The studies generally find that detailing activity corresponds to an uptick in ordering, including off-label prescribing. The "free" lunches, "free" samples, "free" pens and "free" coffee mugs are apparently a cheap investment that pays off. Human nature leaves the physician with a subconscious sense of obligation to "return the favor;" hence, more of the detailer’s drugs get prescribed.

A former drug company rep co-authored an article published recently in PLoS Medicine, a journal from the Public Library of Science. According to this insider, the estimated 100,000 drug company representatives who detail physicians at the office seek out personal information that they can leverage to develop a relationship. Free food, gifts and even money are useful in cultivating the physician’s loyalty.

And speaking of detailers, The New York Times on Nov. 28, 2005, carried an article about the drug company practice of recruiting sales representatives from the ranks of …college cheerleaders. "There’s a saying that you’ll never meet an ugly drug rep," said a physician quoted in that article.

The New England Journal of Medicine in April published results of a NEJM study of 1,662 physicians. More than one-third of the physicians responding to the study survey reported that they had accepted reimbursement from a drug company for costs to attend professional meetings or continuing medical education events. More than a quarter of respondents reported they had been paid for consulting, giving lectures or recruiting patients into drug company clinical trials.

In other words, payments to physicians are a widespread practice in the pharmaceutical industry. This well-studied phenomenon – that freebies may compromise clinical judgment – has caused a number of leading academic medical centers and other hospitals to discontinue entirely the practice of allowing pharmaceutical companies to provide free anything.

Stanford, Yale, University of Pennsylvania, Henry Ford Health System, UCLA and others have instituted "no free lunch" policies. Although it will cost them millions in subsidized lectures, lunches and notepads, their view is that medical centers training the next generation of physicians should train them to be independent of this particular influence. There is even a Web site, nofreelunch.com, where physicians join a registry of like-minded professionals who do not accept the freebies.

The same psychology of creating a subtle sense of obligation that works for pharmaceutical company detailers, works for medical device detailers and is also widespread.

The North American Spine Society (NASS) requires that faculty, moderators and other key leaders of its annual meeting disclose their financial conflicts of interest that exceed $10,000 (amounts less than that do not require disclosure). Spinemarket analyzed the disclosures and segmented them by type. A total of 182 individuals disclosed a total of 512 conflicts involving 67 companies or organizations.

Of these individuals, 83 percent were surgeons. And, one might argue, not just any surgeons – these are the leadership in their field of spine surgery and may be better positioned to serve as "opinion leaders" who can influence other surgeons’ behaviors.

Payments and other support fell into a broad range of categories as this graph of the Spinemarket analysis shows, from trips and travel payments to speaking and consulting arrangements. [See graphic above.] One might conclude that the medical device companies have taken a page from the sales and marketing playbook perfected by the pharmaceutical industry, and have found many ways to funnel financial support to their target audiences. That subtle sense of "returning the favor" goes a very long way toward increasing product sales.