Drug Firms’ Freebies Banned

They are common fixtures in many medical practices: free pens, mugs, stationery, stethoscopes and doctors’ bags, all emblazoned with the logo of a new drug or a pharmaceutical firm. And those catered lunches staffers flock to? It may be courtesy of a major drug supplier.

No more -- at least for all staff and students at Stanford University’s medical school, hospitals and clinics. Under a policy announced Tuesday, even free sticky notes violate ethics rules.

The rules bar the tiniest gift from pharmaceutical and other industry representatives, including drug samples. The change, widely approved by votes at the medical school and the two hospitals, marks the third time in two years that a major academic medical institution has implemented such a stringent policy.

“We were really seeking to do the right thing,” said medical school Dean Philip Pizzo, adding that the policy had been vigorously debated for more than a year. “We want to set a standard.”

Critics of pharmaceutical marketing practices applauded the move, saying any gift can create a sense of loyalty or obligation, whether or not a physician realizes it.

“It’s about time that this happened,” said Alan Cassels, coauthor of “Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients.” “If they’re being wined and dined at lavish dinners, how can they be objective or how can they get a balanced picture of the benefits or harms related to drugs?”

Industry officials objected to the move, saying it would interfere with the relationship between pharmaceutical representatives and doctors. For instance, the policy would prohibit company-catered educational sessions and keep representatives from meeting with doctors unless they have appointments.

“Restricting the ability of sales representatives to give healthcare professionals valuable drug usage and safety information -- which is designed to benefit patients -- would be a serious mistake,” said Scott Lassman, a lawyer for Pharmaceutical Research and Manufacturers of America, an industry trade group. “The fact is America’s pharmaceutical research companies naturally have the most comprehensive information about the medicines they research and develop.”

The change comes as physicians -- especially at academic medical centers such as Stanford -- have come under increased scrutiny for possible conflicts of interest as they accept handouts from pharmaceutical companies ranging from tchotchkes to paid trips.

The pressure partly stems from a policy proposal in the Journal of the American Medical Assn. this year, finding that of the $21 billion the drug industry spends on marketing, about 90% goes to physicians in the form of gifts, lunches, drug samples and sponsorship of education programs.

The article authors implored academic medical institutions to crack down on the practice -- which the medical institutions at Yale University and the University of Pennsylvania have done in the last two years.

“The academic medical center is a place medicine looks to for leadership. It’s looked to for moral medical guidance,” said Arthur Caplan, director of the Center of Bioethics at Penn. “They are just places ... where you try to keep the commercial aspect absent.”

The practice at medical schools is particularly problematic because medical students begin to expect freebies, said Drummond Rennie, a medical professor at UC San Francisco.

And some drug representatives were “almost accosting” doctors in the hospital to ask, “What are you prescribing?” said David Magnus, director of the Stanford Center for Biomedical Ethics.

Even small gifts can have an effect on doctor’s decision making, according to studies by anthropologists, sociologist and economists.

“Many doctors think, ‘It’s just a pen. It’s just a mug. It’s just a clock.’ But it keeps the product name in the doctor’s face -- you look at the clock, and you see Zoloft,” said Jerry Avorn, professor of medicine at Harvard Medical School and author of “Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs.”

“Even if the object is of trivial monetary value, it creates the notion of a friendship. They wouldn’t be investing in those things if there weren’t a payoff,” Avorn said.

Still, some doctors insist they are not influenced by the trinkets and free lunches, said Magnus. “They spend billions and billions of dollars ... on this direct-to-physician advertising,” Magnus said, sometimes bringing in catered Mexican or Thai food, and taking requests from medical staff for future menu items. “The reason why companies spend money on this is that this works.”

Even free sample drugs can play a role, encouraging patients to try to develop loyalty to a newer, more expensive drug -- which may not be as effective as a competitor’s.

“They give you free drugs to give to your patients, and it creates a relationship,” Magnus said. “You get some pens, [and think] ‘Gee, we need to prescribe a statin.’ What are you going to prescribe? Lipitor. ‘Oh, that’s the name on my pen.’ ”

But Michael Shapiro, a USC law and bioethics professor, said free samples can be a boon to poor patients.

“Physicians keep free samples around particularly earmarked for patients and their families who are financially strapped,” Shapiro said. “It’s a way for drug redistribution. It’s maybe not the best way, but it’s one way.”

At Stanford, the change has not come without debate. Some doctors are concerned the policy could sharply increase the university’s costs for putting on educational seminars, said Pizzo, the medical school dean.

That, “to me, underscores the problem. It means that things have become so intertwined that dependency has occurred. And that dependency needs to be broken,” Pizzo said.

The policy, which will go into effect Oct. 1, covers all medical staff members at the medical school, Stanford Hospital and Clinics and the Lucile Packard Children’s Hospital, including students and trainees.

The five-page policy prohibits gift-giving on school, hospital or clinic grounds and restricts sales and marketing representatives to patient areas unless they have an appointment. In addition, companies cannot directly provide food at Stanford, nor can they determine the content of a meeting or lecture course held on campus.

Also, the rules prohibit “ghostwriting,” in which someone under industry auspices writes a research article for an academic researcher, who then claims the work as his own. And the rules largely place restrictions on scholarship winners, mandating that only academic officials choose the student, rather than a company.

“It will be a cultural change,” said Lawrence Shuer, chief of staff at Stanford Medical Hospital and Clinics, who acknowledged he had numerous industry pens and notebooks in his desk drawers -- though he said he never felt compelled to change his prescribing habits. “People have perhaps grown up as physicians [expecting] free gifts and things like lunches for quite some time.”

The new rules won’t resolve all potential conflicts of interest. Magnus, the Stanford bioethicist, said for instance that university rules do not prohibit an industry representative taking a doctor out to dinner in his off-time, although the policy strongly cautions against it. They do not prevent taking a pen or other trinket while at an off-campus conference.

“When you’re on your own time, there’s nothing we can do to stop it. We can discourage it but not stop it,” Magnus said.

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ron.lin@latimes.com

mary.engel@latimes.com