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PHYSICIANS AND THE PHARMACEUTICAL INDUSTRY: AN ALLIANCE WITH UNHEALTHY ASPECTS ROBERT C. NOBLE* Introduction As an academic infectious diseases physician, I have observed the development of an increasingly unhealthy relationship between physicians and the pharmaceutical industry. For a while I was a participant. In my second year of medical school, I gratefully accepted from Eli Lilly and Company a stethoscope, reflex hammer, tuning fork, and a leather bag, but didn'tjoin members of my class for the annual trip to the Lilly Laboratories in Indianapolis, an event legendary for its entertainments and hospitality. Over the ensuing years I have taken many pens, calendars , trinkets, and books from pharmaceutical salespersons, and have given a few continuing medical education lectures paid for by drug companies. In addition, I completed several clinical and in vitro studies financed by pharmaceutical companies, and I used the residual funds for travel and for support of other studies for which funding was not available. In the academic medical center, physician-pharamaceutical industry relationships are closely intertwined and have both healthy and unhealthy aspects. A single event precipitated my reflection on these relationships. While I was waiting for a friend in the hospital lobby at noon, some pharmaceutical salespeople entered bearing boxes of pizzas for a housestaff noon conference. As they passed, the aroma of pizza was distinctive, and a small, poorly dressed boy sitting nearby turned and asked his mother if could he have a pizza. At that moment, I began to wonder who should be eating the pizzas [I]. The unhealthy aspects of the physician-pharmaceutical industry relationships have been evidenced by an increasing number of letters to the editors of medical journals by physicians expressing concern, the *Department of Medicine, MN631, University of Kentucky, College of Medicine, Lexington , Kentucky 40536.© 1993 by The University of Chicago. AU rights reserved. 0031-5982/93/3603-0806$01.00 376 Robert C. Noble ¦ Physicians and the Pharmaceutical Industry publication of guidelines by several professional organizations, and even a U.S. Senate hearing devoted to the promotional practices of the pharmaceutical industry. Despite all this attention, problems remain inherent in physician-pharmaceutical company interactions, and although the pharmaceutical industry is the subject of this article, many of the same problems beset physician interactions with other medically related industries that provide equipment, goods, and services to patients. Physicians are currently awash in a sea of new drugs, many much like the other, and pharmaceutical companies are frantic to find a harbor for their own brands in a tide of look-alike medicines. To accomplish this, the companies have turned to their marketing divisions, and for many years physicians have been the recipients of increasingly lavish promotions to encourage them to prescribe a particular product. A brief description of the pharmaceutical industry's fortunes and problems will show why these companies believe that a heavy emphasis on promotion is necessary. The Pharmaceutical Industry Industry Problems and Pressures The U.S. phaimaceutical industry is highly competitive. None of the major companies holds more than a 7.6 percent share of the market [2]. Despite this, pharmaceutical companies are financially successful. U.S. sales of human-use, dosage-form pharmaceuticals were estimated to be $43.5 billion in 1991, an increase of 10.7 percent from 1990. Sales also increased 10.4% in 1989, and 14.1 percent in 1988 [3]. Much of the financial data on the industry, except for data on profits and promotion expenses, is provided by the Pharmaceutical Manufacturer's Association (PMA), an organization comprising over 100 research-based pharmaceutical companies who produce most of the pharmaceuticals sold in the United States. Drugs and medical suplies constitute a steady 7 percent of the total U.S. health care expenditure, in contrast to the 69 percent expended for hospitals and nursing homes [3]. In 1991, foreign sales accounted for 35 percent of the volume of U.S. pharmaceutical manufacturers [3], and in the same year of an overall U.S. trade deficit, the U.S. pharmaceutical industry had a foreign trade surplus of $1.23 billion [2]. Industry profits are estimated by a nonindustry source to be 28 percent of sales [4]. The Costs of Drugs and Drug Development To...


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