Interactions between physicians and the pharmaceutical industry are not as innocuous as they seem. Pharmaceutical companies spend more than 11 billion dollars each year to promote and market drugs-an estimated $8000-$13000 per physician per year. This money is spent in the form of meals and entertainment as physicians listen to discussions about a particular medication, or as money for books or medical supplies, for example.

Physicians are human; they are not exempt from the usual standards when it comes to receiving gifts. Many other industries have explicit principles saying, 'no one in this company accepts gifts from suppliers or contractors.' Why should doctors be different? Physicians are in a strange position because they write prescriptions for other people to purchase. They are making decisions that affect their expenses, not their own. It's what you might call a fiduciary relationship. They need to be extremely careful to make those decisions in a rational, unbiased way.

The JAMA researcher reviewed 29 studies that addressed the interactions between physicians and the pharmaceutical industry. Most of the studies showed that the physicians' prescribing practices are, in fact, affected by this relationship with drug companies. For example, they tend to prescribe fewer generic medications and more new, expensive drugs even when the drugs don't have any advantage over cheaper medications. Just because something is the most recent and costly medication doesn't mean it's the most effective. But we all tend to believe in the myth of progress. Many physicians are at a loss on how to keep up with so much information about new medications, so talking with the pharmaceutical representative is very convenient.

The researcher reports evidence of four types of influence. Following drug company overtures to physicians, physicians prescribed a drug manufactured by the sponsor of a medical education program more often, hospitals increased their prescribing of a conference travel sponsor's drug, residents increased 'nonrational' prescribing of a drug following a meeting with a company representative and attitudes about  drug company representatives became more positive. The researcher noted that interactions between MDs and pharmaceutical representatives begin in medical school and continue at a rate of about four meetings per month.

In an accompanying editorial, Dr Robert M Tenery Jr, of the American Medical Association's Council has attempted to police physician interactions with drug companies. The most egregious activities have stopped, such as awarding airline miles for prescriptions written, but recently the need for continuing medical education (CME) has driven a resurgence of drug company sponsored junkets, he says. CME credit is a requirement for licensing in most states. Tenery notes that drug company money and influence 'has permeated virtually all levels of physician CME in the form of complimentary meals and entertainment, consultation fees and pseudo CME courses. He concludes that physicians and the drug industry need to develop new industry wide standards to prevent abuses of the system.

The Journal of the American Medical Association 2000; 283:373-380,391-393