Pens, mugs, clocks, notepads and other handouts
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* Janet Rae Brooks

*   © 2008 Canadian Medical Association

## “Clean sweep” initiative ships industry goodies to the Cameroon

Earlier this year, a Minnesota-based operator of hospitals and clinics collected 20 shopping carts of drug company trinkets and shipped them to the west African nation of Cameroon. The idea for the roundup emanated from SMDC Health System's own marketing department after an internal team of physicians drew up new ethics guidelines that banned staff from accepting gifts from drug companies or using items adorned with their logos.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/179/1/28/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/179/1/28/F1)

Concerned that health care workers are walking an ethical tightrope, a United States–based health organization has banned staff from accepting handouts from the pharmaceutical and medical devices industries. Image by: mabus13/iStockphoto.com

For each branded item staff surrendered in a program called “The Clean Sweep Initiative,” staff were entered into a prize draw for vacuum cleaners, sweepers and home-organizing services. An astonishing 18 718 pens, mugs, clocks, tote bags, notepads and other items were collected from SMDC's 4 hospitals and 17 clinics in Minnesota and Wisconsin.

The trinket roundup is part of a growing movement in the United States to end the cozy relationships between doctors and the pharmaceutical and medical devices industries. Among those spearheading the drive is the Boston, Massachusetts–based non-profit organization, The Prescription Project, a $6 million campaign funded by the Pew Charitable Trusts, which grew out an article decrying the financial ties between doctors and drugmakers after research indicated that even cheap gifts can influence prescribing decisions (*JAMA* 2006;295:429-430).

The pharmaceutical industry spends nearly US$30 billion in the United States on marketing annually, including more than US$18 billion on drug samples and US$7.2 billion on gifts for doctors. “If people understand this,” says Prescription Project Executive Director Rob Restuccia, “they get outraged by it.” A 2007 survey found that 94% of physicians have relationships with drug companies, but many still believe they are immune to influence (*N Engl J Med* 2007;357:507-508).

Although the Midwest roundup of drug company trinkets wasn't hatched by the Prescription Project, it champions a raft of recent calls for a ban on gifts, free meals, travel fees and payments to doctors for attending drugcompany meetings. Other troublesome areas include drug companies paying for continuing education courses, doctors with ties to pharmaceutical firms sitting on hospital committees that approve drugs, and doctors at academic medical centers serving as paid spokespeople for drug makers or signing their names to articles ghostwritten by their marketing departments.

The medical profession also needs to examine its acceptance of free drug samples, which the Prescription Project says are intended to encourage use of new drugs, not provide free medicine to poor people. Research has found that only 26% of drug samples go to low-wage earners, Restuccia says.

With the encouragement of the Prescription Project, many academic medical centres, including the University of Pittsburgh and Boston Medical Center, have already taken steps to curb the influence of drug companies. It is also documenting the impact of ethics changes on Yale, Stanford and the University of Pennsylvania. Medical centres may soon find their academic ranking linked to whether they are perceived to practise ethically and scientifically, says Restuccia.

In late April, 2008, the Prescription Project released tool kits to help hospitals and medical schools craft new conflict-of-interest guidelines, incorporating policies from Yale, Stanford, Memorial Sloan Kettering and others.

Further impetus for change will likely be forthcoming if, as expected, the Association of American Medical Colleges' executive-council formally adopts recommendations that its 129 member medical schools and teaching hospitals adopt a zero-tolerance approach to industry handouts (*CMAJ* 2008;178[13]:1651-52).

The pressure on physicians to renounce the goodies is only expected to escalate. Already, the National Physicians Alliance has unveiled an “Unbranded Doctor” campaign, calling on doctors to push back against drug marketing. It offers “Unbranded Doctor” coffee mugs, T-shirts and other items to replace drug company giveaways.

Legislators, meanwhile, are starting to express concern about the effect of drug industry largesse on patient care and costs. Building on disclosure laws in Minnesota, Maine, Vermont and West Virginia, proposed Physician Payments Sunshine Act bills in the House and Senate would require drug makers to publicly disclose gifts and payments to doctors.

Restuccia, who recently received a call from a man worried about receiving a particular pacemaker pushed by his doctor, now wonders about his own mother, who, in her later years, received the artificial Ewald knee, developed by Dr. Frederick Ewald, with the surgery performed by Ewald himself. “At the time, I thought it was great. Now, I wonder, ‚Was there a better knee? Why did she get this one?'” As patients become better informed, physicians can expect more such questions, he warns.

SMDC Health System chose to send its branded trinkets, including clipboards and hold patient charts, to the Evangelical Lutheran Church of Cameroon, which operates 3 hospitals and other clinics, because the advertised drugs are largely unavailable there. SMDC has sent supplies to, and exchanged employees with, the church's flagship hospital for more than a decade. “They were putting patient charts up with a thumbtack,” said spokesperson Kim Kaiser. “Even though these items seem inconsequential to us, they are very valued.” Two other US health systems are considering similar roundups, said Dr. Kenneth Irons, SMDC's chief of community clinics.