Dr. Jonathan Mohrer, a New York internist, used to tolerate visits from drug-company representatives. The reps provided a break in the routine, brought free pens, lunches and drug samples, and, most important, answered questions about new medications. But as the number of visits swelled to as many as 10 a day, his patience wore thin. It finally snapped in the fall of 2004, when the heavily promoted painkiller Vioxx was withdrawn after clear evidence emerged that it increased the risk of heart attacks. "I'd been getting pitches for Vioxx almost every week, even while questions were being raised about it in medical journals," says Mohrer. He kicked the reps out and made it clear he wouldn't take their calls in the future. "It's been a real relief," he says. "I don't know how I juggled it all."
Mohrer is one of a number of doctors who are just saying no to drug-company promotions. Some belong to No Free Lunch, an organization that asks doctors to take a pledge not to receive drug-company representatives. Admittedly, their numbers are small. Founded in 1999, No Free Lunch has just 800 members out of 800,000 practicing physicians in this country. The American Medical Student Association (AMSA) has collected a similar number of pledges among the nation's 68,000 med students, but that's twice as many pledges as it had a year ago. And increasing numbers of hospitals, health-care systems, medical schools and even states are starting to institute restrictive policies. Minnesota has already set limits on gifts, and three other states are weighing similar bills. "There's growing evidence that these relationships color doctors' prescribing practices, even if doctors think they don't," says Dr. Karen Antman, dean of Boston University's medical school, which last month instituted a ban on all gifts and lunches from drug reps and allows reps to visit only if invited.
It's no secret that Big Pharma spends megabucks marketing to physicians. In 2004, the total ran to $23 billion, including $15.9 billion in free drug samples, according to the Pharmaceutical Research and Manufacturers of America (PhRMA). Drug reps provide "solid, scientific, FDA-approved information on the safety and efficacy of our drugs," says Dr. Cathryn Clary, vice president of Pfizer. "So many medicines are getting label updates all the time, it's hard to keep current."
But critics say sales reps do a lot more than educate. They come armed with information from databases telling them individual physicians' prescribing practices. They know before a visit whether a doctor prescribes a competitor's drug—and whether he switches after a sales call. They also bring gifts. True, PhRMA instituted voluntary guidelines in 2002 banning big-ticket items, like harbor cruises and golf outings. But social scientists say that trivial gifts like pens create a sense of obligation, too—all the more so when the friendly person who drops them off, along with free food for the staff, is a regular visitor. It doesn't hurt that the drug logos on pens and notepads keep a drug in the doctor's mind. Even free samples, which patients love (and sometimes depend on), aren't as philanthropic as they seem, given that they're often for the company's newest, most expensive medicines—particularly drugs like birth-control pills or heart medications that a patient could potentially take for years. Once a patient starts taking a drug that works, he wants to stay on it—an obvious boon to manufacturers.
What's the problem with that? Possibly none. The result may be as inconsequential as a physician's prescribing one drug instead of a me-too pill from a competitor. But the bulk of the reps' efforts target pricey new medications—which ultimately drives up costs for consumers. And, critics say, newer isn't necessarily better. In many cases, older, cheaper drugs are just as effective. Occasionally, they're even safer. Serious side effects may be discovered only after pills have come to market, as the withdrawal of the painkiller Vioxx and the recent controversy over the diabetes drug Avandia show.
Fortunately, for doctors who kick the habit, there are independent sources of up-to-date information, such as The Medical Letter on Drugs and Therapeutics—a sort of Consumer Reports for drugs that takes no advertising and costs only $100 a year. Still, reps are nothing if not persistent. Dr. Robert Goodman, the founder of No Free Lunch, recently found several of them parked in front of his rep-free New York clinic. From the open tailgate of their SUV, they were promoting their products and handing out bagels and cream cheese to doctors "like a coffee truck at a construction site," he says. He didn't ask why they were there. He didn't need to.