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Tighter standards
A voluntary code set forth by Pharmaceutical Research and Manufacturers of America revises standards governing how drug reps interact with health care professionals. Here’s what reps at participating companies can’t (and can) do:
•They can’t give non-educational items – pens, mugs and other “reminder” objects usually adorned with a company or product logo – to health care providers and their staff.
•They can’t take doctors or staff out for a meal; occasional meals at the doctor’s office with informational presentations are allowed. The code strengthens previous statements that companies should not provide any entertainment or recreational benefits to health care professionals.
•Sales reps must be sufficiently trained about applicable laws, regulations and industry codes of practice – including the code – that govern interactions with health care professionals. Companies must see to it that employees are trained and hold them to compliance standards.
•Code extras: More detailed standards regarding the independence of continuing medical education; principles for using “non-patient identified” prescriber data, or information that pharmaceutical companies track that does not identify individual patients; and more guidance on speaking and consulting arrangements with health care professionals, including disclosure requirements.
Cathie Rowand | The Journal Gazette
Lisa Jackson owner of the Bagel Station has seen business from drug sales reps decline about 25 percent this year.

No more pens from drug reps

Pharmaceutical group limits gifts to doctors, staffs

Illustration by David Brzezinski | The Journal Gaz

The next time a doctor takes a sip of coffee or writes a prescription, it’s less likely he or she will be drinking from a mug adorned with the name of a blockbuster drug or using a pen bearing a drug company logo.

A revised, voluntary code guiding interactions between drug company representatives and health care professionals, which takes effect Jan. 1, is doing away with non-educational “reminder” gifts – like adorned pens and mugs. And it’s prohibiting another time-honored tradition: drug reps taking doctors out to nice dinners.

Not that all the perks are out the window.

The code, adopted in June and announced in July, is a revision of the 2002 version, also put forth by the Pharmaceutical Research and Manufacturers of America, or PhRMA. The association represents the country’s top pharmaceutical research and biotechnology companies – including Johnson & Johnson and Eli Lilly and Co.

The code is part of an effort to assure legislators and an increasingly skeptical public that interactions between company reps and doctors are on the up-and-up.

Whether the code will fundamentally affect interactions between drug reps and doctors remains to be seen. Some think it will make those interactions – that are already restricted by numerous medical institutions and organizations – more ethical and reduce undue influence. Others are content with the status quo and don’t expect much change; gifts given by reps are typically small and of little consequence, they say.

As of Nov. 5, 32 of 34 companies listed as members on PhRMA’s Web site had signed on to adopt the voluntary code; only member companies New Jersey-based Celgene Corp. and Procter & Gamble Co. based in Cincinnati, hadn’t. A spokesman for P&G said the company planned to sign on before the end of the year. A representative with Celgene said he wasn’t familiar with the code and needed to get more information before he could comment.

Four other drug companies that are not listed members of PhRMA have also adopted the revised code.

The code limits gifts to educational items and meals to occasionally delivering food to the doctor’s office for consumption with an accompanying informational presentation.

It doesn’t affect free drug samples, which proponents say are good for doctors and patients but critics counter can lead doctors to prescribe expensive or subpar medications instead of reliable, cheaper drugs.

The code also outlines detailed standards regarding the independence of continuing medical education and provides guidelines for disclosing relationships with physicians.

Dr. Aaron Carroll hopes the changes will make a difference. He said many patients don’t know about the interactions drug reps have with their doctors – and the perks they dish out – and wouldn’t be pleased to know that these can influence which medications doctors prescribe.

“I’m a researcher, and the evidence (shows) pretty clearly that even small inducements work,” said Carroll, associate professor of pediatrics and director of the Center for Health Policy and Professionalism Research at the Indiana University School of Medicine in Indianapolis. The physician says items as small as pens, pads and paperweights can have an effect; a steak dinner even more so.

A study published in the New England Journal of Medicine in April 2007 showed that 94 percent of physicians reported some type of relationship with the pharmaceutical industry, and more than four in five of these relationships involved receiving food in the workplace. The study didn’t assess the risks, benefits, or appropriateness of physician-industry relationships.

Although most doctors deny gifts influence their prescription decisions, Carroll said, drug companies – with their bulging advertising budgets – wouldn’t spend the money if it didn’t work. Carroll sees patients at Wishard Health Services’ Primary Care Center, which isn’t open to drug reps.

He believes physicians should get information on drugs from medical journals and other reasonably independent sources rather than drug reps who are naturally biased toward what they’re selling.

But because of time constraints, many doctors do get drug information from reps, though that is not the only place they turn.

For questions on insurance coverage, cost and other basic information, local family practitioner Dr. Thomas Bond relies on drug sales reps who visit the office.

But when Bond wants to get information about adverse reactions, how well the drug works or how it interacts with other drugs, he turns to UpToDate, a peer-reviewed information resource on the Web; the Medical Letter, an independent, non-profit publication that evaluates drugs; and medical and trade journals.

“I know they’re not biased,” said Bond, who is with Parkview Medical Group in New Haven.

Bond said reps drop off pens and pads at his office but don’t hand out more substantial gifts, which he wouldn’t accept. The doctor – who has been practicing for 10 years – said it has been a long time since he’s gone to dinner with a drug rep.

For one thing, Bond said he doesn’t have time.

Still, the family physician doesn’t think that patient care or even patients’ perception of the interaction between drug reps and health care professionals will change with the new code. Bond said the drug industry has been decreasing perks for years.

He sees relationships with drug reps as a valuable tool to get basic questions answered quickly. A spokesman for Indianapolis-based Eli Lilly said company-doctor relationships are also important to advance science and medicine.

“There is skepticism around the relationship,” Ed Sagebiel said. But he hopes greater transparency will improve perceptions and renew support for what he deems critical interactions.

Still, there are signs that relationship is going to be further limited.

In October, the Wisconsin Medical Society one-upped PhRMA’s voluntary ban on most gifts.

The medical society approved changes to its policy prohibiting doctors from accepting “gifts from any provider of products that they prescribe to their patients such as personal items, office supplies, food, travel and time costs, or payment for participation in on-line CME (continuing medical education).”

It reasoned that, “A complete ban eases the burdens of compliance, biased decision making, and patient distrust.”

David Welsh, president of the Indiana State Medical Association, said the association hasn’t moved forward with any like-minded ban. But he thinks if such policy were proposed, it could easily gain support here.

Already, most drug reps that Welsh – a general surgeon in Batesville – sees in his office are just dropping off information, he said.

The cutbacks drug reps are making on goodies is something Lisa Jackson knows all about. Jackson owns the Bagel Station, which has locations on East State Boulevard and East Dupont Road in Fort Wayne.

Jackson sees reps from companies such as Lilly, Novartis, GlaxoSmithKline, and Pfizer Inc. She says many reps have been restricted in their spending to no more than $100 per doctor’s office visit, which she says doesn’t go far at bigger offices.

Reps seem to buy fewer cakes and more fresh fruit and health food. They are spending less overall; she estimates rep spending – probably 7 percent of the restaurant’s total sales – is down about 25 percent this year.

“I understand why they’re doing what they’re doing,” Jackson said. “I just wish it weren’t so.”

She can only hope now to recover some of that business as reps shift their focus from going out to dinner with docs, which won’t fly under the new code, to carry-in food – a Bagel Station staple.