==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2441386610.5144/0256-4947.2013.601asm-6-601Original ArticleInteractions between physicians and pharmaceutical sales representatives in Saudi Arabia Alosaimi Fahad Dakheel aAlKaabba Abdulaziz bQadi Mahdi cAlbahlal Abdullah dAlabdulkarim Yasir dAlabduljabbar Mohammad dAlqahtani Faisal d a Department of Psychiatry, King Saud University, Riyadh, Saudi Arabia b Department of Family Medicine, Imam Mohammed Bin Saud University, Riyadh, Saudi Arabia c Department of Family Medicine, King Abdulaziz University, Jeddah, Saudi Arabia d College of Medicine, King Saud University, Riyadh, Saudi ArabiaCorrespondence: Dr. Fahad Dakheel Alosaimi, Department of Psychiatry #55, King Khalid University Hospital, PO Box 7805, Riyadh 11472, Saudi Arabia, T: 966-534-4137, dr.fahad.alosaimi@gmail.comNov-Dec 2013 33 6 601 609 Copyright © 2013, Annals of Saudi Medicine2013This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND AND OBJECTIVES Interaction between physicians and pharmaceutical sales representative (PR) is a major component of the promotional activities by pharmaceutical companies. The lack of studies examining the magnitude of this interaction in Saudi Arabia is evident. The objective of this study is to estimate the magnitude and associated characteristics of physician-PR interaction. DESIGN AND SETTINGS A cross-sectional study was conducted among physicians working in the different regions of Saudi Arabia between March and July of 2012. METHODS A cross-sectional study was undertaken between March and July of 2012 in the different regions of Saudi Arabia. A self-administrated questionnaire was developed and handed to all participants, both in paper and electronic formats. RESULTS A total of 663 participants completed the questionnaire. The participation rate was 66.3% (663/1000). The majority of the participants (72.9%) reported interaction with PRs. This was lower among residents/interns compared to higher ranking employees (55.6% vs 83.6%, P<.001). Approximately half (48.3%) of the interactions occurred at a rate of more than once a month. A majority of the participants (72.1%) occasionally accepted gifts such as stationery (57%), drug samples (54%), meals (38%), and sponsorship of educational activities (30%). The following characteristics were independently associated with physician-PR interaction: non-Saudi nationals, a higher monthly income, Western medical education, working in a private hospital, being a specialist or registrar (rather than resident or intern), working on certain specialties (such as psychiatry and family medicine), and having limited number of patients with high socioeconomic status. CONCLUSION Although lower than seen in many parts of the world, a high prevalence of physician-PR interaction in Saudi hospitals is reported. Delineating associated characteristics may assist with future interventions. Further research should focus on ethical, clinical, prescription, and economic impact of interaction as well as determining the best strategy to reduce negative impact. ==== Body Marketing and promotional activities constitute a large portion of the budget of pharmaceutical companies.1,2 It was estimated that the US pharmaceutical companies spent more than 10% of its sales revenue on promotional activities in 2008, which was calculated into tens of billions of dollars. More than half of this amount was used to cover the expenses of detailing on physicians, nurse practitioners, and physicians’ assistants.1,2 Furthermore, independent estimates of pharmaceutical expenditure on detailing and samples in the United States was twice that officially released.3 In the past few decades, the relationship between physicians and pharmaceutical industry is one of the most controversial ethical issues in medicine.4–6 There is accumulated evidence that such relationships influence physicians’ clinical decisions and researches.7–9 For example, a review of 29 studies in the United States and other Western countries showed that different physicians’ interactions with the pharmaceutical industry was associated with nonrational drug prescription, frequent prescription of expensive medication, and formulary requests of medication that seldom apprehended the important advantages over the existing ones.7 Despite the compelling evidence of negative effects on physicians’ behavior7–9 and the presence of restrictive guidelines,10–12 the interaction is still highly prevalent. For example, around 90% prevalence of interaction between physicians and pharmaceutical sales representatives (PRs) has been reported in recent large studies in the United States and Japan.13–15 A number of studies from different parts of the world examined the demographical and occupational characteristics of physicians engaged in physician-PR interaction.14,16,17 Unfortunately, studies examining the magnitude and relationship of this interaction are deficient in Saudi Arabia. The objective of the current study was to estimate the magnitude, types, and associated characteristics of physician-PR interaction in Saudi Arabia. METHODS Population The current study was conducted among physicians working in major government and private hospitals in Saudi Arabia. All ranks of physicians, both medical and surgical specialties, were included. Hospitals in central, eastern, western, northern, and southern regions of Saudi Arabia were also included. Medical students, other health care workers, and physicians with no patient-care responsibilities were excluded. A PR was defined as a drug company employee who regularly visits physicians to provide information about the company’s products. Study design A cross-sectional study was done between March and July of 2012. The study obtained all the necessary ethical approvals from the institutional review board of the Faculty of Medicine at King Saud University, Riyadh, Saudi Arabia. Sample size From previous studies,13–15 the prevalence of physician-PR interaction was assumed to be 90%. We estimated that 138 participants were required to detect 90% prevalence with 5% accuracy. However, since the 2 groups (with and without interaction) were not assumed to be equal (given 90% prevalence), we estimated that 631 participants were required to detect 20% difference (for example, 50% vs 30%) of given characteristics between the 2 study groups, at 95% confidence level and 80% power. This number was adjusted to the possibility of 10% missing data. The calculation was done using OpenEpi software (version 2.2, Copyright (c) 2003, 2007 Andrew G. Dean and Kevin M. Sullivan, Atlanta, GA, USA). Questionnaire A self-administrated questionnaire was developed and handed to all participants. It included 30 questions arranged in 2 sections. All questions were provided in English. The first section (13 questions) assessed the sociodemographic, economic, and occupational characteristics of the studied participants. These included age, gender, nationality, monthly revenue, income satisfaction, category of hospital, main physician’s duty, job rank, number of years employed, previous work history, specialty, and patients’ socioeconomic status. The second section (17 questions) assessed the presence and (when present) the characteristics of the interaction, such as frequency, place, duration, communication methods, types of gifts offered, and acceptance. Additionally, the second section assessed the type of medical education obtained, any related ethical education obtained, and the knowledge of any local governing regulations for interaction. The scientific content of the questionnaire was validated by a multidisciplinary committee covering ethics, psychiatry, pharmacy, and epidemiology. The questionnaire was then piloted on a small number of participants (N=16) before widespread distribution. The phrasing and suggested answers were modified for some questions based on feedback from the pilot sample. Recruitment Because rosters were readily available for all of the physicians from hospitals scattered over a large geographic area, the questionnaire was distributed to available physicians at the time of the study, i.e., convenience sampling. The questionnaire was distributed by the authors of this study to a number of secondary and tertiary care hospitals in all 5 major regions of Saudi Arabia (central, western, eastern, northern, and southern regions). Informed consent was obtained from all the participants after explaining the objectives of the study. Both paper (75%) and electronic (25%) formats were used. The participation rate was 66.3% of contacted physicians (663/1000). Statistical analysis Data were presented using frequencies and percentage for categorical information, and mean and standard deviation (SD) for continuous data. The prevalence of interaction was presented as percentage of those who answered yes to the question “Have you ever encountered a PR?” Socio-demographic, economic, and occupational characteristics were compared between those who reported and did not report interaction. Significant differences between the 2 groups were calculated using the chi-square test or Fisher exact test (as appropriate) for categorical data, and student t test for continuous data. Characteristics that were associated (significant or had a trend of significance) with physician-PR interaction in univariate analysis (above) were entered into a multiple logistic regression model to define independent relationships. Variables with P>.10 were eliminated and variables with P<.05 were retained in the model using conditional backward stepwise elimination. All P values were 2-tailed. P<.05 was considered as significant. SPSS, version 16.0 (SPSS Inc., Chicago, USA) was used for all statistical analyses. RESULTS A total of 663 participants completed the study questionnaire. Sociodemographic characteristics of the participants were shown in Table 1. About three-fourths (74%) of participants were male, and the average age was 38.2 (10.0) years. More than half (55%) of participants were Saudi. Almost half of the participants (47%) were from the central Region (Riyadh, the Kingdom capital) followed by the western region (27%). The most commonly reported monthly income was between 10 and 19 thousand Saudi Riyals. About one-fifth (22%) of the participants had other financial resources in addition to their main income as a physician. The majority (59%) were satisfied with their income. The occupational characteristics of the study participants are shown in Table 2. Three-fourths of the participants were working in public hospitals. Almost all (96%) of the participants had clinical work assignments, either alone or with academic assignments. The percentage of residents or interns (37%) was slightly more than that of consultants and specialists/registrars (about 30% each). The average working duration was 12.2 (9.3) years. About one-fifth of participants had history of working in Western countries. The participants worked in more than 30 specialties, with the majority working in psychiatry, family medicine, internal medicine, surgery, and pediatrics. More than 60% of the participants described the socioeconomic status of their patients as fair. More than 30% of participants had medical education in Western countries (Table 3). Slightly more than half of the participants were educated or oriented in the ethics of physician-industry relationships. These were mainly lectures (62%), workshops (12%), or multiple sources (13%). Less than 40% of the participants thought that there were rules and polices in Saudi Arabia regulating physician-pharmaceutical industry relationships. About 73% of the participants reported interaction with PRs. As shown in Tables 1–3, the frequency of interaction with PRs was significantly higher in older age compared to younger age groups (P<.001), non-Saudi nationals compared to Saudi nationals (P<.001), eastern region compared to other Saudi regions (P=.038), high income groups compared to low income groups (P for trend <.001), privately owned hospitals compared to public hospitals (P<.001), higher ranking jobs compared to resident or intern jobs (P<.001), longer working duration compared to shorter working duration (P for trend <.001), Western work history compared to non-Western work history (P<.001), Western education compared to non-Western education (P<.001), and higher in certain specialties more than others (example, 92.3% in emergency medicine vs 20.3% on not yet specialized). The following characteristics were independently associated with physician-PR interaction in logistic regression: non-Saudi nationals, higher monthly income, Western medical education, working in a private hospital, being a specialist or registrar (rather than resident or intern), working on certain specialties (such as psychiatry and family medicine but not anesthesiology or not yet specialized), and having patients with higher socioeconomic status (Table 4). The characteristics of the physician-PR interaction are shown in Table 5. Almost half of the interaction (48%) occurred at a rate of more than once a month. Interaction typically occurred in the physician’s clinic or office (82%), at conference or symposium (42%), and to a less extent outside clinic or office (8%). The majority of interactions (48%) took less than 10 minutes. Face-to-face conversation (39%) and phone calls (32%) were the most common methods of communication. About half (52%) of PRs (occasionally) offered gifts and the majority of physicians (72%) (occasionally) accepted. The most common gifts offered were stationery items such as pens and notepads (57%), drug samples (54%), meals (38%), and financial support to attend educational activities (30%). DISCUSSION We are reporting the prevalence and types of physician-PR interaction and their associated demographic and occupational characteristics among groups of physicians of different specialities working in different regions of Saudi Arabia. The study showed that about 72.9% of the participants reported interaction with PRs. Although this is a high prevalence, it is considered lower than reported in many parts of the world that showed prevalence of around 90%. In addition, the frequency of interaction per month in the current study was also lower than reported in many Western studies8,14,16 but was similar to some regional studies.17 For example, in a review article published in 1993, Lexchin reported that 85% to 90% of doctors in the United States, Canada, Britain, and New Zealand meet PRs, on average twice every month.8 Furthermore, around 90% prevalence was reported in more recent surveys in the United States examining huge multispeciality cohorts13,18 as well as single-speciality cohorts, such as psychiatrists15 and ophthalmology trainees.19 Also, more than 90% prevalence was reported in studies examining physicians of different specialities in Japan14 and Libya.17 The lower prevalence of physician-PR interaction in the study may at least be partially explained by the inclusion of a considerable percentage (37%) of residents and interns who significantly had lower prevalence of interaction than the other job ranks. Furthermore, a large percentage (>80%) of those working in public hospitals had significantly lower prevalence of interaction than those working in private hospitals. The relationship of interaction with older age and longer working duration in univariate but not multivariate analysis may be explained by the fact that both characteristics were masked by the well concomitant higher income. Additionally, PRs usually aimed at physicians who are working in areas with no or loosely implemented restrictive rules and policies regarding exposure to industry.14,16,17 This may explain the higher frequency of interaction among physicians working in private hospitals compared to public hospitals. Finally, the current findings suggested that the physician’s speciality is a significant factor for the frequency of interaction. This was similar to previous studies that reported higher frequency of interaction among family physicians but lower frequency of interaction among anesthesiologists and nonspecialized physicians,16–18 probably, reflecting the potential volume of prescription and the availability of time to meet with PRs. Supporting our results, psychiatrists in Vermont (United States) were among the top specialities to receive pharmaceutical gifts and payments.20 Moreover, their interaction with pharmaceutical companies received higher public concern.21 Interestingly, 18% of the 50 drugs intensively advertised in the United States are medications used to treat psychiatric and neurological disorders.22 Neither education about the ethics of the physician-industry relationship nor the knowledge of local policies to govern such relationship was associated with the frequency of physician-PR interaction in the study. Education and discussion about the ethical issues related to exposure to industry have been shown to change the attitude of residents and medical students toward interaction.23–26 However, it is not clear if such intervention will be effective in reducing the frequency of interaction in the future. Additionally, the current findings suggested insufficient ethical education and limited awareness about local policies among the studied participants. Previous studies showed that 62% of physicians and 46% of residents were aware of the presence of any established local or professional guidelines concerning relationships with PRs.27,28 The majority of interactions in the study occurred in the physician’s clinic or office. This may indicate a very tolerant work environment with regard to industry exposure. Similar to previous studies, gift acceptance in the current study was a common practice.19,29 Drug samples and meals were the most common types of gifts offered by PRs.14,29–31 However, attending continuous medical education events was lower than seen in many studies.14,31 Previous studies indicated that accepting a gift is associated with a positive attitude toward interaction and the possibility of influencing the decisions of the physicians.29,32 The study has many advantages, which are listed as follows: bridging the local knowledge gap in physician-PR interaction, surveying a large number of physicians across wide geographic areas, assessing the frequency of interactions across different specialities, and detecting independent relationship factors of physician-PR interaction. Nevertheless, we acknowledge a number of limitations, being a convenience sample. The results should be generalized with caution and should not be regarded as representative to physicians working in Saudi hospitals. The response rate was 66%; however, this was similar to or even better than seen in many similar studies.14,18,33 As a self-reported study, the possibility of underestimation, due to social desirability bias, cannot be excluded especially as the interaction may involve conflicts of interest. In conclusion, although lower than seen in many parts of the world, we are reporting high prevalence of physician-PR interaction. Gift acceptance in the study was a common practice. Many characteristics were independently associated with this interaction, including nationality, income, type of education, category of hospital, job rank, speciality, and patients’ socioeconomic status. Delineating associated characteristics may help plans of intervention. Further research should focus on ethical, clinical, prescription, and economic impact of physician-PR interaction as well as determining the best strategy to reduce any negative impact. Acknowledgments The authors would like to acknowledge the support from College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, KSA. Table 1 Sociodemographic characteristics of the studied participants. Overall N=663 Interaction with PRs P value Yes N=483 No N=180 Gender  Male 485 (74.4%) 120 (71.9%) 47 (28.1%) .817  Female 167 (25.6%) 353 (72.8%) 132 (27.2%) Age (y)  Mean (SD) 38.2 (10.0) 40.1 (9.4) 33.2 (9.8)s <.001 Age groups  20–29 147 (22.9%) 62 (42.2%) 85 (57.8%) <.001  30–39 232 (36.1%) 185 (79.7%) 47 (20.3%)  40–49 156 (24.3%) 129 (82.7%) 27 (17.3%)  ≥50 108 (16.8%) 92 (85.2%) 16 (14.8%) Nationality  Saudi 353 (54.7%) 228 (64.6%) 125 (35.4%) <.001  Non-Saudi 292 (45.3%) 240 (82.2%) 52 (17.8%)  Arabs 166 (56.8%) 134 (80.7%) 32 (19.3%) .501*  Asian 25 (8.6%) 19 (76.0%) 6 (24.0%)  Western 4 (1.4%) 3 (75.0%) 1 (25.0%)  Unidentified 97 (33.2%) 84 (86.6%) 13 (13.4%) Saudi region  Central 292 (47.4%) 201 (68.8%) 91 (31.2%) .038  Eastern 84 (13.6%) 72 (85.7%) 12 (14.3%)  Western 168 (27.3%) 121 (72.0%) 47 (28.0%)  Northern 28 (4.5%) 19 (67.9%) 9 (32.1%)  Southern 44 (7.1%) 34 (77.3%) 10 (22.7%) Monthly income (SR)  <10,000 109 (16.9%) 43 (39.4%) 66 (60.6%) <.001  10,000–19,000 266 (41.2%) 206 (77.4%) 60 (22.6%)  20,000–29,000 110 (17.1%) 89 (80.9%) 21 (19.1%)  ≥30,000 160 (24.8%) 133 (83.1%) 27 (16.9%) Other income  No 513 (78.2%) 367 (71.5%) 146 (28.5%) .201  Yes 143 (21.8%) 110 (76.9%) 33 (23.1%) Income satisfaction  Satisfied 380 (58.7%) 282 (74.2%) 98 (25.8%) .587  Not sure 113 (17.5%) 86 (76.1%) 27 (23.9%)  Dissatisfied 154 (23.8%) 109 (70.8%) 45 (29.2%) PR: Pharmaceutical sales representative, SR: Saudi Riyals. Table 2 Occupational characteristics of the studied participants. Overall N=663 Interaction with PRs P value Yes N=483 No N=180 Type of hospital  Public 474 (74.6%) 318 (67.1%) 156 (32.9%) <.001  Private 110 (17.3%) 101 (91.8%) 9 (8.2%)  Both 51 (8.0%) 48 (94.1%) 3 (5.9%) Main physician assignment  Clinical 570 (90.6%) 413 (72.5%) 157 (27.5%) .247  Academic 25 (4.0%) 19 (76.0%) 6 (24.0%)  Both 34 (5.4%) 29 (85.3%) 5 (14.7%) Clinical job rank  Consultant 176 (29.1%) 142 (80.7%) 34 (19.3%) <.001  Specialist/Registrar 189 (31.3%) 164 (86.8%) 25 (13.2%)  Resident/Intern 225 (37.3%) 125 (55.6%) 100 (44.4%)  Others 14 (2.3%) 11 (78.6%) 3 (21.4%) Working duration (y)  Mean (SD) 12.2 (9.3) 13.8±9.2 7.6±8.1 <.001 Duration groups  0–9 293 (45.6%) 174 (59.4%) 119 (40.6%) <.001  10–19 197 (30.6%) 167 (84.8%) 30 (15.2%)  20–29 114 (17.7%) 95 (83.3%) 19 (16.7%)  ≥30 39 (6.1%) 36 (92.3%) 3 (7.7%) Previous work  Western 122 (20.1%) 104 (85.2%) 18 (14.8%) <.001  Non-Western 484 (79.9%) 327 (67.6%) 157 (32.4%) Specialty  Psychiatry 114 (17.8%) 92 (80.7%) 22 (19.3%) <.001  Family medicine 78 (12.2%) 64 (82.1%) 14 (17.9%)  Internal medicine 74 (11.6%) 55 (74.3%) 19 (25.7%)  Surgery 71 (11.1%) 54 (76.1%) 17 (23.9%)  Pediatrics 61 (9.5%) 51 (83.6%) 10 (16.4%)  Orthopedics 42 (6.6%) 35 (83.3%) 7 (16.7%)  Obstetrics and gynecology 22 (3.4%) 20 (90.9%) 2 (9.1%)  Emergency medicine 13 (2.0%) 12 (92.3%) 1 (7.7%)  Otolaryngology 13 (2.0%) 11 (84.6%) 2 (15.4%)  Anesthesiology 11 (1.7%) 3 (27.3%) 8 (72.7%)  Not yet specialized 59 (9.2%) 12 (20.3%) 47 (79.7%)  Others 81 (12.7%) 63 (77.8%) 18 (22.2%) Patients’ socioeconomic status  Low 145 (22.1%) 107 (73.8%) 38 (26.2%) .084  Middle 408 (62.1%) 308 (75.5%) 100 (24.5%)  High 16 (2.4%) 8 (50.0%) 8 (50.0%)  Mixed or not sure 88 (13.4%) 60 (68.2%) 28 (31.8%) PR: Pharmaceutical sales representative. Table 3 Education and knowledge of the studied participants. Overall N=663 Interaction with PRs P value Yes N=483 No N=180 Medical education  Western 191 (31.2%) 156 (81.7%) 35 (18.3%) <.001  Non-Western 422 (68.8%) 283 (67.1%) 139 (32.9%) Ethical education  No 292 (46.2%) 205 (70.2%) 87 (29.8%) .238  Yes 340 (53.8%) 253 (74.4%) 87 (25.6%) Types of ethical education  Lectures 204 (62.2%) 146 (71.6%) 58 (28.4%) .587  Workshops 38 (11.6%) 28 (73.7%) 10 (26.3%)  Courses 22 (6.7%) 16 (72.7%) 6 (27.3%)  Others 22 (6.7%) 19 (86.4%) 3 (13.6%)  Multiple 42 (12.8%) 33 (78.6%) 9 (21.4%) Knowledge of rules and polices  No 380 (62.1%) 270 (71.1%) 110 (28.9%) .288  Yes 232 (37.9%) 174 (75.0%) 58 (25.0%) PR: Pharmaceutical sales representative. Table 4 Multivariate logistic regression OR of physician’s characteristics associated with the interaction between physician and PRs. Characteristic Reference group OR Confidence intervals P value Lower Upper Non-Saudi nationality Saudi 2.39 1.20 4.76 .014 Higher monthly income <10 000 SR .065  10 000–19 000 2.19 0.93 5.19 .074  20 000–29 000 3.49 1.17 10.45 .026  ≥30 000 5.84 1.55 22.07 .009 Type of hospital Public .004  Private 5.53 1.64 18.68 .006  Both 9.08 1.07 76.96 .043 Clinical job rank Resident/Intern .002  Consultant 0.60 0.22 1.66 .328  Specialist/Registrar 2.96 1.34 6.50 .007 Speciality Others 0  Psychiatry 3.06 1.16 8.08 .024  Family medicine 3.52 1.18 10.49 .024  Internal medicine 1.74 0.57 5.28 .329  Surgery 1.80 0.63 5.13 .269  Pediatrics 2.86 0.95 8.64 .062  Orthopedics 2.50 0.61 10.21 .201  Obstetrics and gynecology 4.51 0.47 43.09 .191  Emergency medicine 3.64 0.33 40.70 .294  Otolaryngology 1.17 0.16 8.43 .874  Anesthesiology 0.10 0.02 0.64 .015  Not yet specialized 0.25 0.06 1.05 .058 Patients’ socioeconomic status Mixed or not sure .007  Low 1.02 0.41 2.52 .973  Middle 0.77 0.34 1.74 .526  High 0.06 0.01 0.31 .001 Western medical education Non-Western 2.63 1.26 5.52 .01 PR: Pharmaceutical sales representative, OR: odds ratios. Table 5 Characteristics of the interaction between physician and PRs. Frequency of interaction Once or less a month 239 (51.7%) 2–3 times a month 86 (18.6%) Once a week 56 (12.1%) 2–5 times a week 50 (10.8%) Nearly every day 31 (6.7%) Place of interaction  Inside clinic or office 380 (81.5%)  Clinic, within hours 175 (37.6%)  Clinic, after hours 160 (34.3%)  Office 122 (26.2%)  Outside clinic or office 37 (7.9%)  Restaurant/Cafeteria during my lunch break 17 (3.6%)  Parking area 13 (2.8%)  Coffee shop, restaurant, or mall outside workplace 9 (1.9%)  Conference/Symposium 194 (41.6%)  Others 26 (5.6%) Duration of interaction (min)  <5 125 (27.8%)  5–9 163 (36.3%)  10–14 93 (20.7%)  15+ 68 (15.1%) Communication methods  Face-to-face 85 (38.8%)  Over the phone 71 (32.4%)  By e-mails 26 (11.9%)  More than one method 37 (16.9%) Gift offer  Never 66 (14.4%)  Rarely 156 (34.1%)  Sometimes 155 (33.8%)  Often 59 (12.9%)  Almost always 22 (4.8%) Gift acceptance  Never 64 (14.3%)  Rarely 61 (13.6%)  Sometimes 158 (35.3%)  Often 101 (22.5%)  Almost always 64 (14.3%) Type of gift accepted  Stationary, such as pens or notepads 212 (57.3%)  Free drug samples 200 (54.1%)  Free meals 140 (37.8%)  Attending CME events 111 (30.0%)  Non-industry-sponsored events 71 (19.2%)  Industry-sponsored events 63 (17.0%)  Funded research 25 (6.8%)  Prepaid promotion cards/codes 21 (5.7%) PR: Pharmaceutical sales representative, CME: continuous medical education. ==== Refs REFERENCES 1 The Congressional Budget Office Promotional Spending for Prescription Drugs Economic and budget issue brief 12 2009 2 Pharmaceutical Research and Manufacturers of America Pharmaceutical Industry Profile 2009 Washington, D.C. PhRMA 4 2009 3 Gagnon MA Lexchin J The cost of pushing pills: a new estimate of pharmaceutical promotion expenditures in the United States PLoS Med 2008 5 e1 18177202 4 Peppin JF Pharmaceutical sales representatives and physicians: ethical considerations of a relationship J Med Philos 1996 21 83 99 8740885 5 Collins J Professionalism and physician interactions with industry J Am Coll Radiol 2006 3 325 32 17412075 6 Komesaroff PA Kerridge IH Ethical issues concerning the relationships between medical practitioners and the pharmaceutical industry Med J Aust 2002 176 118 21 11936308 7 Wazana A Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000 283 373 80 10647801 8 Lexchin J Interactions between physicians and the pharmaceutical industry: what does the literature say? CMAJ 1993 149 1401 7 8221424 9 Zipkin DA Steinman MA Interactions between pharmaceutical representatives and doctors in training. A thematic review J Gen Intern Med 2005 20 777 86 16050893 10 Pharmacists and the pharmaceutical industry: guidelines for ethical interactions American College of Clinical Pharmacy Pharmacotherapy 1993 13 531 3 8247928 11 Guidelines for interactions with pharmaceutical companies JAMA 1993 270 1250 11643149 12 Komesaroff PA Ethical issues in the relationships with industry: an ongoing challenge. New Guidelines open for public comment J Paediatr Child Health 2005 41 558 60 16398836 13 Campbell EG Rao SR DesRoches CM Iezzoni LI Vogeli C Bolcic-Jankovic D Physician professionalism and changes in physician-industry relationships from 2004 to 2009 Arch Intern Med 2010 170 1820 6 21059976 14 Saito S Mukohara K Bito S Japanese practicing physicians’ relationships with pharmaceutical representatives: a national survey PLoS One 2010 5 e12193 20730093 15 Sernyak M Rosenheck R Experience of VA psychiatrists with pharmaceutical detailing of antipsychotic medications Psychiatr Serv 2007 58 1292 6 17914005 16 Alkhateeb FM Khanfar NM Clauson KA Characteristics of physicians who frequently see pharmaceutical sales representatives J Hosp Mark Public Relations 2009 19 2 14 19197653 17 Alssageer MA Kowalski SR A survey of pharmaceutical company representative interactions with doctors in Libya Libyan J Med 2012 7 18 Campbell EG Gruen RL Mountford J Miller LG Cleary PD Blumenthal D A national survey of physician-industry relationships N Engl J Med 2007 356 1742 50 17460228 19 Wang Y Adelman RA A study of interactions between pharmaceutical representatives and ophthalmology trainees Am J Ophthalmol 2009 148 619 22 e3 19570520 20 Chimonas S Rozario NM Rothman DJ Show us the money: lessons in transparency from state pharmaceutical marketing disclosure laws Health Serv Res 2010 45 98 114 19840133 21 Insel TR Psychiatrists’ relationships with pharmaceutical companies: part of the problem or part of the solution? JAMA 2010 303 1192 3 20332407 22 Hollon MF Direct-to-consumer marketing of prescription drugs: a current perspective for neurologists and psychiatrists CNS Drugs 2004 18 69 77 14728054 23 Hopper JA Speece MW Musial JL Effects of an educational intervention on residents’ knowledge and attitudes toward interactions with pharmaceutical representatives J Gen Intern Med 1997 12 639 42 9346461 24 Kao AC Braddock C 3rd Clay M Elliott D Epstein SK Filstead W Effect of educational interventions and medical school policies on medical students’ attitudes toward pharmaceutical marketing practices: a multi-institutional study Acad Med 2011 86 1454 62 21952057 25 Wofford JL Ohl CA Teaching appropriate interactions with pharmaceutical company representatives: the impact of an innovative workshop on student attitudes BMC Med Educ 2005 5 5 15698480 26 Kelcher S Brownoff R Meadows LM Structured approach to pharmaceutical representatives. Family medicine residency program Can Fam Physician 1998 44 1053 6 9 60 9612591 27 Gibbons RV Landry FJ Blouch DL Jones DL Williams FK Lucey CR A comparison of physicians’ and patients’ attitudes toward pharmaceutical industry gifts J Gen Intern Med 1998 13 151 4 9541370 28 Reeder M Dougherty J White LJ Pharmaceutical representatives and emergency medicine residents: a national survey Ann Emerg Med 1993 22 1593 6 8214843 29 Lieb K Brandtonies S A survey of german physicians in private practice about contacts with pharmaceutical sales representatives Dtsch Arztebl Int 2010 107 392 8 20574555 30 Misra S Ganzini L Keepers G Psychiatric resident and faculty views on and interactions with the pharmaceutical industry Acad Psychiatry 2010 34 102 8 20224017 31 McNeill PM Kerridge IH Henry DA Stokes B Hill SR Newby D Giving and receiving of gifts between pharmaceutical companies and medical specialists in Australia Intern Med J 2006 36 571 8 16911549 32 Korenstein D Keyhani S Ross JS Physician attitudes toward industry: a view across the specialties Arch Surg 2010 145 570 7 20566978 33 Morgan MA Dana J Loewenstein G Zinberg S Schulkin J Interactions of doctors with the pharmaceutical industry J Med Ethics 2006 32 559 63 17012493