At the same time, makers of the devices have jumped into the mix by offering free schooling. That has prompted concerns about possible conflicts of interest, since doctors may return the favor when deciding which company's units to implant in patients.

Separately, federal officials started collecting data last year to determine, among other things, if the rate of complications from implant surgery differs between heart device specialists and other doctors. Such specialists, who are known as electrophysiologists, are cardiologists who undergo a year or more of added training at a teaching hospital in the treatment of abnormal heart rhythms, including device use.

That reporting has just started. Patient deaths during defibrillator implants are extremely rare. Recent government data indicates they occur at a rate of about .03 percent. An analysis by The New York Times of the first 45,000 implants reported into the Medicare database indicates that the death rate for patients of nonelectrophysiologists was 1.5 times that for patients of the specialists, and that the complication rate was slightly higher as well. Medical statisticians cautioned that such raw data would have to be analyzed further to determine whether significant differences existed.

It is in places like Rock Hill, a city of 50,000 people, located 30 miles south of Charlotte, N.C., that the broader national debate over physician training, and the role of device makers in it, has been playing out.

The tab for Biotronik for training the four physicians, for example, could total $50,000 or more, according to a consultant's contract and company data. But since last year, Biotronik has more than recouped those costs in sales of defibrillators, which sell for about $20,000 each.

By their own accounting, those doctors estimated that, with only a few exceptions, all of their 100 defibrillator patients got a Biotronik device. That provided the company, which has a scant 1 percent market share nationwide, with an estimated $2 million in revenue.

The doctors, who belong to a practice called Carolina Cardiology Associates, said in an interview that they used Biotronik devices because they thought they were superior, and not because of the free training. They also say they have a strong patient safety record.

"No one can buy my business," said Dr. Jugalkishor K. Shah, the president of Carolina Cardiology. "I think that Biotronik has very good technology."

To read more about this important topic, use the link below:
http://www.nytimes.com/2006/08/01/business/01train.html?_r=1&oref=slogin

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