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April 28, 2008


How dare you interfere with the market's freedom to interfere with the free market!

Besides, whre am I going to get my next free fix, I ask you?

Already, I'm misspelling "where" because of you, you stifler of animal spirits, you.

John: I'm in ur pharma, messin with ur precious bodily fluidz...

I’m just jealous because no ever tries to bribe me with cool swag in my line of work.

Do you think that the recommendation in this report could slow the inflation in health care costs? I'm probably being a bit optomistic.

Smells like a classic collective-action problem. Some of the pharma execs might have been glad to see the race (and associated expenditure) stop, but not if they were going to be the only one stepping out of the race while their competitors continued to gain advantage. By making it part of a guideline binding to all, they get what they could not get separately. Cool. Game theory works.

JT: right on. "Free" in "free markets" too often means free to suffocate real competition in its crib and leave consumers with no real choice.

I was going to say that it sounds like a collective action problem but I see that has already been covered. :)

Jeff and Seb: naturally, I can't speak for anyone else involved, but that was how it seemed to me.

hilzoy: This is really great! As you might guess, I know a bunch of people who just went through this med school process, and they take the swag and admit it's really a big ethical problem.

OCSteve: Think of it this way. People only want to swag you if they look at your and see dollar-signs, if they see some way of converting you and exploiting you. If no one is swagging you, means you're downstream from nobody. What you've lost in goods, you've gained in dignity.

There was an interesting case study for ghostwriting, guest authorship, and financial disclosure involving rofecoxib (Vioxx) in JAMA about two weeks ago. (Link: article )

I've always thought the whole "consulting" thing to be a bit fishy. I'd be interested to see if there has ever been a study/survey looking at who is actually participating (age, rank, affiliation, etc). When pharma attempts to get a new drug approved before the FDA, their scientific panels resemble the WHO's WHO of science. Which makes me wonder: who is doing the grunt work behind the scenes?

Eliminating the gifts is a good idea. I think a lot of young doctors get tempted very easily because they are utterly broke. It's a start I guess.

There also remains the issue of top university officials sitting on the boards of all these big companies. I would imagine they are compensated very generously as well.

Kinda cool to see (presuming, inferring that) medical professionals are weighing in. (A welcome relief from the hegemony of all those darn lawyers and software engineers.) ;)

Following on what Jeff and Seb said, it seems reasonable to suppose that pharmacorp, being clever people and masters of gaming the system, understand that limiting their reach and saving huge sums will not only build their bottom line (sorry Al, but I really doubt it, though it might position them to release some of their precious financial fluids to the benefit of the Third World) but place them more favorably in relation to a foreseeably imploding economy.

A straw in the wind of global change.

Drug companies spend billions wooing doctors — more than they spend on research or consumer advertising.

I'm all for the restrictions, especially if they use the money this frees up for more research.

I’m just jealous because no ever tries to bribe me with cool swag in my line of work.

C'mon, OC, we all know you have a stash of mousepads, coffee travel mugs, and cheap fleece vests hidden away in a closet somewhere!

hilzoy, many thanks for your work on this.

We have already gutted most of this at my hospital. The only thing we allow is for reps to provide lunch if they are giving a lunchtime presentation. Should we knock this off also? Well, we are talking pizza and sandwiches not pheasant under glass. If there is evidence that even such small amounts influence our decisions I would give that up also. I have always looked at this as the rep providing lunch so he can have access to me for ten minutes when I would have run off to the cafeteria instead. Tbh, I am am not sure why the reps come anymore. We use a pretty narrowly limited set of drugs and we have not had a rep come in years to talk about drugs we werent already using.


My mom worked for an orthopedic surgeon in Southern Mississippi, and, at least in that case, the pressure was much more subtle, in that the rep would give lots of samples, and the doctor, who often ended up writing bills off and dealing with a lot of people who were living from paycheck to paycheck in the best of times, would use these samples to get patients their meds, so if they were able to get their insurance or settlement, they would basically be locked in to that. In an ideal world, he would have told them, when they had used up the samples, to move to the generic equivalent, but he was seeing a lot of patients, it was just not feasible to keep track of every patients status and financial condition. So I think that the free sample culture can be, even if done with the best of intentions, problematic.

In re swag: shortly after I got my present job, I was put on the Hopkins Med School Conflict of Interest Committee. It was just astonishing to see the kinds of money that people got, what with me being a philosopher and all. I mean, no one, but no one, offers swag to philosophers. No one offers to put us on speaker's bureaus in an attempt to influence other people's views on the mind-body problem. We get no pens, lunches, etc. It was pretty eye-opening.

In re small gifts: there is research that suggests that any gift, however small, has effects on people's behavior -- it seems to subliminally make you feel grateful, and establish a bond. Thus the report's efforts to channel things (i.e., drug samples) through central administrative bodies when possible: it's gifts offered to individuals that have this effect.

no one, but no one, offers swag to philosophers. No one offers to put us on speaker's bureaus in an attempt to influence other people's views on the mind-body problem. We get no pens, lunches, etc.

There's a joke in here somewhere about philosophers, the mice, and the Ultimate Answer to Life, the Universe and Everything, but I'm not quite getting it...

Over here doctors have a use for the free drug samples without being too strongly tempted to favor the companies providing them.
On of the latest reform attempts made it mandatory to take the cheapest alternative, if there were identical or similar drugs under different brands (the prescriptions even have a default "aut idem" setting, so the pharmacy would do, if he did not). If the doctor wants to deviate from that he has to provide a valid reason. My family doctor for example had to do tests for antihypertensive drugs, so he could justify his "predilection" for a certain version (that one released the active component slower and more reliably, avoiding "peaks").
The free samples come in handy at the end of the quarter because it allows him to dispense necessary drugs after exceeding the tight (imposed) budget without having to go through lots of red tape.
Other "favors" are a different question and I think restrictions should apply.

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