My wife and I are both physicians, and we joke that we could decorate our whole house with junk collected over the years from drug companies. Pens and sticky notes; stuffed animals to put in our children’s beds; coffee cups, tissue and soap dispensers, paperweights, posters, fridge magnets, mouse pads, clocks — all branded with some drug company’s logo. Giving out these freebies is just one tactic in the larger strategy of “drug detailing.” Does it work? Absolutely.

According to the Pew Prescription Project, a project of the Pew Charitable Trusts, whose goal is to promote drug safety for consumers, the pharmaceutical industry spends about $7 billion a year on drug detailing. Jamie Reidy, who wrote the book “Hard Sell” about his days as a drug rep for Pfizer (and upon which “Love and Other Drugs” is based), described it like this: “An official job description for a pharmaceutical salesperson would read: ‘provide health-care professionals with product information, answer their questions on the use of products, and deliver product samples … An unofficial, and more accurate, description would have been: Change the prescribing habits of physicians.” Drug detailing allowed Reidy and nearly 90,000 other drug reps across the country to get into what he calls “The Promised Land”: a doctor’s back office.

Pens are just one form of currency used to accomplish that goal. Free lunches for a doctor and his office staff are another. (The Pew Prescription Project reports that Pharma rings up a $1 billion catering bill annually.) Another oft-used culinary tactic is the “educational dinner,” where a drug rep hosts a physician hired by the company as a consultant to give a lecture that inevitably features the company’s drug. The last one of these I went to was hosted by the drug company Eli Lilly in 2007. A respected psychiatrist gave a talk about attention deficit hyperactivity disorder (ADHD) and suggested over bottles of red wine and a three-course meal that the first drug of choice for the disorder was Strattera. In reality, Strattera was then and still remains a third- and even fourth-line drug for ADHD, behind stimulants like Ritalin, which have a long track record of safety and effectiveness.

Perhaps the slickest tactic I’ve heard about is when a drug rep convinces the doctor to grant him a “preceptorship.” This is where the rep shadows the doctor during office hours to watch how and what he decides to prescribe. In the movie, Gyllenhaal’s character dons a white coat and follows Hank Azaria’s character (Dr. Stan Knight), prompting patients to believe he’s an intern. In truth, I hadn’t ever seen a drug rep try this. But Reidy’s book illuminates the whole shady business, right down to the $500 Dr. Knight receives from Pfizer for doing it.

Social scientists have long known that giving someone a gift, however small, immediately establishes an obligation to give back. It might be the most effective tactic of persuasion known. The result of this and other drug detailing is pretty well-documented: cash for Pharma. The Journal of the American Medical Association reported that relationships between drug detailers and doctors led to reduced generic prescriptions, increased overall prescription rates, rapid uptake of the newest, most expensive drugs, including those of only marginal benefit over existing options with established safety records. As Reidy writes, following his own preceptorship, “all goals were met: rapport had been established (the pediatrician asked if I wanted to start playing tennis with him), and he showed an interest in using my drug. ‘Hey, Jamie,’ he yelled after me as I left the office, ‘make sure you leave me a bunch of those Zithromax samples. I want to try that stuff.’”

Doctors should know the public doesn’t like that we’ve been so cozy with drug companies. A 2008 survey by Pew reported that just over half of Americans believe that accepting gifts from the pharmaceutical industry influences how physicians make prescribing decisions (saying that the impact is either extremely large or large). Those surveyed disapproved of even small gifts to doctors — 86 percent believe free dinners should not be allowed; 78 percent believe free lunches at the office should not be allowed; 70 percent believe free notepads and pens should not be allowed.

The result of that backlash (and, of course, spiraling drug costs) has led doctors, drug companies and the government to establish some ground rules to curb the gift giving and exposure of attending physicians and residents to drug reps. Allan Coukell, a pharmacist and director of the Medical Safety Division at the Pew Health Group, told me some institutions have curtailed preceptorships, recognizing that there is no possible benefit to patients for a salesperson to observe their interactions with a doctor.

To try to gain ground, some institutions have implemented their own drug detailing programs (called “academic detailing”). The Veterans Administration Hospital in Palo Alto, Calif., educated providers about prescribing anti-hypertensive drugs that were in compliance with national antihypertensive medication guidelines. Five pharmacists were trained, like drug reps, in the techniques of academic detailing, and then went out to connect with physicians in the hospital. The results showed a significant decrease in “wrong” medications and a significant increase in scripts written for the right ones. Similar positive results have been found for the use of antibiotics and antidepressants.

The government has also become more involved. As part of last year’s Health Reform law, drug and medical device makers will be required to publicly report payments and gifts they make to physicians. Prior to that, Minnesota, Massachusetts and Vermont had already taken steps to unmask the relationship between Pharma and doctors by publishing who is getting paid by whom on a public database. As a result, Minnesota (the first state to do this) found that psychiatrists who received at least $5,000 from drug makers wrote more prescriptions than those who received less or no money. Proof, again, that drug detailing works.

Since this provision doesn’t start until 2012, we don’t have any results to report. But it’s hard to believe Pharma won’t find loopholes for drug reps to exploit. Either way, it’s worth knowing that if your doctor’s pen has a drug’s logo written on it, it may be more than just a pen.

First, however, let’s trace the history of our thinking on sexual orientation. For that, I turned to my colleague Dr. Ron Holt, a psychiatrist at Kaiser Permanente in San Francisco (I’m a pediatrician with Kaiser in Walnut Creek), who educates communities and physicians around the Bay Area on specific medical issues faced by lesbians, gays, bisexual and transgender individuals. Sexual orientation, Holt explains, refers to a person’s erotic response, regardless of the gender that evokes that response. Sexual orientation, he says, is fixed. This is in contrast to sexual behavior, which a person can alter. In other words, people can’t change their sexual orientation, but they can hide it.

The real controversy has been around what determines sexual orientation. Freud, unlike Lady Gaga, took the position that it was environmental, the result of child-rearing. If you were a boy, and your mother was overbearing or your father cold and distant, you were more likely to be gay. Freud’s view dominated medical discourse for much of the 20th century. Ron Holt notes that historically, theories of sexual orientation have varied from culture to culture, but that Western culture “tended to have a more suppressive attitude toward variations in human sexuality. Anything that was not strictly procreative in nature tended to be viewed with suspicion to outright attack.” That may have led to various attempts by religious groups to try to “convert” gays “back into” heterosexuals (as in the great 1999 independent movie “But I’m a Cheerleader“).

Science and sensitivity began to creep into that discourse. In 1973, the word “homosexuality” was removed from the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatry. The 1990s were an era of discoveries that began to point toward a biological basis for sexual orientation, including a then hotly discussed 1991 study showing differences in the size of certain parts of the brain between straight and gay men. Since then, science has built a case against Freud and in favor of Lady Gaga.

To learn more about where that science stands today, I spoke with Dr. Michael Bailey at Northwestern University. If his name sounds familiar, it’s because he’s been embroiled in a recent classroom controversy. That aside, Bailey is one of the world’s leading experts and researchers into the biology of sexual orientation. He is very confident that Lady Gaga is right. But there are some subtleties you have to get through before you can understand that. For example, if we are “born this way,” then why do studies of identical twins, some done by Bailey himself, reveal in many cases that one twin is straight and the other is gay? If they’re genetically identical, how can they be anything but the same in every way?

“As lay people understand it, ‘environment’ means the social environment. But in this case, it’s intrauterine environment,” he told me. Factors during pregnancy have definite outcomes on sexual orientation. Most likely, the fundamental factor is hormonal, and how hormones influence areas of the brain that determine sexual orientation.

In twin brothers, where one is gay and the other straight, science indicates that each sibling is being influenced by and exposed to the same hormones (or other factors) in different ways. “We don’t know exactly how hormones influence sexual orientation differently in twins. But striking differences between identical twins are not unheard of. For example, [certain brain anomalies] may occur in one twin and not the other.” How differences like that occur, whether they are related to sexual orientation or not, remains unclear. Speculation has focused on many factors, including the intrauterine positioning of each twin and how it may lead to a difference in blood supply (and thus levels of hormones) to them. There’s no final answer, but, says Bailey, “prenatal environment is a lot more important than we ever thought.”

Bailey thinks the best experiment to prove Gaga right comes from Nature. There are small numbers of children born with a condition called cloacal exstrophy, where their abdomen and pelvic structures are incompletely developed. Boys born with this condition don’t have a penis. Since it’s surgically easier to create female genitalia, these boys are assigned to be girls. But in every single case of a boy who has had gender reassignment she declares herself male. “This isn’t possible by statistical fluke,” says Bailey, thus proving the assertion that sexual orientation is inborn.

However, there is a major wild card in this entire discussion, one that puts to the test Ron Holt’s assertion that sexual orientation is fixed: women. While most of the research has confirmed that men are “born this way,” Bailey says, there is an emerging view about women that is very different from men. “Leading researchers are beginning to believe that female sexual orientation is a bit more flexible than that of men,” he says. “Women have a higher rate of bisexual feelings than men. It’s not uncommon for a woman who has been in a lifelong heterosexual relationship to become attached to and develop a physical relationship with another woman.” 

Of course, we’re just in the infancy of our understanding of sexual orientation. I suspect it will take decades of research before we can pinpoint the specifics that lead to phenomena like that between twins, or why women seem to be less rigid in their sexual orientation. In the meantime, I’d rather let science run its course and simply treat people, gay, straight or whatever, with respect and equality regardless of the data. To quote a different song, one by the great band the Smiths: “What difference does it make? It makes none.”

White coats didn’t start out as anything more than a practical piece of clothing. In the late 19th century, surgeons wore white short-sleeved jackets over their street clothes — the beginning of aseptic techniques to minimize infection. Longer coats emerged later, inspired by scientists working in microbiology labs. These, too, were practical, but they gave the doctor an official air as well. In the 19th century, medicine was in its nadir, overrun with quacks and phony tonic salesmen. In response, reputable but frustrated physicians moved to debunk these charlatans and resurrect medicine’s reputation by aligning it with science. And the lab coat as the symbol of modern, rational medicine was born. Initially these coats were tan in color, but as America headed into a new century, white became the color of choice — pure, true, even angelic, befitting the heroic role these doctors played: putting patients under anesthesia to operate and then resurrecting them, miraculously cured.

But medicine has changed over a generation — and so has doctors’ standing. The image of the doctor as omniscient and omnipotent became harder to uphold. When infection caused most of the country’s illness and death, physicians could quickly save lives with antibiotics. The development of vaccines rapidly cured once fatal illnesses like measles and polio. Then, out with the acute and in with the chronic: diabetes, heart disease, cancer, etc. Hospitals transformed from a holy grail of healing to a place where one has to go — again and again — for continuous tests and treatments. And chronic disease management — vomiting, hair loss and chemotherapy — causes its own suffering. Doctors have become increasingly transparent and guess what? We make thousands of mistakes each year, some of which seriously injure or kill patients. We struggle to stay smart because as our understanding of disease has gotten more complex, we can’t keep all the facts — many of which often conflict — stuffed in our heads.

Power shifts have also occurred. In the past, it was a man’s world, and the white-coated elite ruled over all — nurses, patients and students. Today, women constitute 50 percent of medical school graduates, nurses have made sure that doctors show RNs more respect (deservedly so), and patients are more assertive of their rights as partners in their own care. Health care has also become more fragmented. Whereas in the past, it was a doctor-nurse dyad managing a patient, today, it’s doctor, nurse, medical assistant, nurse manager, social worker, dietician, respiratory therapist, lab tech, nurse practitioner (and the list goes on).

Ironically, recent studies have shown that white coats, particularly the pockets and sleeves, can hold significant reservoirs of bacteria, making the very garb we wear to prevent the spread infection one of the best vessels for it. In 2008, the UK’s National Health Service banned the white coat and instituted a whole new dress code for its docs and medical staff. In addition to banning the coats, the NHS also banned long-sleeved shirts for similar reasons. The American Medical Association is exploring similar changes, but it cites a lack of strong evidence, as well as the fact that professional attire like white coats give doctors some legitimacy and patient confidence.

I don’t know what happened to my first white coat — like a lot of things, it got lost along the way from being a young, naïve and idealistic medical student to an attending physician who knows that the more you see, the less you know. After the rush of having one wore off (it took one nasty call night), the white became more functional — I had to have enough pockets to hold onto my reference books, notes, pens, stethoscope, beeper, etc. I definitely didn’t wash it enough, and I had no shame of wearing it with a coffee or ketchup stain.

Since becoming an attending physician, I haven’t put one on because I have an office to keep all those things in. Also, most pediatricians specifically don’t wear them because we’ve been told that little kids find white coats threatening. But it turns out that’s a myth: Studies actually say they prefer that their doctor wear one.

Surgeons have a particularly profound relationship to music. As Siddhartha Mukherjee noted in his book “The Emperor of All Maladies,” music and medicine “go hand in hand. Both push manual skill to the limit; both mature with practice; both depend on immediacy, precision and opposable thumbs.” A 2008 study, in fact, tested whether musical prowess has any impact on performance during laparoscopic procedures (special scopes that surgeons use to perform minimally invasive procedures). Non-surgeons who had experience playing music performed better at suturing using this equipment than did non-musical participants. There’s perhaps no better example of the facility of the musician-surgeon than Theodor Billroth, a 19th century virtuoso who pioneered surgical techniques to dissect abdominal tumors from the body and whose talent on violin and piano forged a close friendship with Brahms.

But surgeons don’t have to play instruments to enjoy music in the operating room. It’s a regular, enjoyable part of the daily routine and one way a surgeon creates a comfortable atmosphere in a sometimes tense setting. Atul Gawande, contributor to the New Yorker and author of “The Checklist Manifesto,” operates to Modest Mouse, Arcade Fire, the Decemberists and other alternative bands. (He does own a Fender ’62 Stratocaster replica at home, but he says he’s rusty.)

So is operating to music a good idea? Lest you go into a panic the next time you hear Lady Gaga while they’re administering the laughing gas, the answer seems to be yes.

It’s a bit of a tricky thing to prove. It’s far from ethical to take a group of surgeons and measure their performance on and off music while they cut into real patients. But studies have offered some insight into the effects of music on surgical performance. One is from the Journal of the American Medical Association and dates back to the grunge rock era, 1994. In this study, researchers took 50 surgeons and measured blood pressure, heart rate and other physiological markers while they performed a series of subtraction problems. Each volunteer performed this task while listening to self-selected music and, later, music selected by the researchers (“Pachelbel’s Canon in D,” which is supposedly included in a lot of “stress reduction” musical compilations).

It turns out that when surgeons listened to music of their own choosing they had very steady vital signs and performed the subtraction task better than when they listened to Pachelbel. That’s encouraging, though it’s important to note that the surgeons who participated listened to music regularly both in and out of the operating room. So if you’re a surgeon and you think investing in an iPod will make you better with a scalpel and sutures, first ask yourself whether you care for music to begin with.

What about the rest of the operating room team? Anesthesiologists are, of course, indispensable to surgery. Does music help or hurt them? In a study out of the U.K., where 70 percent of anesthesiologists say they’ve been subjected to music in the operating theatre (as the Brits call it), 63 percent of those surveyed said that they enjoyed the sounds of music while they worked. Those in another survey who did not said it was because they felt music reduced their vigilance and impaired communication with other staff members. Not surprisingly, the most distracting tunes were ones they hated the most. On the other hand, another study contradicted any deleterious effect of music on anesthesiologists’ performance: That study measured psychomotor performance, and it didn’t change when subjects were listening to self-chosen music, Pachelbel, white noise or no music at all. Finally, surveys of other O.R. team members (nurses, techs, etc.) indicate that music enhances teamwork and communication among members, though, again, most of those surveyed listened to music regularly on their own time.

The next logical question to ask is: What kind of music should your surgeon be listening to while he or she closes your grapefruit of a hernia or bypasses your clogged coronaries? A study from 1976 suggested that rock (sorry, disco), with its varying rhythm and intensity was best. Other surveys have shown that the preferred genre in the operating room is classical, followed by folk, rock, jazz and blues. But, like the JAMA study I mentioned above, most studies hint that music’s positive effects have more do with the personal preference of the surgeon or the O.R. team than any particular genre of it.

A couple of last points: First, there is a body of evidence that music also helps patients going to surgery, including reducing anxiety before and after an operation; it may help patients cope better with pain, leading to their requiring less pain medicine. Finally, here’s an interesting B-side to this story: Take a listen to a 2001 album called “A Chance to Cut Is a Chance to Cure” by a San Francisco music group named Matmos. The two members of the group, Drew Daniel and Martin Schmidt, took their recording equipment to the hospital and sampled the sounds of surgery, creating electronica out of them. Highlights include “California Rhinoplasty” and “Lasik.” Let the sounds of cauterized flesh and dripping anesthetic be music to your ears.

So why buy Proactiv? As a physician who treats a lot of teens with acne, I can’t say I’ve ever recommended it. In fact, I often discourage it, given the price tag.

“The key to acne treatment is good compliance,” says Dr. Jeff Benabio, a dermatologist in San Diego. “Proactiv has system that makes it easy for teens to use properly.”

He’s right, and perhaps the three-step “Proactiv System” helps make it easier for teens. But the real key to Proactiv’s success is celebrity. Endorsements have helped make it the acne product to buy. A-list youth stars like Katy Perry, Justin Bieber, Jessica Simpson, Avril Lavigne and even P. Diddy offer testimonials online and on TV about how terrible it was to have all that acne, and how ProActiv transformed the star into someone beautiful, confident and successful. (P. Diddy famously claimed that he uses ProActiv to “moisturize my situation and preserve my sexy.”) Viewers see those hideous “before” pictures — some mysteriously dark, pimple-faced headshot of an unseen somebody — followed by the “glorious” after shot, glowing and perfect.

Celebrities have been used for ages to endorse health products. To understand why, you would want to read a terrific book by Robert Cialdini called “Influence: Science and Practice.” Cialdini, an emeritus professor at Arizona State University, made a career out of studying the tactics of influence, which he distilled down to seven principles in his book. These principles, he skillfully argues, are so ingrained in our psyches that they will almost automatically get us to comply with a request or buy a product. In using celebrities, Proactiv’s marketers rely heavily on what he calls the Principle of Liking.

The Principle of Liking states that, somewhat obviously, we are more likely to be persuaded to do something by someone we know and like. The startling thing, Cialdini notes, is how easy it is for someone we don’t know but think we like — a celebrity for example — to do the same. Add the physical attractiveness of celebrities because they “are better liked, more persuasive … and seen as possessing better personality traits and intellectual capacities.” This is not a trivial thing: According to Cialdini, attractive defendants are twice as likely to avoid jail as unattractive ones; another study shows that better-looking people are more likely to receive help when they ask for it.

If, like me, you’re curious about just what it costs to exploit Cialdini’s Principle of Liking for Proactiv — it’s not cheap. According to an article in Billboard, Bieber is getting paid $3 million for two years. According to the same article, Guthy-Renker spends about $12-$15 million per year on endorsements.

And those photos sure don’t look like examples of a typical response for moderate to severe acne. I might even wonder if the results are Photoshopped, like so many similar commerical products. (I tried to reach Guthy-Renker many times for comments about this and other issues, but they didn’t return my messages.)

My biggest problem is something else, though: How hard they work to equate confidence with beauty and nothing else. Every celebrity testifies that having pimples was the source of all their insecurities. (Look at that video with Katy Perry. Seriously, you can barely see a zit.) They all claim that Proactiv gave them the confidence they needed to be their best. As a physician who sees plenty of teens with real confidence problems and the consequences they engender — eating disorders, depression, anxiety, drug use — I’d like to see a company with this much influence pull a few gears back on that message.

Despite these concerns, Jeff Benabio doesn’t think Proactiv is a scam. “It’s a good product,” he told me. “It’s just expensive. But if people are willing to pay for expensive wine, why not for expensive acne treatment for themselves or their kids?” Maybe he’s right, but there’s usually a big difference between an expensive wine and the cheap stuff at the corner store. With Proactiv, the only difference is style. Substantively, you’re not paying for anything better than a common drug available for less elsewhere. As for people who want a better deal, Benabio, on his blog, offers a recipe for teens who want to make their own Proactiv for a fraction of the cost.