The hidden persuaders: subtle advertising in radiation oncology.

When a pharmaceutical company gives a radiation oncologist a new stethoscope, with the name of one of the company’s prescription drugs engraved on the instrument, is it a gift, an advertisement, or a bribe? Should the physician accept the stethoscope or refuse it? A gift is something which is transferred to another without the expectation or receipt of an equivalent. An advertisement is the action of informing or notifying, generally for the purpose of selling a product or service. A bribe is an attempt to influence corruptly (1, 2). Is the stethoscope a freely given gift, an advertisement for a product, or a bribe to prescribe the product? The pharmaceutical industry spends $13.9 billion dollars per year on promotion and marketing. It has been estimated that more than $8000 is spent per physician per year in this effort (3, 4). Money spent by pharmaceutical companies and equipment manufacturers on what are generally referred to as gifts may result in higher prescription prices and equipment costs. Gifts may also affect the physician–patient relationship insofar as the physician is supposed to be a fiduciary or trustee whose first consideration should be the patient in all clinical decisions (5). In attempting to influence a physician, the pharmaceutical company may compromise the physician’s objectivity (6–8). We hypothesized that gifts directed to radiation oncologists and medical physicists are frequent and have the potential to influence their judgment. We sought to document the extent of gift-giving by studying six hospitals in North Carolina and Virginia. With the permission of physicians, we studied their clinic examination rooms, patient waiting areas, check-in desks, and nurses’ stations. We recorded gifts or advertising items in plain sight of patients, such as wall posters, calendars, magnets on file cabinets, brochures, pens, note pads, anatomic models, clocks, computer mouse pads, drinking cups, and stethoscopes, which bore the name of the sponsoring pharmaceutical company or medical equipment manufacturer. Items not exposed to public view, because they were inside drawers or cabinets, were not recorded. Sixty-seven promotional and advertising items were discovered. There was a mean of 0.8 advertising items per room (range 0–4) in 25 clinic examination rooms. The seven nursing stations and clinic check-in desks had a mean of 5.6 advertising items each (range 1–8). The ten waiting rooms had a mean of 0.8 advertising items each (range 0–5). The most common items found in clinic examination rooms were “educational” pamphlets, posters, and plastic anatomic models bearing the sponsor’s name. At nursing stations and check-in desks the most common items were pens, mouse pads, and magnets. Waiting rooms most commonly had brochures promoting specific drugs and diagnostic imaging agents. The implications of the gifts from pharmaceutical companies and medical equipment manufacturers found in our clinics are complex. Radiation oncologists are frequently given pens, pads of paper, calendars, books, dinners, trips to resorts for continuing education meetings, invitations to cocktail parties at medical meetings, and other inducements designed to influence prescribing patterns and the purchase of linear accelerators, simulators, and treatment-planning software. By means of a gift, the company is attempting to get a physician to facilitate a purchase. It is one thing to influence someone to buy something. There is something ethically different in persuading an individual to initiate a course of action leading to the spending of a third party’s money (9). Since physicians are not directly purchasing the drugs that they prescribe nor hospital-based equipment they use for their patients, advertising to physicians is a way of persuading them to get someone else to spend money in a certain fashion. Gifts are of central importance as a means of initiating and sustaining relationships. In contemporary society one offers a gift to a person as a means of proffering friendship or a relationship. Gift exchange is also used to mark events