Plme-04-04-30.indd

Policy Forum
Following the Script: How Drug Reps Make
Friends and Infl uence Doctors
Adriane Fugh-Berman*, Shahram Ahari
It’s my job to fi gure out what a physician’s price is. For some it’s dinner at the fi nest restaurants, for others it’s enough convincing data to let them prescribe confi dently and for others it’s my attention and friendship.but at the most basic level, everything is for sale and everything is an 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 In 2000, pharmaceutical companies about family members and memorize (Photo: “Bitter Pills?” by net_efekt, offi ce for objects—a tennis racquet, wheatfi elds/316337784/. Published under the proxy; their staff is dined and fl attered in hopes that they will act as emissaries for a rep’s messages. (See Table 1 for the “friendship” to request favors, in they do so with fi nely titrated doses of Better Than You Know Yourself
Funding: This work was supported by a grant from
doctors. PLoS Med 4(4): e150. doi:10.1371/journal.
the Attorney General Prescriber and Consumer During training, I was told, when you’re out to Education Grant Program, created as part of a 2004 dinner with a doctor, “The physician is eating settlement between Warner-Lambert, a division of Copyright: 2007 Fugh-Berman and Ahari. This is
with a friend. You are eating with a client.” Pfi zer, and the Attorneys General of 50 States and an open-access article distributed under the terms the District of Columbia, to settle allegations that of the Creative Commons Attribution License, Warner-Lambert conducted an unlawful marketing which permits unrestricted use, distribution, and campaign for the drug Neurontin (gabapentin) that reproduction in any medium, provided the original violated state consumer protection laws. Competing Interests: Shahram Ahari is a former
Abbreviations: AMA, American Medical Association
pharmaceutical sales representative for Eli Lilly, and the primary fi ndings of this paper summarize points Adriane Fugh-Berman is an Associate Professor he made in testimony as a paid expert witness on in the Department of Physiology and Biophysics, the defendant’s side in litigation against a New Georgetown University Medical Center, Washington, Hampshire law prohibiting the sale of prescription District of Columbia, United States of America. data. Adriane Fugh-Berman has accepted payment Shahram Ahari is with the School of Pharmacy, as an expert witness on the plaintiff’s side in litigation University of California San Francisco, San Francisco, The Policy Forum allows health policy makers around regarding menopausal hormone therapy.
the world to discuss challenges and opportunities for improving health care in their societies.
Citation: Fugh-Berman A, Ahari S (2007) Following
* To whom correspondence should be addressed. the script: How drug reps make friends and infl uence Table 1. Tactics for Manipulating Physicians
Physician Category
Technique
How It Sells Drugs
Comments
I frame everything as a gesture of friendship. Just being friends with most of my docs Outgoing, friendly physicians are every rep’s I give them free samples not because it’s seemed to have some natural basic effect favorite because cultivating friendship is a mutual my job, but because I like them so much. I on their prescribing habits. When the time aim. While this may be genuine behavior on the provide offi ce lunches because visiting them is ripe, I lean on my “friendship” to leverage doctor’s side, it is usually calculated on the part of is such a pleasant relief from all the other more patients to my drugs.say, because it’ll the rep. docs. My drugs rarely get mentioned by me help me meet quota or it will impress my manager, or it’s crucial for my career.
I visit the offi ce with journal articles that The only thing that remains is for me to Humility is a common approach to physicians who specifi cally counter the doctor’s perceptions be just aggressive enough to ask the doc pride themselves on practicing evidence-based of the shortcoming of my drug. Armed with to try my drug in situations that wouldn’t medicine. These docs are tough to persuade but the articles and having hopefully scheduled have been considered before, based on the not impossible. Typically, attempts at geniality are a 20 minute appointment (so the doc can’t explain to me the signifi cance of my article. This is the closest drug-repping comes to Drug reps usually feel more camaraderie with found further down the prescribing power competing reps than they do with their clients. scale. There are plenty of 6’s, 7’s, and closely associated messages crudely would Thus, when a doctor fails to fulfi ll their end of the 8’s [lower prescribing doctors] who are be deemed insulting for most docs so a rep prescriptions-for-dinners bargain, news gets around eagerly mercenary but simply don’t have really has to feel comfortable about their and other reps are less likely to invest resources in the attention they desire fawned on them. mercenary nature and have a natural tone projected demand on my limited resources docs whom you want to “buy out” is to closely associate your resource expenditure with an expectation—e.g., “So, doc, you’ll choose Drug X for the next 5 patients who are depressed and with low energy? Oh, and don’t forget dinner at Nobu next month. I’d Friendship sells. The highest prescribers (9’s The highest prescribers receive better presents. and 10’s) are every reps sugar mommies and Some reps said their 10’s might receive unrestricted daddies. It’s the equivalent of spitting in the “educational” grants so loosely restricted that they ocean to try to buy these docs out because, were the equivalent of a cash gift, although I did chances are, every other rep is falling head The fi rst thing I want to understand is why If, during the course of conversations, the For reps this is a core function of our job. We’re they’re using another drug as opposed to doctors say something that may contradict trained to do this in as benign a way as possible. No mine. If it’s a question of attention, then their limited usage of our products, then doc likes to be told their judgment is wrong so the I commit myself to lavishing them with it the reps will badger them to justify that latter method typically requires some discretion.
until they’re bought. If they are convinced contradiction. This quickly transforms the that the competitor drug works better in rep from a welcomed reprieve to a nuisance, some patient populations, I frame my drug which can be useful in limited circumstances. We force the doctors to constantly explain or, if I feel my drug would fare well in a their prescribing rationale, which is tiresome. comparison, I hammer its superiority over Our intent is to engage in discourse but also to wear down the doc until he or she simply agrees to try the product for specifi c specifi c patient profi le for our drugs).
Most docs think that if they simply agree From the outset of my training, I’ve been Gifts are used to enhance guilt and social pressure. with what the rep says, they’ll outsmart the Reps know that gifts create a subconscious rep by avoiding any confl ict or commitment, ultimately derive commitments from obligation to reciprocate. New reps who doubt getting the samples and gifts they want, and my clients. With every acquiescent nod this phenomenon need only see their doctors’ fi nishing the encounter quickly. Nothing to statements of my drug’s superiority I prescribing data trending upwards to be convinced. could be further from the truth. The old build the case for them to increase their Of course, most of these doctors think themselves adage is true, especially in pharmaceutical immune to such infl uence. This is an illusion reps try sales: there is no such thing as a free lunch. false promises but I’ll know when they’re lying: the prescribing data is suffi ciently detailed in my computer to confi rm their behavior. Doctors who fail to honor their nuisance. The docs are often corralled into a conversational corner where they have to Table 1. Continued
Physician Category
Technique
How It Sells Drugs
Comments
Occasionally docs refuse to see reps. Some It’s a victory for me just to learn from the One’s marketing success in a particular offi ce can do it for ethical reasons, but most simply lack staff about which drugs are preferred, be strongly correlated to one’s success in providing the time. Even when I don’t manage to see good food for the staff. Goodwill from the staff the doctor, I can still make a successful call provides me with critical information, access, and by detailing the staff. Although they’re on the rare occasions that I might see them. an advocate for me and my drug when I’m not the doc’s side for the most part, it’s amazing However, it’s a greater success when the how much trouble one can rile up when the staff discusses my meds with the doc after I staff are lavished with food and gifts during leave. Because while a message delivered by a credible sounding presentation and then a rep gets discounted, a detail delivered by asked to discuss the usage of a drug on their a co-worker slips undetected and unfi ltered under the guise of a conversation. And the response is usually better then what I might As a rep, I was always in pursuit of friendly Subtle and tactful spokespersons were the ideal “thought leaders” to groom for the speaking the speaker, whose appreciation may be candidates. I politely dismissed doctors who would circuit. Once selected, a physician would refl ected in increased prescribing of a play cheerleader for any drug…at the right price, give lectures around the district. I would company’s products. Local speaking gigs carefully watch for tell-tale signs of their are also auditions. Speakers with charisma, allegiance. This includes how they handled questions that criticized our product, how their prescribing habits fl uctuated, or simply and, occasionally, given satellite telecast These descriptions are based on SA’s experience working for Eli Lilly and testimony in IMS Heath Inc. v. Ayotte, US District Court, New Hampshire. Actual tactics may vary. doi:10.1371/journal.pmed.0040150.t001 a targeted drug’s name stays uppermost specialist prescriptions are perpetuated presents, for example, silk ties or golf bags. As Oldani states, “The essence of pharmaceutical gifting…is ‘bribes that aren’t considered bribes’” [1].
“thought leaders” (physicians respected speaking circuit. Physicians invited and specifi c identifi er [5]. Data that identify states that an “individual market share may express their gratitude in increased a prescriber’s current habits” and is containing demographic information on all US. physicians (living or dead, Script Tracking
An offi cial job description for a pharmaceutical sales rep would read: Provide health-care professionals with product information, answer their questions on the use of products, and deliver product samples. An unoffi cial, and more accurate, description would have been: Change the prescribing habits of physicians. primary customers for prescribing data, which are used both to identify “high- prescribers” and to track the effects of all promotional efforts—by prescription (Photo: “Pills” by Rodrigo Senna, at http://www.fl ickr.com/photos/negativz/74267002/. gifts, and unrestricted “educational” offi ces, and to habituate physicians to A Pharmaceutical Executive article infl uences. By building these multiple dimensions into physicians’ profi les, it is grabbers”). Patients like samples too; possible to understand the ‘why’ behind it’s nice to get a little present from the ‘what’ and ‘how’ of their behavior.” selections that help you to better target (Photo: “Pills” by Sugar Pond, at http://www.
fl ickr.com/photos/sugarpond/236235191/. “cannibalizes” sales. Among the aims of gems”: “Initially considered ‘low value’ effective marketing.” “Growers” are Physicians are considered “low value” sample for part of a course of treatment almost always receive a prescription for Funding Friendship
Representative, Fred Marshall, president While it’s the doctors’ job to treat patients and not One type might be called ‘the spreader’ to justify their actions, it’s my job to constantly article in Pharmaceutical Executive, sway the doctors. It’s a job I’m paid and trained to do. Doctors are neither trained nor paid to negotiate. Most of the time they don’t even realize a ‘loyalist’, who’s very loyal to one level” and can still view aggregated or be a ‘niche’ physician, who reserves our product only for a very narrowly defi ned different messaging strategy for each of [20], about one for every six physicians. (attitudes, beliefs, and values) to fi ne- The Value of Samples
samples is to gain entry into doctors’ 12. Alonso J, Menzies D (2006) Just what the doctor ordered. Pharmaceutical Executive: 14–16. Available: http:⁄⁄www.pharmexec.com/ pharmexec/article/articleDetail.jsp?id=323314. more than half of “high-prescribing” Review. Available: http:⁄⁄www.nh.com/apps/pbcs.dll/article?AID=/20061110/ BUSINESSREVIEW. Accessed 23 March 2007.
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