The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives

I am personally involved and connected to all the comments made about Dr. Brody's comments. I have been involved in the pharmaceutical as well as Medical Device industry for quite some time. In my tenure and experience I have been able to converse with a large number of physicians in a wide variety of disease states and specialties and I can honestly tell you that there have been numerous occasions where physicians have told me that I was helpful and informative. I don't only "throw out some verbage", I act as a consultant on how modern medicine and practices can save the physician, as well as the patient, time and money. With the increased expectations put on physicians how do they find the time to research all the new products, innovations in technology, and managed care issues without the drug companies providing an easy access information highway? There is very little gratitude given to the reps in the pharmaceutical industry and I personally disagree with it. I can't speak for all companies, but for the select ones that I have been employeed with, they train us to be experts in our division. How do you feel when your patients regard your comments and information as fluff and a ploy to put money in your pocket? You would be insulted, as are we. For those of us who are following our ethics, please respect us as we respect you. The one thing I believe many physicians forget is that we are all educated, community involved, family people who are just as human as the next person and we deserve to be looked in the eye and "allowed to speak" and not just "grab a signature". How insulting is that? Just for the record...who do you think funds all of the studies that are helping to work towards cures for diseases such as cancer, aids, and diabetes??? God forbid any of your family members fall victim to such terrible diseases.

Competing interests:   None declared

I appreciate your exploration of this issue in a way that avoids emotional rhetoric and instead explores the logic/evidence (and lack thereof) to support our current practices.

Medical students are becoming more and more aware of the ethical problems that arise when we, as healthcare providers, interact with drug company reps. and their propoganda. AMSA, the biggest medical student group in the USA, has an officual policy to be free of drug company money and advertisements and just held their annual Pharmfree day (http://www.amsa.org/prof/history.cfm) to encourage doctors-to-be to become more aware and active on the issues around this dilemma.

Unfortunately, medical schools have not caught up as of yet, and medical students are not educated on this aspect of practicing medicine - AMSA and those of us who feel that this must change so that students are not coerced into simply following the ways of our mentors and more senior "role models" who sport drug company pens, writing pads, staplers, calendars, clocks, etc...

Personally, it disturbs me to see the "bosom buddy" relationship that doctors have with drug companies. You have doctors, whose ethical duty is to do the best for their patients, allowing drug companies, whose duty it is to profit off of these patients, to become their confidants and trusted sources of information. We sell out our profession and our mission as patient advocates in our desire to keep the free lunches flowing! The same old excuses ("the drug reps don't influence me", "talking to drug reps lowers the price that my patients pay for meds") that have good evidence to DISPROVE them need to be thrown out - if doctors want to continue this "intimacy" with the drug reps. than we should admit that we are doing so at the expense of our patients and not hide behind these blatantly false justifications.

Again, I thank you for helping to educate us all, and I thank the journal for publishing articles like this - I don't think there are many medical journals that would do so!

Sincerely, Anthony Fleg anthony_fleg@med.unc.edu

Competing interests:   None declared

Dr. Brody,

As I go out into the 'field' each morning I can certainly see how you have developed some of your opinions. There ARE too many reps hoping for a moment of the doctors time. Some are so inexperienced and lack a solid science base that the minute or two of face time they are granted is often a waste. And to your point of gifts being offered, this could easily begin to cloud the judgement of some (but certainly not all) physicians.

But for every one rep that offers no value clinically, there are three or four of us out there that do. I am not allowed to give ANY gifts and I believe those companies that adhere to Pharma Guidelines do not as well. Many of us who make a living in this field for our families are decent, good, unbiased people who want to find ways to help you, your office, and the community. As an example, none of my degrees are in marketing or sales. In fact, they are in science and teaching. And I try to focus a portion of my time helping local senior centers and community groups by sponsoring events and making sure they have educational information. And no, not for the sale but for the satisfaction.

I think changes may be necessary, but to avoid and dismiss us all would be ridiculous. There are ways to weed out the useless, time-stealing reps in your office. Here are a few suggestions that may offer some help:

-Clearly communicate on those days when don't have time to talk and see which reps actually LISTEN and respect what your faced with.

-Stay away from reps who only use the fancy, colorful chart and graph pieces. Instead gravitate to those that use actual studies from respected journals and know the information from which they speak.

-Place a time limit on lunch conversations, such as ten minutes with the rep, so that you have time to do charts and decompress too.

By dissolving the relationship of rep-doctor you dissolve a resource with information, office solutions, someone who understands and supports the challenges you face, and oh yes....samples.

Competing interests:   None declared

Thanks for your article. For a variety of reasons, I do not attend drug rep lunches, dinners, or meet with them. But we still have samples in our offices, and many of my partners do.

One interesting phenomenon I've noted is that providers are much more likely to attend the lunches and stay "If a doctor is presenting". They assume that the data being presented is more valid if it is a physician that is speaking. But the physicians who present are typically employed by the drug companies as "experts" on a "speakers bureau". I had an interesting conversation with a family physician who is on the speakers bureau for several pharma companies. I inquired as to how much he was paid for his time, and he told me he typically receives $1000 per 1 hour lunch or dinner presentation plus travel expenses. He practices full- time, and told me "last year I did 160 presentations on my weekends and days off, so you do the math". Physician presenters should disclose their financial relationship to the drug manufacturer. And physicians who are attending should be aware that simply because a physician is speaking doesn't make them less biased or more honest.

Competing interests:   None declared

Over the past few years I've served on the Board of Directors of the California Academy of Family Physicians (CAFP), and have been a lone voice (no exaggeration) in the wilderness when I've called for the Adademy to distance itself from Big Pharma. The belief among CAFP administration and medical leadership is that without Big Pharma, there would be no Academy. With no Academy, of course, the administrative staff would be without jobs, and the good that the Academy does would go undone.

I have no reason to believe that the CAFP staff is incorrect in its assessment of its total dependency for life upon the Big Pharma marketing budget. I wonder though, given that this is the case, if we should have professional organizations at all?

Competing interests:   None declared

Dear Dr. Brody:

Thank you for your article. As the least "rep friendly" physician in my eleven-provider office, I find myself in the unexpected position of disagreeing with you on two points.

First, the issue of samples. I found it jarring to find such a note of cynicism enter your analysis here. The assumption that most samples are either pocketed by office staff or shoveled into the purses of patients either too cheap or lazy to secure their own meds has simply not been true in my experience (certainly others' experiences may vary). A patient need not be near poverty to feel the pinch of medication costs. I'm aware of the possibility that doing away with reps and samples might lower drug costs for all, but I'd argue that the issue of drug costs is not that simple.

Second, the issue of gifts and lunch. You take as a given that every interaction with a rep must include the provision of gifts or lunch. This is simply untrue. I enjoy speaking to reps, but make it clear that I will not partake of their food, nor of their gifts/advertising aids. I also make clear that my primary objectives on any given day are to provide quality, efficient care to my patients and then to go home.If a drug rep either by gracelessness or unfortunate timing should interfere with those objectives, my interaction with that rep will be of the "sign for the samples and run" variety. If a rep can't abide this, he or she may be asked not to return.

Finally, a cynical note of my own. I'd argue that it is possible to listen to reps with "a jaundiced ear" such that I do not need - after the fact - to "research the information received and to correct for bias." I understand that they are salespeople, and take everything they say with a large grain of salt. This does not prevent me from "mining them for what they're worth" informationally.

These are complex and interesting issues, and I appreciate your addressing them. Thank you.

- Andy Alpart

Competing interests:   None declared

Thank you Howard Brody.

Please allow me to expand on the points you make, with which I agree, and to vituperate a bit.

Dr. Brody describes the social transaction between the representative and physician as involving gift giving and information exchange. It also includes the very important establishment and maintenance of personal relationships that have the capacity to elicit loyalty, guilt, shame and other feelings that help influence the choice of drugs by physicians on bases other than evidence. Gift giving is human and usually involves expectation of reciprocity; you give me something and I give or do something in response. Or as an alternative, you leave me medication for my patients who can’t afford it, and I feel justified in taking the samples. Of course, all prescribing is closely monitored by the industry and the samples may go away if reciprocal prescribing does not occur. Those who claim that they are impervious to these influences are perhaps unaware of the degree to which the pharmaceutical industry goes to modify physician behavior.

Pharmaceutical industry investments into visual and print advertising are huge and pay for very sophisticated analysis of physician targets. Some of the photographic and graphic components of journal advertisements, for example, have been refined on the basis of recorded physician eye tracking so that there is no doubt that an “eye-popping” ad will draw the attention of the intended targets.

The selection and training of representatives from this industry is just as sophisticated and thorough. Think of the exchange at your supermarket checkout stand where the clerks stereotypically ask if you have found everything you were looking for. Their behavior, intended to create an opportunity to purchase more items, is the result of standardized training. The same processes are in play with representatives. That some become friends and partners is not surprising. When was the last time you dealt with an unattractive or irritating rep.?

Another tool to strengthen relationships is to move the locus of interaction into multiple and pleasant venues. If you take time from your patients to talk with representatives, they ask you out on a date. Ogden Nash said it, “Candy is dandy, but liquor is quicker.” The pharmaceutical whisper in the ear is softer after a glass of wine.

Increasingly we are joining these Stepford ranks! Family physicians, and obviously physicians from other specialties, are recruited on the basis of their potential for modifying the behavior of colleagues and for the boost that they give to marketing. That boost may be nothing more than the endorsement, through a pleasant informal reference to the nearby representative, who “kindly” provided lunch. If the wise old infectious disease physician stood by the representative, when I finish my residency I will probably invite her or him into my back office.

Just as we believe and know that continuity of relationships is of value in patient care, especially those seriously ill or of advancing age, so in the competitive pharmaceutical world establishment of relationships creates value that is measured in dollars.

You might want to chat about this with your friendly representatives. They are always good listeners.

Competing interests:   None declared

1. I think that there certainly cause for concern and physicians should understand the POTENTIAL for conflict of interest.

2. However, the assumption that removing the pharmaceutical representative from the presence of the physician will remove that potential is too simplistic.

3. The idea that drug reps present skewed facts to physicians to sway their prescribing habits has some merit, but it really is up to the physician to keep abreast of literature. This is why residents all over the country have critical journal evaluation as part of their education. It is OUR responsbility to know how to quickly and objectively evaluate any articles we come across.

4. The slippery-slope hypothesis could also apply: If we do not see drug reps, who present data that may be somewhat skewed, then where does that duty to be impartial and "scientific" stop? -No drug rep friends? -No marriage or domestic partner with anyone working for a drug company or their affiliate/subsidiary -How about owning stock in pharmaceuticals or their affiliates/parent companies? How about companies involved in durable medical equipment or supplies? -What about doctors who are on drug company speaker panels being invited to speak at grand rounds?

5. Finally, many patients in my area are beneficiaries of medication assistance programs, as flawed and bureaucratic as they are. Without them, our working poor who don't qualify for Medicaid would pay out-of- pocket expenses for their meds. Diabetes, hypertension, and dyslipidemias affect a huge proportion of the patients I see--a recent study showed that it takes and average of 7 medications to address these 3 issues. I'm not sure I see the state or federal government offering these meds for free.

6. How about transparency? Patients could be informed told that "Your physician may base their clinical decisions on a wide variety of sources, of varying degrees of scientific rigor, one of which is data provided by pharmaceutical representatives. However, your physician is well-educated and has been trained in the critical evaluation of such data and will always strive to make decisions in your best interest."

I have read that if you ever have a question of whether or not something you're about to do is ethical and don't want to run through the exercise of beneficence, non-maleficence, duty to profession, duty to society, etc., just imagine if you would be embarassed if what you are considering doing is read by your patient in tomorrow morning's front page.

I don't think capitalism will ever go away in our society. I think it a mistake for any one profession to isolate itself in an effort to insulate itself from it. We need to embrace it and find a way to make it compatible with our real values.

Competing interests:   None declared

A few years ago I would have disagreed with the article about Pharmaceutical Representatives. I mistakenly believed in residency that they were providing samples for my Medicaid patients and lunch to update me about new medications.

After starting a solo, private practice, I realized drug reps buy my prescription writing history from pharmacies and are able to pull up on a portable handtop computer my exact prescribing patterns. The former free lunches, of which I ended after 3 months of practice, simply were an hour of wasted time where the reps would tell me how much better their brand name drugs were, compared to low cost generic drugs. I took 5 extra large trash bags of drug rep paraphernalia, from pens to paper, and gave it the local salvation army and banned future "free" gifts from drug reps. Now my office has no advertisements for any drugs, as I do not work for the drug reps.

What about my indigent patients? I agree that many of the samples, which were nonformulary, go to the well off patients who have prescription coverage. The indigent patients in Illinois have a Circuit Breakers program for the elderly where prescriptions are $2 a piece. The similar Illinois Medicaid program is available to all ages based on income, where prescriptions are $ .50 to $4. Most of the samples that I had given out were not covered, as they were third tier on HMO/PPO formularies and not on any formulary for Medicaid/Circuit Breakers. Not giving out nonformulary drugs has cut my number of phone calls from pharmacies in half, as I begin with the generic drugs which are on formulary.

If a doctor feels that a patient requires samples for indigent care, the doctor can fill out a form for the indigent drug program for most companies. Then the drugs will be sent to the patients for free, if they really qualify.

By not having drug reps in the office, I save 1-2 hours per day of time, which I can spend seeing patients. In addition, I choose the drug that I feel is appropriate for the patient. My former sample closet was a 10x9 room that is a consultation room and extra office for storage. My day is a lot more enjoyable without drug reps.

Competing interests:   None declared

As the saying goes, before we go sweeping someone else's back porch, we should look after our own. Before we consider the behavior of others in the world of medicine around pharma reps, family medicine departments and our academic and professional organizations should look at our own. I appreciate Howard Brody's comments and reasoning and would like to see it evolve into an improved code of conduct in engagement with Pharma within family medicine - in both education and practice. I would like to see those faculty members who engage in pharmaceutical sponsored CME - either as presentors or recipients - require evidence based information and cost effectiveness as part of their presentations and, at the outset, be required to acknowledge any conflicts of interest that may exist with their presentations, which is now standard procedure in published peer- reviewed journals.

I would also like to see our professional organizations act on Dr. Brody's suggestion to minimize or eliminate gifting to physicians from Pharma which is not intended for patient care. This would mean "gifts" for our patients at Academy or CME meetings that would decrease drug prices to patients by lowering the amount of advertising directly to physicians. We could point out to the public that we have decreased gifting to physicians through CME and other methods and expect Pharma to show savings for patients or explain why they have not done so. We, as physicians, should then go on and ask similar responsible behavior of our local newspapers because of the misleading nature of direct to consumer advertising. But we can't begin to act on this misinformation to patients until we have taken care of our own back yard and eliminated Pharma from the education and patient care aspects of our work.

Competing interests:   None declared

Many thanks to Dr. Brody for his intelligent and insightful essay. I would like to add one additional thought on the subject. When I was a second-year medical student, I organized a student trip to a medical conference. Eager to help as many of my classmates to attend as possible, I suggested approaching pharmaceutical companies for funding support. One of the first year students shook her head and said, "that money directly increases the costs of patients' medicines." That comment, more than any of the studies I've read over the past few years, has stayed with me. As a result of it, I've never eaten a free lunch or taken a drug company freebie. I think for many doctors, the idea that our patients' inability to afford their medications is, in part, a result of the millions of dollars in free lunches and gifts to physicians is indeed hard to swallow.

Competing interests:   None declared

I read Dr. Howard Brody's ethical reflections article on why physicians should abstain from intercting or spending their valuable time with pharmaceutical representatives. His viewpoint is clear and empassioned. I salute his enthusiasm for this topic.

In making his point, he refers to several studies done within the past 5 years indicating the influence the pharmaceutical industry insidiously exerts on the medical profession.

Unfortunately, Dr. Brody slips when he begins one paragraph with "To the best of my knowledge, few if any physicians who claim the "right" to see reps and to listen to their pitches actually spend the time necessary to research the information received and to correct for bias..."

This assertion by Dr. Brody is wholly unscientific, strictly a personal opinion, and makes a widespread generalization about physicians far and wide. In the interest of fairness, I am asserting my personal opinion in reply.

As a physician with 13 years of both private practice and academic experience, I have come to some conclusions of my own:

1. My time is highly valuable as a physician. This is no surprise. I value my time and if I choose to spend 5 minutes more with one patient or another, this is my choice. Similarly, if I choose to interact with a pharm rep about the latest drug, an office manager about my billing, a medical assistant about how to set up the procedure room, or a physician about how busy medical life can truly be, this should be my professional prerogative.

2. I appreciate the opportunity to learn about the latest innovations that occur regarding medical care. Learning about new drugs and their potential benefits for my patients is something I endeavor to do now and then, not necessarily directly from a pharm rep. But when I do talk with one, I am all business. After all, I am trying to become more knowledgeable. If the interaction is friendly and occasionally informal, I think that is actually normal.

3. I love the medical profession and am fond of teaching. Three years ago, I had the opportunity to show training residents how to be as impartial as possible in regards to the pharmaceutical industry and set up a weekly lunch time session where a pharm rep would bring relevant literature about a drug and we would "context detail" the presentation in a roundtable format with pharmacists, physicians, and training residents. Three years later, the format is still going strong, a testament not to the food but to the collegiality that has developed among fellow professionals.

Sincerely,

Dr. Samuel N. Grief, MD FCFP Assistant Professor in Clinical Family Medicine University of Illinois at Chicago

Competing interests:   None declared

Howard Brody knows that the pharmaceutical industry is very smart, and very successful - it couldn't be the second if it weren't also the first - and that it would hardly throw away billions of dollars, just for the privilege of playing up to doctors. He also knows that nowadays there's more and more evidence that these billions it spends on "educating" doctors, and patients, is indeed not a series of gifts, or of public service activities, but rather an investment, with a suitably high rate of return, thank you very much. Nowadays, that is, in that we (in the medical community) are finally studying, and documenting this -- it was surely well known to the industry itself (based on much more careful and detailed research, undoubtedly) long before any of that money was spent.

Professor Brody also reminds us, in his thoughtful essay, that most doctors have the wonderful capacity to delude ourselves into believing that we're above all this, and impervious to the seductions of industry, no matter what the evidence, and common sense, tell us. My friends and colleagues may be fooled, each of us is more likely to admit, but not I!

Which leads him to wonder what he can possibly say -- that hasn't already been said oh so many times -- to get our attention, and persuade us to abandon an interdependence on industry that is simply incompatible with our ethical obligations to our patients. Thus he focuses on exposing two myths often cited in defense of meeting with company representatives: 1) "I'll hear them out, and then evaluate their claims independently," and 2) "they make think they're using me, but I'll use them, by providing their samples to those of my patients most harmed by the extraordinary prices we (in the US even more than anywhere else) all pay for prescription drugs." I won't rehash his arguments -- suffice it to say that his conclusions should be fairly self- evident -- of course we don't critically evaluate what the reps tell us (if we truly wanted to evaluate new evidence this would be about the most inefficient approach imaginable), and of course "free samples" aren't free, and drug companies provide them because they inevitably lead to increased sales and increased profits.

But these nostrums do provide a seemingly tenable excuse for feeding at the trough, which is why Professor Brody feels it's so important to expose them as false -- he wants us to see that this practice of meeting with reps, which we really engage in because we get something from it (at the expense of our patients) is in reality far from free for us. It's really not in our self -interest, he's telling us: it takes far too much of our time.

I understand that approach -- if we want to convince middle class taxpayers to spend money on health care for the poor, perhaps the best way is to show them that failing to do so will come back to bite every one of us; even if we don't care about prisoners in Russia, we might be willing to make tackling multi-drug resistant TB in the Siberian gulag a priority (ahead of better roads and parks for ourselves, or lower taxes, even) if we can be shown the likely dire consequences -- to all of us -- of failing to do us. In the same way, Dr. Brody suggests, we may think differently about our relationship with industry if we see that changing it is really in our own self-interest.

So good luck to him! But as for me, I'm just a bit ambivalent. Because if it had to, industry could certainly take some of its many billions in profits and make it more in our self-interest to do the wrong thing. Ultimately, it seems to me, we have to be willing to say no to this dependence no matter how much it puts into our pockets, simply because must of us got into this profession because we wanted to serve our patients, and this practice is simply antithetical to that.

Jerome R Hoffman, MA MD Professor of Medicine UCLA School of Medicine

Competing interests:   None declared

I followed, and generally agreed, with the arguement of Dr. Brody up to the point that he described a physician who did appropriate research into new drugs as being guilty of serious time management problems.

Independent of the arguement about drug reps, hopefully we are all doing our best to make ourselves aware of the evidence related to new drugs. If we don't learn enough to compare the newer agents to what we are using now, we don't know if we are optimizing drug therapy. This certainly does not include looking at manufacturer's detail items. There are multiple independent sources available for drug information.

Therefore the arguement that this is time wasted, and the implication that this is required only for those who need to balance their drug rep exposure time, doesn't hold water.

Competing interests:   None declared

Thank you, Howard Brody, for again serving as a moral compass for our profession. The ethical and practical arguments you make for not seeing drug reps are right on target. In fact, in our office we have not seen drug reps for over 10 years. Not having a handy supply of those free samples of the latest, most expensive drugs has not hurt our patients or our practice in the least. It gives us extra time to focus on patient care as you suggest.

However, if more physicians did as you suggest and refuse to see these drug reps, I doubt that the problem would be solved. Already hundreds of millions of dollars are spent on DTC (Direct to Consumer) advertising by the pharmaceutical industry, and I imagine this would only increase. Those TV ads are meant to be very persuasive and repetitive, and the studies I've seen indicate that they are successful at goading patients to ask their physicians for the advertised drugs. Until we as a profession, and the FDA as a regulatory body look at these DTC adds in the same light of ethics and pragmatism, I fear that it will just continue to be business as usual. And that means, of course, that the next Vioxx is just around the proverbial corner.

Competing interests:   None declared

Dr. Brody's analysis is compelling, and invoking the interests of time management for busy practitioners is innovative. However, he does not discuss the number one reason why many practices continue to allow pharmaceutical reps to detail. Pens, paper and other trinkets are fun. Talking with a rep and getting our ego stroked are obligations of the encounter. Pretending that we are learning something of value and are not biased is part denial and part game. But when all is said and done, it comes down to one of two things: either a plea for samples or a plea for food. In our department, it is about food because we eliminated sample distribution several years ago for all the right reasons. Why then, does food remain the one addiction that continues to justify rep detailing?

We have an outstanding department, with outstanding residents, faculty and staff. We emphasize evidenced-based care. We even have had debates about the relationship of pharmaceutical industry, detailing and physicians. Yet, detailing continues because the reps supply food to residents, faculty and staff two to three times a week. On average, the free food amounts to a department gift of approximately $350 per lunch (about $9 per person for 40 people), or approximately $35,000 a year.

The rationale for allowing detailing for food is that: 1) Food is necessary for people to attend conferences; 2) Conference attendees will not come to conference if they have to bring their own lunch; 3) Residents are too busy to make their own lunches; 4) As physicians, we have a right to be fed by the pharmaceutical industry (regardless of our economic income or conflicts of interest to our patients); and 5) In times of very tight budgets, there are no other sources of paying for lunches.

Each rationale becomes increasingly suspect as we go down the list. Perhaps in a future letter, we can outline several alternative approaches to having the industry pay for our lunches. Dr. Brody's commentary shows that the scientific data on detailing, combined with cogent ethcial discussions, leads to an unmistakable addiction conclusion. Many would see a relationship with industry predicated on feeding hungry appetites as a form of prostitution.

Competing interests:   None declared

Dr. Brody in his article demeans the intellegence of the physician in private practice. Mostly physicians read on a daily basis. I for one not only read but participate in cme year round. If the rep tells me something that is hard to believe I do not hesitate to ask for his references on that statement and pursue it. If they have stretched the truth or frankly lied; they are not welcome in my office again.

Dr. Brody must not practice in the real world. Rep's provide samples that I give to my needy patients and to those whose third party providers have not delivered their medicines on time. If you do not see a rep you do not get samples. Most reps are very respective of your time and will only spend a minimum of time. Many just need a signature and will throughout a few words.

For Dr Brody to think that I or any fellow physician would forsake their ethical responsibity for a steak dinner or a pen is sadly mistaken.

Dr. Brody needs to come to my office and I will educate him in the real world

Competing interests:   None declared

To the Editor:

Dr. Brody proposes a dramatic shift in how physicians interact with pharmaceutical representatives. (1) Dr. Brody cites the medical literature to support his contention that the longstanding practice of physicians visiting with pharmaceutical representatives in their offices skews prescribing patterns away from patient’s best interests, and disrupts patient flow. Based on my experience, Dr. Brody’s observations are right on target.

Although Dr. Brody focused on the issue of pharmaceutical representatives in physician offices, the impact of the pharmaceutical industry is much more far reaching. Physician “buy-in” is achieved through lavish support of continuing medical education, generous funding of clinical research highlighting lucrative drugs, and indirectly through marketing to our patient/consumers. The questionable ethics of the cozy relationship between physicians and the pharmaceutical industry raise doubts regarding our motives and taint our public image. (2)

As Dr. Brody notes, medical students and residents may be particularly vulnerable to advances from pharmaceutical representatives. They are insecure in their own knowledge of medications, and offers of free meals and gifts are particularly enticing to those on a limited budget.

As a medical educator, I believe we should have a strategy to responsibly introduce physicians-in-training to pharmaceutical representatives. Pharmaceutical representatives unquestionably offer educational resources that can benefit increasingly strapped training programs. In our training program we allow representatives to provide meals and display their wares at departmental presentations, but draw the line at detailing their products. I agree with Dr. Brody that the downside of facilitating medical student and resident interaction with pharmaceutical representatives in office settings exceeds the benefits, even when caring for underserved populations. (3) Office procedures can be established to enable representatives to drop off samples without interrupting patient care or contacting the physicians or students. A compromise strategy would be to schedule limited time to speak with pharmaceutical representatives. The access physicians provide pharmaceutical representatives and the influence they wield is analogous to the relationship between politicians and lobbyists. Physicians must take steps such as those outlined by Dr. Brody if we are not to be perceived as “in the pocket” of special interests.

John Zweifler, MD, MPH Dept. of Family and Community Medicine University Of California San Francisco,Fresno

(1) Brody H. The Company We Keep. Ann Fam Med 2005;3:82-86 (2) Abelson R, Pollack A. Patient Care vs. Corporate Connections. New York Times. January 25, 2005 (3) Zweifler J, Hughes S, Schafer S, et al. Are sample medicines hurting the uninsured? J Am Board Fam Pract. 2002;15:361-366

Competing interests:   None declared