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.
A Free Lunch?
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.
The Good, the Bad and Big Pharma
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."
He added: "[Physician-industry relationships] bring shame to the profession. They damage the trust between the public and the profession. They raise the cost of care. They threaten patients' health when the wrong drug … is given."
Dr. Peter Schulman, associate professor of medicine at the University of Connecticut Health Center, agreed. "The less those physicians are tied to the pharmaceutical [and device] industry, the better," he said. "Doctors will make better, unbiased decisions regarding therapy for their patients."
But others argue that not all interactions with the pharmaceutical industry are bad. Because physicians often have little time to keep up with new information, some say relationships are necessary for the advancement of medicine and are actually helpful to patients.
Scott Lassman, a senior assistant general council for PhrMA, said that discouraging interactions between physicians and the pharmaceutical industry, "would not be in the best interest of patients."
"We do think the pharmaceutical representatives are able to provide very valuable information about drug products," he said. "We don't think that ought to be physicians' only source of information, but sales representatives can give very valuable information."
Some doctors agree. "It is inevitable that physicians have relationships with people in the pharmaceutical industry," said Dr. Rachelle Smith Doody, chair of Alzheimer's disease research at the Baylor College of Medicine in Texas.
"We would not expect the people who develop our city infrastructure to do so without knowing something about the vendors who support their efforts, or without using the vendor as a source of some information regarding its own products," she said. "Medicine requires some degree of interchange between companies and doctors."
Dr. Keith Isaacson, associate professor of obstetrics and gynecology at Harvard Medical School, added, "There are no longer 'departmental funds' to support research, travel to academic conferences, fellowship training opportunities, et cetera."
He added: "As a result, clinicians have learned to work together with industry. Clinicians have a lot to offer industry such as a good grasp of clinical needs and ideas for new medications and devices. In return, industry offers clinicians funding for research, fellowships and travel."
And, in some physicians' opinions, accepting payment for consulting services or enrollment of patients into clinical trials does not necessary result in bias.
"Payment does not automatically mean bias," said Dr. Charles Blanke, professor of medicine at the Oregon Health and Science University, "but full disclosure of the relationship between company and physician is mandatory. "
Dr. Susan Fisher-Hoch, professor of epidemiology at the University of Texas Health Science Center at Houston, agreed.
"The industry and the profession should be working together to promote health. However, the issue of conflict of interests needs to be clarified, limits set, and statements clearly made publicly."
Disclosure as Absolution
But is disclosure alone enough?
"I don't have a problem with consulting as long as money isn't involved and there is full disclosure," said Dr. Marshall Strome, chairman of the Cleveland Clinic Head and Neck Institute.
However, Hadler said, "Disclosure is not a cleansing event, an admission of guilt or an apology. It is some sort of rite of passage."
Moreover, most doctors may not think to disclose their industry relationships with their most important clients -- their patients.
While no such disclosure requirement currently exists, physicians Isaacson and Blanke admit that this is an interesting and likely a good idea.
Doody is less enthusiastic, however. She said such a disclosure was almost meaningless to the patient.
"Disclosure works in [the scientific conference] setting because speakers and audiences have a shared sense of the usual practice of medicine and conduct of lectures or clinical trials," Doody said.
"Most patients have little understanding of what doctors do outside of the clinic room or hospital."