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Medical school gift restriction policies and physician prescribing of newly marketed psychotropic medications: difference-in-differences analysis

BMJ 2013; 346 doi: (Published 31 January 2013) Cite this as: BMJ 2013;346:f264
  1. Marissa King, assistant professor of organizational behavior1,
  2. Connor Essick, research assistant1,
  3. Peter Bearman, Jonathan Cole professor of the social sciences2,
  4. Joseph S Ross, assistant professor of medicine3
  1. 1Yale University School of Management, New Haven, CT, USA
  2. 2Interdisciplinary Center for Innovative Theories and Empirics, Columbia University, New York, NY 10027, USA
  3. 3Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
  1. Correspondence to: P Bearman psb17{at}
  • Accepted 31 December 2012


Objective To examine the effect of attending a medical school with an active policy on restricting gifts from representatives of pharmaceutical and device industries on subsequent prescribing behavior.

Design Difference-in-differences approach.

Setting 14 US medical schools with an active gift restriction policy in place by 2004.

Participants Prescribing patterns in 2008 and 2009 of physicians attending one of the schools compared with physicians graduating from the same schools before the implementation of the policy, as well as a set of contemporary matched controls.

Main outcome measure Probability that a physician would prescribe a newly marketed medication over existing alternatives of three psychotropic classes: lisdexamfetamine among stimulants, paliperidone among antipsychotics, and desvenlafaxine among antidepressants. None of these medications represented radical breakthroughs in their respective classes.

Results For two of the three medications examined, attending a medical school with an active gift restriction policy was associated with reduced prescribing of the newly marketed drug. Physicians who attended a medical school with an active conflict of interest policy were less likely to prescribe lisdexamfetamine over older stimulants (adjusted odds ratio 0.44, 95% confidence interval 0.22 to 0.88; P=0.02) and paliperidone over older antipsychotics (0.25, 0.07 to 0.85; P=0.03). A significant effect was not observed for desvenlafaxine (1.54, 0.79 to 3.03; P=0.20). Among cohorts of students who had a longer exposure to the policy or were exposed to more stringent policies, prescribing rates were further reduced.

Conclusion Exposure to a gift restriction policy during medical school was associated with reduced prescribing of two out of three newly introduced psychotropic medications.


  • The statements, findings, conclusions, views, and opinions contained and expressed in this article are based in part on data obtained under license from IMS Health information services: Xponent database (2005-09) IMS Health. All Rights Reserved. In the tables the authors’ calculations are based on data from IMS LifeLink Information Assets-LRx Longitudinal Prescripton Database, 2008-09, IMS Health. The statements, findings, conclusions, views, and opinions contained and expressed herein are not necessarily those of IMS Health or any of its affiliated or subsidiary entities.

  • Contributors: MK and JSR conceived and designed the study and drafted the manuscript. All authors participated in the analysis and interpretation of the data and critically revised the manuscript for important intellectual content. CE, MK, and PB obtained the data. MK conducted the statistical analysis. MK accepts full responsibility for the work, had access to the data, and controlled the decision to publish. She is guarantor.

  • Funding: MK and PB received support from the National Institute of Mental Health. JSR is currently supported by the National Institute on Aging (K08 AG032886) and by the American Federation of Aging Research through the Paul B Beeson Career Development Award Program. PB is currently supported by the NIH director’s pioneer award program, part of the NIH Roadmap for Medical Research (grant No 1 DP1 OD003635-01). None of the funders had a role in study design, in the collection, analysis, and interpretation of data, in the writing of the report, or in the decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; JSR receives support from the Centers of Medicare and Medicaid Services to develop and maintain performance measures that are used for public reporting, receives grant support from Medtronic, receives grant support from the Pew Charitable Trusts (which developed and continues to support the AMSA PharmFree scorecard), and is a member of a scientific advisory board for FAIR Health, a not for profit organisation with the mission to achieve fairness and transparency in healthcare reimbursement.

  • Ethical approval: This study was deemed exempt by Yale University’s institutional review board.

  • Data sharing: Owing to the nature of our data license, data sharing is not possible.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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