Any potential advantage of a catchy name is lost when one is faced with new trade names for 400 products a year for perhaps a tenth this number of different specific agents. One wonders whether the few generic names that actually should be learned could not be even better mastered than the numerous variants in brand names for a single drug, if comparable promotion ("education") were devoted to implanting the fewer generic names in the mind of the physician, for example:

SINGLE GENERIC NAMES FOR DRUGS WITH MULTIPLICITY OF BRAND NAMES

vate ownership of names of drugs to protect the public. As a matter of fact, drugs presently distributed by generic names have not often been found inferior in the limited inspections the FDA has been able to make.

It is evident that a vicious circle is created by a mad scramble for a share of the market: the doctor is made to feel he needs more "education" because of the prolific outpouring of strange brands but not really new drugs, produced for profit rather than to fill an essential purpose; and then the promoter offers to rescue him from confusion by a corresponding brand of "education."

THE STYLE OF PROMOTION

Smart and sly. The goal of promotion, even when traveling a circuitous path under the guise of "education," is to achieve uncritical acceptance of a preconceived message-to captivate the mind; stimulation of skeptical thinking could block the purpose. This is in sharp contrast to the objective of true education, which seeks to cultivate the use of the mind for independent judgments. The success of promotion does not depend on the authenticity of the message but on the skill in manipulation of belief. The psychology of persuasion has been studied more assiduously and is better mastered by promoters than by professors. Not only are the rewards and competition in commerce stimulating, but the best techniques of promotion can be ascertained by the concrete measure of sales figures. The educator is hampered in evaluation of his methods because the results are deep in the mind and cannot be given specific price tags.

Preparation of promotional material is generally farmed out to specialized advertising agencies, and these have not always shown a notable sense of responsibility in their use of the mass media

in matters of health. It is to be expected that an advertising agency would be more concerned about the success of a promotional campaign than its impact on medical practice. Whereas medical men of integrity may be consulted in the preparation of promotional material, it seems that they may be overruled by executives occupied with maintaining sales and profits.

Payola?-In conjunction with the actual advertising material, the pharmaceutical companies go to great extremes to sell an appealing "House Image" to the physician to soften his resistance. Lowest on the scale are overt gestures like ordinary entertainment and personal favors. One "ethical" drug company (Eli Lilly) gives medical students new diagnostic instruments each school year to foster "the close association of our two professions," with the proud boast of having enlisted "the co-operation of the dean of your college!" A particularly regrettable maneuver is the exploitation of the natural sympathy between doctors and students by hiring the needy and unsuspecting student as a detail man (Pfizer, Schering).

More subtle wooing takes the form of conspicuously sponsored conferences and television clinics and give-away lavish medical magazines and newspapers sometimes made more fetching with pseudoculture and racy human interest. Grants are made in partial support of independent research, but these usually cover only part of the cost and tend to favor utilitarian studies; and the investigator may unwittingly find his results subject to exploitation (11).

Medical organizations are given monies to support a large part of their activities, and then are in a poor position to criticize practices that infringe on the prerogatives of the medical educator and imperil the knowledge of the physician.

The question might well be raised:

How does all this courting differ from payola?

Promotion is to commerce what prope ganda is to politics. The physician, lik the citizen, had better have a clear m tion of its trustworthiness. In the appli cation of information to the care of the ill, it is not enough for most of what is offered to be accurate; the difficulty of avoiding error is compounded when clever means of misleading the unwary are common practice. And remember, the physician is left by the present laws to look out for himself in matters of promotion to a considerable extent. New proposals are under consideration to rem edy this situation.

Tricks of the trade.-Innumerable in genious devices have been contrived t give promotional material an air authenticity. Some of these can be men tioned to warn physicians to watch for them in "educational" material prepared by pharmaceutical concerns.

Reference is often made to unpublished data from "personal communications, "case reports in the company's files which are collected at random, and even individual testimonials. None of these can be readily evaluated in an acceptable fashion.

Quotations lifted out of context are a favorite means of misusing sound sources, and inferior articles in the medical literature may be selected to support the claims even when super work is available to refute them. On one or two of an impressive list of re erences may have any pertinence to the claims being propounded. Certainly the copy writers cannot be counted on evaluate the evidence critically.

There are a few privately owned magzines published in the format of medica journals that are favorite repositories for superficial studies and commot sources for references in promotions material. One of these was edited and

lished by a drug company that then d the references in its advertisements, s having a handy closed system of tation.

mplied endorsement by vague alluis to use of the product by "many" sicians or hospitals is expected to convincing, as are the results of inquate surveys showing "9 out of 10" wering a mail questionnaire favored product although it is not mentioned t only a small percentage of those stioned bothered to answer.

The appeal to the eye is seldom neged, but the mind may not be taxed all with useful information as to traindications, side effects, toxicity, . Least of all can one hope to find discouraging data on actual or comative cost of "new" preparations sus established forms of a drug.

THE PHYSICIAN'S PREDICAMENT Learning made difficult.-The body of owledge which should be assimilated the physician is burdensome enough hout complicating his access to it. e legitimate medical journals have Itiplied like insects; one must now k his information from 5,000 jourS (over 600 in the United States ne) containing about 100,000 articles ear. These publications are almost all ted and written by amateurs in the lls of communication. The usual medijournal is more a respository of a than an organ designed to interest 1 enlighten the reader. There are nty of sound articles if one can find e to locate them and dig out the ormation. Even the review articles d to be pedantic. The bibliographic s such as Index Medicus list all artis regardless of merit and are of no p in checking on current promotion cause they are months behind the rnals, which in turn are months beid the claims in advertisements based

on "personal communications," "exhibits," and "cases in the company's files."

Editors and publishers may seem to pursue their lonely ways without regard to duplication of effort or real concern for the practicing physician, but this is partly due to inadequate staff. Usually the editor snatches time from some primary task to turn out a journal as best he can without specially trained assistants. Quite limited resources are available to the editor for making the journal more attractive with art work and colored illustrations or more interesting through enlisting the aid of skilled writers.

Because of lavish expenditures for drug promotion, the income from advertisements is enough to make the owners of medical journals covetous of the profits. Two official journals of national societies can be cited as bracketing the field: One general journal publishes 6,000 pages of advertising a year, at $1,100 a page, or an annual income of $6,600,000; another specialty journal receives $260,000 a year from 1,300 pages at $200 a page. All the costs of producing these journals probably do not come to more than 60 per cent of the income from ads plus subscriptions, thus leaving 40 per cent for the owners. It would be hard to beat this as a profitable business, since the raw materials-the talents of the contributors-come free!

Most lamentable is the lack of concern for the authenticity of material in the advertising pages in medical journals, which almost outweigh the editorial text in bulk and influence. Few journals show signs of a determined effort to reject misleading advertisements, and in none are the standards of acceptance high enough. In this respect the owners of the journals exert a strong influence over editors, some of whom surely resent the encapsulation of the editorial text by objectionable material.

of synthetic progesteroids can lead to the genitalia of female infants being mistaken for male, with dire consequences if they are reared as males and then subsequently feminize and menstruate at puberty; they may also be mistakenly assumed in the neonatal period to have congenital virilizing adrenal hyperplasia.

The same advertisement for Norlutin (Fig. 6) has continued to appear regularly in the J.A.M.A. for the ensuing 3 months since the article by Wilkins appeared in that journal; in spite of his warning: "During the past year or two, Norlutin has caused fetal masculinization with sufficient frequency to preclude its use or advertisement as a safe hormone to be taken during pregnancy." The advertisement contains no clue to this complication and no information that is "educational" or enlightening. The startled expression of the woman in this advertisement may have more significance than the artist intended!

The financial subsidy gained through advertisements is a doubtful blessing. The journals come to be regarded as profitable property and as vehicles for advertising rather than scientific periodicals. A journal with an eye toward the glitter of gold may become diverted from its proper function as an outlet of free and pointed criticism.

This lush support inflates the number of publications beyond the natural needs, and the plethora of pages encourages acceptance of inferior articles-and so the bulk with which the reader must grapple is bloated as a consequence of the very promotional material he ought to check against a discriminating literature.

Little wonder that few physicians have the stamina to struggle with the overwhelming task of keeping abreast of new developments through their own medical literature. Medical educators must be especially chagrinned to have succeeded no better in cultivating sound reading habits in students that should last through the lifetime of a busy doctor, and to have done so little to keep the medical literature serviceable and free from external influence.

Believing made easy.-The deficiencies in the medical literature and shortcomings in the education of physicians have provided the golden opportunity for the promoter. The intense discomfort the doctor feels from the frustrations of using his own literature makes him quick to turn to the appealing "educational" material of the pharmaceutical concerns.

The sellers of drugs have launched an impressive array of publications (the paramedical literature) and other devices to gain an influence over the habits and beliefs of doctors. Enviable skill and ingenuity have been devoted to production of attractive and well composed material. It cannot be denied that much of this is dignified and more useful than the journals and postgraduate programs sponsored from within the profession. The temptation to the busy physician, driven by desperation to seek short-cuts through the forbidding jungle of academic creations, is so great that in all probability the readership of the trade publications far outstrips that commanded by professional sources. Less harm would be done if the "educational" material furnished in behalf of promotion was free of bias. It is risky to depend on materials beyond the scrutiny of independent editorial staffs and of necessity dedicated to vested interests.

Tardy and taxing aids.-Valuable reports on the nature and use of drugs by authoritative bodies are regularly published, e.g., the Councils of the American Medical Association and the National Research Council. One might suppose the physician would use these to judge the accuracy of material reaching him through the channels of promotion. Reports such as these are widely scattered in medical journals or appear as separate documents not generally received by many practitioners. It would be a tremendous task for an individual to keep track of all these reports. Compila