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Drug firms woo doctors with perks

Billions spent in bid to gain brand loyalty

By Alice Dembner, Globe Staff, 5/20/2001

Pressing to sell new blockbuster drugs and buy brand loyalty, pharmaceutical companies are bombarding doctors with ever greater numbers of gifts, free meals, and drug samples, spending more than $15 billion last year just to get their message to the people who prescribe their products.

Prime in the drug industry's sights are medical residents, doctors-in-training facing a lifetime of prescribing, whose long hours, poor pay, and inexperience can leave them hungry and vulnerable. Residents in the last few weeks could enjoy some of Boston's best, including dinner at the Four Seasons, Red Sox tickets, or billiards and beer - all compliments of drug companies.

In return, residents usually must listen to a brief company-sponsored lecture. ''Residents are really preyed upon,'' said Dr. Robert Goodman, an internist in New York who is organizing residents and other doctors to refuse drug company freebies. ''The companies are really buying a lifetime of good will from these guys by providing them with all this hospitality.''

Goodman's ''no free lunch'' campaign is part of a growing effort by doctors and hospitals locally and nationally to counter the drug industry's pitch, ranging from restricting drug representatives' access to residents to training their own staff to offer unbiased drug information.

Drug companies have built a powerful army to cajole doctors into using their products. Last year, about 83,000 drug representatives - double the number in 1996 - targeted residents and other doctors, showing an attentiveness that is seductive to young doctors at the bottom of their profession.

''They are among the few people around here who don't treat you like dirt,'' said Brian Green, a third-year resident at Cambridge Hospital who says he nonetheless refuses the perks.

Critics say industry marketing contributes to ballooning national spending on prescription drugs, which rose 19 percent last year to $132 billion for outpatient drugs alone, according to the National Institute for Health Care Management. Top-selling drugs are among those most heavily promoted.

Drug manufacturers develop pills that please the eye. But the industry's largest trade group, Pharmaceutical Research and Manufacturers of America, says companies strive to provide accurate, comprehensive information and work within ethical guidelines established a decade ago by the American Medical Association.

''We think doctors are fiercely independent providers who make their own decisions based on the needs of their patients,'' said the group's spokesman, Jeffrey Trewhitt. ''A modest meal or a modest gift is allowed in the guidelines because we're taking their time to educate them about our products, and doctors are very busy people.''

However, influential voices in the medical profession, including former New England Journal of Medicine editors Marcia Angell and Jerome Kassirer, as well as Public Citizen's Dr. Sidney Wolfe, have called for shielding residents and educating them about the impact of pharmaceutical marketing. The Accreditation Council for Graduate Medical Education, which sets standards for training of residents, is discussing imposing tougher ethical standards.

''We're worried about the environment in which residents are trained because of the intrusion of commercial interest,'' said Dr. David Leach, who heads the council. Some residents themselves are worried. ''It's very easy to go to a drug company lunch any given day, and one could supplement one's meals by going to a fine restaurant at least once a week,'' said Dr. Ruth Potee, a second-year resident at Boston Medical Center. ''One likes to think it doesn't affect your decisions, but it does. You feel obligated to these people who are feeding you. ''

Numerous studies have found that doctors who accept gifts or free meals or spend time with drug salespeople are more likely to prescribe expensive new drugs even when the drugs have little advantage over a cheaper generic. They are also more likely to press hospitals to add the drugs to their prescription lists.

Another study found that information provided by drug reps was inaccurate at least 11 percent of the time - promoting a more favorable view of their drug - and that most residents failed to recognize the misinformation.

Even Trewhitt, of Pharmaceutical Research and Manufacturers of America, acknowledges growing criticism about drug industry violations of ethical guidelines. The AMA and PhRMA are jointly preparing to launch a campaign this summer to educate doctors and sales reps about the guidelines, which allow gifts of up to $100 - such as reference books or stethoscopes - provided they benefit patients. The rules also permit ''a modest meal'' as part of an educational event. An informal AMA survey found that 40-50 percent of doctors weren't familiar with the ethics code.

Dr. Herbert Rakatansky, chairman of the AMA council that wrote the guidelines, said three recent events described to him by the Globe were typical, but apparently unethical. On an April evening, nine residents relaxed in a smoky Boston nightclub, playing pool, downing beers, and filling their plates - all on the tab of drug giant Pfizer. For just 15 minutes, the Pfizer salesman interrupted the fun to talk about a Pfizer-sponsored study of its blockbuster arthritis pill, Celebrex, which racked up about $2 billion in sales in 2000.

A few nights later, GlaxoSmithKline treated some 60 doctors and guests to a four-course dinner at the Four Seasons, an event billed as an educational program on diagnosis and treatment of migraine. Beginning with cocktails and hors d'oeuvres, the evening moved on to tenderloin and lobster. A Harvard professor and Glaxo researcher lectured about one class of migraine drugs, focusing on Glaxo's Imitrex. The speaker skimmed over data on side effects, despite the drug's labeling, which warns of deaths among some users with undiagnosed heart problems.

Another Pfizer event invited residents and a guest to dinner and a Red Sox game. The price for residents: listening to a half-hour talk on Pfizer's cholesterol-lowering drug Lipitor.''Tickets to the Red Sox are not acceptable'' under the guidelines, said Rakatansky. ''A modest meal is not going to the Four Seasons. A billiards night does not qualify as education. Since there is evidence that significant gifts will alter your behavior, you should not accept those gifts.''

Glaxo spokeswoman Mary Anne Rhyne defended the Four Seasons event, saying, ''There was some sharing of valuable information and we need to look into this further to determine if it met our policies.'' Pfizer did not respond to a request for comment.

Such events are just one aspect of the marketing effort to doctors, which begins in medical school, intensifies in residency, and continues through a doctor's career. The barrage includes one-on-one pitches in hospital hallways, lunches at departmental gatherings, sponsorship of medical conferences, and distribution of drug samples, which the firm IMS Health valued at nearly $8 billion last year.

''There's no way they'd spend all this money unless it works,'' said Dr. Colin Doherty, chief neurology resident at Partners Healthcare, who is organizing discussions to help neurology residents ''understand what they're up against.''

On Friday, the first discussion was led by Dr. Jerry Avorn, whose department at Brigham & Women's Hospital studies prescribing patterns. Last year, the department began monthly ''pizza rounds'' for internal medicine residents as a counterpoint to drug company lunches. ''We buy the pizza and try to unhawk the drugs,'' said Avorn. Next month, the department will begin training a ''sales'' force of residents to discourage colleagues from overusing new drugs.

While the Brigham focuses on education, others are pressing to limit drug reps' interactions with residents. Residents in Boston Medical Center's internal medicine department last summer hotly debated whether to ban drug reps from their lunch gatherings. In the end, the majority voted to allow the reps to provide lunch, but to bar them from the educational part of the program. Longstanding bans on drug-company contact during work are in place at Cambridge Hospital's medicine department and Massachusetts General Hospital's infectious diseases and Ob/Gyn departments.

Bob Goodman would like to see more departments and doctors pledge to ''say no to drug reps and their pens, pads, calendars, coffee mugs, and of course, lunch, not to mention dinners, basketball games, and ski vacations.'' Through a Web site and presentations, he is focusing on residency programs, which he sees as ''the best hope of changing the professional culture.''

But Goodman's approach faces resistance, even among those worried about marketing masquerading as education. ''We have an obligation to physicians-in-training to ensure they are capable of dealing with this issue when they leave,'' said Harold Demonaco, MGH's director of drug therapy management. ''Allowing them access to reps in a controlled fashion with some understanding of the techniques used is perhaps a reasonable compromise.''

-- Swissrose (cellier3@mindspring.com), May 20, 2001