In 2016, the pharmaceutical industry spent $29.9 billion on medical marketing in the United States, including $20.3 billion for marketing directly to health care professionals. Of this spending, $5.6 billion was for prescriber detailing (mainly face-to-face visits), $13.5 billion for drug samples, and $979 million for direct physician payments.¹

The United States has, by far, the highest prescription drug prices in the world.² Market exclusivity is an important factor in high U.S. drug prices; on average, top-selling pharmaceuticals in the United States have a patent exclusivity of 14.5 years.^2,3 Additionally, government-funded health plans are forbidden from negotiating lower prices for patients.² These system processes maintain high drug prices that directly harm patients, especially those in marginalized communities.^4–6

Knowing that the high price of drugs is a major detriment to public health in the United States and that the pharmaceutical industry spends vast sums marketing to health care professionals, physicians should refuse visits, gifts, payments, and drug samples from pharmaceutical representatives.

Physicians Should Not Visit with Pharmaceutical Representatives

Pharmaceutical representatives are trained to influence physicians, and they are effective.^7,8 Visits from industry representatives often come with gifts and food, leading to low-value prescribing that is not evidence based.^7,9 Pharmaceutical representatives seek to change the prescribing habits of a physician.⁸ Physicians claim that their behavior is not changed by industry interactions but admit to believing that other physicians can be influenced.¹⁰ Physicians who think they can accept gifts and spend time with industry representatives and not be influenced are in a position of cognitive dissonance.¹⁰ Time spent with these representatives is wasteful because ethical physicians are required to read about new drugs extensively to counteract false information provided by the representatives.¹¹ In the words of family physician and ethicist Howard Brody, “Physicians ought to refuse to visit with representatives as a matter of both professional integrity and sensible time management.”¹²

Physicians Should Not Accept Gifts, Food, or Direct Payments from Industry

Gifts, even small ones such as pens and notepads, influence behavior.^13,14 Direct payments from a pharmaceutical company increase the likelihood that physicians will prescribe that company's medications.^13–15 This arrangement violates our ethical obligation to put the patient first. Unsurprisingly, patients report that they are not comfortable with this arrangement.¹⁶ Considering that many patients experience hardship because their medications are too expensive, perhaps industry could redistribute the $20.3 billion they spend on physician marketing toward lowering drug costs.

Physicians Should Refuse “Free” Samples for Their Patients

It is tempting to think sample medications help underserved patients, but samples do more harm than good. Medications in sample closets are not novel or useful and are often expired or inappropriately used by physicians and staff members.^17–19 Sample medications in family medicine offices are brand-name medications delivered by industry to increase sales of the drug. A sample closet is actually a marketing closet.²⁰ Samples are rarely first-line medications, recommended by guidelines, or superior to less expensive generic alternatives.^17,21 Use of sample-closet medications leads to nonrational prescribing.²² Sample-closet medications are more likely to be used by patients who have health insurance and not by patients most in need.²³ A patient started on an expensive brand-name drug is likely to continue that drug.⁸ Use of sample-closet medications increases the cost of medications for patients, both out-of-pocket and total cost.²⁴ The $13.5 billion the pharmaceutical industry spends annually on sample medications is not designed to help patients; it is designed to increase sales of brand-name drugs.

The Good News: Physician Interaction with Industry Is Decreasing

Numerous national organizations and experts have called for limiting physician-industry interaction.²⁵ The Physician Payments Sunshine Act, part of the 2010 Affordable Care Act, required the industry to report all gifts to physicians starting in 2014.²⁶ There is evidence that this reporting, with strict legislative action, has decreased interactions between physicians and industry.^27,28 All interaction (e.g., detailing, samples, gifts, direct payments) between physicians and industry has decreased slightly over the past decade, from 84% in 2009 to 72% in 2017, according to surveys of physicians.^29,30 In 2017, 55% of physician offices reported accepting samples vs. 64% in 2009.^29,30

Family medicine residency programs have even more substantially decreased their interactions with industry. In 2019, 64% of programs did not allow the use of samples, the acceptance of food or gifts, industry-sponsored residency activities, or other industry interactions, compared with 26% in 2008.³¹ As of 2019, 86% of family medicine residencies do not accept samples, and 84% do not allow visits with industry representatives, a substantial increase from 52% and 43%, respectively, in 2008.³¹ Program directors cite institutional policy and ethical concerns as the main factors driving a decrease in industry interaction.³¹ Restricting contacts with industry during physician training is especially important to promote evidence-based prescribing because practice habits form during this important time in a physician's career.

Conclusion

The high cost of prescription drugs in the United States is a major public health challenge. This high cost is driven by prescribing of expensive brand-name medications, which is influenced heavily by the pharmaceutical industry spending billions of dollars to market directly to physicians. Physicians should refuse gifts, samples, direct payments, and other industry interaction to avoid perpetuating an unjust health system.

It is the professional responsibility of a physician to promote social justice, commit to a just distribution of finite resources, prioritize patient welfare, and not compromise integrity with conflicts of interest.³²

Editor's Note: American Family Physician has a strict policy when it comes to authorship and conflict of interest (https://www.aafp.org/afp/coipolicy). In addition to reviewing disclosure forms submitted by authors, we routinely search public databases of physician-industry interactions to make sure there are no conflicts that were inadvertently omitted. During this search, we frequently uncover numerous reports of lunches and dinners provided by pharmaceutical companies. We carefully review each one to see whether the reports are relevant to the topic of the article and to determine the degree of financial relationship (i.e., a lunch or two vs. hundreds of dollars for meals). Rarely has an author been disqualified based on these meals alone; however, disclosures have sometimes been published with the articles, and the option of disqualification is possible for significant meal payments to avoid the perception of bias.—Sumi Sexton, MD, Editor-in-Chief

Dr. Brown is a contributing editor for AFP.