It begins with some teasers. A pen, a calculator, a vanity bag, a dinner set and so on — things that cost no more than Rs. 2,500. It is the response at the receiving end that changes the game in the nexus between pharmaceutical companies and doctors.

In the second stage, the doctors opt either for cash or goods. Some of the most popular gifts are home appliances — a mixer-grinder, a television or a refrigerator.

The value of the freebies climbs up when the potential of the doctor is high in promoting the drugs or in prescribing investigations at the diagnostic laboratories.

There has also been an instance in which a company set up a home theatre for a doctor. A plasma television or a car for which monthly installments are paid by the pharmaceutical company are common these days.

However, these gifts have become passé as some doctors have switched to all-expense-paid trips abroad. In fact, it is learnt from the medical community that the Asian locations are not preferred for these foreign trips sponsored by medicine manufacturers. Europe and the U.S. are the destinations in demand.

Attending medical conferences with family in various locales is the in-thing. While the conferences are sponsored events, many doctors get drug companies to sponsor their entire trip. Tickets, stay and local tours are all arranged for in a package. The doctor may only be attending the conference for half a day, perhaps.

“Drugs for diabetes, hypertension and chronic renal diseases are the fast-moving drugs and in large volumes,” said a former Health Services doctor. These drugs face the toughest competition in the market because of the large varieties available, and a doctor can be a big help in pushing up the sale of a favourite.

A cholesterol lowering generic drug Atorvastatin is believed to have nearly 150 brands. And the price ranges somewhere from Rs. 40 to Rs.150 for ten tablets of 10 mg each. Likewise, a gastritis drug Pantoprazole has about 250 or more brands and may vary in cost from something over Rs. 20 to about Rs. 100.

Another category of drugs that face tough competition is antibiotics. Cancer drugs and psychotropic drugs are others that require long-term use, bringing more brands and competition and price ranges.

However, it is a fact that not all medical practitioners take the gifts distributed by pharmaceutical companies. A chest specialist and a general medical practitioner in the city suburb said most of the doctors in rural areas went for affordable medicines. “We have to look at the patients in total. There might not be compliance to the prescription if the patient cannot afford the medicines,” one of them said.

However, doctors in urban areas may not know their patients’ backgrounds and may prescribe costly medicines for some who may not be able to afford them, thereby indirectly serving the interests of the pharmaceutical companies.

For the doctors who prove a little tough for the pharmaceutical companies to lure, there are gifts like free subscriptions to costly academic journals. Some doctors fall for it as they are not the only or the direct beneficiary as their department will have some good journals. In some cases, where a doctor may be running a clinic at home or in a small hospital, these journals help him or her stay connected to the fast-changing medicine field.

The pharmaceutical companies took a step back in doling out these gifts quite openly as the norms of the Medical Council of India had become stricter, said a medical representative. Under the scanner are the doctors as well as the drug companies.

Notwithstanding the strict code of conduct for doctors under the Medical Council of India’s code of ethics, the freebies given to doctors are many and at many levels.

A doctor who would prescribe 100 iron tonic bottles a month would definitely be given a preferential treatment over a doctor who prescribed 50 bottles a month, said a doctor who had long moved away from active practice.

“It is a well known fact that most pharmaceutical companies are spending more money on marketing activity than their research,” says Dr. K. V. Babu from Payyanur.

Such activities by pharmaceutical or allied health sector companies definitely lead to a situation where a section of doctors prescribes unwanted costly medicines or investigations to meet the "target” of diagnostic laboratories and pharma companies, he added.

Promotional activity is nothing short of bribery, says Dr. Babu and it was these activities that brought in the amendment in MCI regulations 2009.

It is more difficult to manage doctors than a hospital, says a hospital administrator who has control over two hospitals. The doctors are not happy if the hospital decides to have its own drug policy. They insist on having their meetings with medical representatives, said the administrator. The laboratories too offer commissions if we send in more work to them, he added.

A doctor’s association is not unidirectional, but multidirectional, says Dr. Jayaprakash R. from Thiruvananthapuram. There are pharmaceutical companies, diagnostic laboratories and the neighbouring medical stores.

Recounting his own experience about ten years ago, Dr. Jayaprakash, an associate professor, Paediatrician and Child Psychologist, SAT, Government Medical College, Thiruvananthapurm, said that when he sent a child for an EEG and an MRI to a diagnostic laboratory, an executive from the lab came home offering a commission of Rs. 3,000 for an MRI costing Rs. 6,000 and Rs. 200 for each EEG costing Rs. 600.

“They offered to open an account in my name. Medical ethics bound us not to even accept the prescription pad of the laboratory. My standard norm is to write in my prescription pad to please conduct the test with maximum reduced rate for the patient. The laboratories provide half of the cost of the diagnostic test like a CT or MRI to the doctor,”said Dr. Jayaprakash.

The nexus between medical stores and doctors becomes important for both to keep the business and the practice roaring, said Dr. Jayaprakash, who has authored a book on medical ethics in Malayalam.

Medical ethics is never discussed in medical colleges. IMA does nothing to train members in medical ethics and there are usually no discussions on this issue.

The pharmaceutical companies sponsor their leading practitioner as specialty faculty at conferences. The expert speakers at the meetings are those who are the largest promoter of a particular company who has agreed to sponsor the event. Even after the 2009 amendment to MCI code of ethics, these practices continue discreetly, said Dr. Jayaprakash.

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