Buy your own lunch: No chance of reciprocity

Internist Bob Goodman, MD, says physicians need to stop accepting gifts of any kind from drugmakers. In 1999, a clinic he oversaw as medical director banned drug representatives from visiting or leaving paraphernalia, including free samples. To promote the initiative, he made some buttons that said, "Just Say No to Drug Reps," and later that year, he put his money where his mouth is, founding No Free Lunch, an advocacy group devoted to the crusade.

The group has about 500 members, mostly physicians, although nurses, physician assistants and a few dentists also belong. About the same number have taken the No Free Lunch pledge, vowing not to accept any industry gifts, money or hospitality.

Although small in number, No Free Lunch is making noise. The group created a flap last year when the American College of Physicians and the American Academy of Family Physicians refused to let it set up exhibits at the societies' annual meetings. After Dr. Goodman posted a news release about the matter to the No Free Lunch Web site, AAFP members wrote letters, outraged that their group was denying Dr. Goodman space. AAFP ultimately gave him a booth.

The ethics of how physicians interact with the drug companies continue to be on the front burner, and AMNews reporter Kevin B. O'Reilly recently spoke with Dr. Goodman about his take on the issue.

AMNews: What are you trying to accomplish with No Free Lunch?

Dr. Goodman: We have two goals. The first is to get physicians not to rely on promotional information, and at the same time not to accept gifts from industry. Those two things are related to each other. Fewer physicians would try to obtain information from salespeople if it didn't come with food or money.

An important thing to keep in mind is how easy it is to get medical information, particularly about drugs. It's probably the easiest of all things for doctors to do. Fifteen or 20 years ago you had to do a little bit of work. Now you can get that information in seconds by computer, or by using a PDA at the point of care. It's a very outdated argument to say that doctors don't have time to get unbiased information.

AMNews: Can't doctors evaluate drug-companies' promotional information on their own?

Dr. Goodman: The promotional information tends to be biased, of course, because it's coming from a salesperson. But the part I try to emphasize when speaking with students and residents is the idea of reciprocity and the development of a relationship and the obligation to repay it. It's something very well-studied in the social-sciences literature.

Someone gives you a gift and we say, "Much obliged." That phrase is something interesting to think about. One of the most looked-down upon things in our society is to not return a favor. ... Even very small gifts -- because of this reciprocity thing -- create big obligations, whether it's gifts from Hare Krishnas or return-address stickers from nonprofit organizations in mail.

AMNews: How do you respond to physicians who say, "These gifts might influence other physicians, but not me"?

Dr. Goodman: That's the universal response. In some studies that have been done, when doctors are surveyed about it, that's exactly what you get. The question might be, "Do you yourself think you're influenced by drug-company gifts?" Only 1% say yes. If the question is, "What about other doctors?" then 30% say those other doctors are influenced a great deal.

There are plenty of studies showing strong associations between meeting with reps and getting paid to speak at dinners with how much you believe the information they give you. Ultimately, it's associated with prescribing more expensive medicines instead of generics.

Another line of argument would be to ask why the industry is spending about $20 billion a year just on this. Now, that figure doesn't separate the promotional budget from administrative expenses, but do we think they're throwing away this money? They know it works.

AMNews: Rewarding business partners with gifts does not seem to be a practice unique to medicine. Why should physicians be held to a different standard?

Dr. Goodman: You're right that in other industries this happens, but what about other professions -- lawyers and journalists? Definitely this happens in industry, people receive gifts and the whole thing. Still, many corporate scandals in recent years have been conflict-of-interest violations of fiduciary relationships. This gets attention in the business world, but with doctors, we're somewhat immune. You would think lawyers have lax rules about gifts, but it's doctors who have managed up until recently to have nothing in place.

Now, we have guidelines, but they're not enforceable guidelines -- you don't lose your license.

AMNews: You say that drug companies influence physicians' prescribing habits, but hasn't direct-to-consumer advertising played an even bigger role in pushing people toward drugs that may not be right for them?

Dr. Goodman: It's true that if doctors don't meet with reps, the companies will shift promotional costs to consumers. There has been, for sure, a problem with patients seeing these ads for new drugs they don't need and going to their doctors requesting them.

Doctors are faced with the tough choice of not prescribing the drugs and having to spend 10 minutes explaining the decision, perhaps losing the patient -- or just prescribing the drugs.

AMNews: You object even to free drug samples. Those would seem, more than anything, to benefit the patient directly.

Dr. Goodman: This is a big problem when you have 50 million people without insurance. The samples, as you know, are exclusively the newest, most expensive meds. Once the doctor uses a sample, it's more likely that that's what the patient gets prescribed -- the newer, more expensive medication. ...

I don't buy the distinction between gifts that benefit patients and gifts that don't. The fact is, they're all gifts, and there's really not an ethical distinction. They all create this obligation and create a strong need to repay. It's not a conscious thing. It operates at a much more subconscious level.

AMNews: Isn't continuing medical education a lot cheaper because of drug-company support? Wouldn't patients be hurt if physicians and medical societies refused that support?

Dr. Goodman: That's a sorry argument to make. Doctors are a group that society has agreed to pay a good amount of money. It does not sound good to the public to say doctors are not willing to pay for their own CME.

AMNews: What was your reaction when the ACP and AAFP originally turned down your application for booths in their exhibit halls?

Dr. Goodman: They have these huge exhibit halls -- why deny booth space to this tiny little organization that wants a 10-by-10 booth space? It's a scientific meeting -- you expect differences in opinion. There are plenty of doctors opposed to our message, but none who would say we shouldn't come to the meeting.

AMNews: Should organized medicine be taking a stronger stand on this issue?

Dr. Goodman: Yes, it definitely should. Many of the guidelines still allow much too much. Gifts of small value, even gifts that benefit patients, can influence physicians' prescribing behavior. Doctors need to decide what to do on these issues, and professional societies really need to be models. ... Individual physicians may fail and not be perfect, but professional societies can try do a better job to be closer to perfect.

AMNews: Why have you put so much time and effort into this issue? Aren't there more important battles in health care?

Dr. Goodman: I might put the uninsured issue above it. Still, [the physician practice of accepting industry gifts] really has resulted in bad patient care. It is related to the uninsured issue. The cost of health care is skyrocketing, and prescription drug costs are skyrocketing. Uninsured patients are not able to afford their meds.

The crime is that patients are prescribed newer, heavily promoted drugs when older, cheaper drugs would be adequate. The physician is doing it as a result of drug companies' promotional efforts.

AMNews: Do you think things have gotten better or worse on this issue since 1999?

Dr. Goodman: They've definitely gotten better. There's more attention paid to the issue. The AMA reissued its guidelines back in 2000 and did its educational campaign around the same time. The industry itself put out its own voluntary marketing code in 2002, even though that was just voluntary and somewhat of a PR ploy. Nevertheless, because it didn't want any more bad publicity, the industry has eliminated a lot of the more egregious things: the dine-and-dashes, the sporting-event kinds of things. That said, there are still lots of things going on -- still lots of free lunches and free dinners.

AMNews: What would you like to have achieved on this issue in 10 years?

Dr. Goodman: It would be nice if the No Free Lunch pledge were like board certification. I would like to see in 10 years that the whole issue has just disappeared. It's very annoying that this should be an issue at all, because it's just wrong. Doctors have become so entitled to this after having done this for so long. ...

It's hard to make an argument for why an individual clinician should accept gifts from industry. Doctors can claim they're not influenced, but that's still not an argument for doing this. Industry is still spending money on us, and we're still looking bad.