No more free lunches.

Free pens and pizza lunches. Sponsored conferences and compromised medical education. Courtesy golf and unaffordable holidays. Thought leaders and ghost writers. These are the trappings of doctors and drug companies being entwined in an embrace of avarice and excess, an embrace that distorts medical information and patient care. An article in this theme issue of the BMJ identifies 16 ways in which doctors are entangled with the drug industry. You can probably identify more. The issue explores the extent of this relationship, its effects on research, its influence on prescribing, and the consequences for patients. Our central argument is that doctors, drug companies, and most importantly patients would all benefit from greater distance between doctors and drug companies. It does of course take two to entangle, and we hope that nobody will see this theme issue as anti-drug company. Virtually all of the new drugs developed in the past 60 years—drugs that have transformed medicine— have been either developed or manufactured by drug companies. Doctors and drug companies must work together, but doctors do not need to be banqueted, transported in luxury, put up in the best hotels, and educated by drug companies. The result is bias in the decisions made about patient care. Drug companies are commercial companies that must market their products. Sometimes they bend the rules, but it is doctors who are perhaps more to blame in coming to depend on drug company largesse. How did we reach the point where doctors expect their information, research, education, professional organisations, and attendance at conferences to be underwritten by drug companies? Both doctors and drug companies know there is something unhealthy in this relationship, but seem unable to stop themselves. Some countries and professional organisations— including most recently the World Medical Association—have recognised the dangers in this proximity and have developed codes of practice. 4 The industry itself has codes. Why is that not enough? Again both sides are at fault. Codes of practice are mere window dressing unless they are explicit and vigorously observed. Industry marketers will inevitably see them as the impetus to devise increasingly imaginative campaigns that test the boundaries of the codes. Doctors, meanwhile, too easily convince themselves that their professional integrity is immune to seduction by drug companies. For too many doctors the laws of economics can be broken and the free lunch does exist. Unfortunately it is only in their imaginations. There is growing evidence that doctors’ prescribing habits are influenced by drug companies, either through discussions with sales representatives or through sales drives dressed up as medical education. A British research group finds that doctors who have frequent contact with drug representatives are more willing to prescribe new drugs, do not like ending consultations with advice only, and are more likely to agree to prescribe a drug that is not clinically indicated. It is hard not to be persuaded by a warm smile, a free meal, and a touch of flattery, and an accompanying editorial describes how information supplied to doctors by drug companies is systematically distorted. There is danger too in the glossy reprint from a prestigious journal that the drug company representative brings. Unsurprisingly, the representatives do not bring reprints that are unfavourable to their products. Journals are caught between publishing the most relevant and valid research and being used as vehicles for drug company propaganda. If a journal publishes a trial that favours drug A over drug B, is that a scientific judgment or a business investment to be repaid in lucrative reprint sales? Certainly there are dangers in pharmaceutical advertising in journals and sponsored supplements, which is why journals need systems to prevent advertising influencing editorial content. But the stark reality is that without pharmaceutical sponsorship many journals would not survive. Even so, journals are late in a research process that takes many years of planning, execution, and interpretation. Care in weeding out drug company influence and protecting patients begins at the planning stage. Research ethics committees have a vital role in ensuring that new clinical trials are scientifically justifiable. Drug development and marketing is a multibillion dollar industry, where financial interests influence the design and planning of clinical trials. Many tricks can be used to give companies the results they want, including comparing the new drug with a placebo rather than a standard evidence based treatment or comparing the new drug with an inappropriate existing drug or with too low a dose of the existing drug. 8 Two new studies support these concerns. A systematic review by North American researchers finds that studies sponsored by pharmaceutical companies are four times as likely to have outcomes favouring the sponsor than are studies funded by other sources. European researchers look at Saturday 31 May 2003