Korenstein D, Keyhani S, Ross JS. Physician Attitudes Toward IndustryA View Across the Specialties. Arch Surg. 2010;145(6):570-577. doi:10.1001/archsurg.2010.75
Copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2010
To explore attitudes of physicians from all specialties toward gifts from and interactions with the pharmaceutical and medical device industries.
Anonymous, cross-sectional survey distributed and collected between June 1 and September 1, 2008.
Hospitals in the Mount Sinai School of Medicine consortium in the New York, New York, metropolitan area.
Faculty and trainee physicians from all clinical departments.
Main Outcome Measures
Attitudes toward industry interactions and gifts and their appropriateness measured on 4-point Likert scales.
A total of 590 physicians and medical students completed the survey (response rate, 67.0%); 351 (59.5%) were male, 230 (39.0%) were attending physicians, and 131 (23.7%) of 553 (excluding medical students) were from surgical specialties. Attitudes toward industry and gifts were generally positive: 72.2% found sponsored lunches appropriate, whereas 25.4% considered large gifts appropriate. Surgeons, trainees, and those unfamiliar with institutional policies on industry interactions held more positive attitudes than others and were more likely to deem some gifts appropriate, including industry funding of residency programs and, among surgeons, receiving meals, travel expenses, and payments for attending lectures. Nonattending physicians held more positive attitudes toward receiving meals in clinical settings, textbooks, and samples.
Physicians continue to hold positive attitudes toward marketing-oriented activities of the pharmaceutical and device industries. Changes in medical culture and physician education focused on surgeons and trainees may align physician attitudes with current policy trends.
Physician relationships with the pharmaceutical and medical device industry have received widespread attention in recent years. We now know that nearly all physicians maintain some relationship with industry,1 beginning with near-universal exposure to pharmaceutical industry marketing during medical school.2 Most practicing physicians accept drug samples and gifts, most commonly food in the workplace, and smaller numbers of physicians accept larger payments, such as reimbursement of costs of educational meetings and conferences and speaking and consulting fees.1 Physicians from various specialties differ in the frequency of their interactions with industry, with surgeons reporting fewer interactions than others.1
With greater awareness of the prevalence of these relationships has come greater interest in the potential conflict of interest that they pose,3 with recommendations from individuals and organizations to improve transparency and independent regulation.4 However, the effectiveness of these policies is uncertain.5 Moreover, detailed studies of physician attitudes toward industry relationships thus far have focused only on the pharmaceutical industry, have not included the device industry, and have overwhelmingly surveyed physicians within academic departments of internal medicine or internal medicine residents.6- 8
Our objective was to explore attitudes and perceptions of physicians across multiple specialties toward specific interactions with the pharmaceutical and medical device industries. Because older physicians are habituated to industry interactions, we hypothesized that they would have more favorable attitudes than younger physicians or students. In addition, because the existing literature on the influence of industry on practice has been disseminated in nonsurgical journals, we hypothesized that surgical specialists would be less aware of this literature and therefore less likely to perceive conflicts of interest in relationships with industry.
The Mount Sinai School of Medicine supports a consortium of 11 local affiliated hospitals, of which 8 have residency training programs. Consortium institutions include the Mount Sinai Hospital, the primary affiliated academic medical center, and community-based and municipal hospitals throughout New York, New York (including Manhattan, Queens, and Brooklyn), and northern New Jersey. The school has a policy that bans or limits marketing-related interactions between physicians and industry and that applies to faculty and trainees at all affiliated hospitals. Our study used a convenience sample; potential participants included faculty and trainees from all departments of all consortium hospitals and third- and fourth-year medical students working in those departments. We contacted a representative from each department at consortium hospitals to ask permission to distribute surveys. Representatives included department chairs, residency program directors, and department administrators.
We used 2 methods to identify eligible physicians within participating departments. In small departments, administrators distributed the survey once to all faculty and trainee physicians in their departments. Administrators prespecified the required number of surveys based on the number of potential departmental participants, and this number was used to calculate response rates. For larger departments we attended 1 grand rounds presentation during which we distributed surveys to all eligible attendees at the beginning and collected them at the end. We tracked the number of surveys distributed. Those returned as blank or not returned were considered nonresponders. All potential participants were informed of the voluntary nature of the study and that their responses were strictly anonymous. We administered all surveys anonymously, but participants who completed the survey were able to submit their names and e-mail addresses separately for the opportunity to receive 1 of 2 gift cards worth $100 each. All surveys were distributed and collected between June 1 and September 1, 2008. Gift cards were awarded to 2 randomly selected respondents in September 2008.
Our survey was adapted from previously validated instruments.6,8,9 The 35-item survey contained 7 demographic questions, 14 questions about attitudes toward types of pharmaceutical or device marketing, and 14 questions about the appropriateness of receiving types of gifts from the pharmaceutical or device industries.
Demographic items included standard questions about sex, ethnicity, hospital and department affiliation, level of training, and time since graduation and a question about past collaborations with the pharmaceutical or device industry. Attitude questions were adapted from published surveys8,10 and included items about sample medications, the educational value of industry materials, the effect of industry funding of educational programs, and the effect of marketing on prescribing. Appropriateness items included questions about gifts, samples, and payments for various activities.
Attitude and appropriateness items were scored on different 4-point Likert scales. Participants were asked to rate their attitudes toward pharmaceutical marketing as “strongly agree,” “agree,” “disagree,” or “strongly disagree” and to rate the appropriateness of interactions as “very appropriate,” “appropriate,” “inappropriate,” or “very inappropriate.” The survey required approximately 5 to 10 minutes to complete and was approved by the institutional review board of the Mount Sinai School of Medicine.
We used χ2 tests to test for differences in attitudes toward types of pharmaceutical or device marketing and the appropriateness of receiving types of gifts from the pharmaceutical or device industries comparing physicians by academic department, attending status, and familiarity with the institution's guidelines for interactions between physicians and the pharmaceutical or device industries. For the purposes of analysis, we combined physicians from departments of surgery, surgical subspecialties, and obstetrics-gynecology. Unanswered survey questions were removed from the analysis. Analyses were performed using SAS statistical software, version 9.1 (SAS Institute Inc, Cary, North Carolina). All statistical tests were 2-tailed and used a type I error rate of 0.004 to account for multiple comparisons.
We approached the leadership of 61 departments. Thirty-five departments participated in the study, 3 declined participation, 9 agreed to participate but were unable to distribute surveys during the study period, and 14 did not respond to our inquiry. The 35 participating departments from 9 hospitals represented academic, community, and municipal centers in Manhattan, Queens, Brooklyn, and New Jersey.
We received 590 completed surveys, representing a response rate of 67.0%. Three hundred fifty-one respondents (59.5%) were male, 230 (39.0%) were attending physicians, and most were self-identified as white or Asian. Our sample was well balanced with regard to specialty. Three hundred thirteen respondents (54.2%) were familiar with their institution's policy on industry interactions, and 145 (24.6%) had collaborated with industry. Table 1 contains full demographic data.
Table 2 and Table 3 indicate physician attitudes toward industry marketing and payments. Participants had overall positive attitudes toward marketing-related interactions with the pharmaceutical or device industries. Most agreed that industry educational materials and industry funding of education are useful, although 368 (68.0%) perceived bias in sponsored lectures. Most believed it was acceptable to receive gifts and lunches, and few thought that industry representatives should be banned from meeting with physicians. Participants believed that other physicians were more likely than they to be influenced by industry marketing (284 [52.2%] vs 194 [35.6%]).
Table 4 and Table 5 give the physician assessments of the appropriateness of gifts from industry. Overall, respondents believed that small gifts related to clinical practice, such as modest meals (389 [72.2%]) and textbooks (451 [83.2%]), were appropriate. Larger gifts (137 [25.4%]) and vacations (56 [10.3%]) were deemed appropriate by considerably fewer.
We found significant differences among academic departments in attitudes about marketing and the appropriateness of gifts and payments. Physicians from surgical specialties held generally more positive attitudes toward industry, and many of the differences were statistically significant (Tables 2 and 3). Surgeons were more likely to approve of industry funding of residency programs (97 [75.8%] vs 330 [60.8%], P < .001), and fewer believed that trainees (26 [20.3%] vs 180 [32.9%], P < .001) and attending physicians (14 [10.9%] vs 127 [23.2%], P < .001) should be prohibited from interacting with industry representatives when compared with all other physician specialties. Similarly, surgeons were more likely overall to rate gifts from industry, such as meals (105 [83.3%] vs 389 [72.2%], P = .002), travel expenses (86 [67.7%] vs 288 [53.4%], P = .002), and payments for attending lectures (65 [52.9%] vs 210 [39.4%], P < .001) as appropriate (Tables 4 and 5). Pediatricians held less favorable attitudes toward industry (Tables 2 and 4); for example, fewer pediatricians approved of industry funding of residency programs when compared with all other physician specialties (25 [47.2%] vs 330 [60.8%], P < .001). Similarly, pediatricians were less likely to rate some gifts, such as dinners with no educational component (11 [20.8%] vs 191 [35.5%], P = .001) and industry reimbursement of travel expenses (20 [37.7%] vs 288 [53.4%], P = .002), as appropriate. No significant differences in responses between obstetrician-gynecologists and other surgical specialists were found.
Level of training was associated with attitudes toward industry. As indicated in Tables 3 and 5, nonattending physicians held more positive attitudes toward gifts and lunches (266 [74.9%] vs 138 [61.1%], P < .001) and were less likely to support a prohibition on trainee interactions with industry representatives (88 [24.9%] vs 107 [47.1%], P < .001) compared with attending physicians. Similarly, trainees were more likely to approve of a variety of industry gifts, such as meals in clinical settings (276 [78.9%] vs 134 [60.9%], P < .001), textbooks (313 [89.9%] vs 162 [72.3%], P < .001), and samples (292 [83.7%] vs 163 [73.1%], P = .002) (Table 5), although they were more likely to perceive bias in sponsored lectures (255 [72.7%] vs 141 [63.2%], P = .02) (Table 3).
Of respondents, 54.2% were familiar with their institution's policy toward interactions with industry. Physicians who were familiar with guidelines were less likely to agree that samples improve patient care when compared with those who were not familiar (159 [52.8%] vs 169 [65.5%], P = .002) (Table 3), and a nonstatistically significant trend was seen toward lower acceptability of industry-sponsored gifts and lunches (198 [64.3%] vs 198 [74.7%], P = .007) and the belief that industry representatives should be prohibited from meeting with trainees (122 [39.5%] vs 69 [26.1%], P = .007). Similarly, physicians who were familiar with guidelines differed from those who were not familiar in their ratings of the appropriateness of some gifts (Table 5). In general, guideline-familiar physicians gave lower appropriateness ratings to some meals, textbooks, samples, and payments for attending lectures.
Our study is the first, to our knowledge, to assess attitudes of faculty and trainee physicians toward directed marketing activities of the pharmaceutical and device industries across specialties and levels of training and to describe attitudes toward the device industry in particular. Like others,6,8 we found that physicians hold generally positive attitudes toward these interactions with industry. Most physicians in our study favored the use of samples and industry-sponsored lunches, educational materials, and funding for education. Notably, many participants found large gifts unacceptable and, like participants in previous surveys,8 believed that other physicians were more likely to be influenced by gifts and food from industry than they were.
Our study is the first, to our knowledge, to describe differences in attitudes across specialties. We found that surgical specialists held more favorable attitudes than physicians trained in other specialties toward a variety of interactions with industry. Previous studies1 have shown that surgeons are less likely than family physicians and other specialists to receive samples, gifts, and payments. However, surgeons may also be less likely than others to have been exposed to the literature regarding the potential influence of industry. Most studies of attitudes toward industry8 and of programs to educate physicians about the potential influence of industry7,9,11 have been conducted in cohorts of internists and family physicians, and results have been broadly disseminated at meetings and in journals within these specialties. Furthermore, official policies differ substantially among the specialties; the American Board of Internal Medicine12 has adopted an extremely restrictive policy toward physician interactions with industry, which acknowledges that “the acceptance of even small gifts can affect clinical judgment and heighten the perception and/or reality of a conflict of interest,”12(p469) whereas policies of surgical societies are less restrictive. The American College of Surgeons welcomes industry support for continuing medical education without mention of the potential for conflict of interest, explaining that “collaboration between the medical industry and surgeons and surgical organizations has benefited health care delivery in North America for years.”13(p92) Recently updated guidelines from the American College of Obstetricians and Gynecologists,14 the American Association of Orthopedic Surgeons,15 and the American Urological Association16 caution about potential conflicts of interest in industry relationships but do not ban any types of interactions.
The more permissive policies of surgical societies toward industry interactions may reflect the fact that relationships of surgical specialists with representatives from the device industry may be more complex than relationships of medical specialists with the pharmaceutical industry. Physicians can readily access independent information about drugs, but surgical specialists rely on industry representatives for information about new devices and the training to use them, with industry representatives present even in the operating room.17 The complexity of these relationships may blur the line between scientific collaboration and marketing and make it more difficult for surgical specialists to adopt restrictive guidelines for interactions, and it is a likely contributor to the differences in attitudes we found in our study. However, recent editorials in surgical journals have emphasized the potential influence of industry on physician behavior18,19 and challenged the ethics of many collaborations and gifts,20 which may portend a shift in attitudes within surgical specialties.
We found that attending physicians and those who were aware of relevant institutional policies had less positive attitudes toward industry, particularly with regard to samples, meals, and interactions with industry representatives. We had hypothesized that attending physicians would have more favorable attitudes than nonattending physicians because of habituation to industry representatives. Our findings with regard to attending physicians and guideline awareness may reflect the potential influence of education. Physicians who become aware of restrictive guidelines may be more educated about this issue in general and therefore may be more wary of industry interactions. Similarly, attending physicians who have had a longer professional experience and more opportunity to be educated about potential industry influence have more negative attitudes toward industry marketing interactions.
Our overall finding of favorable physician attitudes toward industry suggests that individual physicians may be out of synch with trends among medical schools and public opinion and even industry itself. Although the evidence that physician-industry marketing relationships result in patient harm is inconclusive, US medical schools have increasingly adopted restrictive policies toward industry interactions,21 and there is widespread public concern that financial relationships between physicians and industry lead to conflicts of interest.22 The public framing of the issue has increasingly demonized physicians as partners with industry in defrauding the public and has equated smaller physician gifts with large fraudulent payments from industry to prominent physicians.23 Although some in the academic medical community3 and the Institute of Medicine24 have called for increased regulation and transparency, the government has been the greater catalyst for change in terms of investigating financial fraud and moving toward stricter guidelines for interactions and more transparency.25 The US Inspector General is increasingly committed to prosecuting physicians for taking kickbacks and has begun issuing subpoenas26 “to send the message to the physician community—particularly surgeons—that you can't do this.”23 The current environment has forced the industry itself to rethink some of its marketing strategies and has led to moves such as the pharmaceutical industry's voluntary ban on branded gifts.
Despite this sea change in public and governmental attitudes during the last several years, the physicians we surveyed retain generally positive attitudes toward many industry gifts, and more than two-thirds still find gifts and lunches from industry acceptable. In fact, our findings are remarkably similar to results of other studies of physician attitudes toward industry from as early as 2001.7,8,10 The disconnect between physician and public attitudes toward industry may relate to the microenvironment in which US physicians practice. Studies of medical students27 and medical residents7 have demonstrated that trainees develop increasingly positive attitudes toward industry over time, presumably because of a “hidden curriculum”27 in the culture of medicine that communicates the acceptability of industry contact and gifts. Restricting contact with industry representatives has been shown to have a long-lasting effect on medical residents, resulting in more negative attitudes toward industry interactions even after the completion of training.28 The positive attitudes of physicians we surveyed are likely to reflect the continuing acceptability of industry interactions and gifts within the culture of medicine despite changing guidelines. Physicians in practice continue to speak frequently with industry representatives,29 and academic physicians enjoy food and other industry gifts when they attend continuing medical educational events and national specialty meetings.30 Although other groups9,11 have found that education about the effect of industry contact may have a modest effect on physician attitudes, physician attitudes are not likely to align with those of the public until the culture of medicine rejects industry marketing interactions more fully.
Our study had several important limitations. First, we used a convenience sample. We attempted to minimize selection bias by surveying all faculty attendees of grand rounds or all faculty in smaller departments, and we achieved a 67.0% response rate. By recruiting participants at departmental grand rounds, we may have inadvertently included some voluntary physicians or we may have oversampled more academically oriented physicians who may be more aware of the influence of industry. This may have biased our study toward more negative attitudes. In addition, there may have been response bias, in which respondents favor socially desirable responses, which would again bias our findings toward negative attitudes toward industry. Furthermore, our small sample size of physicians in some specialties did not allow for analysis of the effect of guideline knowledge within subgroups, and our pooling of surgical specialists prohibits conclusive comparisons.
In conclusion, our study is the first, to our knowledge, to describe differences in physician attitudes toward the pharmaceutical and device industries across specialties and to clarify the influence of training level and guideline awareness. Our finding of overall positive physician attitudes is notable in this time of increasing public concern about potential conflicts of interest, increasing regulation, and a move toward stricter guidelines for physician-industry interactions. Our findings suggest the importance of physician education about the influence of industry, particularly for trainees and surgical specialists who may be less aware of the influence of industry and who may in fact be governed through their specialty bodies by more permissive guidelines. However, large changes in physician attitudes are likely to require shifts in the cultural environment of medicine. If physician attitudes become congruent with the attitudes of the public, the medical profession may be viewed as part of the solution instead of part of what the nation at large perceives to be a problem.
Correspondence: Deborah Korenstein, MD, Department of Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, Campus Box 1087, New York, NY 10029 (email@example.com).
Accepted for Publication: June 14, 2009.
Author Contributions: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Korenstein and Ross. Acquisition of data: Korenstein. Analysis and interpretation of data: Korenstein, Keyhani, and Ross. Drafting of the manuscript: Korenstein and Keyhani. Critical revision of the manuscript for important intellectual content: Korenstein and Ross. Statistical analysis: Ross. Administrative, technical, and material support: Korenstein and Keyhani. Study supervision: Korenstein.
Financial Disclosure: Dr Ross was compensated for his work as a consultant at the request of plaintiffs in litigation against Merck and Co Inc related to rofecoxib from 2006 to 2007.
Funding/Support: Data collection for this work was partially supported by the Attorney General Prescriber Education Grant Program administered by the state of Oregon. Dr Ross is supported by the National Institute on Aging grant K08 AG032886 and by the American Federation of Aging Research through the Paul B. Beeson Career Development Award Program.