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Thoughts on Pharmaceutical Companies and Gifts to Physicians

Charles Atkins, M.D., is a psychiatrist, freelance writer, and member of the Yale clinical faculty. His latest novel, The Cadaver's Ball (St. Martin's Press), will be released in fall 2005.

Whenever the feds—the Office of the Inspector General (OIG) in particular—investigate an issue in health care, it's good to pay attention. That's why I've been thinking more about the relationship between pharmaceutical companies and physicians. For me, this is personal; the drug companies and I go way back, and the phrase "Don't look a gift horse in the mouth" comes quickly to mind, followed by "There's no such thing as a free lunch."

It's gotten to the point that it's impossible not to partake of drug-company largesse when I attend a conference. Drug companies underwrite many of the talks, and even the buses that move us from lecture to lecture at no charge carry ads for popular drugs. Sure, I'll turn down the theater tickets and box seats at sporting events and the expensive tours, wine tastings, and meals, but it's impossible not to receive some form of freebie, however inadvertent.

Back at home, there's the community detailing with expensive luncheons and dinners, mostly with lectures attached, but not always. I receive invitations daily, and it's all free—not to mention the magazines and brochures that show up in my mail, without my having requested them. I can't tell who's been sending them; I wish they'd stop.

There's more too, for example, invitations to cruises, on which I could be paid as a consultant, to discuss "how I prescribe antidepressants." I was even gifted with a pricey, inscribed Mont Blanc pen when I became a medical director—I did not keep it—and the drug rep was upset, because who wants a pen with my name in gold?

As I try to distance myself from the pharmaceutical companies, I'm confronted with complex ethical issues. Or maybe they aren't so complex, but they make me squirm.

For instance, many of us who've tried to maintain some boundaries with the drug companies have gone with the party line: "It's O.K. for them to provide an educational event with a small lunch." Well, I'm not so sure. I do a fair amount of consulting and lecturing—I don't do this for free. Likewise, when the drug companies hire a respected professor to speak to a small group of docs, it costs. I remember one speaker quipping how the drug companies were putting his children through college. If we think about the real price tag for the event, the lunch, which might just be a sandwich, cookies, and soda, isn't the issue; it's the $1,500 or more, plus travel and lodging, that the speaker gets. So if I have 10 or even 20 doctors in the room, the gift per person is not just the $10 for lunch, but could be a couple hundred dollars.

Why would someone give me a gift worth hundreds of dollars? Either they love me, want to sleep with me, or want something else. They are giving a quid and would like a pro quo, which brings me to the line I've heard many colleagues spout: "I'm not influenced by the drug companies; the dinners, the gifts, and the marketing campaigns don't affect my prescribing practices."

I can't make that statement. This becomes even more knotty when we see how much research and how much publishing in the professional journals are either fully sponsored or underwritten by drug companies. Of course I'm influenced by them, I'm just not sure how much and in what ways. I have my suspicions, which are reflected in such questions as, Why are we so quick to abandon old medications when the new ones come out? If people spent the same amount of time, energy, and money extolling the virtues of off-patent medications, would we switch so quickly?

As the federal government has set about publishing compliance guidelines and studying the relationship between pharmaceutical companies and physicians—paying particular attention to pricing, kickbacks, and free samples—a process has started that will have far-reaching implications. But while increased federal scrutiny and internal guidelines will—and have—created change, I'd urge everyone in the medical profession to spend some time thinking through each interaction with a drug company. Ask yourself a few questions. I'd start simply with, How much did this company just spend on me? What do they want from me? And how has this interaction influenced me?

The OIG's "Compliance Program Guidelines for Pharmaceutical Manufacturers Published in the Federal Register" is posted at <http://oig.hhs.gov/authorities/docs/03/050503FRCPGPharmac.pdf>.

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