Black Bags & Coat Patches

Yes, there were a few females in our class of 115. One had gained some notoriety by being runner-up in the Miss West Virginia contest as a senior in college. I guess she would have gone to the big show in Atlantic City had the winner been disqualified for moral turpitude or whatever passed for that in the mid-60s. But here she was in medical school along with a handful of her less glamorous sisters, no longer the beauty queen, just another second year medical student sitting behind her plastic and tubular steel escritoire.

The Dean went on in his usual soft Tidewater drawl. "Gentlemen and ladies. I am pleased to introduce you to Mr. Brown, who is the Eli Lilly representative here on campus. He has some gifts for you all."

Mr. Brown came to the microphone at the front of the lecture hall. "Thank you, Dean Nelson, and greetings to the class of 1969. It is my pleasure, as it has been for the last several years, to give each of you in the second year class your own 'little black bag' courtesy of Eli Lilly. Each of you will receive an authentic leather black bag with your name in gold letters on the side. And in each bag you will find a stethoscope, a reflex hammer and a calendar datebook for the coming year, all courtesy of Eli Lilly."

Mr. Brown sat down and the Dean came to the mike and encouraged us to give Mr. Brown a round of gracious applause, which we did. I still have that bag. It is well made, and my name is still legible. I have the reflex hammer, too. The rubber tip is still soft. "Eli Lilly" is engraved on the handle. The stethoscope was pretty clunky. I think I gave it to my then girlfriend's little brother, and he ran around with it trying to get girls to open their blouses so he could listen to their hearts.

Not long thereafter a revolt of sorts began at Western Reserve Medical School (no "Case" then) where students protested the profligate gift giving of the large pharmaceutical firms. I recall they had a public burning of their Eli Lilly little black bags, and they received some national press attention. I think some of the female med students there also burned their bras as well.

Some of us felt a sense of guilt and general, albeit mild, besmirchment as we contemplated the moral purity of our brothers and sisters at Western Reserve. But I do not recall anybody returning their bags and demanding that they instead be sent to medical students in the Congo.

More than 30 years later, the battle for the hearts and minds of medical students, housestaff and practicing physicians rages on unabated. A recent letter in the September 5, 2001 issue of JAMA suggests that the drug companies are still very successfuly persuading us to use and prescribe their products.

The modest study described in the letter was done at my alma mater, of all places. Residents were stopped during hospital rounds and asked to empty their pockets and bags to determine the number and variety of "branded" items being carried. Of 181 eligible housestaff, 164 participated; 97 percent were carrying at least one item with a drug company slogan or logo on it. When questioned, 91 percent said that drug company-sponsored meals and lectures had favorably influenced them to use or at least strongly consider the use of specific products.

Perhaps most interesting was the response to the question: "If a pharmaceutical company offered to pay you money to wear a small patch on the chest pocket of your white coat to advertise its product, would you consider it?" A total of 21 (13 percent) said "yes," and the most common estimate to make it worthwhile was $100. At least one doctor would do it for nothing, while another asked for $1.5 million.

The authors of the letter seemed pleased that only 21 of the housestaff were willing to emulate NASCAR drivers and plaster themselves with slogans and logos.

The commercial begins as the camera follows the darkly handsome, obviously self-confident physician into the room. His demeanor is serious but not grim. He is dressed in a white button-down collared shirt, a conservatively striped rep tie, short white lab coat, neatly pressed dark slacks and tassel loafers. A stethoscope is casually draped over the back of his neck and dangles in front of his shoulders. On his left upper sleeve is a dark green caduceus circled by the words "University Medical Center." Over his left breast pocket is a bright orange patch that says "VIAGRA" in two-inch high letters.

He approaches the bed in which is propped up a handsome man probably in his 60s, who looks vaguely like Don Ameche. He is asleep and appears calm. The bed is surrounded by medical gadgetry, glowing monitors that beep softly. Two bags of clear fluid are connected to an intravenous line taped to one arm. As the camera pans to the slim, elegantly clad and coiffed 50ish woman who sits next to the bed, we catch a fleeting glimpse of a urine collection bag hanging on the bedrail.

The young doctor approaches her. The camera looks over her shoulder as the physician pulls up a chair. The Viagra patch is easy to see above his breast pocket.

"Is he going to be all right, doctor?" "Yes, I believe he will be." "Doctor?" "Yes?" She points tentatively at the VIAGRA patch. "Viagra. That's the medicine men can take to, um, help improve their, um, performance, isn't it?" "That's correct, Mrs. Anderson." "Do you think my husband might benefit by Viagra when he gets better?" "Oh, I do think it will help him and in fact help both of you. I'll be sure to write a prescription for Viagra when we send Mr. Anderson home." "Thank you, doctor."

He touches her lightly on her hand, a brief smile flickers over his lips and Mrs. Anderson turns towards her sleeping husband, taking his hand gently in hers as the doctor silently exits the room.

A soothing basso voice-over intones: "Viagra. Safe. Effective. Ask your doctor."

By the time advertisements like that appear on television, no one will be shocked since about 15 percent of us will be wearing drug company promotions on our clothing anyway. In the meantime, the American Medical Association, having recognized the impact that drug companies are having on our profession, have started an educational program to help physicians determine ethical guidelines when accepting gifts from the pharmaceutical, medical supply and medical services industry.

This initiative began in August, 2001 and is slated to run actively for 18 months. Advisories and information will be disseminated to all media, medical students, all practicing physicians including housestaff and to the industry itself. The program was underwritten by nine large drug companies, and was brought together and written by the AMA Council on Ethical and Judicial Affairs (CEJA).

Most of the guidelines seem common sensical. First, all gifts should benefit patient care so that, for example, diagnostic tools and textbooks are all right. "Modest" dinner meetings featuring a company-sponsored speaker are acceptable. Gift certificates are, in the words of CEJA, a "grey area which is not per se prohibited by the guidelines." If the gift certificate is for Nieman-Marcus, its propriety is questionable. If, on the other, it is for a selection from the W.H. Saunders publication catalogue, then that would be fine.

The guidelines specifically prohibit sweepstakes or raffles as a way of delivering expensive gifts such as recreational travel. The Council writes: "The sweepstakes or raffle does not affect the permissibility of a gift, (and) since the sweepstakes is not open to the public, the guidelines apply in full force."

In general, the companies are not to pay for travel for meeting attendees unless the attendee is there as a faculty member, or as a member of a focus group for a bona fide research purpose. And even then only "reasonable" reimbursement should be provided.

The chair of the working group which actually wrote the guidelines, Dr. Alan Nelson, wrote a preface to the project. He provided some valuable points to ponder.

First, wrote Dr. Nelson, accept only those gifts that can benefit your patients, and are not of substantial value. Next, use common sense; the more lavish the gift, the more likely a quid pro quo is implied. This point, of course, is well known to our friends in politics.

Use the "60 Minutes" test, says Dr. Nelson. Would you feel comfortable talking to Mike Wallace on camera about the gift? And finally, Dr. Nelson reassures us that we can turn down a questionable gift while making it clear that we appreciate the effort that the industry representative is making to keep us up to date about the latest drugs and therapies. It does not have to be an adversarial relationship.

So now my little black Eli Lilly bag sits on the floor of my closet gathering dust. I have not used it since I stopped having an active nursing home practice a few years ago. And now I no longer feel any guilt about having accepted it and used it all those years

And, by the way, thanks Eli Lilly.

John.Ostrich@kp.org