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Is a Gift Ever Just a Gift?

Ashley Wazana, MD

JAMA. 2000;283:373-380.

ABSTRACT
Context  Controversy exists over the fact that physicians have regular contact with the pharmaceutical industry and its sales representatives, who spend a large sum of money each year promoting to them by way of gifts, free meals, travel subsidies, sponsored teachings, and symposia.

Objective  To identify the extent of and attitudes toward the relationship between physicians and the pharmaceutical industry and its representatives and its impact on the knowledge, attitudes, and behavior of physicians.

Data Sources  A MEDLINE search was conducted for English-language articles published from 1994 to present, with review of reference lists from retrieved articles; in addition, an Internet database was searched and 5 key informants were interviewed.

Study Selection  A total of 538 studies that provided data on any of the study questions were targeted for retrieval, 29 of which were included in the analysis.

Data Extraction  Data were extracted by 1 author. Articles using an analytic design were considered to be of higher methodological quality.

Data Synthesis  Physician interactions with pharmaceutical representatives were generally endorsed, began in medical school, and continued at a rate of about 4 times per month. Meetings with pharmaceutical representatives were associated with requests by physicians for adding the drugs to the hospital formulary and changes in prescribing practice. Drug company–sponsored continuing medical education (CME) preferentially highlighted the sponsor's drug(s) compared with other CME programs. Attending sponsored CME events and accepting funding for travel or lodging for educational symposia were associated with increased prescription rates of the sponsor's medication. Attending presentations given by pharmaceutical representative speakers was also associated with nonrational prescribing.

Conclusion  The present extent of physician-industry interactions appears to affect prescribing and professional behavior and should be further addressed at the level of policy and education.

INTRODUCTION

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There are few issues in medicine that bring clinicians into heated discussion as rapidly as the interaction between the pharmaceutical industry and the medical profession.^1-4 More than $11 billion is spent each year by pharmaceutical companies in promotion and marketing, $5 billion of which goes to sales representatives.^5-6 It has been estimated that $8000 to $13,000 is spent per year on each physician.^7-8 The attitudes about this expensive interaction are divided and contradictory. One study⁹ found that 85% of medical students believe it is improper for politicians to accept a gift, whereas only 46% found it improper for themselves to accept a gift of similar value from a pharmaceutical company. Most medical associations have published guidelines to address this controversy. Perhaps the intensity of the discussion is related to the potential consequences were it confirmed that gifts influence prescription of medication that results in increasing cost or negative health outcomes.

This article addresses the question by way of a critical examination of the evidence. Two review articles^10-11 have addressed the factors affecting drug prescribing, but only 1 has focused on the impact of the physician-industry interaction on the behavior of physicians.¹² This article critically examines the literature and highlights articles with rigorous study methods.

METHODS

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Studies were identified by searching MEDLINE for articles from 1994 to the present, using the expanded Medical Subject Headings conflict of interest and drug industry, limiting the search to articles in English while excluding review articles, letters, and editorials; each identified study was cross-referenced; a database of 400 articles gathered by the Medical Lobby for Appropriate Marketing¹³ was searched; and 5 key informants were sought for their bibliographies on the topic.

A total of 538 studies that provided data on any of the main study questions were targeted for retrieval. Of the 29 studies that were published in peer-reviewed journals and identified as potentially relevant (containing quantitative data on 1 of 3 facets of physician-industry interactions), 10 were from MEDLINE and 19 from other sources. The data extractor (A.W.) was not blinded to the authors of the studies.

Those with an analytical design (having a comparison group) were considered to be of higher methodological quality.

RESULTS

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A total of 29 studies^14-42 were identified (Table 1). Of these, 16 addressed the extent of the physician-industry interaction, 16 identified the attitudes of physicians toward the interaction, and 16 evaluated the effect of the interaction on the practitioner.

View this table: [in this window] [in a new window] Table 1. Interaction, Attitudes, and Impact of the Interaction Between the Medical Profession and the Pharmaceutical Industry*

Interaction Between Medical Professionals and the Pharmaceutical Industry

All 16 studies^{17, 20-21,23-27,30, 32-33,35-39} identified (Table 2) used self-reporting cross-sectional survey designs, and all but 1¹⁷ used a mailed survey. The response rate ranged from 30%²⁴ to 100%.²¹ Most authors claimed that the response rate was consistent with that obtained in similar studies and that a self-report design would tend to underreport the actual frequency of interaction because of underestimates in recall or a social desirability bias.

View this table: [in this window] [in a new window] Table 2. Interaction Between the Medical Profession and the Pharmaceutical Industry*

Interactions with the industry were found to start as early as medical school²⁶ and to continue well into practice. Most physicians met with pharmaceutical representatives about 4 times a month,^{25, 27, 30-32} and the frequency tended to stabilize during residency. Residents do not differ significantly from faculty^38-39 in the frequency with which they experience this interaction. Thomson et al³⁰ found decreased availability of peer physicians (r = 0.36, P<.05) and a positive attitude toward the pharmaceutical representative (r = 0.39, P<.05) to be the only predictors of the number of contacts.

The frequency with which physicians benefit from industry-sponsored meals ³⁹ and samples ³⁹ decreases as they enter practice, while frequency of receiving honoraria, ³⁹ conference travel,²⁵ and research funding²⁵ increases. Both populations frequently use promotional material.²³ One study found that residents receive 6 gifts a year,²⁶ with no comparable data for physicians. All interactions were generally permitted except for lunch rounds,²¹ pharmaceutical representative speakers,^{21, 37} and promotionalmaterial,^{21, 36} which were more controversial. As many as 85% of programs had policies on interactions.^{21, 23, 33, 35-37}

Attitudes Toward the Interaction

All 16 studies^{19, 22-27,29-30,32-34,36-39} reported here (Table 3) used a self-report design with similar rates of response and limitations.

View this table: [in this window] [in a new window] Table 3. Attitudes Toward the Physician–Pharmaceutical Industry Interactions*

Residents and physicians have similar attitudes about pharmaceutical representatives. They believe that representatives provide accurate information about their drugs²⁵ and are equivocal in their beliefs that representatives could provide accurate information on established or alternative drugs.^24-26,38 Most believe that representatives prioritize product promotion above patients' welfare²⁵ and are likely to use unethical practices.^{22, 33} Residents are less likely than physicians are to endorse the influence of the interaction on their behavior.^{22, 24-27,29, 33-34,38-39}

Most deny that gifts could influence their behavior^{19, 24, 26, 32, 34, 38} and are equivocal about the ethics of such a practice,^{22, 33} with residents more likely to admit that without gifts, their interactions with pharmaceutical representatives would be reduced.^{24, 26, 38} Similarly, respondents agree that conference³⁷ and lunch rounds²⁷ attendance would decrease without industry-paid meals. Samples, continuing medical education (CME), and conference travel funding are felt to exert more influence (40% to 55%) than promotional material does (22%).^{19, 29, 34} Each interaction elicited ethical concerns; travel funding generated the most concern (48%²⁹ to 75%¹⁹). Most physicians also agree that pharmaceutical representative speakers should be banned.^{24, 38} Residents' opinions are divided.^{24, 26} Programs with concerns about these interactions were more likely to be military, nontraditional, or to have another source of funding.³⁷

Effect of Interaction

Sixteen studies^{14-18,20, 24, 26-28,30-31,39-42} were identified (Table 4) that assessed the impact of the physician-industry interaction on the knowledge, attitudes, and prescribing practices of physicians. Studies used cross-sectional, case-control, or preinteraction and postinteraction methods to assess the impact of particular interactions.

View this table: [in this window] [in a new window] Table 4. Effect of Physician–Pharmaceutical Industry Interactions on the Practitioner*

Interactions With Pharmaceutical Representatives

There was an independent association between meetings with pharmaceutical representatives and formulary addition requests for the drug of the representative's company, both with respect to control physicians who did not meet representatives and with respect to requests for other companies' drugs.^{17, 39} Most of the requested drugs presented little or no therapeutic advantage over existing formulary drugs, but the merit of the requests was not related to interactions with the pharmaceutical industry. This, as well as the strength, consistency, specificity, and independence of the results, make it unlikely that the interaction occurred because the physician was already convinced of that drug's influence.¹⁷

Interactions with pharmaceutical representatives were also found to impact the prescribing practice of residents and physicians³⁹ in terms of prescribing cost,²⁴ nonrational prescribing,⁴² awareness, preference and rapid prescribing of new drugs,⁴⁰ and decreased prescribing of generic drugs.⁴¹ These findings were independent of other variables in all but 1 study,⁴¹ in which such an analysis was not done.

Attitudinal outcomes were examined in matched residency programs with and without restrictions on interactions. Exposure to pharmaceutical representatives was highly associated with a perception of the benefits of such an interaction and the appropriateness of other interactions. Whether exposure to pharmaceutical representatives or to critical faculty role models influences residents' attitudes remains unknown.³¹ There were other correlates of positive attitudes,^{24, 28, 30} but the directionality of these latter associations is not as clear as with the above quasi-experimental study.³¹

Gifts

Receiving a gift²⁰ and the number of gifts received²⁶ correlated with the belief that pharmaceutical representatives have no impact on prescribing behavior; receiving gifts of high relevance to practice was also associated with a positive attitude.³⁰ The former association was independent of the student's ability to recall the donor.

Samples

Accepting samples was associated with awareness, preference and rapid prescription of a new drug,⁴⁰ and a positive attitude toward the pharmaceutical representative.³⁰

Industry-Paid Meals

There was an independent association between benefiting from sponsored meals and formulary addition requests for any drug³⁹ that was clearly dose-related.¹⁷

Funding for Travel or Lodging to Attend Educational Symposia

Accepting funding to attend a symposium was independently associated with increased formulary addition requests for the sponsor's drug.¹⁷ This interaction was also found to impact hospital prescribing practices 2 years after 2 groups of physicians accepted all-expenses-paid trips to a drug-sponsored symposium. This occurred despite the continued prescribing of the 2 drugs that the new ones were to replace and the lack of concern about the interaction among all but 1 beneficiary.¹⁶ The physicians were not randomly selected, thus raising the unlikely possibility that physicians more partial to the sponsor's drug chose to participate. It is nonetheless striking to note that the changes occurred at an institutional level.

Pharmaceutical Representative Speakers

Resident exposure to pharmaceutical representative speakers at lunch rounds was associated with dissemination and learning of inaccurate information about the sponsor's and competitor's drug.²⁷ Attendance at rounds given by a physician pharmaceutical representative was associated with appropriate and inappropriate treatment decisions by attending residents, independent of variables including the resident's memory of the presenter's affiliation.¹⁵ Although not a randomized trial, the factors leading to attendance seemed unrelated to the outcome.¹⁵

CME Sponsorship

Drug company CME, sponsorship affected presentation content in that the sponsor's drug was always preferentially highlighted, although the same drugs were discussed in each event.¹⁸ Changes in prescribing practice (self-reported) in favor of the sponsor's drug were also found.¹⁴ The participants were not randomized, but it is unlikely that their self-selection reflected a bias for the sponsor's drug. The consistent findings across all events also minimize the lack of control groups. These were findings in settings where industry guidelines were applied.

Honoraria, Research Funding, Employment

Accepting a drug company honorarium to present data on a new therapy and receiving research support were independently associated with a formulary addition request for the sponsor's drug as well as any drug.^{17, 39} One study examined the impact of employment but did not find it significant.¹³

COMMENT

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Limitations

MEDLINE was not personally searched before 1994 and other databases were not searched. However, 1 of the studies examined¹² searched MEDLINE and HEALTH from 1978 to 1993, and the methods ensured a thorough exploration of the published literature.

Industry-Physician Interaction

Residents and physicians interact with the pharmaceutical industry frequently and in multiple settings and fashions, beginning as early as medical school. Residents benefit more from drug-sponsored meals, whereas physicians receive more honoraria, conference travel, and research funding. Both meet equally often with pharmaceutical representatives.

Physicians and residents were similarly skeptical of the motives and comprehensive knowledge of pharmaceutical representatives but expressed a similar lack of concern about the influence of gifts, promotional material, meals, and lunch rounds. They had similar concerns about pharmaceutical representative speakers, CME funding, and conference funding; physicians were more concerned than were residents about the influence of representatives. All admitted that contact with representatives and attendance at educational events would decline were it not for gifts and meals.

Outcome of Interaction

Although some positive outcomes were identified (improved ability to identify the treatment for complicated illnesses), most studies found negative outcomes associated with the interaction. These included an impact on knowledge (inability to identify wrong claims about medication), attitude (positive attitude toward pharmaceutical representatives; awareness, preference, and rapid prescription of a new drug), and behavior (making formulary requests for medications that rarely held important advantages over existing ones; nonrational prescribing behavior; increasing prescription rate; prescribing fewer generic but more expensive, newer medications at no demonstrated advantage.)

No study used patient outcome measures. Studies demonstrating an effect on research findings^43-47 were excluded because they were not limited to physicians or to clinical activity. Some detected an influence of some interactions using self-report measures but were limited by the aforementioned biases and were less informative than the analytic studies reporting specific outcomes. However, most of these studies examined only 1 interaction or the effect of 1 intervention at a time, even if the effect of these interactions was posited as being cumulative. One study gave a high estimate for the effect of 2 interactions but had not entered this finding into the regression analysis.¹⁷

Most studies found a significant association that was consistent and strong for all interactions examined and which was biologically plausible and coherent with other theories⁴⁸ (Table 5). Dose response was demonstrated in all interactions in which it was examined. Some studies were even able to establish specificity by identifying a stronger endorsement of a company's product, although nonspecific outcomes (eg, decreased prescription of nongeneric products, more expensive and less rational treatment) are just as meaningful. The independence of the association was established with a matched analysis or multivariate analysis in all but CME and gifts, although, the bias in the case of CME funding seems small. Nonetheless, the temporal direction of the association was established for only 4 interactions: an increase in the physician prescribing rate of the CME sponsor's drug¹⁴; an increase in hospital prescribing rate of the conference travel sponsor's drug¹⁶; increased nonrational prescribing choice of the sponsor's drug after related resident teaching given by physician pharmaceutical representatives¹⁵; and an association between interactions with pharmaceutical representatives and positive attitudes toward them.³¹ This latter association is limited by the possibility of a confounder responsible for the differences in attitudes among the 2 groups of residents. The causal directions of all other studies are not as clear, suggesting that interactions could have followed the outcomes. Chren and Landefeld¹⁷ argue that their findings demonstrate the impact of interactions with pharmaceutical representatives, honoraria, and sponsored research. There are no ideal data to date, but the literature points to important concerns for 3 interactions with physicians: pharmaceutical representative speakers, CME sponsorship, and conference travel. Many less rigorous studies also detected the impact of the interactions with pharmaceutical representatives. These outcomes occurred despite physicians' forgetting the sponsors' names^{15, 20} or physicians' beliefs that they could not be influenced.¹⁶

View this table: [in this window] [in a new window] Table 5. Hill Criteria for Causality and Industry-Physician Interactions*

Policy Implications

Several professional societies, ^53-57 have developed guidelines to modulate the interaction between physicians and the pharmaceutical industry. Despite the guidelines' recommendation that students and residents should be informed about them, there was a lack of awareness. Among residents, only 23%²³ to 50%³² knew about them, whereas 62% of physicians knew of at least 1 guideline.¹⁹ Also, enrollment in a program with guidelines affected whether they would accept gifts, but having read the national guidelines and awareness of the program's policy did not.²³ Enrollment in a program with guidelines also affected the frequency of and attitude toward these interactions.³¹ Whether it was the guidelines themselves or the presence of critical faculty who served as role models that influenced the interactions cannot be elucidated from these studies. Only a few training programs have proposed their own guidelines (35% of US internal medicine programs,³⁷ 58% of US family medicine³⁵ programs, 61% of US emergency medicine programs,³³ and 25% of Canadian family medicine programs²¹) and fewer distribute these guidelines²¹ or give formal instruction on them.²³

Finally, most such guidelines allow for physician–pharmaceutical representative interaction whereas subsidies for travel and other amenities at a symposium can only be given to residents. This article questions the adequacy of the guidelines for many of the above interactions, specifically, the lack of guidelines regarding resident–pharmaceutical representative interaction, the efficacy of the guidelines for industry-sponsored CME events, and the allowance of industry-sponsored conference travel for residents despite the fact that these have been disallowed for physicians. This is of great concern in terms of travel scholarships, for which residents have conference subschedules designed by a group of mentors hired by the same industry sponsor and are immersed in this group for the duration of the conference. Concerns about CME could be addressed by prioritizing the Association of American Medical Colleges guidelines and concerns by other authors.⁵⁸ Also, the American College of Physicians' suggestion that physicians should be guided in making decisions about their activities by whether they would be willing to have their interactions known does not address the fact that physicians do not always comprehend how interactions affect them.

Another attempt to address growing concern about physician-industry interaction has been the introduction of practical training. Twenty-five percent³⁷ to 75%²¹ of programs taught about industry marketing techniques and critical appraisal of industry product claims. Yet these attempts left many residents wanting: family medicine, psychiatry, emergency medicine, and internal medicine residents wanted more teaching^{26, 33, 38} both in medical school (45%) and residency (60.6%).²¹ Reports of some programs that have been implemented are optimistic,^{9, 22, 33, 59-62} However, 2 of the studies are older^{9, 60} and another program⁶² was conducted infrequently. Also, only short-term effects on attitude and knowledge were examined, leaving the impact on long-term behavior unknown. Clearly, there is a need for systematic interventions. Positive changes in prescription patterns and physician knowledge^{40, 63-64} associated with such alternatives as academic detailing and industry-independent drug information mailings suggest other avenues for action.

AUTHOR INFORMATION

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Funding/Support: No financial assistance was obtained in the preparation of this article.

Acknowledgment: I would like to thank Joel Lexchin, MD, for his meticulous and invaluable contribution in the preparation of this article.

Corresponding Author and Reprints: Ashley Wazana, MD, Psychiatry Postgraduate Education, McGill Research and Training Building, 1033 Pine St W, Montreal, Quebec, Canada PQ H3A 1A1 (e-mail: cxwz{at}musica.mcgill.ca).

Author Affiliation: McGill University, Montreal, Quebec.

REFERENCES

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Perspectives on Continuing Education in the Health Professions: Improving Health Care Through Lifelong Learning
Leach and Fletcher
Chest 2008;134:1299-1303.
ABSTRACT | FULL TEXT  

Who's watching the watchdogs?
Schwartz et al.
BMJ 2008;337:a2535-a2535.
FULL TEXT  

Guided Mentorship in Evidence-Based Medicine for Psychiatry: A Pilot Cohort Study Supporting a Promising Method of Real-Time Clinical Instruction
Mascola
Acad. Psychiatry 2008;32:475-483.
ABSTRACT | FULL TEXT  

New Developments in Managing Physician-Industry Relationships
Rothman and Chimonas
JAMA 2008;300:1067-1069.
FULL TEXT  

Is the relationship between pharma and medical education on the rocks?
Moynihan
BMJ 2008;337:a925-a925.
FULL TEXT  

Rethinking continuing medical education
Pisacane
BMJ 2008;337:a973-a973.
FULL TEXT  

Free lunches are not the answer
Montgomery
BMJ 2008;336:1034-1034.
FULL TEXT  

Exposing Nursing Students To the Marketing Methods of Pharmaceutical Companies
Civaner et al.
Nurs Ethics 2008;15:396-410.
ABSTRACT  

Pharmaceutical Promotion to Physicians and First Amendment Rights
Kesselheim and Avorn
NEJM 2008;358:1727-1732.
FULL TEXT  

Impugning the Integrity of Medical Science: The Adverse Effects of Industry Influence
DeAngelis and Fontanarosa
JAMA 2008;299:1833-1835.
FULL TEXT  

The need for an Institute of Continuing Health Education
Hebert
CMAJ 2008;178:805-806.
FULL TEXT  

Le besoin d'un Institut de l'education continue en sante
Hebert
CMAJ 2008;178:809-810.
FULL TEXT  

Has the hunt for conflicts of interest gone too far? Yes
Stossel
BMJ 2008;336:476-476.
FULL TEXT  

Has the hunt for conflicts of interest gone too far? No
Lee
BMJ 2008;336:477-477.
FULL TEXT  

Doctors' education: the invisible influence of drug company sponsorship
Moynihan
BMJ 2008;336:416-417.
FULL TEXT  

Corporate influences on epidemiology
Pearce
Int J Epidemiol 2008;37:46-53.
ABSTRACT | FULL TEXT  

News media coverage of direct-to-consumer pharmaceutical advertising: implications for countervailing powers theory
Hartley and Coleman
Health (London) 2008;12:107-132.
ABSTRACT  

Child psychiatry and its relationship with the pharmaceutical industry: theoretical and practical issues
Timimi
Adv. Psychiatr. Treat. 2008;14:3-9.
ABSTRACT | FULL TEXT  

To What Extent Do Educational Interventions Impact Medical Trainees' Attitudes and Behaviors Regarding Industry-Trainee and Industry-Physician Relationships?
Carroll et al.
Pediatrics 2007;120:e1528-e1535.
ABSTRACT | FULL TEXT  

Politely Refuse the Pen and Note Pad: Gifts From Industry to Physicians Harm Patients
Iserson et al.
Ann. Thorac. Surg. 2007;84:1077-1084.
FULL TEXT  

Professionalism in Pediatrics
Fallat et al.
Pediatrics 2007;120:e1123-e1133.
ABSTRACT | FULL TEXT  

Pharmacy residents' attitudes toward pharmaceutical industry promotion
Ashker and Burkiewicz
Am J Health Syst Pharm 2007;64:1724-1731.
ABSTRACT | FULL TEXT  

General practitioners and pharmaceutical sales representatives: quality improvement research
Spurling and Mansfield
Qual Saf Health Care 2007;16:266-270.
ABSTRACT | FULL TEXT  

Conflict of Interest in Clinical Practice
Tonelli
Chest 2007;132:664-670.
ABSTRACT | FULL TEXT  

Prescriber Profiling: Time to Call It Quits
Grande
ANN INTERN MED 2007;146:751-752.
FULL TEXT  

Managing Conflict of Interest in Clinical Practice
Camilleri and Cortese
Mayo Clin Proc. 2007;82:607-614.
FULL TEXT  

A National Survey of Physician-Industry Relationships
Campbell et al.
NEJM 2007;356:1742-1750.
ABSTRACT | FULL TEXT  

Pharmaceutical Company Payments to Physicians: Early Experiences With Disclosure Laws in Vermont and Minnesota
Ross et al.
JAMA 2007;297:1216-1223.
ABSTRACT | FULL TEXT  

Conflicts of Interest and the Physician-Patient Relationship in the Era of Direct-to-Patient Advertising
Jagsi
JCO 2007;25:902-905.
FULL TEXT  

Medical Education and the Pharmaceutical Industry: A Review of Ethical Guidelines and Their Implications for Psychiatric Training
Geppert
Acad. Psychiatry 2007;31:32-39.
ABSTRACT | FULL TEXT  

Measuring the Impact of Medical Research: Moving From Outputs to Outcomes
Weiss
Am. J. Psychiatry 2007;164:206-214.
ABSTRACT | FULL TEXT  

Interactions Between Physicians and Industry: A Guide for Clinicians
Jibson
Focus 2007;5:398-406.
ABSTRACT | FULL TEXT  

Ask the Expert: Ethics and Professionalism
Jibson
Focus 2007;5:415-416.
FULL TEXT  

Bibliography for Ethics, Professionalism, and End of Life Care
Focus 2007;5:417-419.
FULL TEXT  

Abstracts for Ethics, Professionalism, and End of Life Care
Focus 2007;5:420-422.
FULL TEXT  

"Our parents, ourselves".
Turiel
JAMA 2006;296:2092-2093.
FULL TEXT  

Interactions of doctors with the pharmaceutical industry.
Morgan et al.
J. Med. Ethics 2006;32:559-563.
ABSTRACT | FULL TEXT  

Industry gifts to healthcare providers: are the concerns serious?
Day
Am J Crit Care 2006;15:510-513.
FULL TEXT  

Optimizing Outcomes in Psychopharmacology Continuing Medical Education (CME): Measuring Learning and Attitudes That May Predict Knowledge Translation into Clinical Practice
Stahl et al.
Focus 2006;4:487.
ABSTRACT | FULL TEXT  

Effects of Using Free Sample Medications on the Prescribing Practices of Family Physicians
Symm et al.
J Am Board Fam Med 2006;19:443-449.
ABSTRACT | FULL TEXT  

Overprescribing of lipid lowering agents.
Smith et al.
Qual Saf Health Care 2006;15:251-257.
ABSTRACT | FULL TEXT  

How Conducting a Clinical Trial Affects Physicians' Guideline Adherence and Drug Preferences
Andersen et al.
JAMA 2006;295:2759-2764.
ABSTRACT | FULL TEXT  

Clinical Trial Investigators and Their Prescribing Patterns: Another Dimension to the Relationship Between Physician Investigators and the Pharmaceutical Industry
Psaty and Rennie
JAMA 2006;295:2787-2790.
FULL TEXT  

Relationships between paediatricians and infant formula milk companies.
Wright and Waterston
Arch. Dis. Child. 2006;91:383-385.
FULL TEXT  

Can Health Journalists Bridge the State-of-the-Science Gap in Mammography Guidelines?
Chew et al.
Science Communication 2006;27:331-351.
ABSTRACT  

Murky waters: the pharmaceutical industry and psychiatrists in developing countries
Khan
Psychiatr. Bull. 2006;30:85-88.
FULL TEXT  

Current Status of Medical Grand Rounds in Departments of Medicine at US Medical Schools
Mueller et al.
Mayo Clin Proc. 2006;81:313-321.
ABSTRACT | FULL TEXT  

Medical Education and the Pharmaceutical Industry: Managing an Uneasy Alliance
Jibson
Acad. Psychiatry 2006;30:36-39.
FULL TEXT  

The Role of the Pharmaceutical Industry in Medical Education in Psychiatry
Lazarus
Acad. Psychiatry 2006;30:40-44.
FULL TEXT  

Health Industry Practices That Create Conflicts of Interest: A Policy Proposal for Academic Medical Centers
Brennan et al.
JAMA 2006;295:429-433.
ABSTRACT | FULL TEXT  

Differences in prescribing between GPs. Impact of the cooperation with pharmacists and impact of visits from pharmaceutical industry representatives
Muijrers et al.
Fam Pract 2005;22:624-630.
ABSTRACT | FULL TEXT  

Ties That Bind: Multiple Relationships Between Clinical Researchers and the Pharmaceutical Industry
Henry et al.
Arch Intern Med 2005;165:2493-2496.
ABSTRACT | FULL TEXT  

Excluding the experts?
Choi
CMAJ 2005;173:849-849.
FULL TEXT  

Medical Students' Exposure to and Attitudes About Drug Company Interactions: A National Survey
Sierles et al.
JAMA 2005;294:1034-1042.
ABSTRACT | FULL TEXT  

Selling Sickness: How the World's Pharmaceutical Companies Are Turning Us All Into Patients; Selling Sickness
Yom
JAMA 2005;294:1114-1116.
FULL TEXT  

Conflict of Interest: Can We Minimize Its Influence in the Biomedical Literature?
Neale et al.
J Am Board Fam Med 2005;18:411-413.
FULL TEXT  

The Contract Research Organization and the Commercialization of Scientific Research
Mirowski and Van Horn
Social Studies of Science 2005;35:503-548.
ABSTRACT  

New Federal Guidelines For Physician-Pharmaceutical Industry Relations: The Politics Of Policy Formation
Chimonas and Rothman
Health Aff (Millwood) 2005;24:949-960.
ABSTRACT | FULL TEXT  

Psychiatric Training Program Engagement With the Pharmaceutical Industry: An Educational Issue, Not Strictly an Ethical One
Mohl
Acad. Psychiatry 2005;29:215-221.
ABSTRACT | FULL TEXT  

The Role of the Pharmaceutical Industry in Teaching Psychopharmacology: A Growing Problem
Brodkey
Acad. Psychiatry 2005;29:222-229.
ABSTRACT | FULL TEXT  

Attitudes and Behaviors of Psychiatry Residents Toward Pharmaceutical Representatives Before and After an Educational Intervention
Randall et al.
Acad. Psychiatry 2005;29:33-39.
ABSTRACT | FULL TEXT  

Psychiatry and the pharmaceutical industry: who pays the piper?: A perspective from the Critical Psychiatry Network
Moncrieff et al.
Psychiatr. Bull. 2005;29:84-85.
FULL TEXT  

The role of the pharmaceutical industry in neurologic education
Gelb
Neurology 2005;64:E7-E10.
FULL TEXT  

Does the C in CME stand for "Continuing" or "Commercial"?
Lexchin and Cassels
CMAJ 2005;172:160-162.
FULL TEXT  

The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives
Brody
Ann Fam Med 2005;3:82-85.
ABSTRACT | FULL TEXT  

Doctors and Drug Companies
Blumenthal
NEJM 2004;351:1885-1890.
FULL TEXT  

Financial Conflicts of Interest in Physicians' Relationships with the Pharmaceutical Industry -- Self-Regulation in the Shadow of Federal Prosecution
Studdert et al.
NEJM 2004;351:1891-1900.
FULL TEXT  

Promotion and Prescribing of Hormone Therapy After Report of Harm by the Women's Health Initiative
Majumdar et al.
JAMA 2004;292:1983-1988.
ABSTRACT | FULL TEXT  

Continuing Medical Education in Diabetes: The Impending Crisis
Leichter
Clin. Diabetes 2004;22:174-177.
FULL TEXT  

Privacy of pharmacy prescription records
Zoutman et al.
CMAJ 2004;171:712-712.
FULL TEXT  

Cost-Related Medication Underuse: Do Patients With Chronic Illnesses Tell Their Doctors?
Piette et al.
Arch Intern Med 2004;164:1749-1755.
ABSTRACT | FULL TEXT  

CME and the pharmaceutical industry: two worlds, three views, four steps
Davis
CMAJ 2004;171:149-150.
FULL TEXT  

The future sponsorship of CME in Canada: Industry, government, physicians or a blend?
Marlow
CMAJ 2004;171:150-151.
FULL TEXT  

State-mandated continuing medical education and the use of proven therapies in patients with an acute myocardial infarction
Patel et al.
J Am Coll Cardiol 2004;44:192-198.
ABSTRACT | FULL TEXT  

Ethical Concerns in Industry Support of Continuing Medical Education: The Con Side
Packer and Parke
Arch Ophthalmol 2004;122:773-776.
FULL TEXT  

Manufacturing Desire:: The Commodification of Female Sexual Dysfunction
Fishman
Social Studies of Science 2004;34:187-218.
ABSTRACT  

Attention to 'Details':: Etiquette and the Pharmaceutical Salesman in Postwar American
Greene
Social Studies of Science 2004;34:271-292.
ABSTRACT  

Reimbursement Incentives to Physicians
Capozzi and Delsignore
JBJS 2004;86:876-877.
FULL TEXT  

The confidentiality of patient and physician information in pharmacy prescription records
Zoutman et al.
CMAJ 2004;170:815-816.
FULL TEXT  

Impact of Clinical Trial Results on National Trends in {alpha}-Blocker Prescribing, 1996-2002
Stafford et al.
JAMA 2004;291:54-62.
ABSTRACT | FULL TEXT  

Are Gifts From Pharmaceutical Companies Ethically Problematic?: A Survey of Physicians
Brett et al.
Arch Intern Med 2003;163:2213-2218.
ABSTRACT | FULL TEXT  

Policies to Regulate Gifts to Physicians From Industry
Tsai
JAMA 2003;290:1776-1776.
FULL TEXT  

Cost and Quality of Industry-Sponsored Meals for Medical Residents
Grande and Volpp
JAMA 2003;290:1150-1151.
FULL TEXT  

A Social Science Perspective on Gifts to Physicians From Industry
Dana and Loewenstein
JAMA 2003;290:252-255.
FULL TEXT  

Developing and Implementing a Program of Grand Rounds for Internists That Is Free of Commercial Bias
McMahon et al.
ANN INTERN MED 2003;139:77-78.
FULL TEXT  

Who pays for the pizza? Redefining the relationships between doctors and drug companies. 1: Entanglement
Moynihan
BMJ 2003;326:1189-1192.
FULL TEXT  

Defending Professional Independence: ACCME's Proposed New Guidelines for Commercial Support of CME
Relman
JAMA 2003;289:2418-2420.
FULL TEXT  

Is academic psychiatry for sale?
Healy and Thase
Br. J. Psychiatry 2003;182:388-390.
FULL TEXT  

Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991-1999
Steinman et al.
ANN INTERN MED 2003;138:525-533.
ABSTRACT | FULL TEXT  

Predictors of Broad-Spectrum Antibiotic Prescribing for Acute Respiratory Tract Infections in Adult Primary Care
Steinman et al.
JAMA 2003;289:719-725.
ABSTRACT | FULL TEXT  

Restoring Balance to Industry-Academia Relationships in an Era of Institutional Financial Conflicts of Interest: Promoting Research While Maintaining Trust
Johns et al.
JAMA 2003;289:741-746.
ABSTRACT | FULL TEXT  

Influence of attitudes and behaviour of GPs on prescribing costs
Szecsenyi
Qual Saf Health Care 2003;12:6-7.
FULL TEXT