Free gifts: redundancy or conundrum?

Abstract

The American Heritage Electronic Dictionary(version 3.6, Houghton Mifflin/Sofkey International; 1994) notes that the phrase “free gift” ought to be considered redundant. But its increasing usage is a sign of how advertisers have expropriated the term “gift” to “refer to merchandise offerings to which an obligation is attached.” This is the conundrum that physicians face in accepting gifts from drug companies. An ethically acceptable gift would, in fact, be a free gift. Over the past decade, physician organizations and others have offered ethical guidance on gifts from the pharmaceutical industry. In 1989, the American College of Physicians (ACP) called on physicians not to accept gifts if they would influence or appear to others to influence clinical judgment. Like other guidelines that followed, the ACP guideline flagged certain types of gifts as inappropriate and others, by their nature, as acceptable. As a useful criterion for determining the acceptability of drug company gifts, the ACP position statement also suggested that clinicians ask a guiding question: “Would you be willing to have these arrangements generally known?”1 Public perception, or more specifically, the physician's sense of shame or chagrin resulting from it, would help arbitrate between appropriate and inappropriate gifts. In this issue of JGIM, Gibbons and his colleagues examine and contrast the attitudes of physicians and patients toward 10 pharmaceutical industry gifts, ranging from a pen to a trip.2 They conclude that patients find pharmaceutical gifts more influential and, in some cases, less appropriate than physicians do. For those physicians who would accept a particular gift, more than 90% indicated a willingness to have that fact “generally known” for all 10 gifts. In several studies, including this one, patients give at least two reasons for concern over drug company gifts—influence over physician prescribing habits and increased costs passed on to patients. This disparity between the perceptions of physicians and of those they serve calls into question the usefulness of this criterion. Might we hold ourselves to a different standard? In one survey, most medical students (85%) found it improper for a politician to accept $50, but far fewer (46%) felt the same about a medical student accepting $50 from a pharmaceutical company.3 How susceptible are physicians to drug promotion efforts? The literature suggests that financial ties to drug companies may influence judgment. Chren and Landefeld found that physicians who requested specific additions to a hospital drug formulary were substantially more likely to have accepted money from those drug companies and more likely to have met with their pharmaceutical representatives.4 Cho and Bero have shown that drug company supported studies published in symposium proceedings more often had outcomes favoring the drug of interest than those without such financial ties.5 Most recently, Stelfox and colleagues concluded that authors who supported the use of calcium-channel antagonists were more likely than others to have financial ties to the manufacturers of these drugs.6 Perhaps the actions of drug companies themselves should also give us reason to pause. The pharmaceutical industry devotes considerable resources to promoting products to physicians. Both print advertising and the fielding of pharmaceutical representatives cost an estimated $5,000 to $6,000 per physician per year.7 Yet some drug companies themselves have corporate policies that prohibit the acceptance of gifts or limit their value to $5 or $10.8 But do physicians recognize the potential influence of drug promotion efforts on their clinical judgment? In a now classic study, Avorn and his colleagues interviewed Boston area primary care physicians about the relative contributions of commercial and scientific sources of information to their practice of prescribing two groups of drugs (propoxyphene analgesics and cerebral vasodilators).9 Most physicians perceived themselves as relying heavily on academic sources for drug information. These primary care physicians maintained that they placed little weight on drug advertisements (68%), pharmaceutical representatives (54%), or patient preference (74%). Yet the study found that commercial rather than scientific sources of drug information dominated their drug choices. The receipt of a gift may open the door for a drug company representative to make a marketing pitch to the physician. In an office or clinic, a gift can seed a long-term relationship, but at a convention, a gift might result in a one-time contact with a drug company representative. If this interaction is what compromises clinical judgment, should we take steps to restrict the access of pharmaceutical representatives to medical offices and meetings? What actions can we take to ground the prescribing choices of physicians on evidence rather than the pull of promotion? Several approaches deserve consideration. First, we can reassess the adequacy of the ethical guidance our professional societies provide on the acceptance of drug company gifts. Second, we can offer educational programs for physicians, particularly those in training, to understand how to better critique claims made in drug promotion. Finally, we can cultivate alternatives to drug company information.