by Dan Richardson

Turn on the television and watch the drug commercials promise to ease your every ill. ("Paxil -- Your life is waiting!") They're ubiquitous. Now imagine the drug companies' representatives stopping by your office to chat about the latest pill.

Crazy? No, it's effective -- and it's how pharmaceutical companies market their wares to physicians.

The big difference between TV commercials and drug sales reps chatting with doctors, nurses and nurse practitioners is that very often these health care professionals get rewarded for their time. The rewards include information -- details about new drugs, leading people in the industry to call the practice "detailing" -- but also trinkets, catered lunches, fancy dinners, ski weekends, even cash payments.

Many physicians say the practice is necessary or helpful, given that no one can possibly keep up with every new drug coming to market. Others, though, are beginning to question the drug rep-doctor relationship. A few clinics, including the Polyclinic in Seattle, are charging sales reps to walk in the door. And the drug industry itself, in the form of the Pharmaceutical Research and Manufacturers of America (PhRMA, pronounced "pharma") this month introduced voluntary guidelines to limit things like sales reps paying for doctors' golf greens fees.

"It's a very hot issue. It's worth taking a look at," says Arthur Caplan, director of the Department of Medical Ethics at the University of Pennsylvania. "I think the average person doesn't understand the extent to which gifts and detailing and advertising are bestowed on people from medical school on. It's very powerful."

The pharmaceutical industry says drug detailing is necessary for docs, helps patient health and distributes millions of drug samples for needy patients. And the industry provides well-paying jobs by any standard.

But take away the drug samples, and Big Pharma (as the industry is sometimes called) spends a Pentagon-like amount of money on getting its message before doctors -- $6 billion or more last year, plus $10.4 billion in free samples, according to PhRMA spokesman Jeff Trewhitt. The $19 billion marketing total (including all those pesky TV ads) is double what drug companies spent just six years ago.

"It certainly is appropriate to provide a modest gift... or a modest meal in recognition of the time the doctors are taking out of their busy schedules," with drug reps, says Trewhitt.

Modest? Divided between the nation's roughly 700,000 physicians, Big Pharma spends something like $8,000 to $10,000 per doctor per year in notepads, dinners, weekend resort conferences and the like.

Maybe that's why the U.S. Department of Health and Human Services announced that this year it will evaluate the extent of drug gifts and payments to doctors from the pharmaceutical industry. And maybe it's why the American Medical Association has launched a program to outline what is and isn't ethical for doctors to take from drug companies.

Of course, the new program costs money. One major sponsor that stepped up to pay the bills: PhRMA.

THE WHOLE POINT of sending out sales reps is to get face time with the doctors who write the prescriptions that pharmaceutical companies ultimately fill.

There are two common scenarios. The first is the rep who gets an appointment to see a physician for maybe 10 minutes to talk up their Prozac, Flonase, Valtrex or whatever. The second is the free lunch, where a rep brings in food for a clinic or meeting in exchange for some time to pitch their drug du jour.

"It is considered to be appropriate to bring in a few sandwiches or some pizza pies," says PhRMA's Trewhitt. "You're not going to buy a doctor's soul for the price of a hoagie sandwich."

Drug reps giving docs minor gifts isn't much different than in other industries. When Krispy Kreme came to town recently, most every media outlet in town got free boxes of donuts, including ours. Yum.

Historically, at least, the drug reps didn't stop -- and the physicians didn't stop taking -- with the free lunches, or lunch-and-learns, as they're sometimes called. Not nearly. Drug reps have often paid for sports or theater tickets, bottles of wine, luxury dinners and weekends at fancy resorts, where docs spend an hour or two hearing about the wonders of some new, expensive drug treatment and spend the rest of the days skiing or golfing.

Many medical workers have stories -- always in the past, you understand -- about some time they took these larger offerings. Ethicist Caplan says he was paid to talk at a conference, only to find out the real paymaster was a pharmaceutical company. Spokane Dr. Jeff Collins, an internist and vice president of the Washington State Medical Association, says he once went to a pharma junket in Seattle, believing the assertion that marketing and education could go hand-in-hand.

"It was so purely marketing and snake oil," he says. The office where he works -- the Physicians Clinic -- takes no drug lunches. Drug reps can make individual appointments, though.

"I think the real issue is, truthfully, these are not education events, these are promotional events. This is marketing," says Collins. A number of studies show that marketing does change prescription practices, he says. "Where manufacturers spend lots of money marketing, they generate market share."

Not all physicians and medical systems agree that drug company gifting is a problem, or even an issue worth discussing.

Consider one letter to the AMA from a California doctor: "It has been my experience that most pharmaceutical reps provide a good deal of information to the physician and often, because of our busy schedules, provide some small trinket in exchange for us taking the time to listen to them... Many physicians earn upwards of several thousands of dollars in the operation room or in detailed consultation. However, if they are to spend 20 to 40 minutes with a drug rep discussing their product and are given a free meal in exchange, it would seem to me that unless the cost of the meal exceeded $1,000, this would be an appropriate exchange of goods for time spent."

Critics logging on to the No Free Lunch anti-detailing Web site blast the "holier than thou attitude" taken by physicians who refuse pharma hand-outs.

"I love my drug reps, lots of good info and fun," writes one physician. "The reps will be here long after you are gone, and meanwhile my partners and I will be learning, earning and having a great time on trips, at ballgames, plays, amusement parks, dinners, meetings, conventions and social events."

"I'm too smart, too educated, too professional to be swayed by that stuff." That's what many pro-gifting physicians, tell critics or believe. It's probably what many in the Spokane area think, says Collins, the internist. Critics say the influence of drug reps is undeniable -- "almost absolutely," says Collins -- and it's hard to say that Big Pharma is spending its billions on fruitless marketing. The National Institute for Health Care Management (which receives insurance industry funding) found last year that sales of the 50 drugs most heavily advertised to consumers in 2000 saw 25 percent increased prescriptions, while the other 9,850 increased by just 4 percent. In other words, doctors are prescribing the Lipitors, Celebrexes and Prilosecs six times as fast as other, lesser-known drugs.

"Probably everybody believes they're immune to advertising, from the guy sitting in front of the television during the Super Bowl to your doctor," says Caplan, the ethicist. "They're both wrong."

Pharmaceutical marketing helps people, says Barbara Smith, who works as a PhRMA lobbyist in Olympia. More than half of pharma advertising to doctors is in the form of free medicine samples. Drug companies also spend money on direct patient-assistance programs. According to Smith, more than 35,000 low-income Washingtonians are participating in assistance programs for no-cost drugs.

Samples help many a poor family to acquire antibiotics for an ailing child, or struggling young women to obtain birth control.

Dr. Elizabeth Peterson, a plastic surgeon and president of the Spokane County Medical Society, agrees with Collins that area physicians are slowly turning away from the most lavish excess sometimes offered by drug reps.

"I think they're wrestling with it. Physicians need to be cautious, but there isn't black and white. There's a considerable gray area," says Peterson.

A few physicians cut off drug reps altogether for ethical reasons; Peterson receives few if any visits as a surgeon, but does have ongoing relationships with surgical implement manufacturers' reps. Most docs, she says, engage drug reps to get the updated dosing and application drug data the reps have. Though that, too, is problematic -- like going to a Ford dealership for information on trucks. You'll get some info, but not the complete story.

There's also a common feeling among doctors that some small amount of drug-gifting is harmless, says Peterson. "If somebody brings a lunch and it's there, are you going to not eat it? I think most physicians feel they won't change their prescribing practices if they eat a lunch."

Just a moment later, though, she acknowledges that drug marketing "works," and doctors need to beware of "subtle and manipulative acts of marketing."

Thus the new PhRMA guidelines, says industry spokesman Trewhitt.

"Sales representatives are trying to convince doctors that their new medicines hold a lot of promise," says Trewhitt. "Make no mistake, it is certainly advertising, it is certainly marketing... But they have got to do it with credibility or they're going to lose the doctor's attention immediately."

The guidelines are mostly just fancy talk, says Virginia Sharpe, director of the Integrity in Science Project at the Center for Science in the Public Interest (which takes no corporate or government money). The guidelines operate under the bad apple assumption -- that any problems with lavish gifts to physicians are the result of a few overzealous drug reps or under-professional physicians, she says.

"What the guidelines don't get at are the systemic problems," says Sharpe. The guidelines are voluntary, for example, and willing doctors can still hire themselves out to speak at drug conventions, take tickets to the ballgame, whatever.

It's an important issue, says Peterson, but neither guidelines nor debates will get to the heart of the matter: A lack of timely, credible pharmaceutical updates for physicians. Most journal articles are months or years behind, she says. Ultimately, doctors need a new mechanism besides drug reps for getting drug information.

"We can debate what's ethical, but in the end we need to get beyond it," says Peterson. "We can't sustain a system where there's a hint of influence-peddling."

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