Fighting freebies


(Original publication: May 4, 2004)

Dr. Robert Goodman tackles two jobs a day: seeing his patients, and running a Web site that urges doctors to stop taking gifts from the pharmaceutical industry.

Goodman, a general practitioner at Columbia University Medical Center, started five years ago. He has since built a national following of 300 doctors who have taken the No Free Lunch pledge. They've promised to refuse "money, gifts, or hospitality from the pharmaceutical industry ... and to not rely on information disseminated by drug companies."

Doctors who take the pledge can trade in their drug-company pens and coffee mugs for white pens, mugs and other items labeled "No Free Lunch." Goodman has a large stash of pens sent in by doctors that he keeps in a file cabinet.

It's well-known that pharmaceutical companies spend millions of dollars annually on marketing to increase visibility, and thus profits, for new drugs. Direct-to-physician marketing is among the most popular strategies. Companies hope that doctors who meet face-to-face with a representative will not only learn about a new drug, but also prescribe it.

To that end, the representatives frequently come bearing gifts branded with a drug's name, ranging from notepads and pens to golf clubs and briefcases. In extreme cases, reps offer exotic "educational" trips to golf resorts or Caribbean islands, Goodman says.

Goodman sees this as an expected side effect of a privatized drug industry, and he doesn't criticize the companies.

"I blame the (medical profession)," he says. "The industry, that's what they're supposed to do. There is this culture of doctors receiving gifts and feeling entitled to the gifts from the industry."

Doctors, he says, should not accept any drug-company gifts, nor rely on the clinical information provided by a drug company. Accepting gifts creates the appearance that a doctor may be biased toward certain companies or, even worse, prescribe inappropriate drugs, he says.

"Medical literature and social-science studies show that gifts influence behavior," he says. "They create a relationship. If you accept (a gift), there is a need to reciprocate. This is why people give gifts or buy drinks in a bar."

The drug industry has clamped down on some of the more excessive gift-giving, but providing free meals for doctors and their staffs remains a popular tactic of the sales reps. Doing so is considered acceptable by the Pharmaceutical Research and Manufacturers of America, which represents all major U.S. drug companies.

During the meal, the sales reps must "provide an informational presentation to the medical staff," according to PhRMA guidelines. The meal may be for one doctor, or for an entire medical staff in a clinic or hospital.

Wanda Moebius, a PhRMA spokesperson, says the meals are an efficient way to reach physicians, who are often free only during meal times.

"Doctors are very busy people," Moebius says. "There's huge changes in the drugs and new drugs that come on the market. Often sales reps are the best sources of information."

Fred Perino, pharmacy director at Phelps Memorial Hospital Center in Sleepy Hollow, says drug reps occasionally give presentations at the hospital, and they provide modest meals to the pharmacy staff. But he listens with a skeptical ear.

"Their job is to promote their employer's product," Perino says. "Our job is to analyze it to make sure it meets our needs and will benefit our patients over what we have already."

Dr. Christopher Wang, chief medical officer for four Open Door Medical Centers in Westchester, is even more wary of sales reps and drug-company data.

"The problem is, even if they fund legitimate research and conduct it legitimately, they only support research questions that will potentially say 'You need to have my drug,' " Wang says. "But they own the research, and when it comes out and it's not positive, they bury it because they own it."

Alan Goldhammer, PhRMA associate vice president of regulatory affairs, says the sales reps can present facts using only the information on the drug's insert, which is approved by the Food and Drug Administration. The FDA, he says, does not require comparative clinical trials, in which a drug's effect could be studied against another drug's effect.

PhRMA's guidelines on the matter, "Principles of Conduct on Clinical Trials and Communication of Clinical Trial Results," acknowledge that the companies own the research and therefore are not required to publish all study results, especially early-phase trials.

Wang was unaware of Dr. Goodman's efforts but praised the No Free Lunch concept. At Wang's clinics, drug reps can visit when there are no patient visits, by appointment only, and only to drop off drug samples, he says. Since the clinics serve mostly low-income families, the free samples are useful.

The policy has cut down on the amount of time patients spend in the waiting room, he says, and forces his medical staff to obtain new drug information from other sources.

"The thing that we found to be debilitating in terms of getting patients seen is (the reps) would just sort of hang out just walk in and start talking to doctors, and patients are piling up outside," Wang says. "It's bad enough to wait because a patient is sick; it's another thing when you're waiting because of a commercial."

Wang and Goodman both use The Medical Letter for information on new drugs. Based in New Rochelle since 1958, the nonprofit semi-monthly publication is independent and peer-reviewed, and accepts no advertising. The Letter is supported through its 300,000-plus subscribers.

To further stress its independence, the Letter doesn't sell back issues in bulk to pharmaceutical companies, who may try to use a positive Letter review of a drug for marketing purposes, says publisher Doris Peter, who holds a doctorate in molecular neurobiology, microbiology and immunology.

Like Goodman, Peter doesn't blame the industry for trying to promote drugs to doctors or patients.

"Physicians have a responsibility not to be doing these things," Peter says. "Patients don't have any idea why a physician prescribes something, and physicians are so busy today. I would hope patients ... can be aware of the tactics, but it's very complex."

Manhattan geriatrician Barrie Raik signed the No Free Lunch pledge several years ago. She says it has helped her turn down some of the lucrative offers from the drug industry.

"Within the last two weeks, I got an invitation to a 'training session' for a new drug. They would pay me $500. It's one thing to turn down a pen, but I knew I wanted to refuse this," says Raik, who is a clinical educator for New York Presbyterian Hospital at Cornell University. "(The pledge) was helpful to me. I kind of pledged to myself to say 'No, I can't do that. It's wrong and outrageous.' "

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