Drugmakers, Doctors Get Cozier

Despite efforts to curb drug companies' avid courting of doctors, the industry is working harder than ever to influence what medicines they prescribe, sending out sales representatives with greater frequency and plying physicians with gifts, meals and consulting fees, according to several new papers.

One study published in the New England Journal of Medicine last week found that 94 percent of doctors have some type of relationship with the drug industry -- most commonly accepting free food or drug samples, which about 80 percent of physicians did. More than one-third of the 1,662 physicians who responded to a survey conducted from November 2003 to June 2004 reported being reimbursed by the drug industry for costs of going to professional meetings or continuing medical education, and 28 percent said they had been paid for consulting, giving lectures or signing up patients for clinical trials.

Two other papers examined in detail the strategies that pharmaceutical representatives, or "detailers," use and how effective the industry is at influencing doctors.

"We now know that virtually every doctor in the United States has some form of relationship with the pharmaceutical industry," said Eric G. Campbell, lead researcher of the New England Journal of Medicine study and an assistant professor of medicine at Harvard Medical School. "They are common. A quarter receive honoraria or some form of payment for their services, and that was much higher than we expected."

Contacts between doctors and drug salespeople have jumped from the average of 4.4 per month reported in 2000, Campbell and other researchers found. In the survey period, drug representatives met with family practitioners an average of 16 times a month, with cardiologists and internists nine or 10 times a month, with pediatricians eight times a month and with surgeons four times a month. Only anesthesiologists, who saw the representatives twice a month, appear to be meeting with the industry less often than before, the study found.

As those numbers suggest, the companies shower more attention on certain doctors, the researchers said. Cardiologists -- whose prescribing patterns tend to influence primary care doctors -- were more likely to be paid for consulting and other services than were family practitioners, pediatricians, anesthesiologists and surgeons, the study found.

"When I send somebody to a cardiologist, if he puts somebody on a medicine, I'm not going to change it," said co-author David Blumenthal, a general internist and the director of the Institute for Health Policy at Massachusetts General Hospital in Boston. "If they use a particular agent, I'm more likely personally to prescribe that agent because I figure the guy is an expert and he has got some reason for picking that brand as opposed to some other brand."

The ties between doctors and drug companies are deepening despite voluntary guidelines to curb excesses, adopted in 2002 by the American Medical Association, the American College of Physicians, the Accreditation Council for Continuing Medical Education and the Pharmaceutical Research and Manufacturers of America. The inspector general of the Department of Health and Human Services issued similar guidance in 2003.

Under the industry code, gifts must be worth less than $100 and should primarily benefit patients -- items such as stethoscopes or medical dictionaries. Meals should be "modest" in cost, and a physician's spouse should not be included. Gifts of cash or tickets to sporting events are inappropriate. Consulting arrangements must be for real services, and doctors should not be paid for listening to marketing pitches.

"Clearly, adequate safeguards are already in place," Ken Johnson, senior vice president of the drug industry association, said in a statement. "The goal is to make sure the focus of conversations between company representatives and physicians remains providing accurate information about medicines."

A former industry insider, however, painted a different picture in an article last week in PLoS Medicine, a journal published by the Public Library of Science. Shahram Ahari, a former drug company representative, and physician Adriane Fugh-Berman wrote that the estimated 100,000 representatives who visit doctors' offices look for details such as family photos or hobbies that they can use to forge a relationship. They use food, gifts and money to make often-overworked doctors feel more appreciated -- and more loyal to the company's drugs. If a physician will not meet with them, the representatives often woo the office staff with flattery and meals.

"Pharmaceutical gifting . . . involves carefully calibrated generosity," Ahari and Fugh-Berman wrote. "Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug's name stays uppermost in a physician's subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags."

Drug companies also purchase prescription records from pharmacies and, with the help of an American Medical Association database, identify individual physicians' prescribing patterns and rank doctors based on how many prescriptions they write, the authors wrote.

The tactics work. Another study in PLoS Medicine last week found that visits by detailers prompted nearly half of 97 physicians to increase prescriptions of gabapentin, a drug approved to treat seizures. In many cases, the drug representatives were pushing non-approved, or "off-label," uses of the drug, the study found.

A study in the Journal of General Internal Medicine in February found that physicians in focus groups said that they understand the potential conflicts of interest but that they still view their meetings with drug detailers as informative and appropriate. Such findings suggest that voluntary guidelines are inadequate, researchers wrote.

In an interview, one District-based physician, orthopedic surgeon Peter E. Lavine, said that drug representatives used to visit his office daily but have cut back in recent years to stopping by about twice a week. The conduct guidelines have eliminated most excesses, Lavine said, and many doctors view the sessions as a way to learn about side effects and how drugs compare.

"The vast majority of physicians appreciate the information but find them [detailers] as a nuisance," said Lavine, chairman of the Medical Society of the District of Columbia.

"They always tend to come in the middle of the day when you are busy seeing patients, and it's very difficult to break away and talk to them. And if they've bought lunch for the staff, then you are sort of obligated to give them a little bit of your time. I think they certainly have a valuable educational benefit. I don't think that physicians are going to change their prescribing patterns for free samples."