Healthy Skepticism Library item: 3850

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Elliott C.
The Drug Pushers
The Atlantic Monthly 2006 Apr 1
http://www.theatlantic.com/doc/prem/200604/drug-reps

Notes:

Ralph Faggotter’s Comments:

This article is one of the best, most insightful and most comprehensive essays I have come across on issues of concern to Healthy Skeptics.

Full text:

the atlantic monthly

Back in the old days, long before drug companies
started making headlines in the business pages, doctors
were routinely called upon by company representatives
known as “detail men.” To “detail” a doctor is to
give that doctor information about a company’s new drugs,
with the aim of persuading the doctor to prescribe them.
When I was growing up, in South Carolina in the 1970s,
I would occasionally see detail men sitting patiently in the
waiting room outside the office of my father, a family doctor.
They were pretty easy to spot. Detail men were usually
sober, conservatively dressed gentlemen who would not
have looked out of place at the Presbyterian church across
the street. Instead of Bibles or hymn books, though, they
carried detail bags, which were filled with journal articles,
drug samples, and branded knickknacks for the office.
Today detail men are officially known as “pharmaceutical
sales representatives,” but everyone I know calls them
“drug reps.” Drug reps are still easy to spot in a clinic or
hospital, but for slightly different reasons. The most obvious
is their appearance. It is probably fair to say that doctors,
pharmacists, and medical-school professors are not generally
admired for their good looks and fashion sense. Against
this backdrop, the average drug rep looks like a supermodel,
or maybe an A-list movie star. Drug reps today are often
young, well-groomed, and strikingly good-looking. Many are
women. They are usually affable and sometimes very smart.
Many give off a kind of glow, as if they had just emerged
from a spa or salon. And they are always, hands down, the
best-dressed people in the hospital.
Drug reps have been calling on doctors since the mid-
19th century, but during the past decade or so their numbers
have increased dramatically. From 1996
to 2001 the pharmaceutical sales force in
America doubled, to a total of 90,000 reps.
One reason is simple: good reps move product.
Detailing is expensive, but almost all
practicing doctors see reps at least occasionally,
and many doctors say they find reps
useful. One study found that for drugs introduced
after 1997 with revenues exceeding
$200 million a year, the average return for each dollar spent
on detailing was $10.29. That is an impressive figure. It is
almost twice the return on investment in medical-journal
advertising, and more than seven times the return on directto-
consumer advertising.
But the relationship between doctors and drug reps has
never been uncomplicated, for reasons that should be obvious.
The first duty of doctors, at least in theory, is to their
patients. Doctors must make prescribing decisions based on
medical evidence and their own clinical judgment. Drug reps,
in contrast, are salespeople. They swear no oaths, take care
of no patients, and profess no high-minded ethical duties.
Their job is to persuade doctors to prescribe their drugs. If
reps are lucky, their drugs are good, the studies are clear, and
their job is easy. But sometimes reps must persuade doctors
to prescribe drugs that are marginally effective, exorbitantly
expensive, difficult to administer, or even dangerously toxic.
Reps that succeed are rewarded with bonuses or commissions.
Reps that fail may find themselves unemployed.
Most people who work in health care, if they give drug
reps any thought at all, regard them with mixed feelings. A
handful avoid reps as if they were vampires, backing out of
the room when they see one approaching. In their view, the
best that can be said about reps is that they are a necessary
byproduct of a market economy. They view reps much as NBA
players used to view Michael Jordan: as an awesome, powerful
force that you can never really stop, only hope to control.
Yet many reps are so friendly, so easygoing,
so much fun
to flirt with that it is virtually impossible to demonize them.
How can you demonize someone who brings you lunch and
touches your arm and remembers your birthday and knows
the names of all your children? After awhile
even the most steel-willed doctors may look
forward to visits by a rep, if only in the selfinterested
way that they look forward to the
UPS truck pulling up in their driveway. A
rep at the door means a delivery has arrived:
take-out for the staff, trinkets for the kids,
and, most indispensably, drug samples on
the house. Although samples are the single
The Drug Pushers
As America turns its health-care system over to the market, pharmaceutical reps are wielding
more and more influence-and the line between them and doctors is beginning to blur

by car l elliott
Illustrations by Marcellus Hall
. . . . .
[Carl Elliott teaches at the Center for Bioethics
at the University of Minnesota and
is the author of several books, including
Better than Well: American Medicine
Meets the American Dream (2003),
and the co-editor of The Last Physician:
Walker Percy and the Moral
Life of Medicine (1999). His article “A
New Way to Be Mad” appeared in the
December 2000 issue of The Atlantic.
the atlantic monthly]

largest marketing expense for the drug industry, they pay
handsome dividends: doctors who accept samples of a drug
are far more likely to prescribe that drug later on.
Drug reps may well have more influence on prescriptions
than anyone in America other than doctors themselves, but
to most people outside the drug industry their jobs are mysterious.
What exactly do they do every day? Where do they
get their information? What do they say about doctors when
the doctors are not around? Reps can be found in hospitals,
waiting rooms, and conference halls all over the country, yet
they barely register on the collective medical consciousness.
Many doctors notice them only in the casual, utilitarian way
that one might notice a waitress or a bartender. Some doctors
look down on them on ethical grounds. “Little Willy Lomans,”
they say, “only in it for the money.” When I asked my friends
and colleagues in medicine to suggest some reps I could talk to
about detailing, most could not come up with a single name.
These doctors may be right about reps. It is true that
selling pharmaceuticals can be a highly lucrative job. But in
a market-based medical system, are reps really so different
from doctors? Most doctors in the United States now work,
directly or indirectly, for large corporations. Like reps, many
doctors must answer to managers and bureaucrats. They are
overwhelmed by paperwork and red tape. Unlike my father,
who would have sooner walked to Charleston barefoot than
take out an ad for his practice, many doctors now tout their
services on roadside billboards. My medical-school alumni
magazine recently featured the Class of 1988 valedictorian,
who has written a diet book, started her own consulting
firm, and become the national spokesperson for a restaurant
chain. For better or worse, America has turned its healthcare
system over to the same market forces that transformed
the village hardware store into Home Depot and the corner
pharmacy into a strip-mall CVS. Its doctors are moving to
the same medical suburb where drug reps have lived for the
past 150 years. If they want to know what life is like there,
perhaps they should talk to their neighbors.
The King of Happ y Hour Gene Carbona was almost a criminal. I know this
because, thirty minutes into our first telephone conversation,
he told me, “Carl, I was almost a criminal.”
I have heard ex-drug reps speak bluntly about their former
jobs, but never quite so cheerfully and openly. These days
Carbona works for The Medical Letter, a highly respected
nonprofit publication (Carbona stresses that he is speaking
only for himself), but he was telling me about his twelve
years working for Merck and then Astra Merck, a firm initially
set up to market the Sweden-based Astra’s drugs in
the United States. Carbona began training as a rep in 1988,
when he was only eleven days out of college. He detailed two
drugs for Astra Merck. One was a calcium-channel blocker
he calls “a dog.” The other was the heartburn medication Prilosec,
which at the time was available by prescription only.
The Atlantic Monthly april 2006
Prilosec is the kind of drug most reps can only dream
about. The industry usually considers a drug to be a blockbuster
if it reaches a billion dollars a year in sales. In 1998
Prilosec became the first drug in America to reach $5 billion
a year. In 2000 it made $6 billion. Prilosec’s success was not
the result of a massive heartburn epidemic. It was based
on the same principle that drove the success of many other
1990s blockbusters, from Vioxx to Viagra: the restoration of
an ordinary biological function that time and circumstance
had eroded. In the case of Prilosec, the function was digestion.
Many people discovered that the drug allowed them
to eat the burritos and curries that their gastrointestinal
systems had placed off-limits. So what if Prilosec was $4 a
pill, compared with a quarter or so for a Tagamet? Patients
still begged for it. Prilosec was their savior. Astra Merck marketed
Prilosec as the “purple pill,” but, according to Carbona,
many patients called it “purple Jesus.”
How did Astra Merck do it? Prilosec was the first proton
pump inhibitor (a drug that inhibits the production of stomach
acid) approved by the Food and Drug Administration,
and thus the first drug available in its class. By definition this
gave it a considerable head start on the competition. In the
late 1990s Astra Merck mounted a huge direct-to-consumer
campaign; ads for the purple pill were ubiquitous. But consumer
advertising can do only so much for a drug, because
doctors, not patients, write the prescriptions. This is where
reps become indispensable.
Many reps can tell stories about occasions when, in order
to move their product, they pushed the envelope of what is
ethically permissible. I have heard reps talk about scoring
sports tickets for their favorite doctors, buying televisions for
waiting rooms, and arranging junkets to tropical resorts. One
rep told me he set up a putting green in a hospital and gave
a putter to any doctor who made a hole-in-one. A former
rep told me about a colleague who somehow managed to
persuade a pharmacist to let him secretly write the prescribing
protocol for antibiotic use at a local hospital.
But Carbona was in a class of his own. He had access to so
much money for doctors that he had trouble spending it all.
He took residents out to bars. He distributed “unrestricted
educational grants.” He arranged to buy lunch for the staff of
certain private practices every day for a year. Often he would
invite a a group of doctors and their guests to a high-end restaurant,
buy them drinks and a lavish meal, open up the club
in back, and party until 4:00 a.m. “The more money I spent,”
Carbona says, “the more money I made.” If he came back to
the restaurant later that week with his wife, everything would
be on the house. “My money was no good at restaurants,” he
told me, “because I was the King of Happy Hour.”
My favorite Carbona story, the one that left me shaking my
head in admiration, took place in Tallahassee. One of the more
important clinics Carbona called on was a practice there consisting
of about fifty doctors. Although the practice had plenty
of patients, it was struggling. This problem was not uncommon.
When the movement toward corporate-style medicine
got under way, in the 1980s and 1990s, many doctors found
themselves ill-equipped to run a business; they didn’t know
much about how to actually make money. (“That’s why doctors
are such great targets for Ponzi schemes and real-estate
scams,” Carbona helpfully points out.) Carbona was detailing
this practice twice a week and had gotten to know some of the
clinicians pretty well. At one point a group of them asked him
for help. “Gene, you work for a successful business,” Carbona
recalls them saying. “Is there any advice you could give us to
help us turn the practice around?” At this point he knew he
had stumbled upon an extraordinary opportunity.
Carbona decided that the clinic needed a “practicemanagement
consultant.” And he and his colleagues at Astra
Merck knew just the man: a financial planner and accountant
with whom they were very friendly. They wrote up a contract.
They agreed to pay the consultant a flat fee of about $50,000
to advise the clinic. But they also gave him another incentive.
Carbona says, “We told him that if he was successful there
would be more business for him in the future, and by ‘successful,’
we meant a rise in prescriptions for our drugs.”
The consultant did an extremely thorough job. He spent
eleven or twelve hours a day at the clinic for months. He
talked to every employee, from the secretaries to the nurses
to the doctors. He thought carefully about every aspect of
the practice, from the most mundane administrative details
to big-picture matters such as bill collection and financial
strategy. He turned the practice into a profitable, smoothly
running financial machine. And prescriptions for Astra Merck
drugs soared.
When I asked Carbona how the consultant had increased
Astra Merck’s market share within the clinic so dramatically,
he said that the consultant never pressed the doctors
directly. Instead, he talked up Carbona. “Gene has put
his neck on the line for you guys,” he would tell them. “If
this thing doesn’t work, he might get fired.” The consultant
emphasized what a remarkable service the practice
was getting, how valuable the financial advice was, how
everything was going to turn around for them-all courtesy
of Carbona. The strategy worked. “Those guys went
Drug reps are easy to spot in a hospital or clinic. They are
often young and strikingly good-looking. They are usually
affable and sometimes very smart. And they are always,
hands-down, the best-dressed people in the hospital.
the drug pushers The Atlantic Monthly
berserk for me,” Carbona says. Doctors at the newly vitalized
practice prescribed so many Astra Merck drugs that
he got a $140,000 bonus. The scheme was so successful
that Carbona and his colleagues at Astra Merck decided
to duplicate it in other practices.
I got in touch with Carbona after I learned that he was
giving talks on the American Medical Student Association
lecture circuit about his experiences as a rep. At that point
I had read a fair bit of pharmaceutical sales literature, and
most of it had struck me as remarkably hokey and stilted.
Merck’s official training materials, for example, instruct reps
to say things like, “Doctor, based on the information we
discussed today, will you prescribe Vioxx for your patients
who need once-daily power to prevent pain due to osteoarthritis?”
So I was unprepared for a man with Carbona’s
charisma and forthright humor. I could see why he had
been such an excellent rep: he came off as a cross between
a genial con artist and a comedic character actor. After two
hours on the phone with him I probably would have bought
anything he was selling.
Most media accounts of the pharmaceutical industry
miss this side of drug reps. By focusing on scandals-the
kickbacks and the fraud and the lavish gifts-they lose sight
of the fact that many reps are genuinely likeable people. The
better ones have little use for the canned scripts they are
taught in training. For them, effective selling is all about
developing a relationship with a doctor. If a doctor likes a
rep, that doctor is going to feel bad about refusing to see
the rep, or about taking his lunches and samples but never
prescribing his drugs. As Jordan Katz, a rep for Schering-
Plough until two years ago, says, “A lot of doctors just write
for who they like.”
A variation on this idea emerges in Side Effects, Kathleen
Slattery-Moschau’s 2005 film about a fictional fledgling
drug rep. Slattery-Moschau, who worked for nine years as a
rep for Bristol-Myers Squibb and Johnson & Johnson, says
the carefully rehearsed messages in the corporate training
courses really got to her. “I hated the crap I had to say to
doctors,” she told me. The heroine of Side Effects eventually
decides to ditch the canned messages and stop spinning her
product. Instead, she is brutally honest. “Bottom line?” she
says to one doctor. “Your patients won’t shit for a week.” To
her amazement, she finds that the blunter she is, the higher
her market share rises. Soon she is winning sales awards
and driving a company BMW.
For most reps, market share is the yardstick of success.
The more scripts their doctors write for their drugs, the
more the reps make. Slattery-Moschau says that most of her
fellow reps made $50,000 to $90,000 a year in salary and
another $30,000 to $50,000 in bonuses, depending on how
much they sold. Reps are pressured to “make quota,” or meet
yearly sales targets, which often increase from year to year.
Reps who fail to make quota must endure the indignity of
having their district manager frequently accompany them
on sales calls. Those who meet quota are rewarded handsomely.
The most successful reps achieve minor celebrity
within the company.
One perennial problem for reps is the doctor who simply
refuses to see them at all. Reps call these doctors “No Sees.”
Cracking a No See is a genuine achievement, the pharmaceutical
equivalent of a home run or a windmill dunk. Gene
Carbona says that when he came across a No See, or any
other doctor who was hard to influence, he used “Northeast-
Southwest” tactics. If you can’t get to a doctor, he explains,
you go after the people surrounding that doctor, showering
them with gifts. Carbona might help support a Little League
baseball team or a bowling league. After awhile, the doctor
would think, Gene is doing such nice things for all these people,
the least I can do is give him ten minutes of my time. At that point,
Carbona says, the sale was as good as made. “If you could
get ten minutes with a doctor, your market share would go
through the roof.”
For decades the medical community has debated
whether gifts and perks from reps have any real effect.
Doctors insist that they do not. Studies in the medical literature
indicate just the opposite. Doctors who take gifts
from a company, studies show, are more likely to prescribe
that company’s drugs or ask that they be added to their
hospital’s formulary. The pharmaceutical industry has managed
this debate skillfully, pouring vast resources into gifts
for doctors while simultaneously reassuring them that their
integrity prevents them from being influenced. For example,
in a recent editorial in the journal Health Affairs, Bert
Spilker, a vice president for PhRMA, the pharmaceutical
trade group, defended the practice of gift-giving against
critics who, he scornfully wrote, “fear that physicians are
so weak and lacking in integrity that they would ‘sell their
souls’ for a pack of M&M candies and a few sandwiches
and doughnuts.”
Doctors’ belief in their own incorruptibility appears to
be honestly held. It is rare to hear a doctor-even in private,
off-the-record conversation-admit that industry gifts
have made a difference in his or her prescribing. In fact,
according to one small study of medical residents in the
Canadian Medical Association Journal, one way to convince
doctors that they cannot be influenced by gifts may be to
give them one; the more gifts a doctor takes, the more likely
that doctor is to believe that the gifts have had no effect.
This helps explain why it makes sense for reps to give away
even small gifts. A particular gift may have no influence,
but it might make a doctor more apt to think that he or
she would not be influenced by larger gifts in the future.
A pizza and a penlight are like inoculations, tiny injections
of self-confidence that make a doctor think, I will never be
corrupted by money.
Gifts from the drug industry are nothing new, of course.
William Helfand, who worked in marketing for Merck for
thirty-three years, told me that company representatives were
giving doctors books and pamphlets as early as the late 19th
century. “There is nothing new under the sun,” Helfand says.
“There is just more of it.” The question is: Why is there so
much more of it just now? And what changed during the
past decade to bring about such a dramatic increase in reps
bearing gifts?
The Atlantic Monthly april 2006
An ethic of salesmanship One morning last year I had breakfast at the Bryant-
Lake Bowl, a diner in Minneapolis, with a former
Pfizer rep named Michael Oldani. Oldani grew up
in a working-class family in Kenosha, Wisconsin. Although
he studied biochemistry in college, he knew nothing about
pharmaceutical sales until he was recruited for Pfizer by the
husband of a woman with whom he worked. Pfizer gave
him a good salary, a company car, free gas, and an expense
account. “It was kind of like the Mafia,” Oldani told me.
“They made me an offer I couldn’t refuse.” At the time, he was
still in college and living with his parents. “I knew a good
ticket out of Kenosha when I saw one,” he says. He carried
the bag for Pfizer for nine years, until 1998.
Today Oldani is a Princeton-trained medical anthropologist
teaching at the University of Wisconsin at Whitewater.
He wrote his doctoral dissertation on the anthropology of
pharmaceutical sales, drawing not just on ethnographic
fieldwork he did in Manitoba as a Fulbright scholar but also
on his own experience as a rep. This dual perspective-the
view of both a detached outsider and a street-savvy insider-
gives his work authority and a critical edge. I had invited
Oldani to lecture at our medical school, the University of
Minnesota, after reading his work in anthropology journals.
Although his writing is scholarly, his manner is modest and
self-effacing, more Kenosha than Princeton. This is a man
who knows his way around a diner.
Like Carbona, Oldani worked as a rep in the late 1980s
and the 1990s, a period when the drug industry was undergoing
key transformations. Its ethos was changing from that
of the country-club establishment to the aggressive, newmoney
entrepreneur. Impressed by the success of AIDS
activists in pushing for faster drug approvals, the drug
industry increased pressure on the FDA to let companies
bring drugs to the market more quickly. As a result, in 1992
Congress passed the Prescription Drug User Fee Act, under
which drug companies pay a variety of fees to the FDA,
with the aim of speeding up drug approval (thereby making
the drug industry a major funder of the agency set up
to regulate it). In 1997 the FDA dropped most restrictions
on direct-to-consumer advertising of prescription drugs,
opening the gate for the eventual Levitra ads on Super
Bowl Sunday and Zoloft cartoons during daytime television
shows. The drug industry also became a big political
player in Washington: by 2005, according to The Center
for Public Integrity, its lobbying organization had become
the largest in the country.
Many companies started hitting for the fences, concentrating
on potential blockbuster drugs for chronic illnesses
in huge populations: Claritin for allergies, Viagra for impotence,
Vioxx for arthritis, Prozac for depression. Successful
drugs were followed by a flurry of competing me-too drugs.
For most of the 1990s and the early part of this decade, the
pharmaceutical industry was easily the most profitable business
sector in America. In 2002, according to Public Citizen,
a nonprofit watchdog group, the combined profits of the top
ten pharmaceutical companies in the Fortune 500 exceeded
the combined profits of the other 490 companies.
During this period reps began to feel the influence of
a new generation of executives intent on bringing market
values to an industry that had been slow to embrace them.
Anthony Wild, who was hired to lead Parke-Davis in the
mid-1990s, told the journalist Greg Critser, the author of
Generation Rx, that one of his first moves upon his appointment
was to increase the incentive pay given to successful
reps. Wild saw no reason to cap reps’ incentives. As he said
to the company’s older executives, “Why not let them get
rich?” Wild told the reps about the change at a meeting in
San Francisco. “We announced that we were taking off the
caps,” he told Critser, “and the sales force went nuts!”
It was not just the industry’s ethos that was changing;
the technology was changing, too. According to Oldani,
one of the most critical changes came in the way that
information was gathered. In the days before computers,
reps had to do a lot of legwork to figure out whom they
could influence. They had to schmooze with the receptionists,
make friends with the nurses, and chat up the
pharmacists in order to learn which drugs the local doctors
were prescribing, using the right incentives to coax what
they needed from these informants. “Pharmacists are like
pigeons,” Jamie Reidy, a former rep for Pfizer and Eli Lilly,
told me. “Only instead of bread crumbs, you toss them
pizzas and sticky notes.”
But in the 1990s, new information technology made it
much simpler to track prescriptions. Market-research firms
began collecting script-related data from pharmacies and
hospitals and selling it to pharmaceutical companies. The
American Medical Association collaborated by licensing
them information about doctors (including doctors who do
not belong to the AMA), which it collects in its “Physician
Masterfile.” Soon reps could find out exactly how many prescriptions
any doctor was writing and exactly which drugs
those prescriptions were for. All they had to do was turn on
their laptops and download the data.
In the 1990s, new technology made it easy for any rep
to track any doctor’s prescriptions. The result was an arms
race of pharmaceutical gift-giving. If GS K flew doctors
to Palm Springs for a conference, you flew them to Paris.
the drug pushers The Atlantic Monthly
What they discovered was revelatory.
For one thing, they found that a
lot of doctors were lying to them. Doctors
might tell a rep that they were writing
prescriptions for, say, Lipitor, when
they weren’t. They were just being
polite, or saying whatever they thought
would get the rep off their back. Now
reps could detect the deception immediately.
(Even today many doctors do
not realize that reps have access to
script-tracking reports.)
More important, script-tracking
helped reps figure out which doctors
to target. They no longer had to waste
time and money on doctors with conservative
prescribing habits; they could
head straight to the “high prescribers,”
or “high writers.” And they could get
direct feedback on which tactics were
working. If a gift or a dinner presentation
did not result in more scripts, they
knew to try another approach.
But there was a rub: the data was
available to every rep from every company.
The result was an arms race of
pharmaceutical gift-giving, in which
reps were forced to devise ever-new
ways to exert influence. If the Eli Lilly
rep was bringing sandwiches to the office staff, you brought
Thai food. If GSK flew doctors to Palm Springs for a conference,
you flew them to Paris. Oldani used to take residents
to Major League Baseball games. “We did beer bongs, shots,
and really partied,” he told me. “Some of the guys were
incredibly drunk on numerous occasions. I used to buy
half barrels for their parties, almost on a retainer-like basis.
I never talked product once to any of these residents, and
they took care of me in their day-to-day practice. I never
missed quota at their hospital.”
Oldani says that script-tracking data also changed the
way that reps thought about prescriptions. The old system of
monitoring prescriptions was very inexact, and the relationship
between a particular doctor’s prescriptions and the work
of a given rep was relatively hard to measure. But with precise
script-tracking reports, reps started to feel a sense of ownership
about prescriptions. If their doctors started writing more
prescriptions for their drugs, the credit clearly belonged to
them. However, more precise monitoring also invited micromanagement
by the reps’ bosses. They began pressuring reps
to concentrate on high prescribers, fill out more paperwork,
and report more frequently back to management.
“Script tracking, to me at least, made everyone a potentially
successful rep,” Oldani says. Reps didn’t need to be
nearly as resourceful and street savvy as in the past; they
just needed the script-tracking reports. The industry began
hiring more and more reps, many with backgrounds in sales
(rather than, say, pharmacy, nursing, or biology). Some older
reps say that during this period the industry replaced the
serious detail man with “Pharma Barbie” and “Pharma Ken,”
whose medical knowledge was exceeded by their looks and
catering skills. A newer, regimented style of selling began
to replace the improvisational, more personal style of the
old-school reps. Whatever was left of an ethic of service gave
way to an ethic of salesmanship.
Doctors were caught in a bind. Many found themselves
being called on several times a week by different reps
from the same company. Most continued to see reps, some
because they felt obligated to get up to speed with new
drugs, some because they wanted to keep the pipeline of
free samples open. But seeing reps has a cost, of course: the
more reps a doctor sees, the longer the patients sit in the
waiting room. Many doctors began to feel as though they
deserved whatever gifts and perks they could get because
reps were such an irritation. At one time a few practices
even charged reps a fee for visiting.
Professional organizations made some efforts to place
limits on the gifts doctors were allowed to accept. But these
efforts were half-hearted, and they met with opposition from
indignant doctors ridiculing the idea that their judgment
could be bought. One doctor, in a letter to the American Medical
News, confessed, “Every time a discussion comes up on
guidelines for pharmaceutical company gifts to physicians, I
feel as if I need to take a blood pressure medicine to keep from
a having a stroke.” In 2001 the AMA launched a campaign
to educate doctors about the ethical perils of pharmaceutical
gifts, but it undercut its message by funding the campaign
with money from the pharmaceutical industry.
Of course, most doctors are never offered free trips to
Monaco or even a weekend at a spa; for them an industry
gift means a Cialis pen or a Lexapro notepad. Yet it is a rare
rep who cannot tell a story or two about the extravagant
gifts doctors have requested. Oldani told me that one doctor
asked him to build a music room in his house. Phyllis
Adams, a former rep in Canada, was told by a doctor that
he would not prescribe her product unless her company
made him a consultant. (Both said no.) Carbona arranged
a $35,000 “unrestricted educational grant” for a doctor
who wanted a swimming pool in his back yard. “It was the
Wild West,” says Jamie Reidy, whose frank memoir about
his activities while working for Pfizer in the 1990s, Hard
Sell: The Evolution of a Viagra Salesman, recently got him
fired from Eli Lilly. “They cashed the check, and that was
it. And hopefully they remembered you every time they
turned on the TV, or bought a drink on the cruise, or dived
into the pool.”
The trick is to give doctors gifts without making them
feel that they are being bought. “Bribes that aren’t considered
bribes,” Oldani says. “This, my friend, is the essence
of pharmaceutical gifting.” According to Oldani, the way to
make a gift feel different from a bribe is to make it personal.
“Ideally, a rep finds a way to get into a scriptwriter’s psyche,”
he says. “You need to have talked enough with a scriptwriter-
or done enough recon with gatekeepers-that you
know what to give.” When Oldani found a pharmacist who
liked to play the market, he gave him stock options. When
he wanted to see a resistant oncologist, he talked to the
doctor’s nurse and then gave the oncologist a $100 bottle
of his favorite cognac. Reidy put the point nicely when he
told me, “You are absolutely buying love.”
Such gifts do not come with an explicit quid pro quo,
of course. Whatever obligation doctors feel to write scripts
for a rep’s products usually comes from the general sense
of reciprocity implied by the ritual of gift-giving. But it is
impossible to avoid the hard reality informing these ritualized
exchanges: reps would not give doctors free stuff if they
did not expect more scripts.
My brother Hal, a psychiatrist currently on the faculty of
Wake Forest University, told me about an encounter he had
with a drug rep from Eli Lilly some years back, when he was
in private practice. This rep was not one of his favorites; she
was too aggressive. That day she had insisted on bringing
lunch to his office staff, even though Hal asked her not to.
As he tried to make polite conversation with her in the hall,
she reached over his shoulder into his drug closet and picked
up a couple of sample packages of Zoloft and Celexa. Waving
them in the air, she asked, “Tell me, Doctor, do the Pfizer and
Forest reps bring lunch to your office staff? ” A stony silence
followed. Hal quietly ordered the rep out of the office and
told her to never come back. She left in tears.
It’s not hard to understand why Hal got so angry. The
rep had broken the rules. Like an abrasive tourist who has
not caught on to the code of manners in a foreign country,
she had said outright the one thing that, by custom and common
agreement, should never be said: that the lunches she
brought were intended as a bribe. What’s more, they were
a bribe that Hal had never agreed to accept. He likened the
situation to having somebody drop off a bag of money in
your garage without your consent and then ask, “So what
about our little agreement?”
When an encounter between a doctor and a rep goes well,
it is a delicate ritual of pretense and self-deception. Drug reps
pretend that they are giving doctors impartial information.
Doctors pretend that they take it seriously. Drug reps must try
their best to influence doctors, while doctors must tell themselves
that they are not being influenced. Drug reps must act
as if they are not salespeople, while doctors must act as if
they are not customers. And if, by accident, the real purpose
of the exchange is revealed, the result is like an elaborate
theatrical dance in which the masks and costumes suddenly
drop off and the actors come face to face with one another
as they really are. Nobody wants to see that happen.
the new drug reps? Last spring a small group of first-year medical students
at the University of Minnesota spoke to me about a
lecture on erectile dysfunction that had just been given
by a member of the urology department. The doctor’s PowerPoint
slides had a large, watermarked logo in the corner. At
one point during the lecture a student raised his hand and,
somewhat disingenuously, asked the urologist to explain the
logo. The urologist, caught off-guard, stumbled for a moment
and then said that it was the logo for Cialis, a drug for erectile
dysfunction that is manufactured by Eli Lilly. Another student
asked if he had a special relationship with Eli Lilly. The urologist
replied that yes, he was on the advisory board for the company,
which had supplied the slides. But he quickly added that
nobody needed to worry about the objectivity of his lecture
because he was also on the advisory boards of the makers of
the competing drugs Viagra and Levitra. The second student
told me, “A lot of people agreed that it was a pharm lecture
and that we should have gotten a free breakfast.”
Doctors insist that gifts and perks from reps have no
real effect. Studies in the medical literature indicate just
the opposite. Doctors who take gifts from a company
are more likely to prescribe that company’s drugs.
This episode is not as unusual as it might appear. Drug
company–sponsored consultancies, advisory-board memberships,
and speaking engagements have become so common,
especially among medical-school faculty, that the urologist
probably never imagined that he would be challenged for
lecturing to medical students with materials produced by
Eli Lilly. According to a recent study in The Journal of the
American Medical Association, nine out of ten medical students
have been asked or required by an attending physician to
go to a lunch sponsored by a drug company. As of 2003,
according to the Accreditation Council for Continuing Medical
Education, pharmaceutical companies were providing 90
percent of the $1 billion spent annually on continuing medical
education events, which doctors must attend in order to
maintain their licensure.
Over the past year or two pharmaceutical profits have
started to level off, and a backlash against reps has been felt;
some companies have actually reduced their sales forces. But
the industry as a whole is hiring more and more doctors as
speakers. In 2004, it sponsored nearly twice as many educational
events led by doctors as by reps. Not long before, the
numbers had been roughly equal. This raises the question,
Are doctors becoming the new drug reps?
Doctors are often the best people to market a drug to
other doctors. Merck discovered this when it was developing
a campaign for Vioxx, before the drug was taken off
the market because of its association with heart attacks and
strokes. According to an internal study by Merck, reported
in The Wall Street Journal, doctors who attended a lecture by
another doctor subsequently wrote nearly four times more
prescriptions for Vioxx than doctors who attended an event
led by a rep. The return on investment for doctor-led events
was nearly twice that of rep-led events, even after subtracting
the generous fees Merck paid to the doctors who spoke.
These speaking invitations work much like gifts. While
reps hope, of course, that a doctor who is speaking on behalf
of their company will give their drugs good PR, they also
know that such a doctor is more likely to write prescriptions
for their drugs. “If he didn’t write, he wouldn’t speak,” a rep
who has worked for four pharmaceutical companies told
me. The semi-official industry term for these speakers and
consultants is “thought leaders,” or “key opinion leaders.”
Some thought leaders do not stay loyal to one company but
rather generate a tidy supplemental income by speaking and
consulting for a number of different companies. Reps refer
to these doctors as “drug whores.”
The seduction, whether by one company or several, is
often quite gradual. My brother Hal explained to me how he
wound up on the speakers’ bureau of a major pharmaceutical
company. It started when a company rep asked him if
he’d be interested in giving a talk about clinical depression
to a community group. The honorarium was $1,000. Hal
thought, Why not? It seemed almost a public service. The
next time, the company asked him to talk not to the public
but to practitioners at a community hospital. Soon company
reps were making suggestions about content. “Why don’t
you mention the side-effect profiles of the different antidepressants?”
they asked. Uneasy, Hal tried to ignore these
suggestions. Still, the more talks he gave, the more the reps
became focused on antidepressants rather than depression.
The company began giving him PowerPoint slides to use,
which he also ignored. The reps started telling him, “You
know, we have you on the local circuit giving these talks,
but you’re medical-school faculty; we could get you on the
national circuit. That’s where the real money is.” The mention
of big money made him even more uneasy. Eventually
the reps asked him to lecture about a new version of their
antidepressant drug. Soon after that, Hal told them, “I can’t
do this anymore.”
Looking back on this trajectory, Hal said, “It’s kind of
like you’re a woman at a party, and your boss says to you,
‘Look, do me a favor: be nice to this guy over there.’ And
you see the guy is not bad-looking, and you’re unattached,
so you say, ‘Why not? I can be nice.’” The problem is that it
never ends with that party. “Soon you find yourself on the
way to a Bangkok brothel in the cargo hold of an unmarked
plane. And you say, ‘Whoa, this is not what I agreed to.’ But
then you have to ask yourself, ‘When did the prostitution
actually start? Wasn’t it at that party?’”
Thought leaders serve an indispensable function when
it comes to a potentially very lucrative marketing niche: offlabel
promotion, or promoting a drug for uses other than
those for which it was approved by the FDA-something
reps are strictly forbidden to do. The case of Neurontin is
especially instructive. In 1996 a whistle-blower named David
Franklin, a medical-science liaison with Parke-Davis (now
a division of Pfizer), filed suit against the company over its
off-label promotion of this drug. Neurontin was approved
for the treatment of epilepsy, but according to the lawsuit,
Parke-Davis was promoting it for other conditions-including
bipolar disorder, migraines, and restless legs syndrome-for
which there was little or no scientific evidence that it worked.
To do so the company employed a variety of schemes, most
involving a combination of rep ingenuity and payments to
doctors. Some doctors signed ghostwritten journal articles.
One received more than $300,000 to speak about Neurontin
at conferences. Others were paid just to listen. Simply having
some of your thought leaders in attendance at a meeting is
valuable, Kathleen Slattery-Moschkau explains, because they
will often bring up off-label uses of a drug without having
to be prompted. “You can’t get a better selling situation than
that,” she says. In such circumstances all she had to do was
pour the wine and make sure everyone was happy.
The litigation over Neurontin cost Pfizer $430 million in
criminal fines and civil damages for the period 1994 to 2002.
It was well worth it. The drug’s popularity and profitability
soared. In spite of the adverse publicity, Neurontin generated
more than $2.7 billion in revenues in 2003, more than 90
percent of which came from off-label prescriptions.
Of course, sometimes speakers discover that the drug they
have been paid to lecture about is dangerous. One of the most
notorious examples is Fen-Phen, the diet-drug combination
that has been linked to primary pulmonary hypertension and
valvular heart disease. Wyeth, the manufacturer of Redux,
or dexfenfluramine-the “Fen” in Fen-Phen-has put aside
$21 billion to cover costs and liabilities from litigation. Similar
events played out, on a lesser scale, with Parke-Davis’s diabetes
drug Rezulin, and Wyeth’s pain reliever Duract, which
were taken off the market after being associated with lifethreatening
complications.
And what about reps themselves? Do they trust their
companies to tell them about potential problems with their
drugs? Not exactly. As one veteran rep, voicing a common
sentiment, told me, “Reps are the last to know.” Of course, for
a rep to be detailing a drug enthusiastically right up to the
day it is withdrawn from the market is likely to erode that
rep’s credibility with doctors. Yet some reps say they don’t
hear about problems until the press gets wind of them and
the company launches into damage control. At that point,
Slattery-Moschau explains, “Reps learn verbatim how to
handle the concern or objection in a way that spins it back
in the drug’s favor.”
Some believe that the marketing landscape changed dramatically
for both reps and doctors in 2002, after the Office
of the Inspector General in the Department of Health and
Human Services announced its intention to crack down on
drug companies’ more notorious promotional practices. With
the threat of prosecution in the air, the industry began to
take the job of self-policing a lot more seriously, and PhRMA
issued a set of voluntary marketing guidelines.
Although most reps agree that the PhRMA code has
changed things, not all of them agree that it changed things
for the better. Some say that as long as reps feel pressure to
meet quota, they will find ways to get around the rules. As
one former rep pointed out, not all drug companies belong
to PhRMA, and those that don’t are, of course, not bound
by PhRMA’s guidelines. Jordan Katz says that things actually
got worse after 2002. “The companies that tried to follow
the guidelines lost a ton of market share, and the ones who
didn’t gained it,” he says. “The bottom line is that if you
don’t pay off the doctors, you will not succeed in pharmaceuticals.
Period.”
A World Without Doctors? In 1997, John Lantos, a pediatrician and ethicist at the
University of Chicago, wrote a book called Do We Still
Need Doctors? We will always need health care, of course.
But, as Lantos observes, it is not clear that we will always
need to get our health care from doctors. Many of us already
get it from other providers-nurses, physical therapists, clinical
psychologists, nutritionists, respiratory therapists, and
so on. The figure of “the doctor” is not cast in stone. It is
really just a particular configuration of roles and duties and
responsibilities, each of which can be changed.
Many have already been changed. Sometimes I think
of my father as one of the last small-town, solo family doctors
left in America. His kind of practice has been largely
replaced by teams of specialists working in group practices
underwritten by insurance companies and for-profit healthcare
chains. I doubt that any of the doctors my family has
ever visited, except for a pediatrician who took care of our
children when we lived in Montreal, would recognize us if
they passed us in the street. Last year, while driving in Wisconsin,
I filled up my car at a combination gas station, pharmacy,
and walk-in medical clinic. I don’t mean to complain.
As long as our health insurance has been paid up, we have
usually gotten good care. We simply live in a country that
has decided that the traditional figure of the doctor is not
worth preserving in the face of modern economics. Instead,
we put our trust in the market.
Some drug companies have cut their sales forces, but the
industry is hiring more and more doctors as speakers: doctors
are often the best people to market a drug to other doctors.
This raises the question: are doctors becoming the new reps?
Perhaps we are right to do so. We can get used to a world
without doctors. As Lantos points out, we have gotten used
to a world where we have shoes but no cobblers. We can
copy documents without scriveners, make tools without
blacksmiths, and produce books in the absence of bookbinders.
We have left the old world behind, and for the most
part, we don’t miss it.
As the figure of the traditional doctor fades away, it is
being replaced by a figure akin to the drug rep, one whose
responsibilities are to compete as vigorously as possible
in the medical marketplace. Patients are being replaced by
“health-care consumers,” who shop for the best medical bargains
they can find. If it is true that the drug rep does not
put my interests first, the same is true of everyone else in
the marketplace; and we believe that such problems in the
marketplace will be sorted out by the invisible hand. Buyers
will stop buying from sellers who provide them with inferior
goods. This model of medicine is not unlike that advocated
thirty years ago by Robert Sade, a surgeon at my old medical
school, the Medical University of South Carolina. Writing in
The New England Journal of Medicine, Sade argued, “Medical
care is neither a right nor a privilege: it is a service provided
by doctors and others to people who wish to purchase it.”
He is now the vice chair of the AMA’s Council of Ethical
and Judicial Affairs.
Many doctors seem resigned to this shift. They see themselves
as a beleaguered group whose lives are made miserable
by third-party payers, personal-injury attorneys, and
hospital bureaucrats. Whatever idealism they may have had
about the practice of medicine is being pushed aside by the
concrete realities of hustling in the new medical marketplace.
Many academic physicians seem cowed by the power of the
drug companies, upon whom some depend for research
funding. For some, it’s not so much a question of whether
medicine has become a business as what kind of business it
has become. When I talked recently to a gastroenterologist
at an Ivy League medical school about his work as a thought
leader for a variety of drug companies, he shrugged and said,
“Better a whore than a concubine.”
Which is not to say that pockets of resistance can’t be
found, especially among younger physicians and medical
students. The American Medical Student Association may
be the only mainstream medical organization with a principled
position against taking industry gifts. It stands in
striking contrast to the American Academy of Family Practice,
which last year refused to grant exhibition space at
its annual conference to No Free Lunch, a physician-led
advocacy group that advises physicians to “Just say no to
drug reps.” The AAFP said that the group’s goals were “not
within the character and purpose” of the conference. But it
allowed pharmaceutical companies, McDonald’s, and the
Distilled Spirits Council of the United States to exhibit. (It
reversed its decision about No Free Lunch after protests by
a number of AAFP members.)
Whether doctors and reps are all that different from one
another is no longer clear. Doctors know a lot more about
medicine, and drug reps dress a lot better, but these days
both are Organization Men, small cogs in a vast health-care
machine. They are just doing their jobs in a market-driven
health-care bureaucracy that Americans have designed, and
that we defend vigorously to critics elsewhere in the world.
Like anyone else, doctors and reps are responding to the
pressures and incentives of the system in which they work.
When Michael Oldani and I were having breakfast, he
told me a story about a rep he interviewed for his dissertation.
The rep had recently spent a day doing a “preceptorship,”
a practice in which a drug company pays doctors to
let a rep shadow them while they see patients. This rep
was shadowing a high-prescribing psychiatrist (she called
him “Dr. C”) at a med-check clinic. Med-check clinics are
extremely busy sites where psychiatrists see large numbers
of patients in quick succession, mainly to make sure that their
medications are in proper order. At one point during the
day, the rep said, a cheerful man in a wheelchair rolled into
the office. Barely looking up from the stack of charts on his
desk, Dr. C started quizzing the man about his medications.
After a few minutes the man interrupted. “Look at me, Dr. C.
Notice anything different?” Dr. C pushed his glasses up on
top of his head and looked carefully at the patient for a few
seconds before replying, “No, I don’t. What’s up?” The man
smiled and said excitedly, “I got my legs cut off!”
After a moment of silence, Dr. C smiled. The man laughed.
Neither seemed upset. In a few minutes the session ended,
and the next patient came in.