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Pharmaceutical Industry Interactions in Family Medicine Residencies Decreased Between 2008 and 2013: A CERA Study

Steven R. Brown, MD; David V. Evans, MD; Adriane Fugh-Berman, MD

Background and Objectives: Most medical residents have some interaction with the pharmaceutical industry. It is not known if this interaction has changed over time. We determined whether interactions between family medicine residencies and the pharmaceutical industry have changed in the past 5 years.

Methods: We surveyed program directors of US family medicine residencies with questions addressing industry-sponsored gifts, drug samples, access of industry representatives to trainees, and industry-sponsored residency activities. The questions were part of a larger 2013 survey administered by the Council of Academic Family Medicine Educational Research Alliance (CERA). The authors compared results from 2008 and 2013.

Results: The response rate to the 2013 CERA program director survey was 56% (251/445); 47% (208/445) of surveyed directors viewed and answered all survey questions. Between 2008 and 2013, residency programs that accept no gifts or industry-sponsored food increased from 48% (137/286) to 73% (151/208). Residencies refusing samples increased from 52% (148/286) to 78% (166/212), and residencies that do not allow industry representatives to have access to learners increased from 43% (124/286) to 74% (157/212). Residency programs that forbade industry-sponsored activities remained stable (67% versus 73%). About half (49%) (101/208)) of programs in 2013 qualified as “pharma-free,” compared to 26% (75/286) in 2008.

Conclusions: In 2013, one of two family medicine residencies disallow gifts, drug samples, interactions between residents and pharmaceutical sales representatives, and pharmaceutical industry-sponsored activities. This proportion is twice what was observed in 2008. Restrictions increased in all categories except industry-sponsored activities.

(Fam Med 2015;47(4):279-82.)

Most medical students and residents have some interaction with the pharmaceutical industry.1 Between 54% and 90% of residents have accepted gifts or food.2-6 Interaction with the pharmaceutical industry affects prescribing habits, and many prescribing habits are formed during medical training.7 Access to sample closet medications8-11 and trainee exposure to pharmaceutical promotion12 are associated with non-rational prescribing and less knowledge about evidence-based prescribing. Sponsorship of conferences13 and gifts from the pharmaceutical industry14 also influence physician behavior.

In recent years, many organizations and individuals have called for an end to industry involvement in training programs, including a prominent group of academic leaders,15 the Josiah Macy, Jr Foundation,16 the Institute of Medicine,17 and the Association of American Medical Colleges.18 Starting in 2014, the “Sunshine” provision of the 2010 Affordable Care Act requires the pharmaceutical industry to publicly report payments and gifts to physicians and teaching hospitals.19 We hypothesize that the increased focus on physician-industry relationships has led to changes in many programs in the past 5 years.

Indeed, there is some indication that the frequency of interactions between physicians in practice and the pharmaceutical industry may be changing.20 In 2008, we surveyed US family medicine residencies and found that 74% allowed some interaction with the industry (interactions included gifts, food, samples, visits from pharmaceutical representatives, and industry-sponsored residency activities).21 Qualitative findings suggested that many residency programs expected change in subsequent years.21 In 2013, we surveyed family medicine residencies again to determine whether industry interactions had changed.




We surveyed program directors at all Accreditation Council for Graduate Medical Education (ACGME)-accredited family medicine residencies in August and September 2013. The questions were rolled into a larger omnibus survey conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA). Pretesting of the survey was done on family medicine educators who were not part of the target population to assure question clarity. The Institutional Review Board of the American Academy of Family Physicians approved the project. The sampling frame for the survey was all US family medicine residency program directors as identified by the Association of Family Medicine Residency Directors (AFMRD). Email invitations to participate were delivered with the survey utilizing the online program Survey Monkey. Two reminder emails were sent to nonrespondents after the initial email invitation.

The CERA survey included five questions that are the subject of our analysis: (1) Does your medical school/residency have any interaction with pharmaceutical companies? (2) Does your residency allow gifts from industry or industry-supported food? (3) Are drug samples accepted at the residency? (4) Are industry representatives allowed access to medical students and/or residents at the family medicine center? (5) Are any industry-sponsored residency activities allowed? Question 1 was new; questions 2–5 were the exact same questions we asked previously for a prior publication.21

US family medicine residencies are categorized by program type: university based, community based university affiliated, community based nonaffiliated, and military.22 In this survey, programs self-
reported their program type.

All statistical analyses were performed using Fisher’s exact test to determine significant differences in proportions or program type between 2008 and 2013. As described in our original 2008 study,21 we designated family medicine residencies that answered “No” to questions 2 through 5 as “pharma-free;” these programs allowed no industry gifts, food, samples, interaction with students or residents, or sponsorship of residency activities.




The response rate to the 2013 CERA program director survey was 56% (251/445), similar to the 62% (286/460) of programs that responded to our freestanding 2008 survey. In the 2013 CERA survey, six respondents did not complete the section of the questionnaire that contained our questions. Due to a programming error in skip logic that affected early responses, some early respondents never viewed questions 2–5, so 245 respondents answered question 1 (“Does your medical school/residency have any interaction with pharmaceutical companies?”) but, between 208 and 212 respondents viewed and answered questions 2–5. In other words, 98% of respondents began our survey section, but due to the programming error, 83% of respondents (47% [208/445] of the entire sample) answered all questions.

In 2013, 62% (152/245) of responding programs responded “no” to the question: “Does your medical school/residency have any interaction with pharmaceutical companies?” This question was not asked in 2008.

See Figure 1 comparing the answers between 2008 and 2013 in regard to gifts, samples, exposure to representatives, and industry-sponsored residency activities.

Figure 1

Forty-nine percent (101/208) of programs responding to all four questions in 2013 were pharma-free, compared to 26% (75/286) in 2008 (P<.001).

University-based programs were no more likely to meet the pharma-free criteria than other programs. Fifty-one percent (18/35) of responding university-based programs were pharma-free compared to 49% (67/137) of community-based, university-affiliated programs, and 45% (13/29) of community-based, non-affiliated programs; differences among groups were not significant. Forty-three percent (3/7) of the responding military programs met pharma-free criteria.




Interactions between family medicine residencies and the pharmaceutical industry have decreased dramatically in recent years. In 1992, only 10% of family medicine residencies had no interaction with industry.6 This percentage increased to 26% in 200821 and 49% in 2013. Half of family medicine residencies now have no interaction with the pharmaceutical industry. If our sample is representative of all 445 family medicine residencies, this means approximately 100 family medicine residencies have ended pharmaceutical interaction in the past 5 years.

Community residency programs are just as likely to limit interactions as family medicine residencies at university centers, a consistent finding in both 2008 and 2013. This finding is particularly relevant because 88% of family medicine residencies are located in a community setting, not at a university.22

Family medicine residencies have less interaction than residencies in other specialties. Recent surveys show 56% of internal medicine residencies accept “some kind of support” from industry,3 more than half of surgical residencies report industry support for academic events,4 and 87% of ophthalmology residencies report visits from industry representatives.5

Our findings match a pattern in the literature that shows industry interaction with physicians is decreasing. A 2009 survey showed that the percentage of physicians with any relationship with industry decreased from 94% in 2004 to 84% in 2009.20 Additionally, the number of physicians that receive drug samples decreased from 78% to 64%, and the number of physicians receiving any gifts, including food, decreased from 83% to 71%. However, a 2011 survey of medical students and residents in diverse specialties found that industry interactions are still common; half (49%) of residents had met with pharmaceutical representatives, and 36% had attended industry-sponsored lectures.2

Programs are limiting industry interactions at an accelerating pace. The reasons for this are likely multifactorial. Interactions between medical schools and pharmaceutical companies have been under scrutiny,15-19 and more than two thirds (70%) of medical schools now earn an “A” or “B” grade on the American Medical Student Association scorecard for their interaction policies. However, in 2013, only four medical schools banned pharmaceutical representatives from campus.23

While there is substantial evidence that interaction with the pharmaceutical industry leads to non-rational prescribing, and many view these interactions as negative, there are some that argue that interaction with industry in a teaching context can be beneficial. Qualitative data from our 2008 survey indicate that some program directors feel residents benefit from industry interaction to learn this skill for practice,21 and some curricula are built around this concept.24

Our study has several limitations. While the same survey questions were asked in both the initial and follow-up study, the 2008 study was a stand-alone study, while the 2013 survey was folded into the CERA program director survey. Although the response rates to both surveys were robust, 43 programs never viewed questions 2–5, and it is unknown what their answers may have been. However, the fact that 62% (152/245) of responding programs responded “no” to the question “Does your medical school/residency have any interaction with pharmaceutical companies?” implies that the missing answers to the remaining questions may have qualified more programs as pharma-free, so our results may have been even more dramatic had those responses been completed and analyzed.

It is also possible that the responding programs were not representative of all programs. While it is possible that those who responded to the 2008 stand-alone survey viewed industry interactions more negatively, the CERA omnibus survey covered five different topics ranging from hospitalist trends to maternity care, so there is little reason to suspect that only those concerned about industry interactions would complete this survey. In this way, the 2013 survey is likely more representative of family medicine residencies as a whole. Additionally, the difference between the 2008 and 2013 sample could explain the decrease in interaction seen. However, even with a lower response rate in 2013, the absolute number of programs reporting less interaction is increased. This makes a non-representative sample less likely to explain the difference.

Our questions addressed the daily learning environment of residents but did not cover many influences (for example, direct payments to faculty physicians, sponsored research, or involvement in ghost-written articles) that could expose learners to industry bias and thus be relevant to a training program. Program directors may also not be aware of resident interaction in other learning sites, such as a rotation with a community provider. We did not ask about institutional policies and did not compare policies of medical schools and academic medical centers to community programs. We also did not survey pharmaceutical industry support for research in academic medical centers and this influence as a possible conflict of interest. These questions are possible areas for further research.

In summary, an increasing number of family medicine residencies restrict interaction with industry. Despite mounting evidence that pharmaceutical interaction is harmful to rational prescribing, about half of family medicine residencies still allow some interaction in the form or gifts, samples, meetings with representatives, or industry-sponsored activities.

Acknowledgments: This paper was a poster presentation at the 2014 Scholarly Teaching Symposium, University of Arizona-Phoenix.

The authors thank Rachel Trippett, MD; Jay Siwek, MD; Alicia M. Bell, MS; Paige Clark, MD; and Anthony Fleg, MD for designing and implementing the original survey, Richard Gerkin, MD, and Cara Olsen for statistical assistance, and CERA advisor Mark Stephens, MD.

Corresponding Author: Address correspondence to Dr Brown, University of Arizona-Phoenix, Department of Family and Community Medicine, 1300 N. 12th Street, Suite 605, Phoenix, AZ 85006. 602-839-2668.



  1. Sierles FS, Brodkey AC, Cleary LM, et al. Medical students’ exposure to and attitudes about drug company interactions: a national survey. JAMA 2005;294:1034-42.
  2. Austad KE, Avorn J, Franklin JM, et al. Changing interactions between physician trainees and the pharmaceutical industry: a national survey. J Gen Intern Med 2013;28(8):1064-71.
  3. Loertscher LL, Halvorsen AJ, Beasley BW, Holmboe ES, Kolars JC, McDonald FS. Pharmaceutical industry support and residency education: a survey of internal medicine program directors. Arch Intern Med 2010;170:356-62.
  4. Nakayama DK, Bozeman AP. Industry support of graduate medical education in surgery. Am Surg 2009;75:395-400.
  5. Wang Y, Adelman RA. A study of interactions between pharmaceutical representatives and ophthalmology trainees. Am J Ophthalmol 2009;148:619-22.
  6. Brotzman GL, Mark DH. Policies regulating the activities of pharmaceutical representatives in residency programs. J Fam Pract 1992;34:54-7.
  7. Zipkin DA, Steinman MA. Interactions between pharmaceutical representatives and doctors in training: a thematic review. J Gen Intern Med 2005;20(8):777-86.
  8. Adair RF, Holmgren LR. Do drug samples influence resident prescribing behavior? A randomized controlled trial. Am J Med 2005;118:881-4.
  9. Chew LD, O’Young TS, Hazlet TK, Bradley KA, Maynard C, Lessler DS. A physician survey of the effect of drug sample availability on physicians’ behavior. J Gen Intern Med 2000;15:478-83.
  10. Brewer D. The effect of drug sampling policies on residents prescribing. Fam Med 1998;30:482-6.
  11. Boltri JM, Gordon ER, Vogel RL. Effect of antihypertensive samples on physician prescribing patterns. Fam Med 2002;34:729-31.
  12. Austad KE, Avorn J, Franklin JM, Campbell EG, Kesselheim AS. Association of marketing interactions with medical trainees’ knowledge about evidence-based prescribing: results from a national survey. JAMA Intern Med 2014; 174(8):1283-90.
  13. Huang FY, Weiss DS, Fenimore PG, et al. The association of pharmaceutical company promotional spending with resident physician prescribing behavior. Acad Psychiatry 2005;29:500-1.
  14. Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000;283(3):373-80.
  15. Brennan TA, Rothman DJ, Blank L, et al. Health industry practices that create conflicts of interest: a policy proposal for academic medical centers. JAMA 2006;295:429-33.
  16. Josiah Macy, Jr. Foundation. Continuing education in the health professions: improving healthcare through lifelong learning. Published 2008. Accessed July 31, 2014.
  17. Institute of Medicine of the National Academies. Conflict of interest in medical research, education, and practice. Released April 2009. Accessed July 31, 2014.
  18. Association of American Medical Colleges. Industry funding of medical education, Report of the AAMC Task Force. Published July 2008. Accessed July 31, 2014.
  19. Centers for Medicare and Medicaid Services. Open payments. Accessed September 14, 2014.
  20. Campbell EG, Rao SR, DesRoches CM, et al. Physician professionalism and changes in physician-industry relationships from 2004 to 2009. Arch Intern Med 2010;170(20):1820-6.
  21. Fugh-Berman A, Brown SR, Trippett R, et al. Closing the door on pharma? A national survey of family medicine residencies regarding industry interaction. Acad Med 2011;86(5):649-54.
  22. American Academy of Family Physicians. Family medicine residency programs by structure (as of July 2013). Accessed September 14, 2014.
  23. American Medical Student Association. Majority of US medical schools have strong pharmaceutical conflict-of-interest policies: AMSA Survey to Review Policies at US Teaching Hospitals Next. Accessed September 14, 2014.
  24. Montague BT, Fortin AH, Rosenbaum J. A systematic review of curricula on relationships between residents and the pharmaceutical industry. Med Educ 2008;42:301-8.

From the Banner Good Samaritan Family Medicine Residency and Department of Family and Community Medicine, University of Arizona-Phoenix (Dr Brown); Department of Family Medicine, University of Washington (Dr Evans); and Department of Pharmacology and Physiology and Department of Family Medicine, Georgetown University Medical Center, Washington, DC (Dr Fugh-Berman).


Copyright 2017 by Society of Teachers of Family Medicine