"Free" is a great thing. It costs you nothing if you get something for free, right? Or does it? It the world of medicine, drug company sales reps in Dallas, Houston and elsewhere in Texas try keep sample cabinets in healthcare providers' offices well stocked with the latest medications for doctors to give out when needed.



Most individuals like going home with free samples because it saves them a trip to the drugstore, plus their co-pay, if they have one. And MDs are happy to pass them out because samples often help patients get immediately started with a treatment.

But several leading medical centers are now restricting the use of samples. In addition, a small group of doctors are shutting down their sample cabinets. They say that medical professionals should be selecting the most appropriate medication for a patient based on the best scientific evidence available, not just grabbing something from the sample cabinet that might fit the bill.

"The doctor will say, "Here, start on this, and let's see how it works," " said David J. Rothman, president of the Institute on Medicine as a Profession, a research group at Columbia. The question to the doctor is: If you didn't have it in your drawer, would that have been your drug of choice?

The free samples crackdown is due in part to the growing concern about the close ties between physicians and drug companies. Rothman says that physicians don't realize the extent to which their medical judgment is influenced by their acceptance of the samples. He pointed to recent studies finding that the number of doctors who treated high blood pressure with the "first line" drugs recommended by national guidelines was low, but increased sharply when free samples were removed.

Currently, the University of Michigan Health System has completely banned free samples, and the University of Pennsylvania and Stanford University medical schools have prohibited staff members from accepting them, although samples can be given to Stanford's pharmacy for use in free clinics.

A number of medical groups and practitioners have also changed their policies. Dr. Jonathan Mohrer, an internist in Forest Hills, Queens (NY), said he closed his sample cabinet in part because his office was overrun with pharmaceutical sales reps. "It was totally spinning out of control," Dr. Mohrer said. "They were meeting each other and schmoozing in the waiting room - it was like a party."

Mohrer's staff spent a portion of their time arranging the cabinet, throwing out expired medications and trying to locate the right drug. Patients were kept waiting while sales representatives were ushered in.

And yet, some medical professionals say there's an upside to the passing out of free samples. Using samples, a doctor can see if a patient can tolerate a new medication before the patient buys a 30-day supply. Physicians who treat low-income individuals like to have samples for them, as well as for uninsured patients.

Samples also provide patients with the convenience of one-stop shopping. If a patient has waited some time to see a doctor and rearranged their whole working schedule, it may be another four or five days before they can fill a prescription. Some doctors feel that for individuals who are busy, working people, with family responsibilities, there shouldn't be any further delay. In addition, many MDs say they like using samples because the sales reps are an important source of medical education, keeping doctors current regarding the latest drug therapies.

The drugs promoted through free samples have a tendency to be newer medications that doctors are less familiar with, some experts report. Critics of samples say they prefer using older drugs, because the side effects are already known. They also say that helping poor and uninsured patients is not the intent of the sample distribution. Critics feel that Medicare's prescription-drug coverage, the proliferation of generic drugs and improvements in drug company patient-assistance programs have all made access to medication much easier these days.

It's also not at all clear whether or not samples save patients money. Critics say samples may actually drive up the cost of health care in the long term, because the drugs being promoted are the most expensive, brand-name types. And, since many medical conditions require lifelong treatment, the patient would have to purchase the drugs sooner or later.