Its director, New York City general internist Bob Goodman, says the pledge drive is designed to educate and convince physicians not to accept free products from drug companies. US pharmaceutical companies spend about $13 billion annually on drug promotion, and since 1994 their sales forces have grown from 35 000 to 56 000 people.

Doctors who sign on to the "drug-free-practitioners list" must pledge to be "free of company money and influence in their clinical practice, teaching and research." In a Jan. 15 interview, Goodman said that he has not yet tallied the number of physicians who have taken the pledge.

Gifts from US drug companies to physicians range from free flights to attend conferences to tickets to sporting events and enticements such as free drug samples and pens. Some studies indicate that gifts of this type affect prescribing practices.

In Canada, drug companies have increased their self-monitoring (CMAJ 2000;163[6]:749) and now publicly rap the knuckles of companies that violate industry rules concerning the continuing medical education events they sponsor. But Dr. Joel Lexchin, a Toronto emergency physician who has been a longtime critic of drug company promotions, says freebies are still common.

Goodman is particularly concerned about the free drug samples that are provided routinely in both countries. He says that even though the samples may help poor people, patients end up paying for them through generally higher drug prices.

They may also end up paying higher out-of-pocket costs because samples are usually provided for only the newest, most expensive medications. If they work, says Goodman, a physician is more likely to prescribe them, increasing the cost to the patient or insurer. "When physicians use samples they are more likely to prescribe inappropriately more expensive drugs. Physicians accept these samples at the expense of the patient, literally.

"Samples force the doctor into marketing for the drug company," adds Goodman. "It's ingenious."

Goodman's hospital, the Columbia Presbyterian, has already banned samples, as has the Boston Medical Center and the University of Wisconsin Hospital and Clinics.