Iowa practice draws notice for its "no-gift" policy

Doctors argue that drug rep meetings are not a good use of a physician's time.

By Andis Robeznieks — Posted Feb. 14, 2005

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Iowa gastroenterologist Dean Abramson, MD, has two pens in his pocket: one from a local guitar studio and the other from the FAO Schwarz toy store.

It's unlikely that Dr. Abramson will be using a drug firm's pen anytime soon. It's also unlikely that he will be using any company notepads or having a meal picked up by a pharmaceutical sales representative, either.

After years of cajoling the five other physicians at the Gastroenterologists P.C. office in Cedar Rapids, Iowa, Dr. Abramson was able to elicit a unanimous decree that the practice will no longer accept drug company gifts or meals. He posted a notice on the front door and sent an announcement to the local newspaper. A few days later, word of what the practice did was reported on the Internet and was receiving widespread exposure.

Dr. Abramson said he's "totally, completely" surprised by the attention but hopes it has an impact on "skyrocketing" drug costs and what he thought was the government's failure to address the issue. "We're just doing our small part to try and combat that," he said. "But we won't have much of an impact unless this happens in a lot of clinics."

Dr. Abramson said he doubts the absence of drug company sales reps will hurt his practice's ability to keep up to date on the latest medical developments. "I don't think we're missing a darn thing," he said. "I really don't trust any of the information that they peddled to us, and I think there was just an increasing realization that there was no benefit to the information they were providing."

These remarks were applauded by Howard Brody, MD, PhD, a professor at Michigan State University's Dept. of Family Practice and Center for Ethics and Humanities in the Life Sciences.

In the January/February issue of the Annals of Family Medicine, Dr. Brody wrote about the ethical problems of accepting gifts. But if ethical arguments aren't enough to convince doctors to stop taking gifts, Dr. Brody said sales rep meetings are not a prudent use of a doctor's time because of the need to double-check everything he or she was told in the meeting.

"I'd hate for physicians to think there was nothing unethical about accepting gifts, but there are practical issues as well," Dr. Brody said.

Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America, disagreed with the assertions of Drs. Brody and Abramson. "The length of the meeting is controlled by the doctor, and it can be 30 minutes or ... five to 10; that is the prerogative of the physician," he said. "Also, [sales reps] are trying to put their best foot forward, and they have to retain their credibility if they want to get in the door again."

Trewhitt noted that expensive dinners and frivolous gifts are not permitted in the PhRMA Code on Interactions with Healthcare Professionals that went into effect July 1, 2002. Under the code, gifts must be under $100 and have some value to patients.

"Entertainment is not proper," he said. "A sterling silver serving tray is not appropriate, but a medical dictionary or stethoscope would be."

AMA guidelines on industry gifts were approved in 1990 and state that physicians should accept only gifts that have some benefit to patients, are of modest value and come with no strings attached. Cash payments should not be accepted. In 2001, an educational campaign was conducted to remind doctors of these guidelines.

Although Dr. Brody said he thinks both codes could be stricter, he admits to seeing some signs of change. These include fewer nonmedical gifts such as golf balls or tickets to sporting events being given to physicians.

Michael Goldrich, MD, the chair of the AMA Council on Ethical and Judicial Affairs, praised Dr. Abramson and his partners for their new policy.

"The AMA guidelines are meant to provide a minimum standard," he said. "Certainly physicians who establish stricter standards for their practice are only to be commended."

Although he's not accepting tickets, golf balls or meals, Dr. Abramson said he will still accept free drug samples to help financially stressed patients. He said there are few generic alternatives for inflammatory bowel disease and other disorders that he regularly treats.

Because of the nature of his practice in a university clinic and because there are widely available generic drugs available for his patients, Dr. Brody said he doesn't accept free samples. But he doesn't criticize physicians who give them to patients who need to stretch their dollars.

Nevertheless, he said a more effective way to make medicine more affordable to low-income patients is for drug companies to expand their discount and assistance programs.

Trewhitt said this is being done.

Through its Web site (link), PhRMA companies helped distribute some 18 million free prescriptions to more than 5.5 million patients, and through the Together Rx prescription program (link), discounts of 25% to 40% are offered for 275 different drugs, Trewhitt said.

"There are more discount programs and we're in the process of publicizing them," he said. "We anticipate a dramatic improvement in patient assistance and discount efforts in 2005."

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External links

"The Company We Keep: Why Physicians Should Refuse to See Pharmaceutical Representatives" abstract, Annals of Family Medicine, January/February (link)

AMA ethical opinion on gifts to physicians from industry (E-8.061) (link)

PhRMA Code on Interactions with Healthcare Professionals, in pdf (link)

"A Social Science Perspective on Gifts to Physicians from Industry" extract, JAMA, July 9, 2003 (link)

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