Four out of five doctors surveyed nationally said they let drug and medical device companies pick up their food and drink tabs, suggesting that little has changed despite efforts to curb the long-standing practice.

But at least one Pittsburgh medical center is developing a policy to establish clearer ethics rules, thereby avoiding potential conflicts of interest.

The survey, which was published today in the New England Journal of Medicine, is the first to document the extent of the relationships between doctors and sales representatives since 2002, when a leading industry group adopted voluntary guidelines discouraging companies from giving doctors gifts or tickets.

The industry spends more than $20 billion a year on marketing, he noted, the bulk of which goes to physicians in the form of samples, lunches, sponsorship of educational programs and other things, according to previous research.

Lead author Eric Campbell said the study was not designed to assess whether the relationships influenced doctors' prescribing habits or affected patient care. Nonetheless, he said it was clear that many doctors benefited directly from the industry's marketing tactics and it was safe to assume that drug companies also benefited.

"If the companies didn't benefit from the relationships, they wouldn't be doing it," he said.

Consumer advocates say the study is proof the new rules aren't working.

"These findings are fairly disturbing. There appears to be no dialing back at all on these relationships," said Merrill Goozner of the Center for Science in the Public Interest.

The survey was conducted by researchers from Massachusetts General Hospital, Yale University and the University of Melbourne in Australia.

Questionnaires were sent to more than 3,000 physicians in six specialties in late 2003 and early 2004. It found that 94 percent of physicians reported some relationship with the pharmaceutical industry. Most relationships involved the receiving of food and beverages (83 percent) or drug samples (78 percent).

Thirty-five percent of respondents said they received reimbursement for costs associated with professional meetings or continuing medical education, and 28 percent received payments for consulting, giving lectures or enrolling patients in trials.

Seven percent of doctors said they received tickets to cultural or sporting events, items that researchers said clearly fell outside ethical guidelines.

Cardiologists were more likely to receive direct payments from drug companies in the form of consulting fees or lectureships than physicians in other specialties. Researchers surmised cardiologists were targeted by industry because their opinions influence the prescribing patterns of nonspecialists.

Family practitioners reported an average of 16 meetings with industry representatives each month. Researchers speculated their popularity was related to the number of drugs they prescribed compared with doctors in other specialties.

Dr. Barbara Barnes, associate dean for continuing medical education at the University of Pittsburgh School of Medicine, said the results are not all that surprising. She noted that earlier studies have reached similar findings.

Officials at Pitt and the University of Pittsburgh Medical Center are working to finalize an overall policy on the relationship between health care professionals and industry representatives, Dr. Barnes said, as well as a communications plan for that policy, a timetable for implementation and mechanisms to ensure compliance.

She co-chairs a task force on industry relations with Dr. Randy Juhl, Pitt's vice chancellor for research conduct and compliance.

To complement that effort, UPMC also has been working with a law firm, McDermott Will & Emery, to develop "best-in-class" policies and processes for monitoring and managing individual and institutional conflicts of interest, officials said.

While many policies and procedures already are in place, "what we don't have is a central policy that applies to both institutions," Dr. Barnes said. And in some areas, "we need to be more explicit," she said.

She said the effort to develop an overall policy arose in part from recommendations made in an article published early last year in the Journal of the American Medical Association.

That article, authored by Harvard University researchers, proposed that academic medical centers "take the lead in eliminating the conflicts of interest that still characterize the relationship between physicians and the health care industry."

Among other recommendations, the article suggested that all gifts and free meals be prohibited and that the providing of drug samples to physicians be replaced by vouchers "or other arrangements that distance the company and its products from the physician."

The Pharmaceutical Research and Manufacturers of America, the leading trade group, in 2002 adopted voluntary rules limiting the value of gifts to $100 or less and banning free entertainment tickets.