Patient Perceptions of Physician Acceptance

of Gifts From the Pharmaceutical Industry

Arch G. Mainous III, PhD; William J. Hueston, MD; Eugene C. Rich, MD

Objective: To examine patient perceptions of profes- physicians. Compared with office-use gifts, more respon-
sional appropriateness and the potential impact on health dents believed that personal gifts to physicians have a
care of physician acceptance of gifts from the pharma- negative effecton both health care cost (42% vs 26%)
ceutical industry. and quality (23% vs 13%). After controlling for demo-

graphic variables, as well as awareness and exposure

Design: A random-digit dialing telephone survey.
Setting and Participants: A sample of 649 adults (\m=ge\18
years old) living in Kentucky.
Main Outcome Measures: Patient awareness of office-
use gifts (eg, pens, notepads) and personal gifts to phy-
sicians from the pharmaceutical industry, patient expo-
sure to office-use gifts, and attitudes toward physician
acceptance of both office-use and personal gifts.
Results: The survey had a response rate of 55%. Eighty-
two percent of the respondents were aware that physi-
cians received office-use gifts, while 32% were aware that
physicians received personal gifts. Seventy-five percent
reported receiving free samples of medication from their
to physician gifts, individuals with at least a high
school education were 2.4 times as likely to believe
that personal gifts have a negative effect on the cost of
health care and 2.3 times as likely to believe that per-
sonal gifts would have a negative effect on the quality
of health care.
Conclusions: These results suggest that the public is gen-
erally uninformed about personal gifts from pharmaceu-
tical companies to physicians. If public perception re-
garding the objectivity of the medical profession is to serve
as a guide, these findings suggest a reevaluation may be
in order for guidelines regarding physician acceptance
of gifts from the pharmaceutical industry.
(Arch Fam Med. 1995;4:335-339)

From the Departments of
Family Practice (Dr Mainous)
and Internal Medicine
(Dr Rich), University of
Kentucky, Lexington; and the
Department of Family
Medicine, University of
Wisconsin\p=m-\Madison,Eau
Claire Family Practice
Residency (Dr Hueston).
MUCH
controversy sur¬
rounds the issue of the
pharmaceutical indus-
try's marketing of
products directly to
physicians via gifts to physicians.1"4 Al¬
though it has been several years since the
American Medical Association and the
American College of Physicians pub¬
lished guidelines for gifts to physicians
from industry,5,6 debate continues regard¬
ing the effect and ethics of pharmaceuti¬
cal industry gifts to physicians.7"9
Several studies have examined phy¬
sician perceptions of influence and ethi¬
cal dilemmas in receiving gifts from the
pharmaceutical industry.10"13 Further, a va¬
riety of studies have focused on the inter¬
actions between pharmaceutical indus¬
try representatives and physicians.10,14,15
Chren and Landefeld16 found that re¬
quests by physicians to have drugs added
to a hospital formulary were strongly as-
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sociated with the physicians' interactions
with the companies manufacturing those
drugs. Physicians who have more con¬
tacts with pharmaceutical industry repre¬
sentatives prescribe more costly medica¬
tions in clinical scenarios.17
Although the basis for much of the
concern regarding the perceived ethical im¬
proprieties is based on physicians' con¬
cern over their clinical decisions being in¬
fluenced by pharmaceutical company gifts,
the impetus for guidelines has also come
from the desire that the medical profes¬
sion should be perceived as outside phar¬
maceutical industry influence. In the
American College of Physicians position
paper on physician interaction with the

METHODS
The data are from the 1994 Kentucky Health Survey (KHS).
The KHS is an annual statewide omnibus survey of adult (18
years of age and older) Kentucky residents about health is¬
sues. Fhe KHS has been gathering data annually since 1988.
The KHS aims to gather data regarding health issues and prob¬
lems in Kentucky. The survey contains questions that are
asked annually in an effort to examine trends and questions
submitted by investigators that are nonannual but focus on
current specific issues. The questions regarding physician
acceptance of gifts from the pharmaceutical industry were
included in the 1994 survey by us.
The survey used random-digit dialing with Waks-
berg clustering.18 The design offers every residential tele¬
phone line in Kentucky an equal probability of being se¬
lected. Further, Waksberg clustering supplies an almost
completely unbiased sample of households with tele¬
phones.19
The 1994 survey had a response rate of 55%, supply¬
ing a sample of 649 individuals. The survey's margin of er¬
ror is slightly less than ±4 percentage points at the 95%
confidence level. The 1994 KHS averaged 15 minutes to
complete.
VARIABLES
The American Medical Association guidelines indicate that
trivial gifts that benefit patient care are acceptable. Con¬
sequently, for the present study gifts were classified as to
whether they could be conceptualized as benefiting pa¬
tient care (office-use gifts) or as personal gifts to the phy¬
sician with no benefit for patient care. The following in¬
troduction was read to each respondent to indicate this
dichotomy:
Many gifts are given to doctors by companies which pro-
pharmaceutical industry, this desire for a public percep¬
tion of professional independence is clearly expressed.6
Position 1 of the paper says
Gifts, hospitality, or subsidies offered to physicians by the phar¬
maceutical industry ought not to be accepted if acceptance might
influence or appear to others to influence the objectivity of clini¬
cal judgement. A useful criterion in determining acceptable ac¬
tivities and relationships is: Would you be willing to have these
arrangements generally known?6(p624)
Despite the prominence of patient views of physician be¬
havior in medical organizational guidelines of physi¬
cian gift acceptance behavior, essentially no research has
focused on patient perceptions of pharmaceutical indus¬
try influence of physician behavior or patient percep¬
tions of the ethical propriety of the gifts the American
Medical Association guidelines suggest to be accept¬
able.3
The purpose of this study was to assess patient per¬
ceptions of professional appropriateness and the poten¬
tial impact on health care of physician acceptance of gifts
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duce medicine and medical equipment. These gifts in¬
clude things doctors use at their offices like free samples
of medicine or pens and pads of paper with the company's
name on it, as well as larger more personal gifts like clocks,
radios, and dinners at expensive restaurants.
Patient awareness of physicians' receipt of office-use
gifts was measured by asking the respondents if they were
aware that physicians receive free gifts like samples of medi¬
cine or pens and pads of paper. Similarly, the respondents
were asked to indicate their awareness of physician re¬
ceipt of personal gifts like clocks, radios, or dinners at ex¬
pensive restaurants.
Patients' degree of personal experience with physi¬
cians' receipt of gifts was measured by asking the respon¬
dents if they had ever received free samples of medicine
from their physician.
Attitudes toward the impact of physician receipt of gifts
on the cost of health care were measured for both office-use
gifts and personal gifts. In terms of assessments of office-
use gifts, the patients were asked if they thought that ac¬
cepting free gifts like medicine samples, pens, and pads of
paper had a negative, positive, or no effect on the cost of health
care provided. Similarly, the patients were asked about the
effect of accepting personal giftslike clocks, radios, and din¬
ners at expensive restaurants on the cost of care. The re¬
ceipt of certain gifts by physicians (eg, gifts for office use)
could be perceived as enhancing quality of care by allowing
the physician to provide samples of medicine; on the con¬
trary, the receipt of expensive gifts by physicians for per¬
sonal use could diminish quality of care by implying an in¬
fluence toward inapproriate clinical decisions. Therefore,
attitudes toward the impact of physician receipt of gifts on
health care quality were assessed for both office-use gifts and
personal gifts using the same item format as that used in the
assessments of the effect of gift receipt on the cost of care.
In an effort to gain a better understanding of patient
attitudes toward the professional appropriateness of
RESULTS
The demographic characteristics of the sample are shown
in Table 1. These characteristics are similar to age-
adjusted state population parameters.20 Eighty-five per¬
cent of the respondents have a regular physician, and those
who have a physician are very positive about the care that
they are receiving. Specifically, 49% report excellent qual¬
ity of care, 43% report that their care is good; 7% believe
that their care is fair, and 1% believe the quality of the
care provided by their physician is poor.
Patients' awareness of physicians' acceptances of gifts
from pharmaceutical firms varies depending on whether
the gift had some benefit to patients. Eighty-two per¬
cent of individuals were aware that physicians received
gifts with a possible patient benefit, such as samples of
medicine, pens, and pads of paper. In contrast, 32% of
respondents were aware that physicians received per¬
sonal gifts such as clocks, radios, or dinners at expen¬
sive restaurants.
A large majority of the sample has had direct expo-
 physician acceptance of gifts, the respondents were asked
their opinion of how many dollars worth of free office-use
and personal gifts it is acceptable for a physician to re¬
ceive in 1 year. Rather than use the term "acceptable," the
survey used the term "okay" so as to make the items un¬
derstandable to the broad range of respondents with vary¬
ing educational levels. For the purpose of analyses, the eight
possible response categories were collapsed into the fol¬
lowing three: less than $25, $25 to $1000, and "okay for
physicians to accept as much as they are offered."
In addition to standard demographic characteristics
(age, gender, race, education, income, and residence), sev¬
eral variables were measured that may have importance as
mediators of patient attitudes regarding physician behav¬
ior. These questions were asked as proxies for a positive
or negative relationship with a physician. The respon¬
dents were asked if they have a physician whom they can
consult whenever they have medical problems or ques¬
tions. Further, for those individuals who did have a regu¬
lar physician, the respondents were asked to rate the qual¬
ity of care they are receiving from their physician (excellent,
good, fair, or poor).
ANALYSIS
Descriptive statistics (eg, frequencies, proportions,
means, and SDs) were initially computed, 2 Cross-
classification analyses were performed to examine the
differences between the type of gifts and patient atti¬
tudes toward their effect on the cost and quality of
health care. 2 statistic was also computed between
the types of gifts and the value of gifts that it is accept¬
able to receive in a year. A substantial proportion of
individuals responded that they did not know an answer
to a variety of the attitudinal questions and these "don't
know" responses are reported in the descriptive and
bivariate statistics. Refusals on each question were elimi¬
nated from the analyses. Refusals accounted for no
sure to pharmaceutical industry office-use gifts pro¬
vided physicians. Seventy-five percent of the sample
to
reported receiving free samples of medication from their
physicians, with less than 1% indicating "don't know"
to this question.
In addition to differences in awareness of the
receipt of office-use and personal gifts, respondent
attitudes regarding the effect of gift acceptance on
both the cost and quality of health care differed
depending on whether the gift had a possible benefit
to the patients (Table 2). Compared with office-use
gifts, more respondents believed that personal gifts to
physicians have a negative effect on both health care
cost and quality.
Table 2 presents patient attitudes toward the value
of gifts that it is acceptable for physicians to accept in a
year. The acceptable value of received gifts differs sig¬
nificantly (P=.0001) depending on whether the gifts have
a potential patient benefit. Particularly striking is the dif¬
ference in patient attitudes regarding the acceptable limit
for office-use and personal gifts. Nine percent of the re¬
spondents believed that office-use gifts should be lim-
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morethan 1% of any item regarding gifts from the phar¬
maceutical industry.
In an attempt to gain an understanding of patient char¬
acteristics that may be influencing the attitudes, several bi¬
variate and multivariate analyses were computed. First, the
relation between awareness of personal gifts and the ex¬
pressed attitudes toward the effect of the acceptance of gifts
on cost and quality of health care was addressed with a 2
statistic. Second, exposure to pharmaceutical industry gifts,
as measured by receipt of medication samples, was ana¬
lyzed via 2 for its relation to the expressed attitudes to¬
ward the effect of the acceptance of gifts on cost and qual¬
ity of health care.
Because an underlying purpose of this study was to
examine patient perceptions of the impact of physician
acceptance of gifts on aspects of the delivery of health
care, multiple logistic regression analyses were com¬
puted to examine characteristics in relation to different
attitudes. Analyses were computed with the dependent
variables of attitudes toward the effect of personal gifts
on the cost of health care and the quality of health care.
In both cases, the attitudes were recoded to 0 for assess¬
ments of gifts having a negative effect or to 1 for assess¬
ments of gifts not having a negative effect (ie, no effect
or positive effect). This dichotomization was undertaken
because it was surmised that patient perceptions of nega¬
tive effects of gifts was the most important issue related
to policy guidelines regarding the acceptance of gifts.6
No regression was computed for the acceptable yearly
value of personal gifts because of the large proportion of
individuals who responded "don't know." The logistic
regressions each entered the following patient character¬
istics: age, race, gender, education, income, rural or
urban residence, awareness of personal gifts, exposure to
pharmaceutical industry gifts, and the patient report of
having a regular physician. The analyses relating patient
characteristics to expressed attitudes were computed
only with individuals who expressed an attitude.
ited to less than $25 per year, while 32% of respondents
believed that personal gifts should be limited to less than
$25 per year.
Patient attitudes toward the effects of personal gifts
on health care cost and quality was not significantly as¬
sociated with prior patient awareness of personal gifts to
physicians. Patients who were aware-of-such gifts were
just as likely as those with no awareness to have nega¬
tive opinions about the effect of such gifts on the cost
(P=.34) and quality (P=. 12) of health care. Likewise, prior
awareness of personal gifts was not significantly associ¬
ated with the dollar amount that a patient believed phy¬
sicians should accept in 1 year (P=.31).
Whether a patient had received medication samples
was associated with differences in attitudes toward gifts
(Table 3). Those who had been exposed to pharmaceu¬
tical gifts through medication samples were more likely
than nonexposed respondents to view personal gifts as
having a negative effect on the cost of health care. Pa¬
tients who had received medication samples were also
less likely to believe that personal gifts had a positive ef¬
fect on health care quality. Exposure to medication

*Except for age, data are given as number (percent). Refused indicates
refused to answer question on this variable.
'Data are given as percepts.
samples was not associated with attitudes about the ac¬
ceptable value of gifts in 1 year (P=.65).
The results of the logistic regressions on the atti¬
tudes toward the effect of gifts on the cost and quality of
care indicated that only patient education was associ¬
ated with attitudes about pharmaceutical industry gifts
to physicians. In general, better educated respondents were
more likely to view personal gifts as having a negative
effect on health care costs and quality. Specifically, in¬
dividuals with at least a high school education were 2.4
times (P=.003) as likely as those with less than a high
school degree to believe that personal gifts have a nega¬
tive effect on the cost of health care. Further, patients
with at least a high school education were 2.3 times
(P=.02) as likely as those with less than a high school
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"Data are given as percents.
degree to believe that personal gifts would have a nega¬
tive effect on the quality of health care.
COMMENT
Although a majority of patients are familiar with certain
types of gifts to physicians from the pharmaceutical in¬
dustry, most are not aware of the personal gifts to phy¬
sicians that are the subject of greatest debate and con¬
cern. Patient attitudes toward physician acceptance of gifts
are significantly different for gifts with possible patient
benefits in contrast to personal gifts with no patient ben¬
efits. Patients are more likely to see personal gifts to phy¬
sicians as having negative effects on both the cost and
quality of health care than gifts with possible patient ben¬
efit. It should be noted, however, that less than half of
the patients thought that the acceptance of personal gifts
has a negative effect on either the cost or the quality of
care. Further, patients are generally divided regarding the
value of personal gifts that it is ethically acceptable to re¬
ceive in a year, but they seem rather tolerant in placing
limits on gift acceptance. Essentially equal portions of
respondents believe that it is ethically acceptable for phy¬
sicians to accept gifts worth only a trivial amount, while
others believe that it is acceptable to receive as much as
is offered.
It appears that there are few predictors of patient at¬
titudes toward personal gifts to physicians. Prior receipt
of sample medications was associated with differences
in attitudes. Interestingly, patients who had.benefited from
pharmaceutical gifts to physicians through medication
samples had a more negative view of personal gifts than
those who had not received medication samples. While
we cannot ascribe an exact cause for this difference, it
can be speculated that providing medication samples to
patients may have made them more aware of the per¬
sonal contact between the pharmaceutical industry and
physicians and thus more concerned that personal gifts
to physicians could influence prescribing behaviors.
An additional finding worth noting is that al¬
though patients are more likely to see personal gifts to
physicians as having negative effects on both the cost and
quality of health care than office-use gifts, a substantial
proportion of patients believed that these gifts with pos¬
sible patient benefit may have a negative effect on the cost
and quality of health care. Receipt of gifts that may be
perceived as innocuous, like pens and pads of paper, are
perceived by more than a quarter of the patients as hav¬
ing a negative effect on the cost of health care. Conse¬
quently, a réévaluation of physician attitudes toward these
seemingly benign gifts may also be in order.
Only the patient's educational level was signifi¬
cantly related to attitudes toward gifts after controlling
for other demographic variables. Higher-educated pa¬
tients are more likely to view personal gifts to physi¬
cians as having negative effects on health care cost and
quality even after controlling for such factors as place of
residence and income. Educational attainment is not syn¬
onymous with an awareness of these gifts and so the re¬
sults suggest that more educated patients, even if ini¬
tially unfamiliar with the practice, may be assessing the
impact of gifts based on other perspectives provided by
their profession or social setting.
The lack of patient knowledge regarding physi¬
cian receipt of gifts from the pharmaceutical industry
is not totally surprising. Patients tend to be unaware of
a variety of aspects of their physicians and their prac¬
tices.21 This ignorance of gift acceptance has more
than likely contributed to a lack of discussion of the
ethics of pharmaceutical industry gifts to physicians
outside the medical community. However, although
several individuals within the medical community
have discussed the ethics of accepting gifts,1,4,22 this
lack of discussion in the general community may con¬
tribute to a shortage of physician self-reflection on this
issue. Evidence has suggested that the greater a physi¬
cian's exposure to pharmaceutical representatives, and
the more likely an individual is to receive gifts from
the pharmaceutical industry, the more likely physi¬
cians are to believe in the appropriateness of gift
acceptance.11,13 Moreover, physicians tend to believe
that prescribing habits are not affected by accepting
gifts,10,23 even though current evidence suggests that
physician interactions with pharmaceutical companies
does affect physician behavior.16
This study has several limitations. First, although
a probability sampling design was used, the
response
rate was of a level suggesting that a nonresponse bias
should be considered in interpretations of the find¬
ings. Unfortunately, response rates to random-digit
dialing telephone surveys have been declining in the
past decade, and although methods to increase
response rates have been instituted at significant cost,
it has been noted that very little change occurs in sur¬
vey results by including the originally hard-to-obtain
respondents.24 Second, the study is based on a tele¬
phone survey, thereby limiting the sample to individu¬
als with telephones. This limitation will omit only a
small proportion of the general population,25 but a
possible exclusion of some individuals from lower
socioeconomic backgrounds must be considered.26
Third, the data are limited to the adult residents of one
state (Kentucky). Consequently, the results may not
be generalizable to other states.
Despite the limitations noted, this study suggests that
the public is generally uninformed about personal gifts
from pharmaceutical companies to physicians. Guide-
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lines from various medical associations6 suggest that phy¬
sicians should only accept gifts if they would be willing
to have their patients know about them. Because few in¬
dividuals are aware of these gifts, the utility of this strat¬
egy of ethical assessment of physicians accepting per¬
sonal gifts from the pharmaceutical industry is
questionable. The proposed voluntary policies concern¬
ing these practices may warrant further scrutiny.
Accepted for publication November 28, 1994.
Correspondence to Department of Family Practice,
University of Kentucky, Chandler Medical Center, Lex¬
ington, KY 40536-0284 (Dr Mainous).
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