Drug and Device Companies Woo Physicians in Many Ways

BOSTON, April 25 -- Despite new regulations governing physician-industry relationships, there has been no letup in the pursuit of high-prescribing physicians by pharmaceutical and other medical marketers, researchers here reported.

In a national study of more than 3,000 physicians in six specialties, most of the respondents reported some kind of relationship with industry during the previous year, Eric G. Campbell, Ph.D., of Harvard, and colleagues, reported in the April 25 issue of the New England Journal of Medicine.

Cardiologists, a high-prescribing group, were more than twice as likely as family physicians to be the beneficiaries of largess, while pediatricians and anesthesiologists were least likely to get invited to paid events, such as speaking tours, or be given lucrative perquisites.

In addition, physicians in solo or group practices and those in university or medical-school practices were preferred to those working in hospitals, clinics, or HMOs, the researchers reported.

"More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials," Dr. Campbell and colleagues wrote.

The study was a follow-up to the 2002 physician-industry code of conduct issued by the Pharmaceutical Research and Manufacturers of America (PhRMA), Dr. Campbell said.

This code states that interactions between company representatives and physicians should primarily benefit patients and enhance the practice of medicine. It also discourages companies from giving physicians tickets to entertainment and recreational events, goods (golf balls and sporting bags) that do not offer benefit patients, and token consulting and advisory relationships that are used to reimburse physicians for their time, travel, or out-of-pocket expenses.

The American Medical Association and the American College of Physicians have also adopted new codes that are similar to that of PhRMA.

To determine the current status of physician-industry relationships the researcher surveyed 3,167 physicians in anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics in late 2003 and early 2004. The raw response rate for this probability sample was only 52%, and the weighted response rate was 58%.

Of the respondents, 94% reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%).

More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials.

The frequency of physician-industry relationship differed significantly according to specialty and primary practice organization, the researchers said.

For example, cardiologists were more than twice as likely as family physicians to receive payments (OR, 2.20, 95% CI 1.43-3.38) and were also significantly more likely to receive payments than were pediatricians, anesthesiologists, other internists, or surgeons (P

The possibility that companies may target these opinion leaders is further suggested by the higher frequency of industry payments to physicians who have developed clinical practice guidelines and to those who train other physicians.

The survey also found that physicians in hospitals and clinics were less likely than those in solo or group practices to attract industry representatives.

Physicians in small practices, the researchers said, may have more freedom in their prescribing choices. Also, hospitals and clinics may have policies designed to restrict industry relationships, and these organizations may provide their own information through educational programs, making physicians less dependent on industry representatives.

In all specialties except anesthesiology, physicians met more frequently with industry representatives than the average of 4.4 meetings a month reported in a study in the year 2000.

The reason for this apparent increase is unknown, Dr. Campbell said, but it may reflect an intensification of industry marketing since the 1990s or result from differences in study design.

The researchers listed several study limitations. First, the respondents may have under-reported their associations with industry. Second, the study may not apply to specialties other than those studied. Third, the results may have been influenced by unmeasured characteristics, such as working hours or type of patients.

Fourth, they said, the overall weighted response rate of 58% reflects the difficulty of obtaining physicians' responses to surveys, a limitation especially salient with regard to cardiology, which had the lowest rate (43%) among the specialties surveyed.

Finally, they said, this study did not assess the risks, benefits, or overall appropriateness of these relationships, a logical next step in this discussion. However, they said, these judgments cannot be made solely on the data from this study, although they have been described extensively elsewhere.

Despite these limitations, the investigators said that the high prevalence of physician-industry relationships underscores the need to consider their implications carefully.

"The variations in the nature and frequency of physician-industry relationships among specialties and practice settings suggest that specialties, organizations, and practice leaders with an interest in reporting and managing physician-industry relationships may need to develop guidelines and recommendations that are specific to the context of each specialty and setting," Dr. Campbell wrote.