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,
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
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
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
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>.▪