The Drug Pushers by Carl Elliott Atlantic Monthly

The article is published online at: . http://www.theatlantic.com/doc/prem/200604/drug-reps

Below are some snippets.

From “detail men” to sales reps to drug pushers:

“Drug reps have been calling on doctors since the mid-nineteenth 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 direct-to-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.”

“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.”

The attributes of a successful drug rep:

“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. “
“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?

“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.”

Gifts and freebies to doctors biggest expenditure, biggest return on investment:

“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.”

 “After awhile even the most steel-willed doctors may look forward to visits by a rep, if only in the self-interested 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 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.”

 “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.

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.”

See complete article at:  

http://www.theatlantic.com/doc/200604/drug-reps
The Atlantic Monthly | April 2006
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 Carl Elliott

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