Doctors were caught in a bind. Many found themselves being called on several times a week by different reps from the same company. Most continued to see reps, some because they felt obligated to get up to speed with new drugs, some because they wanted to keep the pipeline of free samples open. But seeing reps has a cost, of course: the more reps a doctor sees, the longer the patients sit in the waiting room. Many doctors began to feel as though they deserved whatever gifts and perks they could get because reps were such an irritation. At one time a few practices even charged reps a fee for visiting.
Professional organizations made some efforts to place limits on the gifts doctors were allowed to accept. But these efforts were halfhearted, and they met with opposition from indignant doctors ridiculing the idea that their judgment could be bought. One doctor, in a letter to the American Medical News, confessed, “Every time a discussion comes up on guidelines for pharmaceutical company gifts to physicians, I feel as if I need to take a blood pressure medicine to keep from having a stroke.” In 2001 the AMA launched a campaign to educate doctors about the ethical perils of pharmaceutical gifts, but it undercut its message by funding the campaign with money from the pharmaceutical industry.
Of course, most doctors are never offered free trips to Monaco or even a weekend at a spa; for them an industry gift means a Cialis pen or a Lexapro notepad. Yet it is a rare rep who cannot tell a story or two about the extravagant gifts doctors have requested. Oldani told me that one doctor asked him to build a music room in his house. Phyllis Adams, a former rep in Canada, was told by a doctor that he would not prescribe her product unless her company made him a consultant. (Both said no.) Carbona arranged a $35,000 “unrestricted educational grant” for a doctor who wanted a swimming pool in his back yard. “It was the Wild West,” says Jamie Reidy, whose frank memoir about his activities while working for Pfizer in the 1990s, Hard Sell: The Evolution of a Viagra Salesman, recently got him fired from Eli Lilly. “They cashed the check, and that was it. And hopefully they remembered you every time they turned on the TV, or bought a drink on the cruise, or dived into the pool.”
The trick is to give doctors gifts without making them feel that they are being bought. “Bribes that aren’t considered bribes,” Oldani says. “This, my friend, is the essence of pharmaceutical gifting.” According to Oldani, the way to make a gift feel different from a bribe is to make it personal. “Ideally, a rep finds a way to get into a scriptwriter’s psyche,” he says. “You need to have talked enough with a scriptwriter—or done enough recon with gatekeepers—that you know what to give.” When Oldani found a pharmacist who liked to play the market, he gave him stock options. When he wanted to see a resistant oncologist, he talked to the doctor’s nurse and then gave the oncologist a $100 bottle of his favorite cognac. Reidy put the point nicely when he told me, “You are absolutely buying love.”
Such gifts do not come with an explicit quid pro quo, of course. Whatever obligation doctors feel to write scripts for a rep’s products usually comes from the general sense of reciprocity implied by the ritual of gift-giving. But it is impossible to avoid the hard reality informing these ritualized exchanges: reps would not give doctors free stuff if they did not expect more scripts.
My brother Hal, a psychiatrist currently on the faculty of Wake Forest University, told me about an encounter he had with a drug rep from Eli Lilly some years back, when he was in private practice. This rep was not one of his favorites; she was too aggressive. That day she had insisted on bringing lunch to his office staff, even though Hal asked her not to. As he tried to make polite conversation with her in the hall, she reached over his shoulder into his drug closet and picked up a couple of sample packages of Zoloft and Celexa. Waving them in the air, she asked, “Tell me, Doctor, do the Pfizer and Forest reps bring lunch to your office staff?” A stony silence followed. Hal quietly ordered the rep out of the office and told her to never come back. She left in tears.
It’s not hard to understand why Hal got so angry. The rep had broken the rules. Like an abrasive tourist who has not caught on to the code of manners in a foreign country, she had said outright the one thing that, by custom and common agreement, should never be said: that the lunches she brought were intended as a bribe. What’s more, they were a bribe that Hal had never agreed to accept. He likened the situation to having somebody drop off a bag of money in your garage without your consent and then ask, “So what about our little agreement?”
When an encounter between a doctor and a rep goes well, it is a delicate ritual of pretense and self-deception. Drug reps pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as if they are not salespeople, while doctors must act as if they are not customers. And if, by accident, the real purpose of the exchange is revealed, the result is like an elaborate theatrical dance in which the masks and costumes suddenly drop off and the actors come face to face with one another as they really are. Nobody wants to see that happen.
Last spring a small group of first-year medical students at the University of Minnesota spoke to me about a lecture on erectile dysfunction that had just been given by a member of the urology department. The doctor’s Power-Point slides had a large, watermarked logo in the corner. At one point during the lecture a student raised his hand and, somewhat disingenuously, asked the urologist to explain the logo. The urologist, caught off guard, stumbled for a moment and then said that it was the logo for Cialis, a drug for erectile dysfunction that is manufactured by Eli Lilly. Another student asked if he had a special relationship with Eli Lilly. The urologist replied that yes, he was on the advisory board for the company, which had supplied the slides. But he quickly added that nobody needed to worry about the objectivity of his lecture, because he was also on the advisory boards of the makers of the competing drugs Viagra and Levitra. The second student told me, “A lot of people agreed that it was a pharm lecture and that we should have gotten a free breakfast.”
This episode is not as unusual as it might appear. Drug company–sponsored consultancies, advisory-board memberships, and speaking engagements have become so common, especially among medical-school faculty, that the urologist probably never imagined that he would be challenged for lecturing to medical students with materials produced by Eli Lilly. According to a recent study in The Journal of the American Medical Association, nine out of ten medical students have been asked or required by an attending physician to go to a lunch sponsored by a drug company. As of 2003, according to the Accreditation Council for Continuing Medical Education, pharmaceutical companies were providing 90 percent of the $1 billion spent annually on continuing medical education events, which doctors must attend in order to maintain their licensure.
Over the past year or two pharmaceutical profits have started to level off, and a backlash against reps has been felt; some companies have actually reduced their sales forces. But the industry as a whole is hiring more and more doctors as speakers. In 2004, it sponsored nearly twice as many educational events led by doctors as by reps. Not long before, the numbers had been roughly equal. This raises the question, Are doctors becoming the new drug reps?
Doctors are often the best people to market a drug to other doctors. Merck discovered this when it was developing a campaign for Vioxx, before the drug was taken off the market because of its association with heart attacks and strokes. According to an internal study by Merck, reported in The Wall Street Journal, doctors who attended a lecture by another doctor subsequently wrote nearly four times more prescriptions for Vioxx than doctors who attended an event led by a rep. The return on investment for doctor-led events was nearly twice that of rep-led events, even after subtracting the generous fees Merck paid to the doctors who spoke.
These speaking invitations work much like gifts. While reps hope, of course, that a doctor who is speaking on behalf of their company will give their drugs good PR, they also know that such a doctor is more likely to write prescriptions for their drugs. “If he didn’t write, he wouldn’t speak,” a rep who has worked for four pharmaceutical companies told me. The semi-official industry term for these speakers and consultants is “thought leaders,” or “key opinion leaders.” Some thought leaders do not stay loyal to one company but rather generate a tidy supplemental income by speaking and consulting for a number of different companies. Reps refer to these doctors as “drug whores.”
The seduction, whether by one company or several, is often quite gradual. My brother Hal explained to me how he wound up on the speakers’ bureau of a major pharmaceutical company. It started when a company rep asked him if he’d be interested in giving a talk about clinical depression to a community group. The honorarium was $1,000. Hal thought, Why not? It seemed almost a public service. The next time, the company asked him to talk not to the public but to practitioners at a community hospital. Soon company reps were making suggestions about content. “Why don’t you mention the side-effect profiles of the different antidepressants?” they asked. Uneasy, Hal tried to ignore these suggestions. Still, the more talks he gave, the more the reps became focused on antidepressants rather than depression. The company began giving him PowerPoint slides to use, which he also ignored. The reps started telling him, “You know, we have you on the local circuit giving these talks, but you’re medical-school faculty; we could get you on the national circuit. That’s where the real money is.” The mention of big money made him even more uneasy. Eventually the reps asked him to lecture about a new version of their antidepressant drug. Soon after that, Hal told them, “I can’t do this anymore.”
Looking back on this trajectory, Hal said, “It’s kind of like you’re a woman at a party, and your boss says to you, ‘Look, do me a favor: be nice to this guy over there.’ And you see the guy is not bad-looking, and you’re unattached, so you say, ‘Why not? I can be nice.’” The problem is that it never ends with that party. “Soon you find yourself on the way to a Bangkok brothel in the cargo hold of an unmarked plane. And you say, ‘Whoa, this is not what I agreed to.’ But then you have to ask yourself, ‘When did the prostitution actually start? Wasn’t it at that party?’”
Thought leaders serve an indispensable function when it comes to a potentially very lucrative marketing niche: off-label promotion, or promoting a drug for uses other than those for which it was approved by the FDA—something reps are strictly forbidden to do. The case of Neurontin is especially instructive. In 1996 a whistle-blower named David Franklin, a medical-science liaison with Parke-Davis (now a division of Pfizer), filed suit against the company over its off-label promotion of this drug. Neurontin was approved for the treatment of epilepsy, but according to the lawsuit, Parke-Davis was promoting it for other conditions—including bipolar disorder, migraines, and restless legs syndrome—for which there was little or no scientific evidence that it worked. To do so the company employed a variety of schemes, most involving a combination of rep ingenuity and payments to doctors. Some doctors signed ghostwritten journal articles. One received more than $300,000 to speak about Neurontin at conferences. Others were paid just to listen. Simply having some of your thought leaders in attendance at a meeting is valuable, Kathleen Slattery-Moschkau explains, because they will often bring up off-label uses of a drug without having to be prompted. “You can’t get a better selling situation than that,” she says. In such circumstances all she had to do was pour the wine and make sure everyone was happy.