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

When I asked Carbona how the consultant had increased Astra Merck’s market share within the clinic so dramatically, he said that the consultant never pressed the doctors directly. Instead, he talked up Carbona. “Gene has put his neck on the line for you guys,” he would tell them. “If this thing doesn’t work, he might get fired.” The consultant emphasized what a remarkable service the practice was getting, how valuable the financial advice was, how everything was going to turn around for them—all courtesy of Carbona. The strategy worked. “Those guys went berserk for me,” Carbona says. Doctors at the newly vitalized practice prescribed so many Astra Merck drugs that he got a $140,000 bonus. The scheme was so successful that Carbona and his colleagues at Astra Merck decided to duplicate it in other practices.

I got in touch with Carbona after I learned that he was giving talks on the American Medical Student Association lecture circuit about his experiences as a rep. At that point I had read a fair bit of pharmaceutical sales literature, and most of it had struck me as remarkably hokey and stilted. Merck’s official training materials, for example, instruct reps to say things like, “Doctor, based on the information we discussed today, will you prescribe Vioxx for your patients who need once-daily power to prevent pain due to osteoarthritis?” So I was unprepared for a man with Carbona’s charisma and forthright humor. I could see why he had been such an excellent rep: he came off as a cross between a genial con artist and a comedic character actor. After two hours on the phone with him I probably would have bought anything he was selling.

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.”

A variation on this idea emerges in Side Effects, Kathleen Slattery-Moschkau’s 2005 film about a fictional fledgling drug rep. Slattery-Moschkau, who worked for nine years as a rep for Bristol-Myers Squibb and Johnson & Johnson, says the carefully rehearsed messages in the corporate training courses really got to her. “I hated the crap I had to say to doctors,” she told me. The heroine of Side Effects eventually decides to ditch the canned messages and stop spinning her product. Instead, she is brutally honest. “Bottom line?” she says to one doctor. “Your patients won’t shit for a week.” To her amazement, she finds that the blunter she is, the higher her market share rises. Soon she is winning sales awards and driving a company BMW.

For most reps, market share is the yardstick of success. The more scripts their doctors write for their drugs, the more the reps make. Slattery-Moschkau says that most of her fellow reps made $50,000 to $90,000 a year in salary and another $30,000 to $50,000 in bonuses, depending on how much they sold. Reps are pressured to “make quota,” or meet yearly sales targets, which often increase from year to year. Reps who fail to make quota must endure the indignity of having their district manager frequently accompany them on sales calls. Those who meet quota are rewarded handsomely. The most successful reps achieve minor celebrity within the company.

One perennial problem for reps is the doctor who simply refuses to see them at all. Reps call these doctors “No Sees.” Cracking a No See is a genuine achievement, the pharmaceutical equivalent of a home run or a windmill dunk. Gene Carbona says that when he came across a No See, or any other doctor who was hard to influence, he used “Northeast-Southwest” tactics. If you can’t get to a doctor, he explains, you go after the people surrounding that doctor, showering them with gifts. Carbona might help support a Little League baseball team or a bowling league. After awhile, the doctor would think, Gene is doing such nice things for all these people, the least I can do is give him ten minutes of my time. At that point, Carbona says, the sale was as good as made. “If you could get ten minutes with a doctor, your market share would go through the roof.”

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. A particular gift may have no influence, but it might make a doctor more apt to think that he or she would not be influenced by larger gifts in the future. A pizza and a penlight are like inoculations, tiny injections of self-confidence that make a doctor think, I will never be corrupted by money.

Gifts from the drug industry are nothing new, of course. William Helfand, who worked in marketing for Merck for thirty-three years, told me that company representatives were giving doctors books and pamphlets as early as the late nineteenth century. “There is nothing new under the sun,” Helfand says. “There is just more of it.” The question is: Why is there so much more of it just now? And what changed during the past decade to bring about such a dramatic increase in reps bearing gifts?

An ethic of salesmanship

One morning last year I had breakfast at the Bryant-Lake Bowl, a diner in Minneapolis, with a former Pfizer rep named Michael Oldani. Oldani grew up in a working-class family in Kenosha, Wisconsin. Although he studied biochemistry in college, he knew nothing about pharmaceutical sales until he was recruited for Pfizer by the husband of a woman with whom he worked. Pfizer gave him a good salary, a company car, free gas, and an expense account. “It was kind of like the Mafia,” Oldani told me. “They made me an offer I couldn’t refuse.” At the time, he was still in college and living with his parents. “I knew a good ticket out of Kenosha when I saw one,” he says. He carried the bag for Pfizer for nine years, until 1998.

Today Oldani is a Princeton-trained medical anthropologist teaching at the University of Wisconsin at Whitewater. He wrote his doctoral dissertation on the anthropology of pharmaceutical sales, drawing not just on ethnographic fieldwork he did in Manitoba as a Fulbright scholar but also on his own experience as a rep. This dual perspective—the view of both a detached outsider and a street-savvy insider—gives his work authority and a critical edge. I had invited Oldani to lecture at our medical school, the University of Minnesota, after reading his work in anthropology journals. Although his writing is scholarly, his manner is modest and self-effacing, more Kenosha than Princeton. This is a man who knows his way around a diner.

Like Carbona, Oldani worked as a rep in the late 1980s and the 1990s, a period when the drug industry was undergoing key transformations. Its ethos was changing from that of the country-club establishment to the aggressive, new-money entrepreneur. Impressed by the success of AIDS activists in pushing for faster drug approvals, the drug industry increased pressure on the FDA to let companies bring drugs to the market more quickly. As a result, in 1992 Congress passed the Prescription Drug User Fee Act, under which drug companies pay a variety of fees to the FDA, with the aim of speeding up drug approval (thereby making the drug industry a major funder of the agency set up to regulate it). In 1997 the FDA dropped most restrictions on direct-to-consumer advertising of prescription drugs, opening the gate for the eventual Levitra ads on Super Bowl Sunday and Zoloft cartoons during daytime television shows. The drug industry also became a big political player in Washington: by 2005, according to the Center for Public Integrity, its lobbying organization had become the largest in the country.

Many companies started hitting for the fences, concentrating on potential blockbuster drugs for chronic illnesses in huge populations: Claritin for allergies, Viagra for impotence, Vioxx for arthritis, Prozac for depression. Successful drugs were followed by a flurry of competing me-too drugs. For most of the 1990s and the early part of this decade, the pharmaceutical industry was easily the most profitable business sector in America. In 2002, according to Public Citizen, a nonprofit watchdog group, the combined profits of the top ten pharmaceutical companies in the Fortune 500 exceeded the combined profits of the other 490 companies.

During this period reps began to feel the influence of a new generation of executives intent on bringing market values to an industry that had been slow to embrace them. Anthony Wild, who was hired to lead Parke-Davis in the mid-1990s, told the journalist Greg Critser, the author of Generation Rx, that one of his first moves upon his appointment was to increase the incentive pay given to successful reps. Wild saw no reason to cap reps’ incentives. As he said to the company’s older executives, “Why not let them get rich?” Wild told the reps about the change at a meeting in San Francisco. “We announced that we were taking off the caps,” he told Critser, “and the sales force went nuts!”

It was not just the industry’s ethos that was changing; the technology was changing, too. According to Oldani, one of the most critical changes came in the way that information was gathered. In the days before computers, reps had to do a lot of legwork to figure out whom they could influence. They had to schmooze with the receptionists, make friends with the nurses, and chat up the pharmacists in order to learn which drugs the local doctors were prescribing, using the right incentives to coax what they needed from these informants. “Pharmacists are like pigeons,” Jamie Reidy, a former rep for Pfizer and Eli Lilly, told me. “Only instead of bread crumbs, you toss them pizzas and sticky notes.”

But in the 1990s, new information technology made it much simpler to track prescriptions. Market-research firms began collecting script-related data from pharmacies and hospitals and selling it to pharmaceutical companies. The American Medical Association collaborated by licensing them information about doctors (including doctors who do not belong to the AMA), which it collects in its “Physician Masterfile.” Soon reps could find out exactly how many prescriptions any doctor was writing and exactly which drugs those prescriptions were for. All they had to do was turn on their laptops and download the data.

What they discovered was revelatory. For one thing, they found that a lot of doctors were lying to them. Doctors might tell a rep that they were writing prescriptions for, say, Lipitor, when they weren’t. They were just being polite, or saying whatever they thought would get the rep off their backs. Now reps could detect the deception immediately. (Even today many doctors do not realize that reps have access to script-tracking reports.)

More important, script-tracking helped reps figure out which doctors to target. They no longer had to waste time and money on doctors with conservative prescribing habits; they could head straight to the “high prescribers,” or “high writers.” And they could get direct feedback on which tactics were working. If a gift or a dinner presentation did not result in more scripts, they knew to try another approach.

But there was a rub: the data was available to every rep from every company. The result was an arms race of pharmaceutical gift-giving, in which reps were forced to devise ever-new ways to exert influence. If the Eli Lilly rep was bringing sandwiches to the office staff, you brought Thai food. If GSK flew doctors to Palm Springs for a conference, you flew them to Paris. Oldani used to take residents to Major League Baseball games. “We did beer bongs, shots, and really partied,” he told me. “Some of the guys were incredibly drunk on numerous occasions. I used to buy half barrels for their parties, almost on a retainer-like basis. I never talked product once to any of these residents, and they took care of me in their day-to-day practice. I never missed quota at their hospital.”

Oldani says that script-tracking data also changed the way that reps thought about prescriptions. The old system of monitoring prescriptions was very inexact, and the relationship between a particular doctor’s prescriptions and the work of a given rep was relatively hard to measure. But with precise script-tracking reports, reps started to feel a sense of ownership about prescriptions. If their doctors started writing more prescriptions for their drugs, the credit clearly belonged to them. However, more precise monitoring also invited micromanagement by the reps’ bosses. They began pressuring reps to concentrate on high prescribers, fill out more paperwork, and report more frequently back to management.

“Script-tracking, to me at least, made everyone a potentially successful rep,” Oldani says. Reps didn’t need to be nearly as resourceful and street savvy as in the past; they just needed the script-tracking reports. The industry began hiring more and more reps, many with backgrounds in sales (rather than, say, pharmacy, nursing, or biology). Some older reps say that during this period the industry replaced the serious detail man with “Pharma Barbie” and “Pharma Ken,” whose medical knowledge was exceeded by their looks and catering skills. A newer, regimented style of selling began to replace the improvisational, more personal style of the old-school reps. Whatever was left of an ethic of service gave way to an ethic of salesmanship.

Presented by

Carl Elliott teaches at the Center for Bioethics at the University of Minnesota and is the author of several books, including Better Than Well: American Medicine Meets the American Dream (2003), and the co-editor of The Last Physician: Walker Percy and the Moral Life of Medicine (1999). His article "A New Way to Be Mad" appeared in the December 2000 issue of The Atlantic.

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