Free Gifts to Doctors May Be Bad for Your Health

More and more physicians and medical ethicists acknowledge gifts from pharmaceutical companies create a climate of potential abuse and improper influence.

Speaking of ethical responsibility, full disclosure demands that I state that my daughter and son-in-law are physicians, each of whom demonstrate the finest aspects and practices of his and her profession. I, personally have an internist/family doctor who is competent, eager to answer every question that I have, after reading WebMD, and a cardiologist who has seen me through by-pass surgery and six years of making sure I do not have to be "opened up" again. I freely acknowledge that, as a patient, I must try their respective patience.

Whenever I visit one of my physicians, I cannot fail to notice drug company logos decorating pens, floor mats, sticky-notes, wall clocks and a plethora of other decorating items. While the extent of expensive gifts has declined, through the voluntary efforts of the American Medical Association, the American College of Physicians, and the Pharmaceutical Research and Manufacturers of America (PhRMA), a study published in the New England Journal of Medicine [NEJM] on April 26, 2007,statesalmost every doctor in the country has some type of relationship with pharmaceutical manufacturers, whose clear goal is to influence physicians to prescribe the company's newest, most expensive drugs. The companies offer physicians everything from scratch pads to expensive dinners, to pizza, trips worth thousands of dollars to attend medical conferences and substantial consulting fees.

What is the function of the "drug rep"? A discussion reported in PloS, a peer review publication for physicians, in April, 2007, reported on the marketing techniques of the drug representative. A former representative of Eli Lilly, said, "During training, I was told, when you're out to dinner with a doctor, the physician is eating with a friend. You are eating with a client. It's my job to figure out what a physician's price is. For some it's dinner at the finest restaurants, for others it's enough convincing data to let them prescribe confidently and for others it's my attention and friendship...but at the most basic level, everything is for sale and everything is an exchange." While, as I state below, a doctor will assert that a trip with his or her spouse, will not influence the physician's behavior, the study in PloS demonstrates that the average physician is no match for the highly trained salesman sent out by the drug companies. Often, the doctor will not realize he or she is being manipulated!

According to the New England Journal's study, the sheer percentage of physicians who have financial relationships with the drug industry is astounding. Ninety-four percent of all physicians have these relationships. Most commonly, it's things like receiving free samples of drugs or receiving food and beverages which may be consumed by their staffs. But a third of physicians are reimbursed for costs associated with professional meetings or CME [compulsory classes in "continuing medical education"]. About a quarter are paid to serve on advisory boards, work as consultants or enroll patients in clinical trials. Those are the big-ticket items, versus getting free Chinese food for the staff on Wednesdays. An analysis of the Journal's study demonstrates the enormity of the extent to which physicians accept gifts. Eighty-three percent of the doctors surveyed reported receipt of food or gifts, others reported receipt of tickets to sporting or cultural events, fees for participating in panels, meals and lodging at seminars, and the like.

Not all doctors are treated the same. Drug samples and gifts of free food are widely given; but other types of relationships-serving as consultants on boards, receiving speakers' fees-are concentrated among "thought leaders" in a specialty. Those are the doctors who develop guidelines for clinical practice, who publish the leading papers in major medical journals, who run large residency programs in major health centers. They have the potential to influence the prescribing practices of other physicians. The industry appears to form tighter relationships with these doctors.

Pediatricians were less likely than internists to have receivedreimbursements or payments. Anesthesiologists were less likelyto have received samples, reimbursements, or payments than werefamily practitioners, internists, or cardiologists. Cardiologistswere more than twice as likely as family practitioners to receivepayments for professional services and were also significantlymore likely to receive payments than were pediatricians, anesthesiologists,or surgeons. All of this is presented in exhaustive (and sometimes befuddling) graphs and tables in the Journal.

Does this relationship between drug company and physician influence the latter's choice of treatment or medication?

We don't know, because, as the report in the NEJM indicates, there's no national data linking these relationships to patient outcomes. We know these relationships benefit companies, because they're selling drugs. They wouldn't do it if it didn't work. We know it benefits doctors because they get meals, rewards, trips, consulting and advisory fees, and so on. We don't know to what extent it benefits patients. If you look at the cost of all these things-billions of dollars per year-there's no doubt that it increases the prices people are paying for drugs. That price is not just reflected in what you shell out at the pharmacy, because you may only have a co-pay, but It drives up prices for Medicare and Medicaid, which we all pay for through our taxes. And what if you're taking a medicine that's not covered by your insurance?

If a company hosts a continuing-medical-education seminar at a beautiful resort in Florida, and the doctor gets to go down there for a few days, listen to the leading people in the field and maybe whack a white ball around on the golf course, does that create the opportunity to influence the physician's behavior? Or if a doctor receives $5,000-$10,000 for serving on a speakers' board, does that influence him?

Some might say that's not much money, but it would pay for a normal vacation for a family of four. Doctors work very hard, work many hours under tremendous pressure, studied years to acquire knowledge and state that he or she is not likely to be unduly influenced. For that doctor, I recommend reading the study in PloS that examines the ways drug companies influence doctors and showing that doctors are not trained to recognize this subtle manipulation.

This is not an issue that is going to disappear. Even if there is no adverse consequence to patients, the aura of impropriety is pervasive.

Many University Medical Centers and major health organizations are prohibiting all gifts from drug representatives, directly or indirectly. Among these are Stanford, University of California, Yale and the University of Pennsylvania.

With all due respect to my physician-relatives and friends, this is a trend that needs expansion.