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The notion that continuity and adequacy of care are improved by having a usual source of care may have different implications in different types of health services. In particular, from a patient''s perspective, prevention is more voluntary (i.e., a matter of choice) than acute care. Having a usual source of care, in concept, can facilitate such planning. Although it is known that having a usual source of care improves access to preventive services, as discussed, whether a regular doctor contributes more than a regular site to the improvement of access to preventive services is yet to be explored.

Recent publications have detailed elements of the overall context within which finder''s fees ought to be understood. (11) We can touch only briefly upon these elements presently. A PriceWaterhouseCoopers report has suggested that in order to maintain levels of profitability, pharmaceuticals companies will have to launch, on average, between twenty-four and thirty-four new drags per year. (12) This in part explains why as of 1999 more than 450 medicines were under development for heart disease, cancer, and stroke, and why a further 191 were being developed for Alzheimer''s, arthritis, and depression. (13) This also explains in part the surge in numbers of physicians involved in clinical trials: 30,000 more physicians were involved in clinical trials in the United States in 1998 than a decade earlier, an increase of 600 percent. (14) Over the same period, there has been 60 percent increase in numbers of community-based clinical trials conducted. (15) As the latter data indicate, community-based physicians, most often remunerated through monetary incentives, are increasingly competing with researchers in academic institutions for access to research subjects. (16) The conduct of clinical trials is shifting from the teaching hospitals of academic institutions to the offices of private physicians and CROs. (17)

Over the past 5 years, a series of articles in leading American newspapers has revealed the extent to which the conduct of clinical trials may be affected by inducements offered by corporate research sponsors and accepted by some unscrupulous physicians. (1) The cases described were disturbing. They involved physicians engaged in excessive "enrollment activities" in exchange for money. Some of these physicians perpetrated fraud, falsifying their recruitment records in order to increase their profits. Others ignored exclusion criteria designed to ensure the safety of subjects and the validity of research results, referring their patients to research investigating treatments for conditions from which they did not suffer. (2) One of the articles reports that physicians focusing exclusively on commercial research regularly divulge annual incomes upwards of $1,000,000 with profits in excess of $300,000. Two physicians accumulated well over $10,000,000 through clinical trials activities in less than a decade. (3) Another article reported the role of finder''s fees and payments to parents in increasing the enrollment of children in medical research in the United States from 16,000 in 1997 to 45,000 in 2001. (4) It also highlighted the fact that subjects may be exposed to serious harm through referrals by zealous and inexperienced physicians, drawn to recruitment activity by offers of up to $5,000 per patient referred. Finally, several other "disturbing recruitment practices" were reported by the U.S. Department of Health and Human Services'' Office of Inspector General in its report on subject recruitment practices. These include many cases of patients being harassed for participation; a nursing home resident being told to participate in research or leave the home; and a subject who died and was later found not to have met the inclusion criteria for the study. (5)

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