From free pens to all-expenses-paid vacations, pharmaceutical companies appear to be pulling out all the stops to get their branding on doctors.
And their efforts could be working, leading some to question whether the marketing is working to the detriment of patients.
A new study in the current issue of the New England Journal of Medicine found that 94 percent of more than 3,000 physicians surveyed reported some type of relationship with the pharmaceutical industry.
While many of these interactions were as seemingly innocuous as receiving free food in the workplace and free drug samples, more than a quarter of the physicians reported receiving payments for consulting, giving lectures and even enrolling their patients in trials.
The relationships between physicians and the pharmaceutical industry have come under increasing scrutiny over the last 20 years, but data remain scant on what effect, if any, these relationships have on the provision of health care.
Meanwhile, the pharmaceutical industry has borne the brunt of blame for unchaste relationships with physicians. But many doctors say it remains unclear whether physicians shouldn't accept some of the responsibility as well.
Previous studies have shown that most physicians have had at least one free meal at some point on the pharmaceutical industry's tab. Additionally, many have been offered free drug samples, drug paraphernalia and even free trips.
The Pharmaceutical Research and Manufacturers of America (PhRMA), the industry group that represents the country's leading pharmaceutical research and biotechnology companies, adopted voluntary rules in 2002 that limited the value of gifts to $100 or less and banned offerings of free entertainment.
Yet, the new study shows physicians continue to be bombarded with gifts -- incentives that Dr. Nortin Hadler says come attached with expectations.
"There are no 'free lunches,' or trips or widgets," said Hadler, who is a professor of medicine at the University of North Carolina at Chapel Hill and author of "The Last Well Person."
Many physicians and social scientists claim that any sort of gift will affect anyone's judgment, even physicians'.
Dr. Marvin Bittner, associate professor of internal medicine at the Creighton University School of Medicine, said, "Some social scientists have said that gifts, no matter how small, create a sense of obligation. They distort judgment."
Others physicians argue, however, that they and their medical practice are not swayed by such gifts.
"Food and the trivial amounts paid for lectures and doing clinical studies don't influence anyone very much, in my opinion," said Dr. James Young, chairman of the Medical Division Office at the Cleveland Clinic.
However, studies in the past have shown that drug promotion increases prescribing of targeted drugs -- whether the doctors themselves realize it or not.
In light of this, some doctors argue that the physician-industry relationship should be avoided at all costs.
Dr. Jerome Kassirer, former editor of the New England Journal of Medicine and author of "On the Take," said, "[Physicians] should take no food, no gifts, no free samples, no appointment to speaker's bureaus, no consultations to promote products."