Dr. Daniel Carlat sank into a choice seat at Lincoln Center, surrounded by other psychiatrists, all staying at the same four-star hotel in Manhattan and attending the same show for free. His deal with a pharmaceutical company to provide testimonials to other doctors had paid off well.
"It just kind of gave me a feeling of euphoria," said Carlat, a practicing psychiatrist and assistant clinical professor of psychiatry at Tufts University in Boston. "Sort of like you've made it into the upper crust of society."
The practice of using doctors to pitch products to other doctors is legal, though several states — including New York — are trying to curb it. They are opposed by the pharmaceutical industry, which argues the practice is a kind of professional consultation.
Carlat was on the "speakers' bureau" for the pharmaceutical companies, speaking to large groups of doctors, or holding intimate, expenses-paid meals with a pharmaceutical representative and one or two doctors. In one year, he earned $30,000 — about one-fifth of his salary. Ultimately, his conscience started nagging him and he quit.
"My role in the company was not by any means to serve as a source of unbiased medical information," he said. "But my role was really simply to be a part of their marketing machinery and that was the value I had for them."
Pharmaceutical companies argue that doctors are an essential part of educating colleagues as new drugs are developed.
"The information about medicines provided by technically trained company representatives, some of whom are health care professionals themselves, is important education for physicians who must understand side effects and the proper use of potent prescription pharmaceuticals," Ken Johnson, senior vice president of Pharmaceutical Research and Manufacturing of America, said in a written statement.
At the end of January, PhRMA, the drug industry's lobbying arm, said it is considering scaling back on smaller gifts to doctors, including pens, coffee mugs and other items. Johnson said the idea is not a response to pressure about its marketing practices.
In a survey published last year by the New England Journal of Medicine, 95% of doctors said they had contact with drug or device companies, and 35% were reimbursed for costs associated with professional meetings. Another 28% accepted consulting or lecture fees, while 7% took free tickets to games and other events.
Some doctors see a benefit to the practice.
Wayne Weart, a professor of clinical pharmacy and outcome sciences at the Medical University of South Carolina in Charleston, has a clinical doctorate of pharmacy and has long worked on speakers' bureaus for drug companies. He says the industry has changed its ways in recent years.
When drug companies pay Weart to speak at a medical school or conference, he said, "they can't influence the topic, the speaker, the venue, any of these things." He said the drug companies provide unrestricted grants for his speaking engagements and he must disclose to the audience the connection he has to the company.
Weart, who said the side work pays "a fair amount," won't participate if he is expected to promote one drug over the other, or if he feels the research is unsatisfactory.
Dr. Paul Root Wolpe, a senior fellow at the University of Pennsylvania Center for Bioethics, said there's nothing wrong with doctors speaking about pharmaceuticals, but a conflict of interest can arise when they are paid.
"Best intentions go astray among the pressures of money and relationships," Wolpe said. "I don't think it's intrinsically unethical, but you are creating a situation in which it's very difficult to retain ethical integrity."
"The best way to teach people about new drugs and their impact is to get the experts in the field to talk about it," said Wolpe. "What I didn't hear anywhere in that process is that that has to be sponsored by the drug companies."
Some hospitals and medical schools ban doctors from accepting gifts from drug reps, including the University of Pennsylvania, Yale University and Stanford University.
The Physician Payment Sunshine Act, currently in the Senate Finance Committee, would create a database disclosing the names and addresses of doctors who receive gifts or payments. It would also include pharmaceutical company names and the value of the gift or payment. The measure co-sponsored by New York Sen. Charles Schumer was referred to committee in September and hasn't budged since, despite support from medical ethics groups.
Drug companies oppose the act.
PhRMA adopted voluntary rules in 2002 that limit the value of gifts to $100 or less and says that all forms of free entertainment, including sporting events and golf outings, are inappropriate. The group argues that these rules cut the risk of problematic relationships between drug reps and doctors.
Measures similar to the Physician Payment Sunshine Act have passed in New York's Assembly, but either did not have a counterpart in the Senate or were unsuccessful in that chamber. State Senate Health Committee Chairman Kemp Hannon said such bills are being considered.
Another bill in the Assembly would prohibit pharmaceutical companies from buying data on the prescribing habits of doctors — information used for direct marketing and to recruit a sales force, sponsors say.
At least eight states and the District of Columbia have laws or resolutions related to pharmaceutical marketing, including California, Florida, Maine and Minnesota.
Initially, Carlat didn't have a problem with the work he was doing, but he gradually became concerned.
"I stopped because I decided that it was unethical to alter and to tweak information that would ultimately affect patients' welfare and patient safety," he said.