Sani Hlais, MD, MPH; Claudine Nasr, MD; Hassane Awada, MD; Grace Abi Rizk, MD.

1. Attitudes of residents and faculty members in 3 academic hospitals in Beirut toward gifts offered by pharmaceutical companies. Sani Hlais, MD, MPH; Claudine Nasr, MD; Hassane Awada, MD; Grace Abi Rizk, MD. Beirut, Nov 12th 2006.

3. Background • “Dancing with the porcupines” (Lewis et al, CMAJ 2001). • Promotional activities influence prescription of medications. (…) • Early interaction with residents can have a long lasting effect on their future attitude and behavior. (McCormick et al, JAMA 2001). • Academic institutions have been slow to regulate such interactions. .(Wager, BMJ 2003).

4. Lebanon • Lack of any national or institutional code of ethics dealing with pharmaceutical promotional activities. • No official restrictions on accepting gifts from companies. • No published data about interactions of residents and physicians with pharma.

5. objectives • Assess the attitudes of residents and faculty members toward gifts offered by pharmaceutical companies. • Identify predictors of respondents’ attitudes.

6. Population • All residents and FM @ HDF, AUH, St- Georges. • Except radiol and lab. • 1030: 615 faculty members and 415 residents.

7. The tool:Questionnaire: 1- 24 questions about gifts • 4- point Likert scale ranging from 0 (not problematic) to 3 (very problematic). • Questions varied with respect to the type of gifts, their monetary and academic values, as well as the receiver . 2- demographic and identification data.

8. Questionnaire • Anonymous • direct contact of respondents • the local mailbox in the hospital • double envelope

9. Statistical analysis • Unpaired t-tests and χ2 tests: compare faculty members and residents’ responses. • Paired t-tests: compare different pairs of responses for the same respondent. • Factor or Principal component analysis with oblique rotation: data reduction and factor structure.

10. Statistical analysis (cont’d) • Two- step cluster analysis. • Discriminant analysis: determine the predictors of membership in different clusters.

11. Results: • Rate of response: 45% (460 of 1030). • Residents : 61 % (255). • FM: 33 % (205). • (17 % of FM: more than 10,000 $/ month).

12. The least problematic: 15$ antibiotic guide. The most problematic: 300$ cell phone 13 respondents (9 residents, 4 FM): nothing problematic 2 respondents (1 resident, 1 FM): all gifts problematic

13. Results (cont’d) • Attitudes res = attitudes FM, but FM significantly more critical toward many expensive and/or non academic gifts.

14. Results (cont’d) • By receiver: practically same attitude. • By monetay value: expensive more controversial. • By academic value: lower  more controversial.

15. Results: Factor analysis • Expensive. • Common. • Non- academic.

16. Results: 5 Clusters:

17. Results: 5 clusters

18. Results: 5 clusters

19. Results: Discriminant analysis: • Residents: • 2nd hospital  more critical toward common gifts. • Female: less critical toward common & expensive gifts. • Measures of restriction  more critical toward common gifts

20. Results: Discriminant analysis:(cont’d) • FM: • Measures of restriction during residency  more critical toward gifts, especially common ones. • High income  tolerant attitude toward expensive gifts.

21. Discussion: • Faculty members more critical. • Factors determining attitudes: monetary and academic value. • Results comparable to literature (Brett et al, Arch Intern Med 2003). • Some attitudes in violation of codes (UK and Australia) (acceptance of recreational gifts: music CD …)

22. Discussion: All gifts large and small • 2 respondents : all gifts problematic. • « no free lunch ». • Social science approach: indebtedness, obligation and reciprocity.(Katz D, Am J Bioethics 2003).

23. Measures of restriction: • Associated with negative attitude toward common gifts in both residents and FM. • Interest of early interventions.(Mc Cormick, et al. Effect of restricting contact between pharmaceutical company representatives and Internal Medicine residents on posttraining attitudes and behavior. JAMA 2001).

24. Strength of the study: • First in Lebanon and Middle East. • Anonymity and double enveloppe: reduce social desirability bias. • Clear question : ethically problematic. • Analysis : detection of the factor structure. • Excellent reliability: Cronbach’s α = 0.91

25. Limitations • Generalizability to a non- academic setting. • Data reduction = data loss. Risk of error inflation by using factors in cluster analysis, and then clusters in discriminant analysis. • Cross- sectional study: generating hypotheses about measures of restriction, no causality. • Other variables not assessed (type and frequency of contact with pharmaceutical companies)

26. Conclusion: • Monetary and academic values were the main deterinants of attitudes toward gifts. • Residents less critical in accepting gifts. • Measures of restriction during residency were significant predictors of residents and later faculty members’ attitudes.

27. Conflict of interest: • NONE DECLARED!!!