The nation's largest pharmaceutical trade association now says its members can no longer hand out those trinkets and freebies, and it sharply curtailed when, where and how drug companies can wine and dine physicians.
The new code of conduct, which goes into effect Jan. 1, was designed to squelch, once and for all, any negative perceptions that doctors are influenced by or make prescribing choices as a result of gifts from drug manufacturers.
"It's ridiculous to think that a physician is going to be influenced by a cheap pen and a coffee mug," said Ken Johnson, a spokesman for Pharmaceutical Research and Manufacturers of America, which released its revised "Code of Interactions with Healthcare Professionals" last month.
"But there was a perception that somehow these interactions were influencing prescribing decisions. In the final analysis, the perception became the reality, and we just decided it wasn't worth the fight any longer."
Often called "detailing," pharmaceutical representatives, or drug reps, use promotional items and other creative means -- including plying the physician with gifts and dinners -- to capture the interest of busy doctors and, theoretically, drum up prescriptions.
Comment: It would seem that the simple pens and coffee mugs may not have been the influencing factor. Maybe the gifts and dinners had more to do with it.
In 2000, pharmaceutical companies spent more than $15.7 billion on promoting prescription drugs in the United States, according to the Kaiser Family Foundation.
More than $4.8 billion was spent on the one-on-one promotion of drugs to doctors by drug reps. The average sales force expenditure for pharmaceutical companies is $875 million annually, according to MedAdNews, a pharmaceutical trade magazine.
Do freebies influence?
Many physicians bristle at the suggestion they could be influenced by trivial promotional items.
Many of the items -- like bagels or notepads -- are more of a convenience to the staff and are irrelevant in determining patient care, doctors say.
"For some staff, it may mean altering their lunchtime routine on some days, so I'm sure they will miss it," said Doug Hanson, chief operating officer for Preferred Medical Associates, a physician group that is part of the Via Christi Wichita Health Network.
"But will that impact patient care? I don't think so, because our physicians prescribe based on what they believe will be of the greatest benefit to patients, not on who provides the best goodies to their staff."
But the promotional items may have more of an influence than physicians think.
Haavi Morreim of the Markkula Center for Applied Ethics at Santa Clara University wrote:
"This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it's the drug representative's job to get the products' names in front of the physicians."
A few years back, however, before PhRMA ratcheted up its code in 2002 amid public scrutiny and Congressional inquiries, those "freebies" weren't so trivial.
Drug companies have footed the bill for posh dinners, swank hotels, resort packages and expensive entertainment venues or sporting events for physicians, all on the pretext of educational advancement.
Last year, the New England Journal of Medicine found that almost every physician has accepted something from a drug rep, although how often or how much varied by doctor and specialty.
According to the survey, 78 percent of physicians accepted drug samples; 83 percent accepted gifts such as lunches or tickets to ballgames; 35 percent were reimbursed for continuing medical education expenses; and 28 percent were paid for consulting, speaking, serving on advisory boards or enrolling patients in clinical trials.
Some physicians are uncomfortable with the more lavish offerings.
"When I was a new physician 25 years ago, I remember some of the doctors talking about getting new TVs, all kinds of stuff," said Wichita family physician Joe Davison.
"When I became a doctor, I went on a couple of trips -- Scottsdale, stuff like that. I don't think those had any lasting influence... (but) I quit going out to dinner with those guys a long time ago. I just didn't want to be encumbered."
Controversy continues
Although PhRMA began restricting the expensive gifts in 2002, controversy over the ethics of relationships between drug manufacturers and doctors has continued.
Last year, Congress held hearings about drug industry gifts, some pushing for legislation that would create a national registry to record gifts and payments to doctors by the makers of drugs and medical devices, according to news reports.
PhRMA said it was done defending the gifts and, with few exceptions, has completely revised the industry's promotional policies.
"As an industry, we do some things to cause people to scratch their heads," PhRMA's Johnson said. "But by and large, this is an industry that dedicates itself to inventing new medicines that allow people to live longer, healthier, more productive lives. That's how we want people to see us."
As of January, for instance, pharmaceutical companies can sponsor educational conferences over which they have no operational control, but they cannot provide any entertainment or recreational items, including trips or sporting events.
Wichita Clinic has had a policy in place for at least a decade that discouraged physicians from taking lavish gifts or dinners from drug reps.
Banning trinkets seems a bit extreme, but busy doctors continue to appreciate the educational lunches, said Donna Johnson, Wichita Clinic's director of medical affairs.
"It seems trivial, but I think there's a perception out there by the public whether it's wrong or not," she said. "But doctors depend on those reps to provide them with information on new drugs -- everything from patient safety to indications and contraindications... the issue always is, how do you communicate that with very busy physicians?"
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