Andrew D Beggs,
Final Year Medical Student
Guys, KIngs & St. Thomas' School of Medicine, London SE1

Email Andrew D Beggs:
andrew.beggs@kcl.ac.uk

Sir,

As all encompassing the reach of the drug companies is, we as health care professionals have it within our power to prevent untoward influence by these companies.

The ability to say "no" and look at evidence sceptically is one of the most important things in medicine that has been drilled in during time at Medical School.

If drug companies want to come and give us a free lunch and promote their drug, so what? If we are weak minded enough to let this influence us then we are we are not putting what we have learnt into practice from our epidiemiology lectures at all. In the evaluating the evidence of studies funded by drug companies we all know that these studies are going to have an inherent bias and thus must be taken with a pinch of salt.

The actions of US medical students are commendable in banning any hospitality from drug companies towards medical students in an attempt to prevent bias. However this seems a "hammer to crack a nut" solution. Surely it would it not be easier for medical students to critically evaluate the evidence that these drug companies present at free lunches and challenge their evidence for their products?

Surely as responsible, mature and intelligent adults we have it within our power not to fall for the "snake oil" salesmanship sometimes used by the drug companies?

Competing interests:   I was taken out for dinner by Phillips Medical Systems last month at the British Society of Nuclear Medicine Annual Conference. As I will not be buying a PET or CT scanner in the next 20 years, this may be of lesser influence.

Dr Deepak Malhotra,
Consultant, Aviation Medicine
Sydney, Australia

Email Dr Deepak Malhotra:
DeepakMalhotra@omnus.com.au

Ray Moynihan has just completed the work I started in Australia by being associated with a TV program on Channel 9 on 5th August 2001. Amongst the extravagance we showed was a function held for Doctors and wives on a SHOW BOAT with semi-naked dancing girls. I took a hidden camera and filmed many a drug company sponsored function. The resulting outrage resulted in a change in the code of ethics in Australia and most companies have abandoned such functions. Bribery still exists and unfortunately it is accepted by our colleagues.

I was amazed by the attitude shown by my colleagues here, who openly said to me that I had stopped them receiving free meals. I still wonder if such poverty stricken doctors who rely on drug companies for a meal would survive as a ordinary person in a third world country ?

The medical community in general and specially the so-called consultants should stop doing a snow job on General Practioners at the behest of Pharmaceutical Companies.

I would also ask doctors to look at references quoted in Pharmaceutical company advertising. Mostly they are quoted as 'data on file'..which essentially is a non refereed paper.More than 80% are drug company sponsored and only the positive results are published.

How do I know so much? I have worked for a Pharmaceutical Company.

Competing interests:   None declared

John J. Messmer, M.D.,
Assistant Professor, Family & Community Medicine
University Physician Group, 941 Park Dr., Palmyra PA 17078

Email John J. Messmer, M.D.:
jjm23@psu.edu

When I was a first year medical student we were given a stethoscope, doctor's bag, reflex hammer and some books and other things. I don't even remember who sponsored the items. Many of my classmates refused the gifts as they said they could not be bought. They would be unable to prescribe for another four years; how could they be bought?

If we are that easily influenced perhaps we do not deserve the trust our patients and the public give us. We all agree that the underlying reason for free lunches, dinners, and other pharmaceutical benefits, including funding of CME and journals, is promotion. I have always made it clear to representatives of pharmaceutical companies that I make the decision based on information from many sources. I have no hesitation to contradict what reps tell me or to demand valid information. I have received information from the medical departments of pharmaceutical companies and disputed the data in discussions with reps.

On the rare occasion when a rep asks me specifically to prescribe the medication being promoted, I tell them I will do so only as appropriate. I have never been told I would receive anything only if I prescribe some product. If I did, that rep would be forbidden to return and I would file a formal complaint with his or her employer.

When I have spoken for pharmaceutical companies, I make it clear the opinions are mine alone. I discuss competing products' benefits including generic products.

Each of us is faced with a multitude of ethical dilemmas daily. We are expected to do what is best for our patients regularly. We give up personal time for them every day. We accept payment, some of us accept huge payments, for our services daily. When an interventional cardiologist recommends angioplasty rather than medical treatment, is it because he or she will be paid much more for the procedure or because it is in the patient's best interest? We choose whether to see patients more or less frequently when paid fee for service knowing full well the more we see them the more we earn. Yet, this is OK, but listening to constitutionally protected free speech is wrong?

Despite my opinion that doctors should be able to receive promotional information objectively and without undue influence, I will agree to refuse all gratuities from the pharmaceutical industry and will encourage the professional societies to which I belong to eschew all pharmaceutical support ONLY when members of Congress refuse all contributions designed to influence their decision making. If it's wrong for us, it is certainly wrong for them.

Competing interests:   I have served as consultant to and lectured for several pharmaceutical companies.

Henri Sueke,
PRHO
Royal Liverpool University Hospital, L7 8XP

Email Henri Sueke:
hsueke@doctors.net.uk

Do the articles in this weeks BMJ condeming the unethical doctor-drug company relationship, have bearing on drug companies advertising in medical journals? The portrayal of running athletes next to a drug treating arthritis or a happy smiling person next to an antidepressant in a prestigious medical journal may lead to tendencies of some doctors to prescribe drugs which are not indicated.

Maybe medical journals should examine whether it is ethical to allow drug companies to use their reputation to enhance their profit margin at the patients expense?

Competing interests:   None declared

Horst Herb,
rural G.P., Principal of Dorrigo Medical Centre
Dorrigo, NSW 2453, Australia

Email Horst Herb:
horst@dorrigomedical.com

In Australia, >70% of General Practitioners use a software package for health record keeping that is sponsored by the pharmaceutical industry. Whenever a prescription is printed, a banner ad occupies the screen for several seconds. Some advertisements appear context sensitive to the current prescription and patient.

If we assume that the conclusion of this issue's BMJ hot topic is correct - namely that prescription habits are largely influenced by advertising as opposed to peer reviewed published evidence, then we have a situation where marginal cost savings to the GP in the form of sponsored software may create a more considerable cost increase to the public health system through induction of irrational prescribing habits. Small savings costing the nation dearly.

Competing interests:   None declared

Steven Murphy,
Family Medicine resident
Harbor-UCLA Medical Center, 90501

Email Steven Murphy:
dr.murphy@uwalumni.com

I am not very surprised by the findings presented in "Who pays for the pizza?" If advertising didn't work, companies wouldn't spend millions on it. From my friends in the ad world, face to face encounters and 'friendly gestures' are key pieces of successful ad campaigns. Several writers have suggested that we, as highly intelligent professionals, can resist such marketing techniques. That is a conclusion that may be right for an individual but is not generalizable to the population as a whole. The evidence presented by Mr. Moynihan seems strong and deserves our attention. When the prognosis could be serious, it is imprudent to ignore early signs and symptoms.

Competing interests:   I am a member of the housestaff union, JCIR.