—The days are long gone when the only gifts that pharmaceutical companies gave physicians were pens, notepads, and free lunches.During the last decade, it has become common, and sometimes even expected, for pharmaceutical companies to offer frequent-flier miles, trips to exotic locations, and other gifts that have nothing to do with patient care. Some companies skip the formalities and just offer cold, hard cash to physicians who prescribe their products. These promotional activities are now considered unethical under the AMA's guidelines. Patients unknowingly pay for these gifts, at no benefit to themselves.In 1989, the 100-plus member Pharmaceutical Manufacturers Association spent $5 billion of its $32.4 billion total sales revenues on marketing—more than $8000 per allopathic and osteopathic physician in the United States. Over the last several years, the percentage of revenues spent on marketing and promotion has nearly equaled the percentage invested in research and development.