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Am Fam Physician. 2007;75(10):1447-1448

See related Editorial on page 1453.

to the editor: At our practice, we continue to regularly receive a barrage of invitations to free dinners, offers to attend professional athletic venues, and all-expenses-paid consultant meetings at five-star hotels. These events are sponsored by pharmaceutical companies under the umbrella of medical education and research. Why is this still occurring? In the late 1980s and early 1990s, the major medical organizations and medical journals established guidelines to address the relationship between the pharmaceutical industry and medicine. Studies and literature reviews show that gifts to physicians from the pharmaceutical industry influence prescribing patterns of residents and physicians, and the formulary requests of physicians.1

Despite this, the amount of money pharmaceutical companies spend on direct marketing to physicians continues to rise at a rapid pace. According to the U.S. General Accountability Office, drug companies spent $16 billion on direct marketing to physicians in the United States in 2001, more than $19,000 per physician. Promotions to physicians accounted for more than 80 percent of all marketing spending by drug companies in 2001. Direct-to-consumer spending by pharmaceutical companies was $2.7 billion in 2001, up 145 percent since 1997.2

The amount of money spent on promotional activities affects prescribing habits and the cost of medications. Systematic reviews have confirmed that prescribing patterns of physicians differ depending on the frequency of contacts with pharmaceutical representatives. Physicians who have more frequent contact with the pharmaceutical industry are less likely to prescribe generic drugs and more likely to prescribe new drugs.3

The pharmaceutical industry may be influencing clinical practice guidelines and are beginning to fund postgraduate education. Major medical journals require authors to disclose any potential conflicts of interest with pharmaceutical companies; however, there is no similar requirement for clinical practice guideline panel members. In a cross-sectional survey of 192 authors of 44 clinical practice guidelines published between 1991 and 1999, 87 percent had some tie with the pharmaceutical industry, and 58 percent had received financial support to perform the research. Another concerning trend is that residency and fellowship programs are using pharmaceutical monies to fund residency activities.4,5

Where are the major medical associations on these issues? Major journals are dominated by pharmaceutical advertisements, and continuing medical education (CME) is increasingly being underwritten by pharmaceutical companies. At major medical meetings, physicians are enveloped in the embrace of the pharmaceutical industry from registration to the exhibition hall to “breakfast and dinner lectures.” It is time for our major associations to step forward and address the effect the pharmaceutical industry has on rising drug costs and rational prescribing patterns. Our leaders need to address the industry influence on publication bias, clinical practice guidelines, CME, and medical education. If we continue to slip backward, every facet of our profession is in danger of being dominated by pharmaceutical industry agendas.

editor's note: At American Family Physician, we strictly separate continuing medical education (CME) content and advertising. This policy is in keeping with the rigorous standards of the Accreditation Council of Continuing Medical Education (ACCME) ( The ACCME oversees the CME accreditation process, and prohibits any comingling of advertising and CME content. For this reason, you will not see any advertisements in the middle of our clinical review articles. In addition, advertising and potentially related CME content should not be juxtaposed. Toward this end, we do not run advertisements near our articles and other CME content that might be perceived as being related to the subject matter. The ACCME's policy has provisions that allow for CME content to be generated by individuals who have financial relationships or other conflicts of interest with a relevant commercial entity. These conflicts can be “resolved” by mechanisms that include independent peer review, or comparison of the content with “best evidence.” However, at AFP, we go a step further and do not consider articles written by authors who have close ties to the manufacturers of drugs or devices related to the subject matter. (AFP's conflict of interest policy is available in our Authors' Guide Although AFP accepts advertising, we work hard to ensure that our clinical content is free of any commercial bias and is based on the best evidence available.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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