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-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.
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 by-product 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 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.
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 health-care 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.
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.
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 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 “practice- management 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.