A Drug Rep Tells All

Most people who read this blog understand how drug companies use their reps to try to influence the kinds of medications that physicians prescribe. The question is: do they really have an effect on how most doctors practice medicine? 

Below, an insider’s look at how drug reps operate from the Carlat Psychiatry Blog. A former Eli Lilly rep may sum it all up when he says: “Gift giving is the key. You are programmed as a human to reciprocate . . . As a matter of fact, the smaller the gift, the greater the sense of obligation.”

Thursday, March 27, 2008 : A Drug Rep Tells All

Shahram Ahari, former Eli Lilly drug rep, recently spoke to the Tufts Progressive Medical Students Organization. It was a fascinating talk, because Ahari told us about how he and his colleagues used every trick of salesmanship in the book to increase prescriptions of Prozac and Zyprexa and therefore to maximize their bonuses.

The key criteria of employment as a drug rep, he said, are being good
looking and mastering the art of small talk. No huge surprise here, but
it’s helpful to remember that drug reps do not come to doctors to
educate, but rather to persuade.

"Gift giving is the key," he said. "You are programmed as a human to
reciprocate. You feel obliged to return the favor. As a matter of fact,
the smaller the gift, the greater the sense of obligation."

Do you consider samples to be a part of the company’s civic duty? Think
again. "Samples are a marketing tool. They always have strings
attached. Typically, we would provide two weeks worth of samples, which
worked out wonderfully. Just like a drug dealer, the first one is free,
and then you’re hooked."

A member of the audience who had once been a consultant to industry
made an interesting comment about samples. His job was to track
doctors’ prescribing behavior in response to sampling practices, and to
provide physician-specific "response curves" to companies. Using these
curves, reps determined how to maximize their "return" on sampling. If
you "hit" Doctor Smith 10 times per year with samples, he might
prescribe more product than Doctor Jones, who might require less
sampling. To drug companies, doctors are pawns in a game of
cost-benefit analysis.

Ahari recalls well that food makes doctors more receptive to the
message. "We took painstaking efforts to determine what you like. We
had a $60,000 budget for food, and we used this to make ourselves seem
a necessity to clinics who wanted to make their staff happy."

But food pales compared to what Ahari called "the most sinister tool in
our armamentarium: our computer." He was referring, of course, to
prescription data-mining. "We knew all your prescribing data, and we
used it fine-tune our pitch."

Do you think drug reps are there to provide you with crucial medical
information? Fuggedabout it! "I was in your office in order to
influence you to prescribe Prozac or Zyprexa. We focussed on providing
information to manipulate your prescribing, not to teach you how to
treat your patients. Mostly, we wanted to build a good relationship, so
that you’d like us. We are the one spot of sunshine in your day, a
person who steps in the door and is actually interested in how you’re
doing. We’re fun, witty, attractive, and we come bearing gifts. No
wonder we’re accepted into your offices."

12 thoughts on “A Drug Rep Tells All

  1. ‘ He was referring, of course, to prescription data-mining. “We knew all your prescribing data, and we used it fine-tune our pitch.” ‘
    This seems to skirt on the edge of violating privacy rules. I guess only patient records are private, not doctor’s. I can see a valid reason to know which doctors are prescribing which drugs in case they need to be contacted for recalls or changes in use recommendations. But, why should the amount or number of patients they treat be medically necessary?
    A bit of cross correlation might also be able to determine who the patients are. Drug companies might also have a valid reason for knowing which patients are taking their drugs, but why does this need to correlate with who is prescribing them?
    The few doctors I know well don’t allow drug reps into their offices. I don’t know how typical this is.

  2. All you have to do is pay attention and exercise common economic sense, they are in business to profit, for no other reason. In my office I did not accept gifts or food, not a pen, not a piece of paper, I did not provide them my time. I had two rules about samples 1; If what I was treating was short term (pain, infection) I would check for samples first. 2; If I was starting long term treatment, the patient and I would decide what medication first, then see if I had samples.
    It didn’t take very long before the drug reps (pushers) stopped coming to my office.

  3. Robert & Dr. Matt
    Dr. Matt– I wish more docs followed your example. Drugs would be a little less expensive if we didn’t have to pay for all of those reps . . .
    Robert– You may not be ready for this.
    Guess how drug companies began getting the info?
    The AMA was selling it to them.
    This from 2002:
    “Drug manufacturers produce doctor profiles using information from health-data companies and other medical groups such as the AMA. The information is used to help companies target their drug sales. Doctors at the recent winter meeting of the AMA say the marketing programs are an invasion of their privacy and result in unwanted harassment by drug sales representatives advocating the industry’s latest, and often most expensive, medications.
    “So far, the AMA has ignored the physicians’ request. The organization could lose at least $20 million annually if it is forced to stop selling physician data to drug companies. AMA leadership is planning to meet with certain drug manufacturers to encourage responsible use of the data. It also plans to develop best-practice guidelines for sales representatives.”
    Since then, the NEJM reported “the AMA has has created a Prescribing Data Restriction Program. Physicians are now able to deny all sales representatives access to their individual prescribing data. The restriction is limited to sales representatives and their direct supervisors; physicians will not be able to deny access to other officials at pharmaceutical companies.”
    (2006)

  4. General and specific observation.
    I’m aware of some group practices and hospitals that have the drug reps call on an experienced hospital pharmacist, who evaluates the drugs and then presents to the clinicians. In some cases, if the pharmacists and clinicians approve, the pharmacists may ask for samples. They will make exceptions for focused presentations by true experts.
    There is a broad issue in psychotropic drug “fashions”, significantly but not exclusively driven by drug marketing. There was a short but interesting comment in Medscape by a psychopharmacologist, who worked primarily with children but covered all age groups. Some of her comments were that SSRIs were not the answer to every psychiatric conditions. The SNRIs may be very helpful, but need to be used with great caution due to withdrawal effects.
    She also mentioned that too many clinicians underprescribe older drugs, and ignore off-label indications for several conditions. In the latter, she mentioned direct stimulants (e.g., amphetamines, methylphenidate) as sometimes quite useful for depression in older adults. While anticonvulsants are often prescribed for manic and bipolar mood disorders, they are an alternative in unipolar depression and anxiety states. But who is there to educate about these approaches, often with drugs off patent?
    The singular, and even N=3 of data not being anecdote, it strikes me as significant that I’ve encountered three friends, all on valproate and sometimes extremely frightened they had Parkinson’s syndrome, because they had benign hand tremor. Their physicians had either not picked this up, or recognized that in the absence of contraindications such as asthma, low-dose beta blockers can stop the tremor.

  5. Ideally doctors should be prohibited from receiving any incentives from drug companies because even small gifts lead to unintended bias. All available evidence suggests that no policy would be effective for reducing adverse influence.
    If prohibiting gifts is not achievable, another option would be to make all gifts taxable. As an example, if doctors were invited to a meeting and served a meal then the drug company would be obliged to issue them with a form giving the value of the meal. At tax time doctors would have to declare, and pay tax, on all gifts that they received from drug companies.
    Dana J, Loewenstein G. A Social Science Perspective on Gifts to Physicians From Industry JAMA. 2003;290:252-255
    Katz D, Caplan AL, Merz JF. All gifts large and small: toward an understanding of the ethics of pharmaceutical industry gift-giving. Am J Bioeth. 2003;3(3):39-46

  6. I think the drug rep controversy is much ado about very little.
    During my entire career in the investment business, I have dealt with Wall Street analysts and salesmen. We vote periodically on which firms and analysts add the most value to our money management efforts and direct our commission business accordingly. Over the years, I have gone to lunch (and sometimes dinner) to meet with their analysts, though most of the time we meet in my office (without food). The key point is that going to lunch or dinner is considered a normal business courtesy in our business, and it has never influenced me in determining whether a given firm is adding value or not. At the same time, when I am invited as part of a small group to meet with a company management, it would be inappropriate and unethical for anyone other than my own employer to pay for my airfare and hotel costs.
    If I were a doctor, it is inconceivable to me that accepting pens, pads, or sandwiches and soda for me and my staff would influence my prescribing behavior. Accepting lavish entertainment would be another matter. Ideally, if there is a generic drug that could address a patient’s issue, it should be prescribed unless there is evidence that the patient can’t tolerate it. Indeed, over 60% of all prescriptions written now are generics. Furthermore, since doctors have expertise and other sources of information available to them, including their medical specialty societies, an interaction between a doctor and a drug rep is more than a fair fight, in my view. On the other hand, DTC advertising should be banned like it used to be. Moreover, I have a lot bigger problem with the rapid growth of ultra expensive specialty drugs for patients with cancer, AIDS, organ transplants and the like. This is now a $60 billion dollar a year segment and is growing faster than drug spending overall. Comparative effectiveness research and perhaps even QALY metrics would be useful here. As a taxpayer, I have a hard time paying Genzyme $300K per year for Cerezyme to treat Gaucher’s disease even though there are only 1,500 patients currently on the drug in the U.S. (5,000 worldwide).
    I would also note that prescription drugs are one area of healthcare where price transparency is actually pretty good. It is easy to find out how much drug stores charge for a given drug before one agrees to buy it, and price comparisons can be made against other similar drugs that could be prescribed. I think doctors should make it part of their body of knowledge to be aware of which brand name drugs are more expensive than others and whether or not there is a suitable generic that can be prescribed. The only thing I would say to doctors who would allow their prescribing patterns to be influenced by a pretty, perky drug rep in a snappy pants suit bearing pens, pads, coffee mugs or food is: shame on you.

  7. Barry–
    First, let me say that I suspect that you are very honest.
    I also suspect you may be somewhat insulated from much of what actually goes on on Wall Street.
    The history of the relationship between analysts and money managers is fraught with corruption. As former analyst Dan Reingold wrote
    in the Financial Times not long ago: “analysts are still allowed to go over the Chinese wall to provide advice to their firms’bankers and corporate clients. In this way, an analyst often becomes privy to material, not-yet-public information about an acquisition, a large financing, a new product offering or some other big event.
    “Intentionally or not, sometimes that information gets passed on to selected money managers to the unfair disadvantage of most investors. [Often, this happens over dinner at an expensive restaurant-mm]
    You write: “We vote periodically on which firms and analysts add the most value to our money management efforts and direct our commission business accordingly” —
    Here is how Business Week
    describes that voting process : “Analysts also need to shine in surveys such as Institutional Investor’s annual rankings, in which money managers vote for their favorite stockpickers, so they spend too much time lobbying clients rather than crunching numbers. [MORE LUNCHES AND DINNERS–mm}’Analysts get focused on saying what they think the client wants to hear to win the vote,’ says Henry J. Herrmann, chief investment officer at Waddell & Reed Inc., a money manager.”
    I don’t know if you know Hank Herrmann, but he is extremely honest and is telling it like it is. He
    also realizes that the II elections naming the “best analysts” are mainly popularity contests.
    At least 80 percent–perhaps 90 percent–of the analysts voted “best” in II’s rankings are merely doing the bidding of the corporations they write about, helping to boost their company’s own investment banking business while saying what money managers wanted to hear about stocks they own.
    These are not the best analysts on the street. (Here I’m thinking of people like Mary Meeker–who knew nothing about Internet stocks and the hundreds of analysts’ reports that I simply threw into my wastebasket at Barron’s.
    There were some very good analylsts who I read–but I could the number on my fingers. No need for toes.
    In Bull! I write about an analyst receiving death threats from money managers because he wrote negatively about stocks they owned. The money managers felt they “owned” the analysts, he said.
    Finally, if you read the post (Drug Rep Tells All) you’ll find that she explains that very small gifts cement relationships. IF someone takes you to lunch–or even a nice dinner-it does not feel like a bribe (the way a trip to St. Thomas would).
    It just feels like that person likes you . . .and, in return, you like him.
    When I was at Barron’s, I never let a source take me to dinner, very rarely went to lunch with a source. And when I did, we went Dutch. Small courtesies add up.

  8. Maggie,
    Your suspicion is correct. I am very honest as anyone who knows me will affirm.
    While I don’t want to get into a detailed discussion of Wall Street business practices and ethics on a healthcare blog, I would just say that over a 36 year career dealing with Wall Street analysts and salesmen trying to sell me something, sustaining ethical behavior is just not that hard and requires little more than basic honesty and common sense.
    Standards also vary a lot by industry. While journalists dealing with sources probably feel a need to be extremely careful about accepting anything of even nominal value, a purchasing agent for an auto manufacturer probably operates in a different paradigm.
    With respect to doctors and drug reps, I know what your post says, but I just don’t buy it. Suppose I’m a cardiologist who firmly believes that Plavix can help a great many of my patients with heart disease avoid a heart attack or stroke. Whether I like or dislike the drug rep from Bristol Myers is not going to influence my prescribing pattern. On the other hand, if Prilosec will help patients with GERD just as well as Nexium, and I know full well that Prilosec is far cheaper, shame on me if I let myself be influenced by the Astra Zeneca rep. If there are two or three branded drugs and no generic equivalents for a given condition, and they are all comparable in both effectiveness and cost, I might be moved to prescribe the one with the best drug rep, but, under those circumstances, neither the patient nor the payer is hurt.
    Bottom line: I still think it’s much ado about very little.

  9. Barry,
    I think you are comparing apples to oranges. For each and every disease process there is a multitude of medications, each with different side effects, half lives, dosing instruction, pharmicokinetics, cost, value etc, to get an idea just get yourself a copy of the PDR. now, you just spent 8 hours seeing 30 patients, you have three hours of paper work to do, five phone calls to return, 10 labs to review and you have to call in a script for GERD for a patient. Do you really think you are going to remember which one costs the least??? how many medication prices do you think you are going to remember? Dont forget the pricing keep changing!! Given, in this case, most of the proton pump inhibitors are equally eficacious, you are going to pick the one easiest to remember, both name and does….and WOW, guess what, you are holding a pen that says Nexium 40mg a day. BINGO
    Do you really think you are not influenced by those things that have been shown to influence all other humans?

  10. You Have Now Been Sampled (Drug Reps, Part 2)
    While the pharmaceutical industry’s image and reputation has suffered, and has been complicated with their declining profits due to a few reasons, these companies still apparently insist on keeping most of their gift- givers on board. Known presently as simply drug reps today, this job has become a vocation void of a sense of accomplishment, which will be described below.
    So they may be named at times in different ways, these promoters will be referred to as drug reps, which number close to 100,000 in the U.S. presently, it is believed. The cost to the pharmaceutical industry of these employees is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes.
    The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples.
    While historically drug reps have used their persuasive abilities to influence the prescribing habits of doctors in an honest and ethical manner. However presently, most health care providers now simply refuse to speak with them, or have banned all drug reps permanently from their practices for a number of reasons, including the recommendations from their colleagues. It is possible that this may be due to the following reasons:
    1. The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are a waste of their time. Yet they will accept your samples still. The credibility you possibly have as a rep is not considered anymore to be present in your vocation due to various controversies associated with the pharmaceutical industry, it is speculated.
    2. Most drug reps in the U.S. are hired for their looks and their personality. As a result, many are somewhat ignorant in regards to anything that is clinically relevant to a medical practice, so doctors seem to know this and have responded in such ways. Most drug reps have college degrees that do not correlate with their profession as a drug rep, which is to say that the clinical training of drug reps is limited. In fact, many consider this of such a serious nature that an Act is presently being considered called the SafeRx Act that would certify pharmaceutical reps, and this would be mandatory. One main reason would be to ensure personal accountability for their tactics and statements, I believe, which may improve the quality and safety of their function in the medical community.
    3. Many drug reps, it is believed, are void of any ethical considerations due to ignorance of what they are coerced to do or say to prescribers by their employer, and this allows them to embellish the benefits of their promoted products at times in addition to offering inducements to doctors. This is usually due to the rep being unaware of the consequences of their actions at times, yet at other times what reps say is with premeditated intent for potential financial gain for such a drug rep. Worse yet, due to pressure to keep their high-paying jobs, they always are anxious to please their superiors, who require them to offer various types of inducements to physicians that are designated targets of a particular drug company. Such tactics are especially true with the larger drug companies. These reps are in fact coerced to spend these individual promotional budgets assigned to them by their employer. While legally risky, the drug companies continue to dispense to their reps these large budgets reps have been forced to be responsible for dispensing, and are required to spend these budgets. In fact, so much emphasis is placed on this promotional spending, there seems to be an association between the money a rep spends and the progression that occurs with their career working for their pharmaceutical employer. Disclosure laws are being considered presently to mandate the release of all funds dispensed from pharmaceutical companies, which is to say to allow others to see where their money goes and who it goes to, as it is presently very secretive, overall. It is not unusual for a big drug rep to spend 50 thousand dollars a year for clinic lunches alone. In addition, drug reps hire doctors as speakers for certain disease states, and they find many other ways to spend this money they are required to spend.
    4. Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies, which allows them to track the scripts a doctor writes, and the data is free of the patient names. Yet the names the products prescribed are well illustrated and available to the drug reps. This allows reps to tailor their tactical approach with any given doctor, if they see the doctor at all during an office visit. Worse yet, doctors who greatly support the promoted products determined by this data allow reps to reward those doctors who favor the rep’s products that they promote, and this could be considered a form of quid pro quo. Laws are being considered presently to prevent this practice of allowing reps to have this data. Doctors are opposed to the data the reps have as well about them for privacy and deceptive reasons, so they say.
    5. Overall, reps can be best described as far as their function goes with their profession is to, whenever possible, manipulate doctors with remuneration or other forms of inducements, as they also continue to sample such doctors along with others their promoted meds. Also, frequent lunches are in fact bought often for doctors’ offices and their staff as a method of access, primarily, as stated earlier with the money reps spend earlier for this type of function. Essentially, because of the income and benefits the drug reps receive that they would likely not be able to obtain with any other job, they are compelled to do such unethical if not illegal tactics mentioned earlier that they perhaps normally would not do in another setting. Usually these drug reps rarely refuse to implement such tactics encouraged to them by their employers.
    6. Samples keep the prescriber from selecting what may be their preferred choice of med due to cost savings from samples left with a medical office by a drug rep. In addition, doctors are now being paid by prescription providers, which are called pharmacy benefit managers (PBMs) that are typically owned by a managed care company to have a doctor switch their patients to generic substitutes, if they exist, and this is often not disclosed to such patients. Apparently, these PBM companies are doing this in response to the activities of the branded drug companies, as they continue pay doctors often for various reasons, which are questionable in themselves.
    It is likely that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment, ultimately. It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Clearly, greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative.
    “What you don’t do can be a destructive force.” — Eleanor Roosevelt
    Dan Abshear