Pharmaceutical Industry Influences on Physician Prescribing: Gifts, Quasi-gifts, and Patient-Directed Gifts

Dana Katz, Arthur L. Caplan, and Jon F. Merz (2003) cogently argue that inexpensive and even trivial gifts from pharmaceutical companies can significantly influence physician prescribing behavior. They also argue that because the pharmaceutical industry influences physicians in many other ways, the relative influence of these small gifts on medication prescribing is unclear. If more objective medication prescribing by physicians is the essential purpose of regulating gifts, then we should consider some other gift-related influences. I will briefly discuss three concerns:

1. Medication/product sampling;
2. Gifts and payment for quasi educational-professional activities; and
3. Direct-to-consumer (DTC) drug promotions.

The marketing of medications to physicians by the pharmaceutical industry has been increasing as measured by dollars spent and by the variety of methods used to influence physicians (Growth Seen in Ads for Direct-to-Consumer Drugs 1998; IMS Health 1999). One method is for pharmaceutical detailers to provide office practices with supplies of branded medications in order to promote their use and prescription. Are these samples also gifts? Free medications can ingratiate physicians to suppliers. Samples might give detailers an avenue to personally address individual physicians in order to further other marketing techniques, including developing the kind of "amicable relationship" to which Katz, Caplan, and Merz refer. Physicians' supplies of medications might potentiate the inherent physician-patient power differential because physicians, whose prescribing power is meaningless to patients who cannot afford drugs, control a means of access to drugs for these more vulnerable patients. Physicians with stores of samples must choose how they are best distributed: by need, by merit, or by idiosyncratic measures and biases. Of course, physicians who distribute gratis medication can operate from a range of motives. Well- intentioned physicians might use samples to assess a medication's efficacy and tolerability before having patients commit to purchasing a supply. Often physicians continually provide impoverished patients with expensive, chronic-use medications. This practice is most supportable when no acceptable generic equivalent exists. Samples for personal or family use have less professionally redeeming value as gifts and might, in fact, carry a monetary value in excess of the AMA's $100 threshold. Acceptance of these drug samples might create obligations or indebtedness that is more personally based than the obligations created by accepting samples for patient use.

The pharmaceutical industry has developed programs that blur distinctions between gift-giving and bona fide professional compensation. For example, pharmaceutical companies have offered physicians payment for attending meetings of specious advisory boards at which little advising by physicians, and a great deal of marketing to physicians, occurs. These companies also conduct dinner-lecture programs in which physicians enjoy a meal (typically in a fine restaurant) while listening to a physician lecture on a medical condition that the sponsor's medication is intended to treat. Physicians might be further enticed to attend with the promise of a gift check to be used for "professional or practice-related" activities. These lectures are not necessarily bounded by the objectivity-educational standards of the American College of Graduate Medical Education.

Discussions of influences on physicians should include indirect yet powerful influences created by the industry. DTC advertising has created a new and growing pressure on physicians to keep abreast of new drug releases and associated market claims. In 1996 $600 million was spent on DTC advertising (Growth Seen in Ads for Direct-to- Consumer Drugs 1998) By 1999 annual spending exceeded $1.5 billion (IMS Health 1999). For some drugs, such as Zyban, 90% of promotional spending has been directed toward consumers (IMS Health 1999). More recently, medication-related "gifts" from industry have been directed to patients who can receive financial incentives to seek a particular medication through coupons for discounted or free product (see http://ibscrohns.about.com/library/weekly/aa011903a.htm). These gifts are intended to influence physician prescribing, as are gifts given directly...