Drug company gifts: Marketing technique poses ethical questions for some

Brown student wants to see the practice end in Medical School; others contend that the practice translates into getting the best treatments to patients who need them.

by Scott J. Turner

Four weeks ago, the Lifespan health system, home base for many of the faculty in the Medical School, proposed strict guidelines to limit interactions with sales representatives, particularly from the pharmaceutical industry.

A month earlier, the federal government warned drug firms against offering financial enticements to healthcare professionals to prescribe or to suggest certain medications, or to switch from one drug to another in treating patients.

From free pens, pads and drug samples to high-priced meals to underwriting medical education programs, the pharmaceutical industry spends billions annually to market its products. Some members of the medical community call a close link between the healthcare profession and drug industry part of a “golden age” of medicine, helping patients to get the latest and best treatments.

Research has shown that accepting gifts and hospitality from pharmaceutical companies affects prescribing patterns to benefit drug companies, often to the detriment of the patient. To fourth-year medical student Jaya Agarwal, drug company marketing is “bribery” and “ bad medicine.” She wants doctors, nurses, even fellow medical students, to make their own evidence-based decisions on which medications will best help patients.

Last year, Agrawal was president of the American Medical Student Association (AMSA), the nation's oldest and largest independent medical student group, involving more than 30,000 physicians-in-training.

One of Agrawal’s AMSA initiatives was the “ PharmFree Campaign.” This nationwide effort asks medical students to pledge not to accept industry gifts. It supplements AMSA’s “No Free Lunch” movement to persuade students to avoid meals from drug reps. One common marketing strategy for drug reps is to show off new products during the lunch hour while providing free food as compensation to attendees taking time out of their busy routines.

In the next few months, Agrawal hopes to work with Medical School administrators on the issue. She would like to see the school adopt an across-the-board ban of industry gifts. Earlier this semester, she discussed the topic with first-year medical students during an orientation session devoted to professionalism.

“This issue doesn’t become reality until your third year of medical school when you go into the clinics and hospitals and start attending drug-sponsored lunches to learn about new products,” she said. “It is not a system that puts patients first. One form of professionalism is getting information for patients from non-biased sources. It is a bad habit to rely on drug representatives for information.

“Accepting industry gifts is a dependency developed during the third and fourth years of medical school. I appreciated the opportunity to speak with first-year students before they became indoctrinated in this practice.”

Not everyone agrees with Agrawal.

Earlier this year, PhRMAadopted a new marketing code to more tightly govern the industry’s relations with healthcare professionals, especially when it comes to meals, travel and other items of substantial value. The code is voluntary.

“What [Agrawal] is suggesting is that medical students and doctors close out a principal source of technical information,” said Trewhitt.

To the industry and to some physicians, face-to-face contact is an efficient way to discuss new medications. Accepting a meal or mug in exchange for samples and information on uses and side effects is reasonable, because it translates into getting the best treatments to patients who need them. Funding continuing medical education programs leads to better-educated physicians, Trewhitt said.

Across the healthcare spectrum, the question is asked: To take or not to take from drug companies? Consider the free drug samples offered by drug reps. What better way is there for a company to get a new drug into a physician’s repertoire than to hand it over free? Moreover, it is almost standard practice to dispense free drug samples to patients who have the most difficultly affording prescription drugs, said Trewhitt.

“Providing free samples of a new medicine gives a physicians hands-on experience using the new medicine to observe close up how it works so a physician can tell whether or not it is helpful to patients,” said Trewhitt.

“Also, when a physician receives free samples, in most cases those are shared with elderly or other patients who have trouble paying for medications.”

Hogwash, said Howard Schulman, M.D., clinical assistant professor of medicine. Sooner or later a patient who was given free samples will have to continue treatments by having a prescription for the drug filled. If they have no pharmacy coverage, they will pay dearly.

“It’s a myth that free samples help the poor,” said Schulman. For an elderly patient, for example, there can be a $1,000 to $2,000 per year difference when you compare a brand-name drug versus a generic.

In a letter late last year to Rhode Island Medical News, Schulman wrote, “For physicians concerned about the potential loss of office samples, I can happily report that for the past three years, since I have had my own practice, I have had a policy that I do not speak with drug reps or accept samples, and it has been great.

“Not only are the reps ill-informed, but they have a habit of getting in your way just when you have a second to breathe. …When patients ask for samples, I tell them that I do not have any. This is not an issue, and I have not lost any patients because I do not give out samples.”

Trewhitt defends industry representatives, saying, “There are very rigorous training programs from what I have seen and heard from companies. Salespeople must be able to demonstrate to physicians that they can answer technical questions. You will lose your credibility if you try and blow smoke.”

Ed Wing, M.D., has a relationship with drug companies that is both positive and negative. Wing circulated the proposed Lifespan guidelines. He chairs the Department of Medicine, the flagship department in the Medical School. He is physician-in-chief at Rhode Island Hospital and The Miriam Hospital, and executive physician-in-chief at Memorial Hospital of Rhode Island, The VA Medical Center and Women & Infants Hospital.

For the past two years, Wing has stopped drug reps from sponsoring lunches for residents and students. The Department of Medicine spends more than $70,000 per year supplying lunches for residents at Rhode Island Hospital and The Miriam Hospital.

“The pharmaceutical industry is progressive and very important to academic medicine and to physicians, in general,” said Wing. “It has put billions of dollars into vital research and into saving lives. I take care of patients with HIV. They now live because of new medications. Before, there were no drugs for treatment, and patients died.

“On the other hand, the industry puts a tremendous amount of money toward marketing drugs to all levels of those in medical training and in practice. Much of what they do in marketing is inappropriate.”

As much as possible, Wing says, he tries to restrict medical students and residents from having contact with drug reps. “I think sales people offer biased information. The medical literature says they do influence decision-making. If a person is influenced in training, they will be influenced in their career.”

Schulman said the drug industry has sunk “10,000” tentacles into medicine. “I worry that well-respected medical experts, who become industry consultants, may begin to prescribe a new drug in place of one that already is effective, or espouse a new product, which may lead other physicians to follow in their footsteps,” he said.

In addition, Schulman is concerned that physicians who depend on industry funding to conduct drug studies may be overly influenced by that dependence. “More often than not, attendees at continuing medical education [CME] programs or hospital grand rounds do not know the extent of industry funding for the session or for associated research,” he said.

Industry may help fund a CME program, but it is the accredited medical group that runs it, said Trewhitt. “A company can recommend a speaker, but not choose one. These top physicians have their credibility to maintain. I don’t think they will be dictated to by a pharmaceutical company.”

Schulman doesn’t buy it. “In many ways drug industry tactics unduly influence prescribing patterns of physicians, the studies they conduct and the process of continuing medical education,” he said.

Often, an academic researcher who conducts an industry-sponsored study is also a consultant to the funding firm, said Schulman. “The problem is that not enough critical attention, analysis or publicity has been paid to this conflict of interest,” he said. “Even worse, the participants are so steeped in this culture that they themselves do not realize how uncritical and biased they have become.”

On behalf of the American Medical Association, Herbert Rakatansky, M.D., helped draft guidelines on gifts to physicians from industry. A clinical professor of medicine, Rakatansky is the former chair of the AMA’s Council on Ethical and Judicial Affairs.

The guidelines present a middle ground, said Rakatansky. For example, the rules say that any gifts should be of minimal value, and they must come in the context of furthering patient care and medical education. Also, physicians should control the interactions.

“In the real world, I think doctors need to work with industry, such as collaborating on clinical trials,” said Rakatansky. “You can’t stay away completely. But in those relationships, doctors have a moral obligation to patients. Physicians must always make decisions in a patient’s best interest. Industry is obligated to owners and stockholders. We know that.”

Many physicians disagree with Wing. “They claim that they can process the information they receive, and that meals won’t sway them,” he said. “Some argue that restricting drug reps hurts education about new treatments.”

Like Agrawal, Wing wants physicians to use bias-free approaches, such as the online Medical Letter, to determine best treatments.

“Giving you samples is a way for a drug rep to get a foot in the door,” said Wing. “Once you begin relying on that system, it is hard to stop. It’s a system that hurts patient care and drives up costs in the long run.”

When it comes to medical students and residents, “it is a problem of trying to influence people in training under the guise of education,” said Wing. “It is a situation that is not science based. In fact, it is biased against education.”

Agrawal thinks the public opinion is turning against drug companies.

“Voluntary rules, federal warnings, they all add up to public relations strategies,” said Agrawal. “They don’t have teeth. Some departments in Brown Medical School still provide drug-sponsored lunches. One department even offers professional memberships using funds from drug companies.

“Industry does what it does because it works. I believe that advertising of new and expensive drugs increases their use. Under this system, physicians have no incentives to find their own sources of information. The time has come for federal, state or local rules that create and enforce change.”

Before she graduates, Agrawal would like to help the Medical School apply “a tough, consistent position against industry gifts, applied to all departmental faculty and across all educational venues, whether in the Medical School on campus or in the hospitals.

“When asked, most physicians admit they attend drug-sponsored lunches for the food and the same extends to other gifts,” she said. “If you are honest with yourself, it's not about learning about new therapies; it's just taking a bribe.”

Drug company gifts: a response