By Arlene Weintraub
As the medical industry is reassessing how physicians should disclose the shares of stock and other compensation they receive from health-care companies, another ethical question has sparked a wave of hand-wringing at academic medical centers across the U.S. Can a gift as seemingly worthless as a pen or a slice of pizza influence how doctors do their jobs? So far, the consensus answer seems to be yes.
In recent months, several academic medical centers, including Yale University and the University of Pennsylvania, have barred drug-company sales reps from bringing free lunches to staff physicians. And on Sept. 12, Stanford University announced that its physicians will no longer be able to accept gifts of any size from any type of vendor, including biotech companies and medical-device makers. "It's a slippery slope from pens and Post-Its to bigger gifts," says Dr. Richard Popp, director of the section on ethics and policy for the biodesign program at Stanford. "It is more clear-cut just to say 'don't take anything.'"
Although such policies may seem draconian, they're backed up by evidence that even the smallest of gifts can influence the choices physicians make. Psychologists call it reciprocity—the natural human tendency to want to give something back to the gift-giver. It's the same phenomenon that prompts charitable organizations to fill people's mailboxes with return-address labels, so they'll be more likely to feel obligated to make a donation.
Some experts fear that if a pharma sales representative feeds a physician while describing a new drug to him, or leaves behind pens sporting the drug's name, that doctor may be more apt to prescribe the drug, even if the decision is subconscious. "Most doctors tell me they aren't influenced by gifts, and I think they believe that," says Dr. David Korn, a senior vice-president at the Association of American Medical Colleges in Washington. "But there are real neuropsychological changes that occur when you get a gift, even a ballpoint pen, for God's sake."
Studies have shown, for example, that physicians who request that their hospitals add drugs to their pharmacy rosters are likely to have accepted free meals or trips from drug manufacturers. And physicians tend to have positive attitudes toward sales reps who tote gifts. Such evidence prompted the Journal of the American Medical Association (JAMA) to print guidelines in January calling for more stringent regulation of industry handouts. The practice "creates the wrong message—that pharmaceutical companies will take care of [physicians] somehow," says one of the authors, Dr. Jerome Kassirer, a professor at the Tufts University School of Medicine and former editor of the New England Journal of Medicine.
Pharmaceutical gift-giving is big business. An estimated 90% of the $21 billion the industry spends on marketing is directed straight at physicians. Gifts include fees for speaking engagements, free travel to medical meetings, and research grants. In many venues, such as medical meetings, physicians are now required to disclose big-ticket items such as research funding.
Free drug samples are a major component of the pharma gift basket, too. Physicians often give them to low-income patients who can't afford to buy prescription drugs. But now even those freebies are coming under scrutiny. A study published last year in The American Journal of Medicine reported that medical residents who have access to drug samples were less likely to prescribe generic or over-the-counter medications than they were to scribble scripts for more expensive prescription drugs. (Generic drugmakers generally don't send samples to physicians.) The January JAMA article calls for samples to be banned and replaced with vouchers that low-income patients can take to pharmacies. Such an arrangement would "distance the company and its products from the physician," the paper asserts.
It's unlikely there will ever be an impenetrable wall between physicians and sales reps who want to hand out Post-Its to promote their new products. However, one fact is becoming increasingly clear: In academia, there soon may be no such thing as a free lunch.
Weintraub is the science editor for BusinessWeek in New York