Gifts: What's all the fuss about?

Most doctors tell us they aren't unduly influenced by gifts from pharmaceutical companies.

By Dennis Murray
Senior Editor

Nearly all physicians' offices are littered with freebies: pens, coffee cups, notepads, clocks, golf balls, all bearing the logo of a pharmaceutical company. Most doctors don't give a second thought to accepting such "gifts"—or even the occasional lunch. They consider them compensation for the time detail reps take away from their busy schedules.

Physicians become more wary, however, when the gifts are bigger: a round of golf, a weekend at a resort, tickets to a tennis match, or dinner and a show. Certainly, doctors are aware that these fancy perks are a way of buying their loyalty.* However, of the MDs and DOs who responded to our 2002 Ethics Survey, 71 percent don't think that accepting gifts, trips, and hospitality diminishes their objectivity.

Indeed, many physicians found the suggestion insulting. "I prescribe based on science and my experience," says a New Mexico internist. "I'm not unduly influenced." A Seattle cardiologist agrees: "I see no problem with drug companies lobbying for your support," he says. "If the drug's cost is prohibitive, patients will let you know. If it doesn't work, you'll hear about that, too. If it's totally inappropriate and there's a bad result, you'll hear from the patient's lawyer."

One physician says she quit the AMA over the issue. "It's an insult to think that I would prescribe a drug just because I went on a trip or dinner to learn about it," she says. "If a drug is good, helps my patients, and is economical, I will use it. Otherwise, I won't."

When put to the test, is it really true that freebies have no influence over doctors? The answer is most likely, No. According to an analysis of 16 studies that was published in JAMA in 2000, physicians' interactions with pharmaceutical sales reps do appear to lead to more prescribing of newer, costlier drugs and less prescribing of generics.

Some of our respondents' experiences confirm this. "We have in-house pharmacy data that show that certain drugs are prescribed more often after being detailed in our clinic," says a Michigan internist. And many physicians told us they prescribe brand-name drugs even when a cheaper alternative is available. "When I'm busy, the first drug that comes to mind is probably the one I'll use," says a Philadelphia ob/gyn. No doubt, free samples help keep certain brands foremost in doctors' minds.

Some doctors actively try to limit the influence: While they accept samples to save patients money, they've sworn off all other gifts from drug reps—including low-cost items like notepads and pens. "I don't want even the suggestion of an influence," says Mary Ann Bauman, an internist in Oklahoma City.

Still, the companies find ways to court doctors. "I've recently been offered trips to Boca Raton and Phoenix under the guise of academia," says a Massachusetts internist. "I know better now, after having been seduced into a weekend at a resort on the pretense of making myself available as a consultant. No one asked me a single question the whole weekend."

The AMA says that gifts shouldn't be of "substantial value" (defined as more than $100) and should be of primary benefit to the patient, not the doctor. (Under these guidelines, a medical textbook would be okay to accept; tickets to a football game would not.) The AMA also discourages accumulating "points" to be used to choose a larger gift and receiving payments to offset conference registration fees or travel costs.

Guidelines from the American College of Physicians-American Society of Internal Medicine are somewhat less specific: "Ideally, physicians should not accept any promotional gifts or amenities, whatever their value or utility, if they have the potential to cloud professional judgment and compromise patient care."

Translation: Use good sense.

The Pharmaceutical Research and Manufacturers of America (PhRMA) recently adopted voluntary marketing guidelines for salespeople of its member companies. "The new code makes it crystal clear that the interactions of company sales representatives with health care professionals are to benefit patients and enhance the practice of medicine," says PhRMA president Alan F. Holmer.

Indeed, the code is very specific. For example, it forbids detail representatives from offering meals to physicians without some sort of accompanying informational presentation. It also frowns upon gifts of substantial value, including VCRs, artwork, travel vouchers, golf bags, and entertainment—in short, anything that's not directly connected to patient care. Even a $30 gift certificate to a book store is a no-no under the new rules, unless the certificate is redeemable solely for a medical textbook or other health-related book.

Critics of the code label it a pre-emptive strike designed to keep regulators off the backs of pharmaceutical companies. "Obviously, the PhRMA guidelines are meant to foster good public relations," says Bob Goodman, a New York City internist and creator of No Free Lunch (www.nofreelunch.org ), an organization of physicians who have pledged not to accept any drug company gifts.

Nevertheless, Goodman welcomes the guidelines and is optimistic that the industry will follow them. "The issue of physicians and gifts has gotten a lot of media coverage recently, and the pharmaceutical companies don't want any more bad publicity," he says. In fact, soon after the new guidelines were approved, Goodman adds, a major drug company rescinded its invitation to take a group of physicians to dinner and a Broadway show.

But, in Goodman's view, responsibility doesn't lie solely with pharmaceutical companies. Doctors are part of the problem, he says, because many have come to expect generous perks from drug companies. "It may take a while to change the culture, but we're seeing some very encouraging first steps."

*See "Details, details: What your colleagues think of drug reps," June 7, 2002.

 

Dennis Murray. Gifts: What's all the fuss about?. Medical Economics 2002;19:119.