Medicine wins when doctors say no

I need to come clean about something. I did take the little black doctor bag.

Upon completing medical school, all the graduates were offered a free bag from a drug company. Since our class was full of semiradicals from the antiestablishment, war-hating tumultuous '60s, taking a free gift from "the man" was no small violation. But it was a cute little bag, and I had worked really hard to get it.

It was a small sign of things to come. Hardly a day goes by without yet another story about the evil influence of Big Pharma on medicine. Last month, Governor Deval Patrick signed legislation directing state regulators to ban most restaurant meals and small gifts that pharmaceutical companies provide doctors and requiring public disclosure of industry payments or gifts over $50. I applaud this effort to make interactions between doctors and pharmaceutical companies transparent.

Pediatricians are considered small fish by the medical industry in that we do not perform procedures using expensive (and lucrative) equipment, and the medications we use are cheap and infrequent. However, as the medical director of our practice, I have had a bird's eye view of the insidious creep of outside influence from the medical industry.

In the early days of my practice in the 1980s, I often saw pharmaceutical representatives pull their sample-laden suitcases through the waiting rooms. A drug rep would buttonhole me and my colleagues as we moved between patient exam rooms, thrusting a recent studies at us about how a certain product had been shown to be superior. These attractive and often charismatic sales reps would somehow spit out a quick spiel before you had time to think. The path of least resistance was to accept the "unbiased study," along with several free samples for the practice. And then, of course, the treats would follow - pads of paper, pens, and perhaps a new toy for the kids in the practice - usually with drug logos stamped on them.

When Ceclor, an antibiotic used to treat resistant bacteria, was introduced in the '80s to treat ear infections, drug reps were all over pediatricians' offices. Since I had their studies in hand, samples of the "purple medicine" nearby, and easy access to dosage charts, it was the path of least resistance to use the drug, which at the time, was a good medication.

If you were a cardiologist or urologic surgeon, the treats would be more likely a posh dinner at a four-star restaurant and tickets to a ballgame.

As pharmaceuticals and medical equipment became a larger part of medical care, the stakes got higher, and the industry found new and more effective ways to influence physicians. Medical schools and hospitals have long partnered with the medical industry to sponsor educational conferences and research. As federal funding for research has leveled off, academic centers have become more dependent on industry to fund important research and educational forums. However, despite rigorous disclosure policies, it has become apparent that the slippery slope to unbiased medical practice is hard to navigate.

When I accepted the position of medical director for our practice in the mid-'90s, I had a new window on the powerful influence of the drug industry. Accepting a dinner invitation at a first-class restaurant to hear about a new cholesterol-lowering medication, I joined a group of medical directors from all over Massachusetts. The invitation seemed harmless to me at the time. I could tolerate a pitch about fat while munching on filet mignon and savoring pastries. I was concerned, though, the following week when the charming host for the evening called me and offered to pay me hundreds of dollars "under the table" if I allowed a drug rep to pitch our group at our next practice meeting. Now even a traitor who accepted a black bag from "the man" knew an ethical line had been crossed here.

Our group decided to ban all sales reps from the office a decade ago, as the medical community became more aware of the corrupting influence of pharmaceutical detailing. We would accept no more free samples. No more pizza lunches. And certainly no more posh evenings out for me. The decision was a hard one for the group, because the sample medications were often used for patients who could not afford medications. And the lunches were popular with the staff; after all, nobody was giving them free anything.

It turned out that deciding to remain drug-rep free was harder than we thought. Time went on, and before I knew it the familiar suitcases on wheels were back in the waiting room. What was going on? While it seemed that we were sabotaging our own policy, it became apparent that the staff allowed "Pharma creep" mostly in the interests of the patients. For example, it was helpful to be able to provide vomiting babies a bottle of Pedialyte in the office, and while most of our mothers breast fed their babies, the ones who did not were grateful for bottles of formula. We always needed more pens, and the pizza was really tasty. The insidious nature of the industry was difficult to fight.

While the evidence-based practice of medicine and the medical-industrial complex need each other, especially as funding becomes scarcer for research and development of life-saving medications, it is critical that we vigilantly guard against subtle pressures than can affect our judgment.

I was reminded of this just the other day, when I asked one of our staff for a pen. Guess what was on the pen: a multihued ad for Carvediol, a medication for hypertension and heart failure.

Dr. Victoria Rogers McEvoy is chief of pediatrics of the Mass. General West Medical Group and an assistant professor at Harvard Medical School.