The Pharmaceutical Research and Manufacturers of America recently revised its voluntary Code on Interactions with Healthcare Professionals to discourage drug companies from giving physicians free gifts such as non-educational lunches and items imprinted with their product logos.¹ The new guidelines went into effect Jan. 1. While some physicians dismiss the idea that drug company gifts and visits can influence their care, we are convinced otherwise.

Family physicians, compared with doctors in other specialties, have the highest number of visits with drug reps,² and evidence of the negative effects of these visits is mounting. One review of 29 studies concluded that interaction with drug reps was associated with less rational prescribing practices and higher prescribing costs and that it decreased physicians’ likelihood of prescribing generics by 66 percent.³ The review also found that physician receipt of drug samples was associated with a greater awareness of and preference for a new drug, among other findings.

A few years ago, our group (a residency teaching site with five faculty physicians and 14 staff members) developed a policy to make our office “pharma-free” to decrease the influence of drug companies. When the policy first went into effect, we had an office-wide purge of drug company office supplies and samples. Physicians were told that they could still meet with pharmaceutical reps or go to drug company-sponsored events on their own time, but not in the office. Our office manager simply stopped scheduling “drug rep lunches” and explained our office policy when drug reps called.

Previous articles have discussed how to work with drug reps and organize sample closets.^4,5 Here’s why we decided to eliminate them from our practice entirely.

1. It’s the best policy for our patients

Since going pharma-free, our group feels more confident that we’re basing our prescribing decisions on clinical evidence and not being influenced by the name of the newest and most expensive (but not necessarily the best) medication on our pens or notepads. Drug companies in the United States spend almost twice the amount on marketing ($57.4 billion in 2004) that they spend on research and development ($31.5 billion).⁶ Physician detailing, including medication samples, represents nearly two-thirds of the marketing budget. Reducing in-office advertising to physicians would save money and could ultimately help make medications more affordable.

2. It relieved us of our sample closet

A major trigger for our office’s new policy was an upcoming health plan audit, which would have included a review of our sample closet. Although we did have an organized, locked closet with a sample log, we struggled to get physicians to document sample medications completely and correctly. Extra staff time was also needed to log medications, check expiration dates and track medication samples. Closing the sample closet not only rid us of our audit headache but also eliminated the medicolegal risk of samples being used by office staff or relatives.

A few patients initially questioned the lack of samples, but they understood our explanations about the added expense to the health care system and the inconvenience to our office. We use a handout (http://www.nofreelunch.org/downloads/Why we don’t have free samples.doc) that explains the downside of sample medications and why our office no longer stocks them.

For patients who are struggling with drug costs, we have a couple of options:

Low-cost, generic medications. Often patients can achieve large savings by using generics and calling local pharmacies to comparison shop. In addition, programs such as Rx Outreach (http://www.rxoutreach.com) supply discount generic medications to people who earn less than 250 percent of the federal poverty level. We encourage our patients to see if they qualify. Patients complete the forms and send them in with a three-month prescription.

Prescription assistance programs. Sites such as http://www.needymeds.com and http://www.rxassist.org can help low-income patients obtain name-brand medications. Although completing forms for prescription assistance programs can be time-consuming, it requires far less time than that required to manage a sample closet. In addition, we have found that fewer patients need these programs since Medicare Part D came into effect.

3. We’re more efficient without detailing visits

Although we enjoyed the (generally unhealthy) food provided by the drug reps, we found ourselves spending more and more time listening to sales pitches. Detailing visits took up precious time during lunch and between patients, and we often suspected that the information we were receiving was biased. Alternatively, we have found that our local health plans, hospital and medical society provide inexpensive CME with fewer strings attached. Our physicians have also subscribed to publications such as The Medical Letter and the Prescriber’s Letter for unbiased reviews of new medications.

Although some of our physicians and staff were initially reluctant to give up the free lunches, overall the response has been positive. The office flow is more efficient, and our staff doesn’t spend time scheduling detailing lunches or visits.

4. We’d rather advertise our own office

We’ve noticed that drug company pens show up not only in medical practices but also at local restaurants, dry cleaners and the like. Our office decided to purchase inexpensive pens with our office name, phone number and Web site printed on the side. We are happy to give them out or have patients take them home because it’s good advertising.

Making the leap

Eliminating samples and visits from drug reps may not be the best policy for every office, but our group has found advantages, including greater respect from our patients. We encourage other offices to think about becoming pharma-free.