A new survey has claimed that nearly every doctor in the USA has “some type of relationship with the pharmaceutical industry,” which often involves gifts, entertainment or cash payments.

A study carried out by researchers at Massachusetts General Hospital-Partners Health Care System, Yale University, and Australia’s University of Melbourne and Royal Melbourne Hospital, and published in this week’s New England Journal of Medicine, found that 94% of physicians reported a relationship with drugmakers. 83% said they received food in the workplace and free samples (78%), while 35% were reimbursed for costs associated with professional meetings or continuing medical education. 28% were paid for consulting, delivering lectures or enrolling patients in clinical trials, while 7% said they had received tickets to cultural and sporting events.

The researchers mailed questionnaires to 3,167 doctors in 2003 and 2004, offering them $20 for their time, and 1,662 replied. They included anaesthesiologists, cardiologists, family doctors, surgeons, internists and paediatricians with experience ranging from less than 10 years to over 30 years. The survey found that cardiologists were more than twice as likely as family practitioners to receive payments, although the latter group met more frequently with industry representatives than physicians in other specialties.

A summary of the study noted that "relationships with industry are a fundamental part of the way medicine is practised today [but] the real questions relate to how much is too much and how far is too far''. Lead researcher Eric Campbell, assistant professor of health care policy at the Institute for Health Policy at Harvard Medical School and Massachusetts General Hospital in Boston, added that “we know that these relationships have benefits and risks, and we know that they benefit the companies that are involved, and we know from our data that they benefit doctors."

“However,” he went on, “the real question is to what extent do these relationships benefit patients, and the answer is, we don't know."

The relationship between drugmakers and doctors is a thorny issue and the industry responded quickly to the survey’s findings. Pharmaceutical Research and Manufacturers of America senior vice president Ken Johnson said that “to help make sure the information they provide is accurate and well-substantiated,” sales reps must comply with strict Food and Drug Administration regulations. He also noted that in 2002, PhRMA introduced a voluntary code of conduct limiting the value of gifts to $100 or less and banning free entertainment tickets. “In the end, pharmaceutical marketing is one of several important ways for healthcare providers to receive the information they need to make sure medicines are used properly and patients are safely and effectively treated," Mr Johnson concluded.

’Finely-titrated doses of friendship’

This latest survey follows studies published this week in the Public Library of Science journal PLoS Medicine which claimed that standard sales techniques used by reps influenced the drugs that doctors chose to prescribe.

Georgetown University Medical Center’s Adriane Fugh-Berman and a former Eli Lilly rep wrote that physicians are influenced by “finely titrated doses of friendship’, administered by field force workers. The paper, which is co-authored by Shahram Ahari of the University of California, San Francisco’s School of Pharmacy and another ex-Lilly worker, also notes that if a physician refuses to meet with a rep, “their staff is dined and flattered in hopes that they will act as emissaries for a rep's message." Physicians who end up prescribing the rep's drugs are then rewarded with gifts, such as golf bags or silk ties.

The authors concluded by saying that "every word, every courtesy, every gift, every piece of information provided is carefully crafted not to assist doctors or patients, but to increase market share for targeted drugs."

Whether doctors are swayed by a free lunch or indeed free golf bag is a highly debatable point, however, and Thomas Stossel, professor of medicine at Harvard Medical School, told Bloomberg that the ties between industry and medicine should be encouraged. Noting that about 85% of medical progress can be attributed to the work of drug and device companies, while 15% stems from public funding, he said “the corporate involvement in medicine is a natural, evolutionary adaptation to opportunity. Products beget more products. They need to be marketed, because doctors need to know they exist. It's a natural, symbiotic relationship.''