A Prescription for Trouble
Are your doctors influenced by drug company perks?
April 10, 2000 (San Francisco) -- Once upon a time, the perks were scandalous.
During the 1980s, drug companies offered physicians gifts of all kinds, from penlights to personal computers and plane tickets, to promote their medications. Of course, these freebies telegraphed a not-so-subtle message to doctors: Prescribe our drug, and the perks will keep coming.
All that changed in 1991: Pressured by Congress, the American Medical Association (AMA) adopted ethics guidelines calling on physicians to refuse any gift of "substantial value," including meals, entertainment and cash. Thus ended some of the more egregious practices, such as awarding frequent flyer miles based on the number of prescriptions a doctor wrote.
But a recent editorial in the January 19 issue of the Journal of the American Medical Association (JAMA) brings bad news: "Many of the troubling practices have returned," says Robert Tenery Jr., MD, a past chair of the AMA's Council on Ethical and Judicial Affairs. Instead of plane trips, Tenery says drug companies are now handing out honoraria and free lunches, and sponsoring "educational" seminars at which drug companies control everything from the choice of salad to the setting, the science, and the speakers.
To make matters worse, physicians often attend these seminars in order to satisfy the continuing medical education (CME) requirements that they must fulfill to keep their state licenses current.
"Industry money and influence has permeated virtually all levels of physician CME in the form of complimentary meals and entertainment, consultation fees, and pseudo-CME courses," Tenery writes.
Doctors, he said, are part of the problem. Because they are so pressed for time, drug reps often resort to paying for fancy meals in order to see them. "Industry representatives have found themselves unable to gain access to physicians without providing something in return," Tenery writes.
A spokesman for DuPont Pharmaceuticals said the company follows a strict code of ethics in approaching doctors. But he noted, "their time is expensive. [And] there are cases where physicians may seek a higher level of honoraria" than those already offered.
Blockbuster Drugs and Subtle Sells
Although the AMA managed to slow the practice of perks for a time, drug companies began to accelerate their efforts in the late 1990s in order to compete with generic drug makers as well as the young upstarts of the biotechnology industry. Sales gimmicks used today, however, are subtler than the blatant gifts of the 1980s.
Tenery, a Dallas ophthalmologist, was recently invited to Newport Beach, Calif., to attend a conference sponsored by Allergan to provide information about its new allergy eye medicine, Alocril. The invitation included round-trip airfare to California, accommodations at a luxury hotel, and a participation fee of $1,000, as well as the promise of participation in more such programs later this year.
Tenery's response is blunt: "They will give you all your meals, lodging, a plane trip to California, and an honorarium of $1,000," he says. "That's the most flagrant [offer] I've seen."
In its defense, Allergan says it is operating within the guidelines. The doctors who speak are volunteers -- peer experts -- and make full disclosure of payments they have received when they speak."
There's no denying that prescription medicines are big business: Sales of non-generic drugs totaled $65.9 million, or 94.4% of all drug purchases in 1997, the last year for which data are available. All told, drug companies spend more than $11 billion annually to market their drugs, according to a study published in the October 11, 1996 Journal of General Internal Medicine.
Pernicious Effects on Prescriptions?
Tenery's concerns may indeed be valid, since perks appear to have an impact on the way doctors prescribe drugs.
In the same issue of JAMA in which his editorial appeared, a study by a Canadian researcher reported that events such as drug company-sponsored conferences, company-purchased meals, research funding, and other gifts significantly increase the rates at which doctors prescribe a company's drug. The study was based on a review of nearly 20 years' of research studies on conflicts of interest and the drug industry.
And, the pressure on doctors to prescribe is mounting, thanks to the effect of direct-to-consumer television ads on patients. A study in the March 6 issue of Health Affairs suggests that patient requests may encourage doctors to prescribe pills instead of lifestyle changes, such as better diet or more exercise.
Such advertising is "increasingly common," according to lead author Michael Wilkes, MD, an associate professor of medicine at the University of California at Los Angeles, yet it "rarely mentions lifestyle changes or other non-pharmacological interventions, which are often as important as pharmacological therapy."
"This may cultivate the belief among the public that there is a pill for every ill, and lead to an even more overmedicated society," Wilkes warns.
The Bottom Line: Doctors Must Set Limits
Some doctors claim that drug-company-sponsored meetings provide an efficient way to find out about new products, new uses for existing drugs, and new dosing recommendations. Drug reps "are [performing] a service that respects my time," says Donald Shuwarger, MD, an obstetrician-gynecologist in Forest, W.Va.
But Olveen Carrasquillo, MD, MPH, a teaching physician in the division of general medicine at the Columbia University College of Physicians and Surgeons, says his division banned visits by drug reps after realizing that some medical trainees were perhaps getting their questions answered by reps and glossy brochures instead of by other doctors.
"Just seeing the rep and all his sales paraphernalia with the attending physician gives the residents the wrong idea," says Carrasquillo.
Tenery agrees: "The mere contact between physicians and drug companies alters practice patterns," he says. "The question is, does that harm patients? And does it spend more of our limited health care dollars?"
Kristi Coale is a San Francisco-based freelance journalist who specializes in science and medical issues. Her work has appeared in Salon, Wired, and The Nation.
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