Free Gifts

The American Heritage Electronic Dictionary(version 3.6, Houghton Mifflin/Sofkey International; 1994) notes that the phrase “free gift” ought to be considered redundant. But its increasing usage is a sign of how advertisers have expropriated the term “gift” to “refer to merchandise offerings to which an obligation is attached.” This is the conundrum that physicians face in accepting gifts from drug companies. An ethically acceptable gift would, in fact, be a free gift.

Over the past decade, physician organizations and others have offered ethical guidance on gifts from the pharmaceutical industry. In 1989, the American College of Physicians (ACP) called on physicians not to accept gifts if they would influence or appear to others to influence clinical judgment. Like other guidelines that followed, the ACP guideline flagged certain types of gifts as inappropriate and others, by their nature, as acceptable. As a useful criterion for determining the acceptability of drug company gifts, the ACP position statement also suggested that clinicians ask a guiding question: “Would you be willing to have these arrangements generally known?”¹ Public perception, or more specifically, the physician's sense of shame or chagrin resulting from it, would help arbitrate between appropriate and inappropriate gifts.

In this issue of JGIM, Gibbons and his colleagues examine and contrast the attitudes of physicians and patients toward 10 pharmaceutical industry gifts, ranging from a pen to a trip.² They conclude that patients find pharmaceutical gifts more influential and, in some cases, less appropriate than physicians do. For those physicians who would accept a particular gift, more than 90% indicated a willingness to have that fact “generally known” for all 10 gifts. In several studies, including this one, patients give at least two reasons for concern over drug company gifts—influence over physician prescribing habits and increased costs passed on to patients. This disparity between the perceptions of physicians and of those they serve calls into question the usefulness of this criterion. Might we hold ourselves to a different standard? In one survey, most medical students (85%) found it improper for a politician to accept $50, but far fewer (46%) felt the same about a medical student accepting $50 from a pharmaceutical company.³

How susceptible are physicians to drug promotion efforts? The literature suggests that financial ties to drug companies may influence judgment. Chren and Landefeld found that physicians who requested specific additions to a hospital drug formulary were substantially more likely to have accepted money from those drug companies and more likely to have met with their pharmaceutical representatives.⁴ Cho and Bero have shown that drug company supported studies published in symposium proceedings more often had outcomes favoring the drug of interest than those without such financial ties.⁵ Most recently, Stelfox and colleagues concluded that authors who supported the use of calcium-channel antagonists were more likely than others to have financial ties to the manufacturers of these drugs.⁶

Perhaps the actions of drug companies themselves should also give us reason to pause. The pharmaceutical industry devotes considerable resources to promoting products to physicians. Both print advertising and the fielding of pharmaceutical representatives cost an estimated $5,000 to $6,000 per physician per year.⁷ Yet some drug companies themselves have corporate policies that prohibit the acceptance of gifts or limit their value to $5 or $10.⁸

But do physicians recognize the potential influence of drug promotion efforts on their clinical judgment? In a now classic study, Avorn and his colleagues interviewed Boston area primary care physicians about the relative contributions of commercial and scientific sources of information to their practice of prescribing two groups of drugs (propoxyphene analgesics and cerebral vasodilators).⁹ Most physicians perceived themselves as relying heavily on academic sources for drug information. These primary care physicians maintained that they placed little weight on drug advertisements (68%), pharmaceutical representatives (54%), or patient preference (74%). Yet the study found that commercial rather than scientific sources of drug information dominated their drug choices.

The receipt of a gift may open the door for a drug company representative to make a marketing pitch to the physician. In an office or clinic, a gift can seed a long-term relationship, but at a convention, a gift might result in a one-time contact with a drug company representative. If this interaction is what compromises clinical judgment, should we take steps to restrict the access of pharmaceutical representatives to medical offices and meetings? What actions can we take to ground the prescribing choices of physicians on evidence rather than the pull of promotion?

Several approaches deserve consideration. First, we can reassess the adequacy of the ethical guidance our professional societies provide on the acceptance of drug company gifts. Second, we can offer educational programs for physicians, particularly those in training, to understand how to better critique claims made in drug promotion. Finally, we can cultivate alternatives to drug company information.

Ethical Guidance from Professional Societies

While recognizing the industry's contribution to education, the AMA's Code of Medical Ethics describes in some detail the nature of acceptable and unacceptable gifts to physicians.¹⁰ Gifts of minimal value related to the physician's work (e.g., pens or notepads) are acceptable, as are gifts of benefit to patients and not of substantial value. But direct subsidies from industry for travel or lodging of physicians just to attend conferences or meetings are not. Of note, both the AMA Code of Medical Ethics and the Accreditation Council for Continuing Medical Education (ACCME) make an exception to their standards.¹¹“Scholarship or other special funding to permit medical students, residents, and fellows to attend carefully selected educational conferences may be permissible,” so long as trainee selection for these programs is done by the academic institution or the accredited sponsor with the training program's full concurrence. The ACP also specifies some gifts as acceptable—trivial gifts such as pens; inexpensive gifts of an educational nature, such as books; honoraria for study participation or for reasonable compensation of time and travel expenses for meeting presentations; and modest hospitality associated with an educational event.

In the United Kingdom, only gifts that are “inexpensive and relevant to the practice of medicine or pharmacy” are permitted. Last year, the U.K. Department of Health announced that it would prosecute companies and wholesale distributors who offer—and health care professionals who accept—gifts, pecuniary advantages or benefits in kind as an incentive to prescribe or supply medicines. (Drug company gifts: UK MCA “will prosecute.” Marketletter, August 4, 1997.) These codes of ethics array gifts along two dimensions, monetary value and educational benefit, and draw a line.

So the nature of the gift matters. Given that, what other dimensions should we consider? Some gifts carry the advertising message. Pens of trivial value may sport the drug's brand name as an ever present reminder. In contrast, drug companies that offer more expensive, but educational gifts such as books may be forgettable. In one study, students who received one or more books accurately recalled titles for 89% of them, but upon doing so accurately associated the books with a pharmaceutical company or product in only 25% of the cases.¹² What if the advertising message were not brand-specific, but were practice-specific? For example, a drug company that manufactures a particular brand of β blocker might give a practice support tool that urges the appropriate use of this class of drugs after myocardial infarction.

The nature of the gift matters to patients as well. More than twice the number of patients realized that physicians received office-use gifts as opposed to personal gifts.¹³ In another study, patients expressed higher approval for gifts considered trivial or of potential value to patient care, but relatively high disapproval for gifts of some monetary value, but of little or no benefit to patients.¹⁴ For example, patients had few objections to gifts that directly benefited them, such as free drug samples.

But are these drug samples really free? Once therapy starts with a free drug sample, the patient often is committed to chronic treatment on a new drug (which may turn out to be more expensive over time) rather than optimal, cost-effective treatment. Also, the physician may become accustomed to prescribing the free drug sample as the treatment of choice. These and other issues warrant further attention by our professional societies as well as individual clinicians.

Education of Physicians

For those training to become a physician, incomes are relatively low, working conditions difficult, and practice styles malleable. This may present a window of time during which physicians are particularly susceptible to the influence of drug promotion efforts. Our ethical vigilance and educational efforts should be correspondingly greater for physicians in training.

The signal that training programs send to their housestaff is important. Brotzman and Mark compared family medicine residency programs that had written policies and restrictions on pharmaceutical representative interactions with residents with those that did not.¹⁵ They concluded that residents in the restricted programs were less likely to view the acceptance of gifts as appropriate. The work by Gibbons and his colleagues underscores this need for educating physicians in training. A particularly troubling finding in this study was that physicians in training overall considered gifts more influential, yet more appropriate than did staff physicians.

Another approach is educational intervention. Hopper et al. conducted a program that introduced residents to the AMA and ACP guidelines on receipt of drug company gifts and demonstrated various types of marketing techniques through brief vignettes.¹⁶ They found that resident attitudes concerning physician interactions with pharmaceutical representatives changed with the educational intervention. Apart from knowledge of guidelines and marketing techniques, we might also teach critical appraisal of the literature through examination of drug promotion claims. Education might recalibrate the judgment and the perception of these physicians.

Alternatives to Drug Company Information

Half of patients suffering from colds receive antibiotics despite medical evidence that antibiotics offer no clinical benefit.¹⁷ Four of five patients do not receive β blockers after a heart attack despite evidence that this treatment would reduce the number of deaths by 40%.¹⁸ And in a study of two leading teaching hospitals, adverse drug events extrapolated hospital-wide totaled 1,900 per hospital per year.¹⁹ More than one in four of these adverse drug events were preventable.

Clearly, there is a need for education. Drug companies maintain that product promotion encourages the diffusion of innovations to provide patients state-of-the-art care.²⁰ For these companies, promotion and education go hand in hand. However, we might ask why we turn to drug companies to educate physicians. Besides the Medical Letter, we can tap other sources for objective drug information. Academic detailing, decision support tools, and journal review articles could all contribute to this effort. Professional societies and medical journals could make a concerted effort to provide continuing education on appropriate drug therapy.

As pharmaceutical benefit management companies and other health care organizations tackle this problem, new concerns over medical product promotion have emerged.²¹ In a survey of managed care plans, 25% of respondents had already accepted a disease management program offered by a drug company, and 76% of those who had not would consider doing so.²² With professional society leadership and a commitment to educate physicians in training and in practice, we can take the steps to make drug company gifts redundant by developing alternatives to drug company information. If we do not work to fill this void, others may do it for us.—Anthony D. So, MD, MPA,Agency for Health Care Policy and Research, Washington, DC.