New curbs urged on doctor perks

Physicians from leading medical schools, including Harvard, are calling for teaching hospitals to sharply limit the gifts and money they accept from pharmaceutical and medical device makers, saying even small gifts can influence doctors to use products that may not be the most effective and cheapest.

Many of the practices the group wants to ban or restrict are common in hospitals around the country and in Massachusetts' renowned academic medical centers, including Harvard's teaching hospitals, guaranteeing that the recommendations will prompt heated debate.

For example, the doctors want to prohibit payments for time to travel to and attend medical conferences, and free meals. Drug companies routinely supply free lunches for medical residents at hospitals, which department heads use to attract the physicians-in-training to noontime lectures and meetings without depleting department funds.

The authors of the proposal include doctors from Harvard Medical School, Columbia University, the Association of American Medical Colleges, the University of Washington, and two University of California campuses; the American Board of Internal Medicine Foundation, a nonprofit group whose aim is to advance medical professionalism, and the Institute on Medicine as a Profession, a nonprofit research organization at Columbia, paid for the research.

The group published its recommendations in today's Journal of the American Medical Association, which is widely read by doctors. It also attacked other popular practices, saying drug companies should not give free drug samples directly to doctors and should develop other ways to distribute the drugs to needy patients. It also said drug makers should not be allowed to sponsor specific continuing medical education programs for doctors that are related to their drugs, or pay doctors to serve as members of company ''speakers bureaus."

''Money is a very powerful incentive, and doctors respond to these incentives just like other people do," said Dr. Jerome Kassirer, one of the authors and a professor at Tufts University School of Medicine and former editor of the New England Journal of Medicine.

Federal and state prosecutors have investigated and criminally charged a number of drug companies in recent years with lavishing expensive trips and consulting fees on doctors to encourage them to prescribe their drugs. These investigations have resulted in multimillion-dollar settlements with companies, including TAP Pharmaceuticals of Illinois and AstraZeneca of London, and prompted organizations including the American Medical Association, a national doctors group, and the Pharmaceutical Research and Manufacturers of America, an industry trade group, to issue voluntary guidelines discouraging the most egregious inducements, such as free trips for doctors to warm, seaside resorts to hear about new drugs. The association's guidelines discourage expensive meals and gifts that are for a doctor's personal use.

The doctors, led by Dr. Troyen Brennan of Brigham and Women's Hospital, a Harvard teaching hospital, said these rules are inadequate. They said that doctors should take more responsibility for setting ethical standards, and that teaching hospitals should lead the charge because research is concentrated there, making unwarranted influence particularly dangerous.

The voluntary guidelines -- and many doctors' thinking on the issue -- contain two serious flaws, they said. One is that small gifts don't matter. For example, Partners HealthCare, the parent organization of Massachusetts General Hospital and the Brigham, allows drug companies to provide free lunches at educational events valued at up to $20 per person. But a growing body of research shows that ''the impulse to reciprocate for even small gifts is a powerful influence on people's behavior," the authors wrote.

Second, they said, many doctors believe they can avoid a conflict of interest by disclosing gifts to patients or an audience of other doctors. But the authors said disclosure ''may be used to sanitize a problematic situation, suggesting that no ill effects will follow." The group did not say whether most doctors disclose their conflicts.

The group said doctors should be allowed to accept consulting fees and research grants from drug and device companies, because these relationships are crucial to developing new drugs and products that help patients. But, it said, the contract should make it clear that the doctor is providing a scientific -- not a marketing -- service, and details should be posted on a hospital's website.

Scott Lassman, a lawyer for the pharmaceutical association, said the additional safeguards the doctors propose are unnecessary because current guidelines already have eliminated the most lavish gifts to doctors. He also said drug companies need to get information on medications in front of busy doctors and sometimes a ''working meal is the easiest way for the company to get in the door."

Teaching hospitals are struggling with these issues, partly because they have come to depend on funding that is now considered suspect, and within hospitals doctors disagree about where to draw the lines. At Mass. General, for example, the Department of Medicine no longer allows drug companies to pay for lunches, but other departments do.

Just yesterday, UMass Memorial Medical Center and UMass Medical School in Worcester hosted a continuing medical education course for doctors about strokes, with Genentech, a biotechnology company based in California that makes a stroke medication called Activase. The hospital advertised Genentech as a sponsor of the stroke program.

Dr. Bruce Meyer, chair of obstetrics and gynecology at UMass and president of the UMass Memorial Medical Group, said Genentech donated money to the UMass Memorial Foundation, earmarked for the neurology department. The company only may donate money to the department generally and not for a specific conference. But Meyer said he cannot know what informal conversations might have taken place between the company and neurologists.

The hospital now is considering further distancing companies from such programs by not giving them credit as a sponsor. He suspects far fewer companies will donate money for educational programs.

At Tufts-New England Medical Center, pharmacy directors said they are working toward stricter rules but often get resistance from doctors. Pharmacy executives said drug company representatives call up the secretaries in various departments and find out what lunch meetings are on the schedule that need a sponsor. In some cases, department heads allow the company employee to attend the lunch and even speak; in other cases they don't.

''What the industry has done is create a set of expectations; it's fostered an entitlement syndrome," said Edward Decker, clinical manager of pharmacy. ''Our residents and even our attending doctors just don't want to give up these free lunches."

Liz Kowalczyk can be reached at kowalczyk@globe.com.