The following post was written by Dr. Stephen R. Smith, professor of family medicine at the Warren Alpert Medical School of Brown University.

One way to thank someone for giving you a gift is to say; “I’m obliged.” That’s exactly what drug companies want doctors to say for the gifts, large and small, that they bestow upon them. That feeling of obligation costs you, the patient, and money and endangers your life. Drug company gifts to doctors must be banned.
Pharmaceutical companies curtailed lavish gifts to doctors, such as luxury vacations and Super Bowl tickets, in the face of public outcry and congressional scrutiny a few years ago. But the practice continues in the form of free food, sumptuous dinners under the guise of education, and free trinkets such as pens and notepads.
Although the dollar value of these gifts might be less than that of gifts in the past, the effect is the same: The gifts make doctors feel indebted for the kindness and, in turn, doctors feel an obligation to prescribe the company’s drugs.  Social science studies tell us that the size of the gift doesn’t matter. When you receive a gift, you feel obligated to reciprocate in some way to the gift giver. The recipient of the gift doesn’t even have to be conscious of this feeling.  Most doctors think their prescribing practices are not influenced by drug company gifts, though careful studies have shown the opposite to be true. Drug companies wouldn’t spend billions of dollars on gifts if they weren’t sure the investment would payoff.
Recently, I received an invitation from Genentech and Novartis to have dinner at a steak house to hear a doctor talk about their new asthma drug, Xolair. The thought of a big, juicy filet mignon was tempting, but I turned it down.
The drug is very expensive ($560 a dose). It has serious and sometimes fatal adverse effects, and should be used in only a few patients who don’t respond to conventional therapy. I didn’t need to hear a paid drug company spokesman tell me about it. I can easily obtain objective, unbiased information from other sources.
These gift giving practices cost taxpayers money. Americans spent $217 billion on prescription drugs in 2006, up 8.5 percent from 2005.The share of that cost paid by Medicare shot up from 2 percent to 18 percent as the new drug plan for Medicare came into effect. The marketing practices of drug companies undermine efforts to get doctors to prescribe effective, low-cost generic drugs, even when scientific studies show that new, expensive drugs are no better.
Aggressive marketing also poses dangers to your health. Pharmaceutical company sales people pushed doctors to prescribe Vioxx, even though cheaper and older painkillers would  have been fine for the vast majority of people given Vioxx prescriptions. Fewer deaths would have occurred by the time the drug was pulled off the market if it hadn’t been marketed so aggressively.
Drug companies have proposed voluntary guidelines they would follow in response to recent scandals. They would limit educational gifts to less than $100 and prohibit non-educational gifts such as coffee mugs and pens, but would still permit free food for doctors and their staffs, free dinners to hear paid speakers, free samples and support of educational meetings. In other words, doctors would still be getting gifts and still be feeling obliged to the drug companies.
The American Medical Association, which received tens of millions of dollars annually selling prescribing information that drug companies use to target their messages to doctors, also supports these voluntary guidelines. The National Physician’s Alliance supports a full ban on gifts from pharmaceutical companies and opposes the AMA’s sale of prescribing data to marketing companies.  Pharmaceutical companies should be banned from giving gifts of any amount or size to physicians. Doctors should write your prescriptions based on the best science and your best interest, not the steak dinner they enjoyed on a drug company’s tab.

Update- 1/2/09, the US pharmaceutical industry is observing a voluntary end to the distribution of “branded office items” (translation: pens, coffee mugs, etc.) to physicians.  Around 40 companies have signed up to the code, but more work still needs to be done. In particular, food gifts are not included in the ban. When you visit your physician and notice the big party trays of sandwiches, by all means, offer that you’ll bring them lunch next time. My mom always said a little guilt goes a long way.

Two interesting articles caught my attention this week and I hope you’ll take the time to read them too. What’s the Right Decision appearing in the Fall edition of Cure magazine and written by Jeffrey Belora, director of Decision Services at University of California, San Francisco Breast Care Center and then in the 12/22 BusinessWeek Health section is a story entitled, “If Health Care Were Run Like Retail…”

In his article Dr. Belora discusses the theory that having all the information can make descision-making easier and the reality that we can never have all the information and that not even more information can make it easier. To paraphrase the good Doctor, “We may be able to narrow the range of uncertainty, but we will still need to weigh the risks and benefits.” He concludes by suggesting that there are some good lessons that could be applied to healthcare by adopting the shared decision-making that works in engineering, aeronautics and other high-stakes, high risk situations. While I don’t dispute his proposal, I’d like to recontextualize his risks and benefits proposition by suggesting that until the healthcare consumer-  or the caregiver watching over someone gets the information they need so they can make intelligent choices (or indeed any choices), the healthcare system will remain broken.

The BusinessWeek article presents the position of Regina Herzlinger, a Harvard B-School professor. Dr. Herzlinger has authored several books including “Who Killed Healthcare” and Consumer Driven Healthcare. Money magazine refers to her as the Godmother of consumer-driven healthcare. My kind of lady.

According to the story, she believes that healthcare insurance purchasing should be mandatory, that consumers should be able to tailor their own healthcare coverage and (most importantly to me) is that a national database would be created that contains prices and outcomes for procedures at every hospital and clinic so consumers could make informed choices. That’s the information part.

In the article, some of Dr. Herzlinger’s critics argue that healthcare is too complicated for consumers to sort out on their own and insurance too costly a burden for the individual. Dr. Robert Galvin global health director for GE says that Americans wouldn’t give up employer-provided health insurance. He’s right in a way. It is complicated. But for 47 million uninsured and 10 million unemployed Americans, that decision has already been made.

While employers have a self-interest in managing healthcare costs, they have less of an interest in (and less time for considering) quality of care. And anyways, who are we trying to kid? Employers don’t pay for health insurance. The consumers of the products and services those employers produce do. Interesting fact: healthcare costs add $1,525 to the cost of every car produced by General Motors. Compare that to Japan where their universal healthcare system results in an upcharge of just $125 per car.

How did we get to the point at which it’s easier to shop for a digital camera than for the place at which you’d like to have heart surgery?

I think we sell the American consumer short. Provide some information and some choices and people will choose. Along the way, we’ll learn that the information they have isn’t adequate enough and their choices aren’t clear and the system will begin to evolve.

This is already happening. Thousands of Americans are evaluating their options and then choosing to have elective surgery performed in hospitals and by doctors outside the United States. Medjourneys.com lists complete packages of hospitals and doctors to choose from, each including a detailed description of specialties, credentials, certifications and references. They don’t publish prices, but family members who have used their services save 40% or more. You can fill out a quick email form and they’ll quote you.  There it is… information and choices.

Think of it. Before that young couple decides to have their first child at Metro Hospital, they might look through Consumer Reports to learn that the care at Main Street General is to their liking and by using them they will save 10% off their insurance premium for the next six months because that particular hospital doesn’t offer delivery of meals to the room. You must bring them in yourself but the good news is that your regular doctor can work in any hospital they choose to. Sorry- but today, this is all promise not reality.

But now we arrive back to the subject of information and choices.  Won’t someone please explain to our healthcare cartel that it doesn’t have to be this way; that information and choices are better for all?

I think we’re all beginning to figure out that to a large degree, We the People are going to have to fix some of this country’s problems ourselves. We’ve heard some great plans for fixing our broken healthcare system. Over the next few weeks, I’d like to offer up some ideas about what we each can do about healthcare.

With apologies to those who occasionally enjoy those cream filled cakes, I use “The Twinkie Effect” as a metaphor for all of those things we’ve eaten and done (and/or rather not done) to our bodies.  Here’s a shocking number: 75% of our healthcare spending goes to caring for coronary artery disease, diabetes, congestive heart failure, asthma and depression says George Halvorson, chairman and CEO of Kaiser Foundation Health Plan and author of “Health Care Reform Now! A Prescription for Change”. (I recommend this book.)  He goes on to say that if just 1% of people with these conditions successfully treated, we could reduce our healthcare costs by $77,000,000,000. (With all the “billion” numbers that have been thrown at us over the last few weeks, personally, I’ve become a bit numb to the meaning. All those zero’s help put it in perspective for me.)

According to the IRS, there are 138 million taxpayers in the United States. That works out to a reduction of $557 per person. But wait. There’s more. Type 2 Diabetes is a “lifestyle” disease, meaning one that you can do something about by changing how you live. For starters, take a thirty minute walk each day.  Skip dessert just two times a week.  Northwestern Mutual has a terrific web application called the Longevity Game. Play it to see how long you can expect to live. Another favorite site of mine is www.fightchronicdisease.org. It’s operated by the Partnerships to Fight Chronic Disease, a national coalition of patient, provider and community organizations.