The Drug Pushers

What has become a classic must-read for those interested in getting an insider’s perspective on drug marketing is bioethicist Dr. Carl Elliotts April 2006 piece in The Atlantic called The Drug Pushers.

It starts by describing the ‘good old days’ when his own Dad was a family doctor whose waiting room would be filled with serious, conservatively-dressed men with large heavy briefcases and sensible shoes. These were salesmen of the drug companies, and were known as ‘detail men’.  Elliott continues:

“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 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.”

But Elliott goes on to say that these reps are so friendly, so easy-going, so much fun to flirt with that it is virtually impossible for physicians to demonize them. A 2003 Blue Cross Blue Shield industry survey found that more than half of “high-prescribing” doctors cited drug reps as their main source of information about new drugs. The current ratio is one drug rep per 2.5 targeted doctors. Low-prescribing doctors are ignored by drug reps.

He asks how doctors can demonize someone who “brings you lunch and touches your arm and remembers your birthday and knows the names of all your children?”

Although free drug 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.

This influence has been well documented in the literature, according to Following the Script: How Drug Reps Make Friends and Influence Doctors published in the Public Library of Science Medicine journal in April 2007:

“Studies consistently show that drug samples do influence prescribing choices. Reps provide samples only of the most promoted, usually most expensive, drugs, and patients given a sample for part of a course of treatment almost always receive a prescription for the same drug.”

Drug reps are hired for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians’ personalities, practice styles, and preferences, and to relay this information back to the company. The Public Library of Science Medicine maintains that this skill in perceptive shrewdness is what can pay big dividends for pharmaceutical sales reps.

“Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician’s family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor’s office for objects—a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols—that can be used to establish a personal connection with the doctor.

“Good details are dynamic; the best reps tailor their messages constantly according to their client’s reaction. A friendly physician makes the rep’s job easy, because the rep can use the ‘friendship’ to request favors, in the form of prescriptions. Physicians who view the relationship as a straightforward goods-for-prescriptions exchange are dealt with in a businesslike manner. Skeptical doctors who favour evidence over charm are approached respectfully, supplied with reprints from the medical literature, and wooed as teachers. Physicians who refuse to see reps are detailed by proxy; their staff are dined and flattered in hopes that they will act as emissaries for the rep’s messages.”

But as New Hampshire physician Dr. Kevin Pho writes in his popular blog KevinMD, there is a type of pharmaceutical sales rep whose actions remain completely unregulated.

“These reps have unfettered access to the top academics of all fields of medicine, are invited by medical societies to give keynote addresses, routinely publish articles in the best journals, and offer advice about medications that is accepted as gospel by doctors everywhere. These reps have medical degrees, and some have become millionaires by taking fat payments from drug companies. The are “the hired guns of medicine”.

Read more about pharmaceutical drug reps in the entire article from The Atlantic.

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