Respectful Insolence

Well, I’m home.

As I’ve mentioned before, I attended the annual meeting of the American Society of Clinical Oncology (ASCO) in Chicago. Although one of the problems with ASCO, at least for surgeons like me, is that it is a meeting completely dominated by medical oncology. Quite frankly, not that much of what is presented at ASCO has a lot of relevance to my surgical practice. There are exceptions, of course. In fact, Monday morning’s sessions on breast cancer were the best of science-based medicine that will change practice. Perhaps I’ll blog about that tomorrow or later in the week. As I write this I’m just too tired from the meeting and the trip home to lay down any serious science for you. That takes thinking and work, and, besides, so monumental were the studies presented that I haven’t quite decided what I think of them yet. (Perhaps my good buddy at another blog should take this on Monday.) In the meantime, I thought it might be of interest to do a bit of an update on the post about drug rep swag that I wrote about three years ago and reposted yesterday. (Remember to go back and read it if you haven’t already; after all, if you’ve been reading this blog less than three years, it’s almost certainly new to you!)

Three years ago, the swag at ASCO was very impressive indeed. There were laser-engraved pens, lights, bags emblazoned with the names of attendees, and a even Bluetooth mouse that could be had easily. This was in addition to huge quantities of the usual “minor” swag, such as pens, Post-It notes with drug company logos, Tote bags, books, and flash drives. This year, as opposed to three years ago, I noticed a distinct decrease in the amount of swag. True, my observations are not scientific at all, but I did note that, for example, the game at the Genentech booth in 2007 that led its participants to get all sorts of goodies appeared to be gone this year, even though the booth looked identical to the one in 2007. Similarly, other than pens, swag that attendees could take home was much more scarce, other than pens, most of which were not even particularly good pens. There also appeared to be a lot more booths offering free coffee and little snacks, like candies or cookies. I also noticed something I hadn’t seen before anywhere at any meeting. It was so odd that it immediately caught my attention:

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So let me get this straight. If you are a physician and happen to be licensed and prescribe in either Vermont, Minnesota, or Massachusetts, Bayer can’t give you a cup of coffee. I wondered about this. Do they actually check? Since I don’t live in any of those states, I decided to find out. No one asked me for my meeting badge, which was emblazoned with my name, institution, and city and state. I just walked up and poured myself a cup of Starbucks coffee, put some half-and-half in it, and drank up, thus forever sealing my fate as a minion hopelessly in the pay and thrall of the evil big pharma. And not just big pharma, but evil German big pharma!

Dr. Len Lichtenfeld of the American Cancer Society apparently had a different experience:

This year tops them all and shows how far we have come in protecting the public and preventing drug companies from unduly influencing the doctors attending ASCO by putting restrictions on which doctors could get a free cup of coffee.

At one drug company booth where they were offering a small cup of espresso to meeting attendees there were signs posted which said that doctors from Minnesota and Vermont were forbidden by state law (yes, that’s right: forbidden) from having a free cup of coffee. There was another sign which said that the drug company could/would report to the federal government and publicly post the name of any other doctor who took advantage of that free cup of coffee.

If you swiped your plastic identification card, and weren’t from Minnesota or Vermont, you got your cup of coffee. No identification card, no coffee. Live in the great states of Vermont or Minnesota? You are just plain out of luck. The coffee bar outside the convention hall is just the place for you.

I wonder which booth Dr. Len managed to hit. The Bayer booth had this sign up, but nothing more. There appeared to be no mechanism to enforce it, because anyone could just walk up to the coffee and pour himself a cup. I also wonder how Bayer apparently interprets the laws from three states as banning even a cup of coffee being provided to physicians while whatever company in whose booth Dr. Len found himself interpreted the law such that it decided that it only applied to two of those states. For example, here is a summary of the Massachusetts law, the relevant portion of which reads thusly:

  • Pharmaceutical or medical device manufacturing companies may only provide or pay for meals for physicians that are modest and occasional in nature, and are directly related to an informational presentation;
  • No pharmaceutical or medical device manufacturing company may provide physicians with financial support related to the costs of attending CME events, conferences, or professional meetings;
  • No pharmaceutical or medical device manufacturing companies may provide inducements or gifts to any physician who is not a salaried employee of the company.

As of July 1, 2010, and annually thereafter, every pharmaceutical or medical device manufacturing company must disclose to the Department of Public Health the value, nature, purpose and particular recipient of any fee, payment, subsidy or other economic benefit with a value of at least $50, which the company provides, directly or through its agents, to any covered recipient, including physicians, in connection with the company’s sales and marketing activities.127 A person who knowingly and willfully violates these rules can be punished by a fine of up to $5,000 for each violation.

I can see how a company might interpret the above statute to ban even a cup of coffee, becaause it may well have not been related to an informational presentation, but Bayer’s does appear to be a very severe interpretation of the law. After all, the company’s booth was plastered with educational materials and helpful representatives more than willing to talk to you about Bayer products. On the other hand, maybe the company’s lawyers insisted on this in order to preclude any possibility of running afoul of these state laws. In any case, it’s very clear that there has been a sea change since I last attended such a large clinical conference. Gifts and free goodies given away by pharmaceutical companies are rapidly going the way of the proverbial dodo. Even getting a cup of coffee from a large pharmaceutical company risks big penalties to the pharmaceutical company (if the physician comes from the wrong state) and the physician’s being branded as hopelessly in the thrall of big pharma, having apparently sold his medical soul for a hit of caffeine.

I’m being a bit sarcastic, but that’s more because I haven’t resolved for myself what should and should be appropriate. Before I try to answer that, let’s check out something else I saw on the exhibit floor at ASCO. Over at the Roche display, there was a rather odd scene:

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First off, the guy standing there vigilant was, as he appears to be, functioning as in essence as a guard. His job was to prevent certain people from entering the confines of the Roche booth. But which people? The answer was on this sign:

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A closer look at the sign revealed this:

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Wow! It’s a no-Americans zone!

Physicians who were not from the U.S. could enter the heaven that awaited them, thanks to Roche. And the people manning the entrances to the booth were checking meeting badges and turning away American physicians. I wanted desperately to know what forbidden rituals of big pharma were going on within the booth. Were Roche and foreign physicians sacrificing goats to the dark gods of big pharma? Were foreign physicians going to get a leg up on their American competition by pledging their souls to Roche in contracts signed by blood? Were there orgies in there, with beautiful incubi and succubi with the word “Roche” tattooed on their nether regions seducing unwitting foreign physicians who had made their way to Chicago?

I don’t know. All I could find was what I could see on the outside looking in:

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My lurid fantasies were completely disappointed. It just looked like nothing more than coffee, drinks, and other snacks. One wonders if Roche was subliminally piping in messages telling these doctors to prescribe more Xeloda and Avastin. I also wonder if it worked.

Yes, I know I’m being facetious. Actually, what was almost certainly going on at the Roche booth was that representatives were talking about potential off-label uses of its drugs, as Dr. Lichtenfeld pointed out two years ago. Personally, I don’t agree with Dr. Lichtenfeld’s apparent self-righteous anger that his foreign colleagues can learn all the latest and greatest off-label uses of Roche’s drugs (many of which aren’t necessarily supported by particularly good evidence) and he can’t or his assumption that the off-label use of Avastin would save his patient’s life. However, I do understand just how bizarre this situation is and how frustrating it could be to my medical oncology colleagues. (Personally, I rarely prescribe anything other than pain medicines for postoperative patients or antibiotics for the uncommon postoperative wound infection.)

Let me lay to rest (or attempt to lay to rest) some of the irritation some of you are no doubt feeling towards me right now. Try to hold your wrath at bay for a moment, and try to remember that I’ve made a bit of fun of some of the excesses of pharmaceutical company marketing since the very beginning of this blog. In fact, one of the very earliest posts on the first iteration of this blog was all about weird stuff doctors get from pharmaceutical representatives and have returned to the issue from time to time. The very reason I wrote my post about the outrageous swag at ASCO three years ago was because it disturbed me.

I understand that the relationship between big pharma and physicians has traditionally been far too cozy. I also understand that big pharma has often gone to great lengths to try to influence physician prescribing practices. I even understand that some of my colleagues yield to the temptation of that filthy pharma lucre. What I haven’t managed to figure out for myself yet is where the line should be drawn. It’s obvious to me that accepting trips or lots of money to speak for a pharmaceutical company to hawk its products is going too far, but is accepting a cup of coffee at a large medical meeting in the exhibition hall going to hopelessly taint a physician’s objectivity? I don’t know the answer to that one. Worse, if we accept that, for example, taking a cup of coffee at a trade show is not going to compromise a physician’s ethics, then the questions become even dicier to answer because then you have to decide where between a cup of coffee and accepting expensive trips or dinners the line should be drawn.

No wonder so many physicans, medical societies, and medical schools are deciding that the easy way out of this question is simply to take an absolutist stance that accepting anything of value from a pharmaceutical company is hopelessly corrupting and to be avoided. Quite frankly, it is a lot easier to do that than to ask the hard questions, namely what level of entanglement between big pharma and physicians is innocuous or even promotes better patient care by providing physicians with science-based information about new drugs and what level results in undue influence. It’s hard not to remember that pharmaceutical companies have traditionally contributed a lot of money to continuing medical education. Should such unrestricted grants for CME be viewed as harmful? I don’t know the answer. I do know that, if I were going to write a post making fun of the contention that we should limit the influence of big pharma among doctors, I’d have a hard time coming up with a more ridiculous example to go full mental Orac on than banning cups of coffee from pharmaceutical companies at a medical meeting or promulgating rules that lead drug companies to exclude American physicians from their booths, and I’ve actually been troubled by pharmaceutical company marketing practices for a long time.

Hey, I know! Maybe big pharma should be excluded from medical meetings altogether! Actually, I’m serious. If we as a profession have decided that the taint of influence due to big pharma is so powerful that even a cup of coffee is dangerous, then how on earth can we justify dozens of booths at a major medical meeting, some of which cost on the order of a quarter of a million dollars transport and staff?

I guess in the future it’ll have to be overpriced, cold coffee sold at the convention center for me and hope my name doesn’t end up on a list of pharma thralls for having accepted a couple of cups of coffee this year at ASCO.

Comments

  1. #1 Electric Landlady
    June 9, 2010

    It’s interesting to read this. I used to be an editor and project manager for a company that made multimedia training programs for pharma sales reps (although we also worked on a no-free-lunch training program for the AMA at one point). A typical program would cover basic anatomy and physiology, pathophysiology of condition X, treatment, pharmacology of drug Y, prescribing information, and sales tactics. A hell of a lot of money and effort and thought went into these things, and in many cases I felt the messages skated as close to the line as they possibly could.

  2. #2 Max
    June 9, 2010

    I was at ASCO as well and thought about the difference from 2008 to 2010 with all the swag going away. My fellowship program banned all contact with drug representatives, but allowed the attendings to receive funding for research. I agree that a line needs to be drawn somewhere, but telling fellows they cannot talk to reps while the attendings are constantly interacting with them and the science liaisons is a bit hypocritical.

    Never mind the fact that in a free market economy many other industries allow similar promotions and free swag, but as doctors we have an ‘ethical’ duty to uphold. Why not teach medical trainees and graduates about ethics and stop pretending that doctors are somehow better than they really are?

  3. #3 CB
    June 9, 2010

    I agree that there is a line that should be drawn but the boundary is very unclear. The question is, are we as a society willing to pay for the studies needed to really decide the question? I think not. Bullets are expensive and tax revenue is down. Perhaps its best to wait till we have a doubling of the NIH budget again.

    But the other issue I have to ponder is weather absolutist policies barring gifts is bad. I’m a professor. I made really good money. I don’t need a pen. Perhaps such policies are not bad for me but for my staff some of the bags and things could be nice for them – but they don’t go to these meetings.

    Lastly, the no contact policy Max mentioned in #2 is too silly to think about. Shame on his fellowship program for curtailing speech. I don’t think that is a line we should have in any democracy.

  4. #4 Robin
    June 9, 2010

    Sounds to me as though they pharma reps are trying to make you angry with these new regs. “Oh, the law says that we can’t give you a cup of coffee.” Which sounds ridiculous (and is, as you pointed out, a really extreme and inaccurate interpretation of the law.) But it erodes support for those regulations. It’s sort of juvenile, but I’m sure that it is calculated.

  5. #5 Christophe Thill
    June 9, 2010

    I seem to remeber having read about studies on the influence of getting gifts on the prescription of a lab’s products by doctors. There was an effect. Perhaps even for something as small and apparently innocuous as a cup of coffee ; but I’m not sure.

  6. #6 Dave Hoffman
    June 9, 2010

    As I peel off the last of my Menactra Post-It notes and write a quick note with a very ancient Zyrtec pen, I had to laugh at this. One of my prized posessions is my Zithromax zebra puppet, which those peds residents in the know had to ask for at the Pfizer booth in 2001, and the rep would determine on the fly if we were worthy.

    The joke of all of this is that swag and meal schmoozing is alive and well in every other segment of the American economy. I have a friend who sells this crap for a living. Why is it that only doctors are stupid enough to be swayed by this stuff to the detriment of their patient clients? My dad worked in the auto parts business and traveled around the world on his suppliers’ expense accounts.

  7. #7 bluefoot
    June 9, 2010

    re the change in the level of swag: after the financial meltdown, the amount and level of swag went way down, independent of any changes in rules. I’ve been to several almost-exclusively Euorpean meetings since the fall of ’08, and the swag was definitely “downgraded” from earlier years. Several vendors and CROs I spoke to all said that budgets were down because of the meltdown, so less swag.

    I’m not sure where the line should be drawn re gifts, but there certainly should be one. I don’t really see the harm in a cup of coffee at a meeting (the coffee is the thing, I don’t care who is providing it and wouldn’t remember later), but perhaps even the pens and post-its work on a subliminal level. Does anyone know if there has been research on this? Does swag, or visiting a booth at a meeting, actually change prescribing habits? Any slaes reps or consultants out there who can weigh in?

  8. #8 Xplodyncow
    June 9, 2010

    If even tiny gifts can influence physicians, then Big Pharma has no business giving freebies to doctors. But is it practical to ban the industry from conferences and such?

    Disclosure: I’ve worked in Big Pharma for the past couple years — in marketing.

    Now that you couldn’t possibly think any less of me, I have two (sincere) questions.

    If Big Pharma is banned from medical conferences:

    * What about researchers who are funded, at least in part, by drug companies? Is their work automatically invalid and unworthy of presentation at medical conferences?

    * Who’s going to fund the conferences? Are attendees willing to shell out more money (and for less free stuff)?

  9. #9 Todd W.
    June 9, 2010

    I think a lot of this stems from Congress’ move to clamp down on industry influence of medical practice. My institution has issued a policy that physicians cannot accept any gifts from pharmaceutical companies, so as to avoid even the appearance of COIs or undue influence. An office for industry interactions was even created to evaluate anything coming in to any of our physicians or researchers from industry.

  10. #10 Jay Gordon
    June 9, 2010

    Key scientists advising WHO planning for influenza pandemic paid by pharmaceutical firms. Secret conflict of interest. http://bit.ly/9j16SS

  11. #11 DayOwl
    June 9, 2010

    I’m with Robin, I think some of it is political backlash. The Roche booth was an unmistakable demonstration against US policies. Freebies are down everywhere too because people in general, including Big Pharma, are more cautious about spending.

    I sure hope you enjoyed that $50.01 cup of coffee!

  12. #12 augustine
    June 9, 2010

    If Big Pharma is banned from medical conferences:

    * What about researchers who are funded, at least in part, by drug companies? Is their work automatically invalid and unworthy of presentation at medical conferences?

    Yes. Until proven otherwise.
    ———————————————————————
    * Who’s going to fund the conferences? Are attendees willing to shell out more money (and for less free stuff)?

    The attendees pay for themselves to go.

  13. #13 lucy
    June 9, 2010

    The swag you get is much better than I find at conferences in my field, though there is less clinical overlap with my science. Its mostly post-its, pens, totes, and candy for me.
    However, the Meeting of the Organization for Human Brain Mapping provides wine at the end of each day during the final poster walk-through and take-down period.
    When I was a mere undergraduate I went to HBM for the first time, and was surprised to see the wine set out. Curious, I asked what kind was on one of the tables, and the concierge person looked at me like I was an idiot and said “uh, red.” So maybe that isn’t the greatest “swag” either.

  14. #14 Dave
    June 9, 2010

    Why is it that only doctors are stupid enough to be swayed by this stuff to the detriment of their patient clients?

    In point of fact, youre not. Similar regulations govern many government workers. Many Wall Street firms have instituted internal rules that ban the reciept of gifts, as have many non Wall Street corporations. But why should we treat doctors differently than say IT workers? Because doctors arent the end consumer. If a IT manager purchases a lesser brand of computer because the vendor gave him more or better swag, he and his company suffer. If a doctor prescribes a lesser drug, the patient, not the doctor, suffers. And the patient doesnt have another option: The patient cannot chose for himself which drug to take, it has to be prescribed by the doctor. Nor may the patient even have the knowledge to assess the other options, or even realise that they exist.

    I certainly agree that banning a free cup of coffee is excessive, but the other side of the coin is what benefit is there? Other than the convenience of the doctor, why allow it? Yes, its the easy way out, but why not take the easy way out?

  15. #15 Kate from Iowa
    June 9, 2010

    It’s not just the medical fields where this is happening guys, we get it all the time in insurance too. What we can and can’t give to the clients (big problem around Christmas and graduation times,) what we can and can’t accept from glass repair and other service vendors (yes…apparetnly post-it notes are too tempting to be trusted in the hands of a service rep,) whether we can or can’t reccommend our own mechanic/restoration person/doctor to a client. Even a couple of years ago what SF logo merchandise could be given to clients (I believe it was nothing above $15.) It was and is not only an exercise in futility (no amount of rule-making is going to stop someone using unethical or criminal tactics from using unethical or criminal tactics,) it’s impractical and infuriating as well. The vast majority of the population is not going to be swayed by a pen and a chocolate bar, but that’s not the way the people making this crap up look at it. Sure, excessive crappage is bad. 90% goes in the trash. But the useful 10% isn’t really going to influence anybody by virtue of being a “gift”; if it influences anyone at all, it’ll be the way any commercial campaign works, by getting a companies name out in front of people, all the time.

    Banning “gifts” that you can get at Office Max for less than a buck is stupid. (I did have an actual point, but the phone kept ringing during this rant. Yes…my boss is at an agents event. Probably being denied swag.)

  16. #17 moderation
    June 9, 2010

    As a primary care physician, if the post-it notes and pens or anything else is supposed to influence me, then Big Pharma is putting their money in the wrong place. I have very little choice over what medication I can prescribe for a patient. Most insurance companies have very strict rules about first and second line medications. They require generics first and trials of their preferred medication, before using an alternate drug. My medication choice for a patient is in large part dictated by a decision tree from their insurance company.

    I think, an important question is: where has the money gone that used to be spent on swag, CME trips, etc.? I believe it is now being spent on direct advertising to the public. I certainly don’t remember seeing ads for prescription medication on TV and in magazines, the way we do now. That creates problems of its own, as often I have patients request a drug that would be inappropriate for them or they have disproportionate expectations of what the medication will do, based on the commercials. I want my patients to be as informed as possible, but drug company commercials are hardly the the best source of info.

  17. #18 LovleAnjel
    June 9, 2010

    I’ll echo Robin’s sentiments. It sounds like they are trying to rile people up to protest the restrictions. Because in no way is a stand of coffee free to everyone walking by a major marketing play, except perhaps for the coffee company.

  18. #19 max
    June 9, 2010

    I am pretty sure the costs to physicians to attend meetings like ASCO are offset by the drug companies through the purchasing of space in the exhibitor hall. So yes, the physicians pay to go, but much less than they would if the drug company booths were not allowed.

    As far as the studies go, the gov’t does not fully fund clinical research and the drug companies run trials to get their drugs approved which creates a marriage of convenience for clinical researchers/academics. While not perfect at least the bias is clear, compared to the academics, whose biases can be hidden. I think the drug companies now publishing how much they give and which doctors is a step in right direction.

  19. #20 Glaxo PharmaBase Orbital
    June 9, 2010

    ————-MESSAGE BEGINS

    “International Zone.” Heh. If they only knew . . .

    Lord Draconis Zeneca, VC, iH7L
    PharmaCOM Orbital HQ
    0010101101001

    MESSAGE ENDS—————————

  20. #21 Dianne
    June 9, 2010

    Here’s my complaint, again, about the restrictions on pens and so on: Pharma companies’ agendas haven’t changed. They still have an interest in selling their products and therefore still advertise. They’ll just do it differently. Direct to consumer advertising for example-what a disaster. Or washing their message through institutions so the bias is less clear and it’s harder for physicians to sort out what is real and what is drug company propaganda. I don’t particularly miss the pens and so on, but I worry about what drug company propaganda I’m mistaking for real research.

  21. #22 Dianne
    June 9, 2010

    Well, ok, I admit I miss Roche’s crepes. You used to be able to pick up lunch at the conference instead of having to buy the overpriced rocks being sold as food at convention centers. But that can be gotten around easily enough. The potential for abuse, less so.

  22. #23 Todd W.
    June 9, 2010

    I wonder, regarding the minor swag, like pens and notepads that have industry logos on them – does having those around keep the company’s name and, consequently, products in the minds of physicians more readily than the companies/products for which the doc does not have belogoed swag?

    In other words, if a doc has clicky pens from Merck (to pick a favorite of the anti-pharma crowd) on his/her desk, are they more likely to think of Merck’s products when writing a prescription than they are to think of competitor products?

    This is a much more subtle method of influencing, but still an interesting question. Are physicians being influenced in such a manner, even though they don’t think that a clicky pen is sufficient inducement to favor one company over another?

    On the other hand, this could backfire on the company. The physician may see the pen as a constant reminder of how big a jerk the sales rep was that gave it to them, thereby associating negative impressions with the company itself. What would Richard Wiseman say about this, I wonder?

  23. #24 Dianne
    June 9, 2010

    Todd: I’ve always wanted to formally study whether pens and so on made a difference to prescribing practices and even invented some protocols in my mind, but it’s one of those projects I’ll never get to.

    Besides which, the only possible conclusion is that the pens must go: If they affect prescribing practices then they’re a corrupting influence and should be outlawed. If they make no difference then they are a waste of money for the drug companies and must go. So they went.

  24. #25 Bob O'H
    June 9, 2010

    Hm. Brings to mind something attributed to Churchill:

    Churchill: Madam, would you sleep with me for five million pounds?

    Socialite: My goodness, Mr. Churchill… Well, I suppose… we would have to discuss terms, of course…

    Churchill: Would you sleep with me for five pounds?

    Socialite: Mr. Churchill, what kind of woman do you think I am?!

    Churchill: Madam, we’ve already established that. Now we are haggling about the price.

  25. #26 henry
    June 9, 2010

    Although, the examples you give sound slightly silly, the reason that these restrictions have to be put in place is precisely because there are MDs willing to sell their souls for financial incentive. You don’t have to look far for examples of this. The pychiatrists in Boston who peddled drugs without declaring that they were being paid by pharmaceuticals and the radiolgist from NY who wrote papers detailing significant results related to early screening CT- however, funding was exclusively from a tobacco company and she (radiologist) had patents for the CT protocols. It is precisely because unscruplous people like this seek to HIDE their agenda- and it is not to help patients, science or humanity -BUT their self interest and bottom line. Sad but true.

  26. #27 Chris
    June 9, 2010

    henry:

    Although, the examples you give sound slightly silly, the reason that these restrictions have to be put in place is precisely because there are MDs willing to sell their souls for financial incentive.

    Sounds like Wakefield.

  27. #28 Jojo
    June 9, 2010

    This is a trend that is creeping into many industries. I work in the aerospace business and we do a lot of Government contracting. They have cracked down hard on what is and is not allowable. We cannot even pick up a government employee from the airport to save them the time of catching a shuttle. We have one on-site auditor who won’t even accept a tootsie roll from one of us. At first we all scoffed at it, but it’s really the only way to maintain the appearance of integrity. This had been so overboard for so long, it’s the only way to clean up the image, and I would suggest that this is true for doctors accepting gifts from Pharma. It may be too far, but it’s also necessary to regain trust.

    From a patient’s point of view on the pens and sticky notes, I’d say they are likely one of the most visible forms of swag being offered to doctors. I pay most of my copays with either a check or my debit card, both of which normally involve me using a pen from the receptionist. I also get lab numbers written on sticky notes. These almost always have some pharma info on them, and certainly do provide the company or drug with exposure in the doctor’s setting. Honestly, it doesn’t look good. If you add in the little calendars with pharma logos on them that we glance at when scheduling our next appointment, the informational posters with pharma logos, and all the other little junky stuff all over, some doctor’s offices look more like NASCAR cars than medical offices.

  28. #29 Composer99
    June 9, 2010

    henry @ 26:

    In both of the examples you provide, the problem is not physicians or psychiatrists accepting ‘swag’ in the form of pens or coffee. It is that they failed to disclose massive potential conflicts of interest.

    I don’t really see much harm in pens, post-it notes and coffee per se. However, I would wager that pharmaceutical marketing departments distribute them in the expectation that they do, in fact, exert some influence (however subtle) on people’s medical pratice. That would be reason enough, I suppose, to refuse the swag.

    If it were me at ASCO, though, whether or not I would refuse coffee depends on the available alternatives. No Starbucks or similar coffee shop within walking distance? Then it’s the Bayer desk for me.

  29. #30 JustaTech
    June 9, 2010

    We were just talking about this today when a rep came over to chat, show us some new posters, and happened to bring a few donuts with her. Now,my lab never, ever, ever has anything to do with anything out of a human (except our researchers, of course), but as a lab under a state institution (paid for by an independent not-for-profit) we are not allowed to get goodies. No pizza, no parties, nada.

    We can still get stuff at the product shows, pens, floating tube holders and the like, but we are not allowed to receive food. And because of the economy the past two years we were asked to “donate” for our crummy grocery-store sandwiches.

    And here’s my issue: We buy from whoever has the best stuff and gives us the best deal. And the few times we have gotten pizza, it was a thank you *after* we bought a freaking huge instrument. It’s not like they gave us pizza and then we bought it. I just don’t see where I’m being bribed. I mean, if a pen from a company I purchase from is that terrible, shouldn’t all the products also have to be un-branded?

  30. #31 Ian
    June 9, 2010

    @Composer99

    And that’s why you’re DESTROYING MEDICINE! Taking a coffee based on its physical proximity/convenience rather than taking a wildly ineffectual principled stand against an industry you have to work with as part of your job? SHAME, sir! SHAME!

  31. #33 Schwa
    June 9, 2010

    My guess at a more likely mechanism for the observed effect of trivial things like coffee and pens is that nine times out of ten, if you stop to fill a cup of coffee at a vendor table, you stick around for the whole pitch. So, coffee, no big deal. 5-10 minutes of face time with a rep trained extensively in manipulation? A rather bigger deal. If you think I’m kidding, see if you can get your hands on a drug rep marketing packet. They’re creepy.

  32. #34 gaiainc
    June 9, 2010

    One of the more useful activities I had in residency was meeting with the pharmacy reps with our PharmD. The conversation would go fine. Occasionally the PharmD would ask a particularly pointed question if the rep was being egregious. Afterwards the PharmD would ask, “So what was wrong, deceptive, etc. about that presentation?”. He would go through the spiel and the supporting literature from the rep showing places where what was said was perhaps not what was real. Great for developing thinking skills. My residents now lack this training and I sometimes think it’s a disservice.

    Then again, they might end up being Lesa credulous of woo as well and the department couldn’t have that.

  33. #35 Reesa
    June 9, 2010

    I was at ASCO. The line for Starbucks was always a 30 minute minimum wait. Coincidence?

  34. #36 Mephistopheles O'Brien
    June 9, 2010

    Several years ago, one of my friends in the medical devices business told me of how his employer was being investigated by the Justice department for its marketing practices. None sounded out of the ordinary for the medical products business (though it was all stuff my employer would never have allowed me to accept) – things like travel expenses to conferences for doctors and their families, meals at 4 star restaurants, that sort of thing.

    The pendulum swings.

    It’s unclear to me whether vendors are now playing it safe, or hoping that by overstating the limitations they can get people to complain to their elected representatives and take the heat off.

  35. #37 JakeS
    June 9, 2010

    Maybe I’m being naive here, but isn’t coffee, ball pens, paper and so on supposed to be included in the conference fee?

    At the one physics conference I’ve seen from the inside (as a gopher, not a participant), that sort of thing was all provided by the conference, out of the participants’ conference fees. (OK, the European Physical Journal did sponsor the ball pens – good pens too, I still use them three years or so later. And I think the conference centre foisted some ads for the local tourist traps on us, but that’s the extent of it.) Granted, it wasn’t a very big conference, but still.

    Incidentally, that seems to me to be a good way to draw the line: If it’s small enough to not be corrupting, the conference should be able to provide it without adding prohibitively to the attendance fee, and the external companies shouldn’t be providing it. If it’s big enough to be corrupting, then the external companies shouldn’t be providing it either. Conclusion: The external companies should Go Away from the conferences.

    Of course, combined conference/trade shows might be a different story. Although I think that one can ask whether it’s a good idea to have scientific conferences and commercial trade shows that tightly integrated in the first place.

    - Jake

  36. #38 Militant Agnostic
    June 9, 2010

    Orac, I thought Lord Draconis Zeneca would have warned you to avoid the coffee at the Bayer booth for good reasons known only to his lordship.

  37. #39 Phoenix Woman
    June 9, 2010

    Sounds to me as though they pharma reps are trying to make you angry with these new regs. “Oh, the law says that we can’t give you a cup of coffee.” Which sounds ridiculous (and is, as you pointed out, a really extreme and inaccurate interpretation of the law.) But it erodes support for those regulations. It’s sort of juvenile, but I’m sure that it is calculated.

    Yeah. It comes off almost like a parody of a really snotty teenager’s deliberately and poutily overenforcing a particular commandment of his or paren;ts, just to get back at them.

  38. #40 Espresso man
    June 10, 2010

    What I can’t understand is why anyone would queue for Starbucks, let alone have any respect for any company that provides Starbucks coffee, but then I am Australian.

  39. #41 Steve
    June 10, 2010

    “How on earth can we justify dozens of booths at a major medical meeting, some of which cost on the order of a quarter of a million dollars transport and staff?”

    I helped set up a booth at a European conference. The floor space alone was £200,000 over three days. The booth, transport, setup, software development, swag, staffing (the girls are all from modelling agencies, etc) cost about £300,000 more. It was only so low because the booth gets reused. If it were a one off cost, the price would be closer to a million pounds.

    £500,000 is about $750,000. That’s a lot of money.

    P.S. I realise that’s still technically “on the order of,” but it’s definitely not “on the close order of”

  40. #42 Jeremy Nimmo
    June 10, 2010

    I don’t know about the legal warnings being stealth lobbying- are the ‘may be hot’ cautions on hot drinks now intended to rally support for tort reform? One doubts any provider of pharmaceuticals, no matter how large, wants to be the subject of an experiment in ‘how an attorney general can become a governor, while wasting millions of dollars’.

  41. #43 Elaine Jesmer
    June 10, 2010

    Holy cow! I don’t know how I found your site – I obviously don’t really belong here – but your posting is the closest I’ve found to addressing the problems I’ve had.

    (Btw, I should mention that having attended at lot of book conventions, although the restrictions are quite different, the swag at Book Expo America {BEA} has diminished proportionally to the swag at the ASCO convention.)

    I wonder if you – or anyone who reads this post and has any suggestions (or better yet, can pull out a checkbook as he/she says “I want to fund this.”) – could please take a look at my site and – y’know – help.

    I wrote a book about chemotherapy for patients and families. I’m a writer who worked in publishing, so I formed a non-profit and self-published, to keep control. As you know, chemo isn’t just for cancer, so one would think I wouldn’t have much trouble marketing a book that doesn’t push any drugs or treatments. I wanted healthcare organizations to buy the book in quantity and give it to their patients, so someone on chemo doesn’t have to go out and buy a book – or worse, be directed to one of those rooms with shelves of books and computers that healthcare organizations swear are wonderful, in lieu of spending a dime they don’t have to spend on something a patient can actually take with him/her. It’s sort of a win-win situation: a tax write-off, a small expenditure, p.r. points for helping patients beyond just giving them drugs.

    What I didn’t figure into my market plan was the news I received from an honest guy at City of Hope in Duarte, CA: Healthcare facilities don’t have money for patient education. Donors want their names on buildings, not on books. How right he is! My own oncologist, who is a bit of a star, wrote the preface to to book; then her group refused to put the book out for patients because they were “afraid of being sued”. Needless to say, they never gave it to a lawyer to review. Even though she paid for printing of 250 books, she’s way nicer about the insult than I am.

    What I’m getting at is, I’m afraid the only way to go here is to go to the drug companies. They love giving things to patients. The book I picked up when I started chemo came from a big drug company: just cut open the shrink-wrap, and watch their company product info spill out. And the book, itself, was cringe-worthy. I was part of a captive audience, and I hated it. Worse, my oncologists’ practice was helping them get to us.

    When I first started the project and thought I wanted to do a calendar for patients, one really big drug company was interested in funding it – if I pushed one of their drugs in the content. I said no.

    I’ll still say no to content placement, but if a drug company sees that this book is an asset to to marketing plan, I don’t see any other choice…

    Do you?

  42. #44 Elaine Jesmer
    June 10, 2010

    I posted my URL address, but it doesn’t show. My site is http://www.elainejesmer.com

  43. #45 Just Wondering
    June 11, 2010

    If a IT manager purchases a lesser brand of computer because the vendor gave him more or better swag, he and his company suffer. If a doctor prescribes a lesser drug, the patient, not the doctor, suffers. And the patient doesnt have another option: The patient cannot chose for himself which drug to take, it has to be prescribed by the doctor.

    What if the IT manager works for a hospital and the system in question processes patient records and because of some software error the patient is given an improper drug or dosage?

  44. #46 redrabbitslife
    June 12, 2010

    It was a lot easier to send the pharma reps packing when I worked in Quebec, because everyone had some form of prescription drug insurance. Here, I have to schmooze to get samples for my patients who can’t afford their drugs. Ontario has something to learn.

    If hear one more word about HyVet, I’m going to throw something. Seriously. I hate reps. I let them leave their stuff and I merrily plug generics. Is that wrong, too?

    (One of the most entertaining ways I realised how far from all the other local docs I am, was when one of the reps came in sighing that something or other had gone generic. He was shocked when my face lit up…. )