The authors also found that little instruction was provided to patients who received samples; side effects and drug interactions were rarely discussed. Office personnel use of samples was observed, and in one office patients had unsupervised access to the storage closet. Personal use of drug samples has numerous medical and ethical concerns that have been fully outlined elsewhere.4 Patients having unsupervised access to samples is inappropriate and dangerous. Prescribing medications on the basis of convenience (ie, the drug on the top shelf of the sample cabinet) may not be the best medicine for the patient.
Gifts, meals, and treats
Chren and Landefeld5 found that physicians who ate more meals paid for by drug representatives were more likely to request new drugs be added to their hospital formulary. Orlowski and Wateska6 found that use of 2 intravenous drugs significantly increased at the hospital after a large number of the physicians attended an all-expense-paid trip to a medical conference sponsored by the pharmaceutical companies that manufactured the 2 drugs. Blake and Early7 found that although many patients did not disapprove of their physician receiving medical books or ballpoint pens, nearly half disapproved of physicians receiving meals from drug companies. Chren and colleagues8 also point out that physician gifts are ultimately paid for by the patient who must buy the medicine. At a time when so many physicians loudly decry for-profit medicine, it is surprising that so many are willing to profit from the pharmaceutical industry.
Educational materials
Are the education materials from drug representatives truly balanced and evidence based, or are they simply another type of promotional or advertising handout? Stryer and Bero9 found that 42% of the printed material distributed by drug representatives did not comply with Food and Drug Administration requirements, and 33% did not provide a balanced presentation of the benefits and risks. Ziegler and coworkers10 reported that more than 10% of the information provided by drug representatives was flatly inaccurate. And all this inaccurate information was favorable toward that particular medication. How does false information benefit the patient or the physician? Continuing medical education (CME) is a very specific term, and the American Medical Association and American Academy of Family Physicians have strict guidelines about how, when, and where prescribed CME can be obtained, and the extent to which pharmaceutical companies can offer CME. The type of informal meeting between the drug representative and the physician that the authors describe is not CME, and it should not be construed as taking the place of formal educational endeavors.
A problematic relationship
Backer and coworkers state that interactions between physicians and drug representatives represent a complex symbiosis. That symbiotic relationship is exactly the problem. In the physician-patient interaction it is the patient who should benefit. Yet, the complex relationship between drug representatives and physicians benefits the pharmaceutical company and the physician only; the patient gains nothing. Problems with interaction between the physician and the drug representative are also emblematic of the larger interaction of the pharmaceutical industry and medical science. Recent editorials have questioned the close nature of the involvement of academic medical centers, their physicians, residents, and medical scientists with the pharmaceutical industry that provides money for drug studies in addition to gifts, samples, and promotional handouts.11,12
We practice medicine in a difficult era. Physicians are assailed by insurance companies who want us to cut costs while providing more care, and by patients who hope insurance incentives or monetary arrangements will not cloud our professional judgment. Many patients still trust us to do the right thing, but their trust may be fading. We can not afford the perception that physicians can be bought for baseball tickets, lunch, and a few pens.