Some Docs Decline Drug Freebies

For the past few years, Dr. Eric Mizuno and his colleagues at Chicago's Northwestern Memorial Physicians Group have banned pharmaceutical-company freebies like sticky pads and calendars from their offices. "It just felt right to not contaminate the environment," Mizuno says. The ban also reduces the number of sales reps crowding the reception area. "There was a time when there were literally more reps in the office than patients," he says.

Drug samples and other giveaways from pharmaceutical companies may seem like part of the standard decor in most doctors' offices, but a growing number of medical centers and individual physicians like Mizuno and his colleagues are beginning to just say no. The most recent example is Stanford University, which this week officially stopped allowing its medical students and faculty to accept any gifts—including free drug samples—from pharmaceutical and medical-device companies. "There is a naive assumption on the part of all of us that we're immune to influence, that gifts don't make a difference," says Dr. Philip Pizzo, dean of Stanford's School of Medicine. "The reality is that the pharmaceutical industry wouldn't be spending over $20 billion a year on these activities if they didn't work."

Yale University, the University of Pennsylvania and the University of California at San Francisco also prohibit gifts. Penn State's Milton S. Hershey Medical Center expects to implement a policy in January. Other schools have specific rules for when doctors can accept anything. The University of Wisconsin says sales reps may not provide free food to its staff or even meet with medical students or residents unless they're in the presence of a faculty physician.

Many doctors and ethicists say the system needs reform, even when it comes to seemingly innocuous freebies. "Everyone assumes 'I can't be bought for a pen or box of doughnuts' and focuses in on the big gifts," says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania. But, he says, influence can be subtle. "You feel you owe something to the gift giver," he says. "That's the power of a gift. If you take it once a week, you'll start to feel you should do something for me. There's no free lunch that way."

If a critical mass of schools adopts a no-gift policy, many physicians believe everyone else will be forced to follow. That may happen soon. In February, the Association of American Medical Colleges formed a task force to figure out how to eliminate conflicts of interest between physicians and pharmaceutical and medical-device companies; a report is expected within a year. Dr. Jordan Cohen, immediate past president of the group, says it's not likely that the task force will recommend keeping the status quo because of the increasing perception that the giveaways are not in patients' best interest. "No patient wants to go to a doctor and think the doctor is prescribing them something because they got a great lunch yesterday from the maker of that drug," says David Coleman, chairman of the department of medicine at Boston University's School of Medicine.

The amount of money involved in these giveaways is staggering. In 2004, pharmaceutical companies spent $37 billion on research and development, according to the Pharmaceutical Research and Manufacturers of America (PhRMA), the industry's trade association. Drug companies spent another $27.7 billion on promotion, including $15.9 billion on free drug samples and $7.3 billion on sales-rep contacts (free lunches and pens), $4 billion on direct-to-consumer advertising and $500,000 on journal advertising, according to IMS Health, a pharmaceutical information and consulting company.

Not surprisingly, the pharmaceutical industry opposes strict limits. Cutting down on free notepads may not necessarily help patients, says Scott Lassman, senior assistant general counsel for PhRMA. "The sales reps traditionally are very well trained," he says, "and they have a lot of extremely useful scientific information about the drug product. They're able to provide this to the physician over a working lunch or a working dinner." He does say, however, that lavish meals or trips to fancy resorts are "clearly out of bounds."

But medical school officials say the interaction between doctors and drug companies needs to be a more even exchange of information—and not an interaction that could be seen as a bribe to use certain products. "The issue here is not to lay blame at the foot of the pharmaceutical industry or to indict commercial entities," says Cohen. "They're trying to find ways to promote their products." But, he says, doctors need to be more aware of the potential for abuse. Medical students, in particular, need to be more critical of high-powered sales pitches. "They're not trained to discriminate marketing promotion from science," says Lee Vermeulen, director of the Center for Drug Policy at the University of Wisconsin Hospital and Clinics.

Free drug samples—the biggest line item in pharmaceutical companies' marketing budgets—remain a sticking point. Many doctors who would like to just say no to meeting with pharmaceutical sales reps still see them in order to get these samples, which they often distribute to poor patients who can't easily afford prescriptions. "This is one of the major ways they gain access to the physician's office," says Cohen. But the samples are never for generics. "They are often for the newest and most expensive drugs," says Pizzo. "They're a way for the industry to get physicians to start prescribing these agents, to get patients used to them." Northwestern's Mizuno still sees some sales reps—mainly because he wants free drug samples for his underprivileged patients.

For its part, the American Medical Association's policy says gifts should be of "minimal value" and should not have any "strings attached." But Cohen says outright prohibitions are actually better—and easier to administer than determining whether an item or meal is "worth $99 or $101." After all, even the cheapest gifts can influence people. "If you've got a pen, it's always giving you the name of the drug company," says Pizzo.

Don't look for those pens any more at Stanford—though the university isn't bringing in dumpsters or staging a bonfire to destroy drug-company loot. "Pens run out of ink," says Pizzo. "Calendars run out in a year. Nothing new will be coming into the system." But if this ban spreads, pharmaceutical companies may just redeploy their marketing dollars and spend more money on direct-to-consumer marketing. So buyer beware.