Medical intervention More doctors just say no to gifts from pharmaceutical sales reps.

Byline: Tim Christie The Register-Guard

Dr. Gail Hacker still remembers the pitch she got from a pharmaceutical sales representative early in her medical career.

"If I put my next five hypertensive patients on his drug, he would send me and my husband out to a nice dinner," she said.

Hacker, a family physician who now works at Lane Community College's health clinic, says she declined the offer. But she says it opened her eyes to the lengths to which the pharmaceutical industry would go to promote its products. And it led her to swear off all the freebies that the industry routinely bestows on doctors and their staffs, from pens and clipboards inscribed with drug names, to free lunches and drug samples.

"I can afford my own pen," she said.

Hacker is among a growing number of doctors, lawmakers and public interest groups who are fighting back against the pharmaceutical industry's aggressive marketing.

Groups such as Nofreelunch.org and the Prescription Project are working to curb the influence of the pharmaceutical industry, which spent nearly $30 billion marketing its wares to consumers and doctors in 2005, including $18.4 billion for drug samples, according to a 2007 study in the New England Journal of Medicine. About $6.7 billion was spent on direct marketing to doctors.

A study published last year in the New England Journal of Medicine found that 94 percent of doctors have some type of relationship with the pharmaceutical industry, 83 percent received food in the workplace, and 78 percent got free drug samples. More than one-quarter were paid for consulting, giving lectures or signing up patients for drug trials.

The Oregon Academy of Family Physicians, representing 1,300 doctors around the state, announced last week that it would no longer accept financial support from the pharmaceutical industry, swearing off unrestricted grants for continuing education seminars, sponsorship of events or advertisements in its publications. But individual members can still see pharmaceutical reps at their discretion.

"This is about taking the institutional view that as a professional medical society, we are committed to decision-making that is based on scientific evidence," said Kerry Gonzales, the group's executive director. "We want to avoid even the perception of influence or impropriety."

The Eugene-Springfield area's two largest medical practices, PeaceHealth Medical Group and Oregon Medical Group, both have policies intended to curb the influence of pharmaceutical representatives, but neither has outright bans on gifts or drug samples.

"We don't encourage any kinds of gifts," said Michelle Anderson, OMG's director of patient and clinical support. "We encourage staff not to accept them."

OMG requires pharmaceutical reps to wear a name badge while in clinics, and it doesn't allow them to bring lunches, although they can bring snacks if they're hosting a talk on a particular medication.

"The providers like to get the information about what's out there," she said. "But they are going to prescribe" a particular drug "because it's the best thing for the patient, not because of any incentive program."

At PeaceHealth Medical Group, gifts such as pens, pads and coffee mugs are discouraged, but not banned, said Bobbe Picolet, manager of clinic operations for the group's family medicine program. Reps are barred from clinic hallways, waiting rooms and drug cabinets.

"They're not happy about it, but they're complying," she said. "They know things are coming down. They're trying to be as nice as they can."

Doctors finally just grew weary of the aggressive marketing, she said.

"Integrity-wise, it's not the right thing to do," she said.

When it comes to drug samples, PeaceHealth Medical Group will accept only those drugs that are in its formulary - certain classes of medicines that are proven effective and affordable, "We don't accept the newest" drugs, she said. "A patient gets on a high-powered (new) drug and they can't afford it" when the samples run out.

Picolet said meals are prohibited unless accompanied by a pre-approved continuing education program. Reps are not allowed to bring in lunch for the clinic staff to pitch a new drug, she said.

"It can't just be a pharmaceutical sales rep making a sales call," she said.

Gifts such as pens, pads and coffee mugs are discouraged as well, she said.

At McKenzie-Willamette Medical Center in Springfield, pharmaceutical representatives can be seen only by appointment, and only to present information on drugs already in the hospital's formulary, spokeswoman Debi Farr said. The hospital doesn't take any drug samples. Reps can bring meals for staff if they're connected to an education event, which occur once or twice a month, she said. The hospital has no policy barring gifts such as pens and mugs, she said.

River Road Medical Group, with four doctors and three physician assistants, is too small to have a policy on dealing with drug reps, said one of its doctors, Lorne Bigley, but he has his own rules.

Bigley said he doesn't talk to pharmaceutical representatives unless they've got a brandnew drug in a brandnew class. He doesn't accept pens, mugs or other gifts. He doesn't accept drug samples unless it's a medication that he already prescribes.

Rather than be swayed by sales pitches, Bigley said he would rather prescribe medicines that are proven to work and to be cost effective.

And he packs his own lunch. When drug reps bring lunch for the office, he won't eat it.

"If I eat it I feel obligated to listen to them," he said.

Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America, defended industry gifts to doctors, saying it was "insulting to suggest that doctors would prescribe medications based on who gave them a slice of pizza, a pen or a medical dictionary."

And in fact, many of the gifts the industry confers on doctors might be considered token: a pen or pad of sticky notes, a coffee mug or a deli sandwich. But studies show that even small gifts can influence doctors' prescribing practice.

"Even those little gifts create a sense of obligation," said Dr. Gary Chiodo, chief integrity officer at Oregon Health & Science University in Portland. The industry "wouldn't be doing those things ifthey didn't work."

Social science research has shown that the impulse to reciprocate for even small gifts is a powerful influence on people's behavior, wrote the authors of a January 2006 article in the Journal of the American Medical Association that called on doctors and academic medical centers to change their ways.

"Individuals receiving gifts are often unable to remain objective; they reweigh information and choices in light of the gift," wrote the authors, who included leaders of Harvard, Columbia, Tufts, University of Washington and University of California medical schools.

Researchers who looked specifically at the relationship between doctors and the pharmaceutical industry found that receiving gifts is associated with positive physician attitudes toward drug company representatives, the researchers said. The rate of drug prescriptions by physicians increases substantially after they see sales reps, attend company-supported education meetings, or accept samples.

The authors called for a ban on all gifts, meals, payment for travel to or time at meetings, and payment for participating in education meetings.

"The standing of the (medical) profession, as much as the integrity of the pharmaceutical and medical device industries, is jeopardized by allowing obvious conflicts to continue," wrote the authors.

OHSU is among the institutions that took notice. The state's only medical school is close to adopting a revised policy toward freebies, following the lead of institutions such as Harvard, Yale and Vanderbilt, which have adopted "zero-tolerance" policies on industry gifts, said Chiodo, the integrity officer.

The revised policy will allow doctors and medical students to accept "not so much as an ink pen," he said.

"I think we're now in a situation where the health care profession needs to eliminate even the appearance of a conflict" of interest, he said.

OHSU's medical students in particular feel strongly about rejecting the marketing freebies, he said. "They clearly had a much stronger feeling that it should be zero tolerance," he said. "They can see how even small things might either influence or create the appearance of influence."

Johnson, the industry spokesman, said the PhRMA ethics code bars its representatives from providing any form of entertainment to doctors, and that only modest meals should be provided when the reps meet with doctors. The code also states that gifts must not exceed $100 in value and should benefit patients or support a medical practice, he said.

Physicians who meet with drug company representatives learn about drug side effects and how to use medicines, Johnson said. Dispensing free samples helps doctors figure out which medications to prescribe.

"The simple fact is company representatives help physicians provide effective patient care," he said.

Critics say that, on the contrary, aggressive marketing by pharmaceutical representatives can undermine the quality of care doctors provide to patients.

Case in point: Vioxx.

After the nonsteroidal anti-inflammatory drug was approved for treatment of arthritis and other chronic pain conditions in 1999, Merck engaged in a costly marketing war that pitted Vioxx against rival drug Celebrex.

Five years later, Merck pulled Vioxx off the market after it was linked to a higher risk of heart attacks and stroke. More than 2 million Americans were taking Vioxx when Merck pulled the plug.

"Anyone who took Vioxx and had a heart attack could lay some claim to the fact that this was related to the marketing of the drug, not only to consumers but to physicians," said Rob Restuccia, executive director of the Prescription Project, a Boston-based nonprofit organization working to curb the influence of pharmaceutical marketers.

Patient care suffers when doctors prescribe new, heavily promoted yet unproven drugs, overlooking cheaper, established drugs that often are equally effective, Restuccia said.

Many doctors are reluctant to stop accepting them, because they can provide poor patients with drugs they might not otherwise afford.

But the patients most likely to benefit from free drug samples are not the poor but rather the insured and the well-off, according to a study published last month in the American Journal of Public Health.

Among all persons who received drug samples in 2003, 82 percent had health insurance all year, while 18 percent were uninsured for all or part of the year. And 72 percent of sample recipients had income of 200 percent or more of the federal poverty line, while 28 percent had income less than 200 percent of the poverty line.

That study prompted the Prescription Project to call on physician groups and academic medical centers to stop accepting drug samples or strictly regulate and limit their use.

The goal of samples is not to provide free medicine but to initiate product use, Restuccia said. Rarely does a patient receive all the samples they need, particularly for a chronic condition, he said.

"We know that by getting the samples, doctors feel compelled, feel obligated to prescribe the drugs," Restuccia said.

ON THE WEB

To see a video featuring a Eugene doctor talking about how he deals with pharmaceutical reps, go to rgweb.registerguard.com/pharm