Marketing to health-care providers takes three main forms: activity by pharmaceutical sales representatives, provision of drug samples, and sponsoring continuing medical education (CME). The use of gifts, including pens and coffee mugs embossed with pharmaceutical product names, has been prohibited by PHRMA ethics guidelines since 2008. Of the 237,000 medical sites representing 680,000 physicians surveyed in SK&A's 2010 Physician Access survey, half said they prefer or require an appointment to see a rep (up from 38. 5% preferring or requiring an appointment in 2008), while 23% won't see reps at all, according to the survey data. Practices owned by hospitals or health systems are tougher to get into than private practices, since appointments have to go through headquarters, the survey found. 13. 3% of offices with just one or two doctors won't see representatives, compared with a no-see rate of 42% at offices with 10 or more doctors. The most accessible physicians for promotional purposes are allergists/immunologists – only 4. 2% won't see reps at all – followed by orthopedic specialists (5. 1%) and diabetes specialists (7. 6%). Diagnostic radiologists are the most rigid about allowing details – 92. 1% won't see reps – followed by pathologists and neuroradiologists, at 92. 1% and 91. 8%, respectively.