interacting with or promoting content from physicians on social media. Physicians should also provide reference to their FCOIs to avoid the appearance of bias and maintain public trust.