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Buying Lunch...And What Else?
IT WAS MY FIRST DAY WORKING AT THE family medicine clinic, and as a typical, dutiful medical student, I was eager to get started. My first patient was an elderly woman with chronic back pain, a problem she’d struggled with for years; she was asking for medication to tide her over until her mail-order prescription was filled. After I completed a thorough history and physical exam, one of the clinic doctors and I conferred, and then we went in together to see her. While the two of them talked, the doctor sent me to get some samples of a drug for her, directing me to a closet in the back of the office. Opening the door, I was stunned to find myself surrounded on four sides with brightly colored, attractively packaged free drug samples in all shapes and sizes reaching from floor to ceiling. In addition to the samples, there were various bins full of other "freebies"—pens, clipboards, penlights, and other useful gadgets. There also were a number of coupons providing discounts on prescription drugs. After a good bit of searching, I found the requested drug sample, returned to the examining room, and gave it to the patient. She smiled gratefully. "This helps me so much," she said.
AFTER A FULL DAY JAM-PACKED WITH PATIENTS, I was starving. By five p.m., I finally had time to grab a bite to eat. A medical technician pointed me to food in the break room. Not only was there food, there was an abundance of food—gourmet sandwiches, salads, and cookies—more than enough for all of the doctors and all of the office personnel, even a newly arrived medical student. One of the techs confirmed my immediate suspicion: the lunch had been provided by a pharmaceutical company representative. I reconsidered. During my early years in medical school, I’d signed a pledge created by an organization called "No Free Lunch" (http://www.nofreelunch.org/pledge.htm), pledging that I wouldn’t accept free lunches or other gifts from pharmaceutical companies. I was—and am—convinced that pharmaceutical companies in the United States devote an excessive portion of their budgets to physician and direct-to-consumer marketing—more than $57 billion annually, according to a 2004 study by Marc-André Gagnon and Joel Lexchin published by them in PLoS Medicine in 2008. This in turn produces a bias positive toward certain brand-name medicines in physicians’ prescribing practices, one that isn’t necessarily optimal for patients. In comparison, data from the same year as the study indicate that spending on research and development was $31.5 billion, or about half the amount spent on marketing. Furthermore, it’s argued that these practices contribute significantly to the skyrocketing costs of U.S. health care. Despite all of this, my resolve (and my growling stomach) was being put to the test. "I’m just going to grab a bite across the street," I said, garnering puzzled looks as I hurried out the door. The next day, I came into the office a little early to catch up on my reading. When there was a knock at the front door, I opened it to find a handsome young man, nattily attired in a suit and stylish tie, carrying a briefcase. He smiled pleasantly at me, informed me that he was a drug company representative, and asked when the supervising physician would arrive. "He’s not here yet," I said, "but he’ll be in shortly." "Great. I just have some samples to drop off. Have you heard about our new drug?" he asked. I hadn’t. I listened politely to a ten-minute presentation on the newest research (in this case, company-funded) on his drug. I was relieved when my preceptor finally arrived. Throughout the day, I was surprised to see a parade of more than a dozen similarly well-dressed, sharp, and articulate pharmaceutical representatives coming through the practice, offering an abundance of information, samples, and promotional items to be distributed to patients. "Dr. Z, here are the samples for Drug A. Have you heard about the latest study for our drug?" a drug representative would say. On hearing that he hadn’t, the rep proceeded to provide a two-sentence summary, then handed him the samples. "Sign here," said the rep. The physician signed. "Thanks for the samples," he said. They shook hands, and the drug rep departed. "Is Tuesday the day for the reps to come through the office?" I asked one of the nurses. "Nope, it’s like this every day," she said, and shrugged.
IT WAS ANOTHER BUSY DAY AT THE OFFICE, and I didn’t have time to stop and eat until the end of the day. One of the techs said that there were still sandwiches in the back, brought in by one of the drug reps. I looked at the sandwiches and the rest of the food. It looked delicious, from yet another gourmet caterer. There had been plenty for everyone in the office, with some left over. "Well, maybe just a cookie, that’s not really a whole lunch," I thought, trying to justify it to myself. "...And maybe a little bit of soda." As my medical rotation period went on, and the busy days continued, my "no-free-lunches" resolve slipped. I’d forget to bring lunch, be swept up in the frenzy that constitutes modern medical practice, and at the end of the day find myself enticed by the tantalizing aroma of chicken parmesan or pizza or gourmet deli sandwiches that beckoned from the break room. Each day, of course, was punctuated by as many as a dozen drug reps bearing free drug samples for doctors and gifts for patients. I ate a sandwich, then an entire meal. Finally one day I ate lunch while the drug rep was still there, waiting in the corner of the room, looking for someone to talk to. Guiltily I tried to listen to as little of her presentation as possible while enjoying the free lunch.
THROUGHOUT MY FOUR-WEEK ROTATION in this family medicine clinic, the free-drug-sample scene with the patient that first morning was repeated dozens of times. The patients were numerous and diverse: a mother of young children seeking a new sleeping pill; a cash-strapped family needing antibiotics for a child’s ear infection; a middle-aged couple interested in trying a new blood pressure medication; an elderly woman with serious heart problems who was living on a welfare-level fixed income. In every case, the physicians in the practice provided samples of the needed pharmaceuticals—sometimes an extensive supply—at no cost to the patients. The patients were thrilled to receive the free drugs, and the physicians were pleased to be able to meet their patients’ needs. But...I wondered, why were all of these free drug samples made available—and why were all of the doctors using them? Pharmaceutical companies know that drug samples are commonly judged to be strikingly influential on prescribing practices. The samples often influence physicians to prescribe the most expensive, newest versions of drugs available—drugs for which data on superiority over much cheaper generic versions sometimes aren’t available. For example, a 2003 national study on the use of samples and blood pressure medications found that physicians who distributed samples of newer, more expensive types of these medicines (ACE inhibitors and calcium-channel blockers) were much more likely to prescribe the more expensive types—even though a series of clinical trials and professional guidelines showed no significant difference between the effectiveness of the expensive and the less expensive drugs. In this study, physicians who distributed the samples also were much more likely to perceive that the more expensive drugs were more effective. Furthermore, studies demonstrating the long-term safety of these new brand-name drugs might not yet be available, leaving patients potentially vulnerable. This was infamously demonstrated in the case of Vioxx, where initial data indicating increased risk of heart attack and stroke were downplayed by the manufacturer; later, when more comprehensive data found significantly increased risk of heart attack and stroke, the drug was recalled. Drug samples easily can be abused or misused, as they aren’t subject to the strict inventory and controls afforded all other prescription drugs, and there is no standardized mechanism to track any adverse drug reactions. The multitude of free lunches and other gifts I observed during my medical rotation were also troubling. According to the 2008 paper by Gagnon and Lexchin, pharmaceutical company marketing expenditures totaled as much as $61,000 per physician, and approximately 80 percent of all pharmaceutical marketing expenditures were targeted specifically to physicians. A 2004 survey in the New England Journal of Medicine revealed that 94 percent of physicians had some type of relationship with pharmaceutical companies in which the companies provide them with food and beverages, drug samples, and other gifts. Even a cursory review of general research on human behavior reveals the powerful effect that gifts have on those who receive them—however small the gifts—and the feelings of reciprocity subsequently engendered in the recipients. In turn, the preponderance of evidence reviewed in a paper in the Journal of the American Medical Association in 2000 by physician and marketing expert Ashley Wazana suggests that drug company gifts have a deleterious effect on the quality of care that patients subsequently receive. Among them: more expensive and newer drugs are added perhaps too rapidly to hospital lists of approved drugs, there is an increase in "nonrational" prescribing practices, and, simultaneously, there is a decrease in prescribing generic drugs.
MY MEDICAL STUDENT EXPERIENCES WITH pharmaceutical companies weren’t limited to this single family practice clinic. A number of similar incidents happened throughout my clinical experience, from the lunches provided at my first psychiatry rotation (where, thankfully, my preceptor showed the pharmaceutical representatives out the door, and then protested their presence at that hospital) to daily noon conferences on my internal medicine rotation—mandatory for all students—that were always preceded by a sales pitch from a drug rep. A research adviser whom I greatly respect invited students to drug company–funded dinners at expensive restaurants; additionally, at all of the academic conferences I’ve attended so far, lavishly catered continuing medical education events sponsored by pharmaceutical companies have been ubiquitous. Considering these aggressive and extremely well-funded marketing practices, and the manner in which they’ve become so ingrained in our profession, I wonder if it’s possible to avoid them. Is it ethically acceptable for this influence to be so hard to avoid? And even if not, have they become so tightly bound to our professional culture that physicians have no choice but to accept them? I consider myself a person of conviction, but my resolve was defeated in the face of such elaborately coordinated, efficient, and expensive marketing campaigns. That my medical school tacitly condoned the practice also came as a surprise. It was difficult for me to speak out against the practice there—given the reliance of medical students on grades given by our attending physicians—although in retrospect I wish I had. Yet an effective marketing campaign is virtually impossible for an individual physician, resident, or medical student to resist; the impetus to change our collective response to these marketing initiatives must come from an institutional or policy level.
A 2006 PAPER IN THE Journal of the American Medical Association recommended that academic medical centers take the lead in creating guidelines to deal with these issues; indeed, many have begun this process. In 2006 the University of Pennsylvania’s School of Medicine banned any pharmaceutical industry–funded lunches from its hospitals (although not all of its clinics have adopted the practice yet). The Yale Physicians’ Group, the practice entity for the physicians of the Yale School of Medicine, recently adopted its own set of guidelines for interactions with industry representatives. Stanford Medical School has adopted a broader policy that prohibits physicians from accepting industry gifts of any size (including drug samples) anywhere on the medical center campus or at off-site facilities where they practice. In January 2007, Detroit’s Henry Ford Health System became one of the first private hospital systems to ban gifts and perks from medical salespeople; by some estimates, the cost of the free lunches provided by pharmaceutical companies to that hospital system alone was $2.5 million a year. These efforts constitute worthy first steps in disentangling the web of physician dependence on the pharmaceutical industry, steps that should be followed by medical schools, private health systems, and other hospitals across the country. Physicians, residents, and medical students shouldn’t be subjected to these pressures, and these industry practices exploit and twist the authority entrusted in physicians. Furthermore, there are alternatives to distributing free drug samples: a low- or no-cost voucher program for uninsured patients is one effective way to ensure that patients with limited resources receive optimal medical care at minimal cost to themselves. Physicians should take responsibility for collectively structuring ways to promote professional behavior when it comes to interactions with and gifts from pharmaceutical company representatives. If physicians aren’t able to regulate their own profession, there are indications that the American public might demand stricter accountability. Senators Chuck Grassley (R-IA), Herb Kohl (D-WI), and others introduced a bill in the U.S. Senate known as the Physician Payments Sunshine Act, which will require pharmaceutical, medical device, and other biotech companies to report any gifts to physicians that exceed $25. (Similar legislation at the state level in Minnesota and Vermont resulted in disclosing embarrassing information about many doctors, such as their tendency to prescribe more expensive drugs from companies that gave them gifts and the fact that some doctors were receiving gifts totaling hundreds of thousands of dollars.) Also related to this bill, Senator Kohl chaired hearings in 2008 before the Senate Special Committee on Aging to examine the relationships between physicians and industry. A related bill has been introduced in the U.S. House of Representatives. Drug companies also are beginning to respond to growing demand for regulated physician-industry relationships. In January 2009, the Pharmaceutical Research and Manufacturers of America (PhRMA) released a (voluntary) revised industry marketing code on interactions with health care professionals. Additionally, a number of major pharmaceutical manufacturers now support revised versions of the Senate and House bills that would require physicians to report gifts and honoraria from the pharmaceutical industry.
IN THE MEANTIME, PHYSICIANS AND MEDICAL STUDENTS will have to go it alone if they want to avoid pharmaceutical companies’ influence. Near the end of my rotation in the family practice clinic, at the end of a hectic day, one of the techs saw me in the hallway. "Hey, there’s some food in the back," she said helpfully. I gathered my resolve. "Thanks, maybe I’ll grab some later," I said, as I walked away, toward the front of the office. A nurse saw me going out the front door. "There’s some food in the break room," she said. "That’s OK," I replied. "I just need to get outside for a few minutes." I kept walking, going out the door and heading for the small food store across the street.
Melinda Morton (mmorton{at}jhsph.edu) is an emergency medicine resident at the Johns Hopkins University School of Medicine. A former Sommer Scholar at the Johns Hopkins Bloomberg School of Public Health, she is involved in research on disaster preparedness and humanitarian assistance. Morton completed medical school at the University of Pennsylvania School of Medicine in 2008 and is a captain in the U.S. Army Reserve. A graduate of West Point, she served more than eight years of active duty before attending medical school.
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