Experts for sale: Even very small gifts can affect doctors' prescribing behavior, experts say.

The average doctor's office these days looks much like a pharmaceutical sales convention: patients wipe their noses with Lipitor tissues and sign forms with Boniva pens attached to Lunesta clipboards. The ubiquity of these drug ads—and the sales representatives that place them—is triggering a backlash.

Since October 2005, a small army of anti-marketers has been descending on doctors' offices in Pennsylvania, aiming to replace information provided by the sales reps with that from unbiased sources. Last year, the Institute on Medicine as a Profession (IMAP), a research and advocacy organization based at Columbia University in New York, called on academic medical centers to set policies against pharmaceutical detailing (JAMA 295, 429–433; 2006).

We spend hundreds of hours synthesizing materials from journals. Jerry Avorn, Independent Drug Information Service

And in February, the Pew Charitable Trusts gave $6 million to fund the Prescription Project, an effort to end conflict-of-interest practices, headed by IMAP and the Community Catalyst, a non-profit advocacy group based in Boston. Drug company reps pay regular visits to doctors, offering free lunches, trips to conferences and targeted spiels about the benefits of their latest product. Some doctors view the practice, known as pharmaceutical detailing, as an easy way to learn the latest about new drugs. But in the past few years, high-profile cases such as the Vioxx debacle have brought aggressive pharmaceutical marketing into the spotlight.

Critics say the sales reps' spiels hype new drugs when older, cheaper medications would suffice. And a growing number of studies have shown that even small gifts can create a sense of obligation, conscious or not, in the receiver (JAMA 290, 252–255; 2003, Thorac. Surg. Clin. 15, 533–542; 2005). “Very small actions, even a gift worth a dollar or less, can affect prescribing behavior, and not necessarily in a way that's consistent with best practices,” says says Margaret K. Cho, associate director of Stanford University's Center for Biomedical Ethics.

Over the next year, IMAP (with funding from the Prescription Project) plans to assess new anti-detailing policies at Stanford University, Yale University and the University of Pennsylvania, which limit or eliminate gifts from sales reps.

“There's a sense of embarrassment that marketing people should have the run of our schools,” says IMAP president David Rothman.

At Stanford, for example, doctors and medical students are prohibited from accepting as little as a pen. Based on the response to these programs, IMAP plans to ultimately develop a handbook for institutions that want to enact similar policies.

“One fear administrators expressed was that faculty would desert them, or that drug companies would retaliate and take away their research money,” says Rothman. “We want to find out, does that happen?”

Prescription Project will also support interventions aimed at insurers and state governments. “I think increasingly, there need to be some public policy changes,” says Robert Restuccia, executive director of Community Catalyst. For example, pharmaceutical companies can buy detailed information on individual doctors' prescribing practices, allowing them to tailor pitches to each physician. New Hampshire recently passed a law barring this practice, a move Restuccia wants to see spread nationwide.

In the meantime, the Pennsylvania program, called the Independent Drug Information Service, is making headway.

“We spend hundreds of hours synthesizing materials from journals so that doctors don't have to do it themselves,” says Jerry Avorn, professor of medicine at Harvard Medical School who heads the program. Funded by the Pennsylvania Department of Aging, the program aims to eventually decrease prescription drug costs by increasing the prescribing of generic drugs whenever possible.

So far, at least, doctors seem to be accepting of the changes, particularly when presented with evidence showing how influential pharmaceutical marketing can be. Avorn says other states have also made inquiries about setting up similar programs.