The Doctor Will See You Now ...an inside look at prescription drug pushing
by Gwen Olsen
http://www.medicalaccountability.net/PagesArticles/GwenOlsenEssay.html
"The doctor will see you now, Sara."; The impeccably well-groomed blonde,
wearing a stylish summer suit, high heels and pantyhose in 90+ degree Texas
heat, was quite a contrast to me and the other shorts and T-shirt clad
patients waiting to see the doctor. Sara quickly gathered her detail bag and
jar of candy. Grinning and chatting with the receptionist at the window, she
deposited her candy jar and a handful of scratch pads and ink pens bearing
her company's logo and drug name at the nurse's station then swept past the
exam rooms to the sample closet. I could hear the doctor's gleeful reception
and greeting in the hallway before the door to the back office had
completely closed. This rep was obviously one of his favorites. I had been
waiting over 45 minutes to see Dr. Dogood. Some of the other patients
waiting had been there when I arrived. Yet, Sara had gotten here only ten or
so minutes ago, had left her business card at the receptionist's window, and
she was already in the back talking to the doctor. Probably has a lunch
appointment, I thought to myself.just then, the deli delivery boy stumbled
into the office with his arms full of boxed lunches.
As I looked up from the latest issue of Ladies Home Journal, I allowed
myself to reflect back over what seemed like a lifetime ago when I had been
young, naïve, and ambitious enough to be one of the best in the
pharmaceutical business. Just a decade ago, Sara could have easily been me.
In 1985, I had joined the pharmaceutical industry at the age of 26. Although
I considered myself intelligent and a fast learner, I was at first
unequipped with the knowledge I needed to have even a basic understanding of
the disease states and physiology or pharmacology involved in the drugs I
was selling. My undergraduate degree was a Bachelor of Arts in Spanish and
Portuguese. That meant I was completely reliant on the product managers and
marketing department for the accuracy of the information I gave doctors.
Reps are trained and indoctrinated in a semi-military style. In fact, basic
sales training classes are much like boot camp and are designed to weed out
the faint of heart or easily intimidated, as working with the egos of
doctors can wear on even the strongest self-esteem. Trainers push new
recruits to the breaking point, often giving them long hours of homework
assignments into the night and weekends. Reps must videotape sales
presentations and continually test their medical product knowledge. The
environment is highly competitive and large numbers do not complete all
tiers of their training before dropping out from the pressure. Those that do
are glorified as the "best of the best" and are then unleashed on the
medical field with a false sense of bravado that soon fades.
Reps are instructed to promote the company's products in a given manner and
with a particular focus. This is called marketing direction. Each
promotional period there is a "tagline" or special message that the rep is
supposed to drive home to the doctor. Sales literature and visual aids are
all geared toward the promotional message, and they are utilized in
role-plays until the presentations flow naturally. Reps are taught to handle
and minimize the objections physicians might have. They are given the
specific wording that best represents the company's position. Often, these
instructions come from the legal department who reviews the sales documents
for legal accuracy. If a visual aid initiates too many negative questions
from physicians, the bar graph, product comparison, and so forth is reworked
for the next sales quarter in a way that presents the information in a more
favorable light. Having already learned the manipulative advantage of
semantics in my study of language, I soon learned the semantics of research
were called statistics.
Most doctors would deny the influence that sales reps have on their
prescribing behavior. However, the fact of human nature is that we tend to
support people that we like and feel are supportive of us. The
pharmaceutical industry knows this all too well, and it provides the means
for busy doctors to be accommodated in their practices by helpful, attentive
sales professionals. Some reps go to great lengths to access and influence
physicians because pharmaceutical companies provide lucrative incentives for
reps who reach sales quotas. A rep stands to make several thousand dollars
in one lump sum as a bonus in addition to his or her quarterly salary.
Merchandise from catalogs and trip incentives are common as well. Reps who
don't meet quotas are looked down upon in group settings and eventually are
informed they have no job security.
Not only do reps provide lunch, medical education, tools and devices,
medical textbooks, calendars, scratch pads and pens, but they can also
influence the doctors' personal lives. In spite of the voluntary guidelines
instituted by the PDMA several years ago which require that gifts given to
doctors remain of nominal (less than $25) value, reps make generous
contributions to office parties, fund-raisers, and golf tournaments with the
assistance of corporate funds. They provide tickets to local sporting events
and ntertainment venues with a little creative financing and expense hiding,
and they coordinate social functions such as boating, fishing, and hunting
expeditions disguised as continuing medical education opportunities.
Even the most ethical, prudent practitioner can be influenced by interacting
with a pharmaceutical rep. Sometimes even against his/her better judgment.
One of my most painful memories as a sales rep was an illustration of this
very point. I was new to the pharmaceutical industry and had attended my
first new drug launch. I remember the pride and exuberance I felt at the
national meeting in which loud speakers pumped out motivating theme music
and medical researchers and marketing managers gave exciting, emotional
speeches. I soaked in every word with anticipation and awe. I believed this
new drug was really going to help people!
During the breaks, scientists and corporate executives chatted amiably with
reps while feasting on an elaborate array of snacks and beverages. Sumptuous
gourmet meals and nightly entertainment further catered to the already
inflated egos of the sales force. Open bars accompanied every event.
T-shirts and ball caps emblazoned with the Suprol logo were distributed,
along with sports bags that would transport all the rep's acquired goodies
back home.
Pumped full of enthusiasm and focused on the key opinion leaders in my
community, I returned to my territory. I bombarded them with studies and
marketing materials in an effort to find support for my new drug. Marketing
direction was very specific. Doctors in each territory had been profiled
prior to the launch, and I was well-informed as to who the Early Adopters
and High-Volume Prescribers (HVPs) of NSAIDs were. (Note: The majority of
drug companies know just what the doctor ordered, primarily because they
subscribe to prescription data service companies that provide their sales
force with detailed information on what doctors are prescribing in their
practices. Pharmacies sell the doctors' prescription information, allowing
companies to pinpoint who is supporting their product line and who is not.
Reps frequently know more about a doctor's prescribing habits than he does
himself! This data often verifies what marketers already know, and that is,
when detail activity or call averages are increased in a doctor's office,
the result is generally an increase in prescriptions for the products being
promoted. The more memorable the presentation or information the doctor
receives, the larger the assumed impact.) I was also aware of marketing's
last-ditch effort directive to ask a reluctant prescriber to give me just
one new start patient, even if it was his or her most difficult patient that
had failed other therapies. The rationale was, if a doctor had success in
one of his or her most difficult patients, he or she would be more inclined
to write prescriptions for additional patients.
One of my doctors who practiced in a small, coastal town wrote large numbers
of anti-inflammatory drugs for his predominantly geriatric population. He
was an older doc himself, very nice, but set in his ways. He had been
profiled as a Late Adopter/Skeptic. After a lengthy debate about the
benefits of my new product, he shared his philosophy with me, which was not
to prescribe a new drug until it had been on the market for a full year.
This way, he could avoid the initial unknown complications that invariably
surfaced with each new product. In other words, he preferred a "better safe
than sorry"; approach.
Still, I persisted in my enthusiasm and, as I had been instructed, asked for
that most difficult patient. I didn't leave until the doctor had committed
to try the drug on at least one patient. He did finally commit, or, to use
sales jargon, I closed him. I left triumphant.or so I thought.
I continued drumming up support for Suprol® and had just gotten it added to
my major teaching hospital's formulary when I got the bad news. An emergency
teleconference was called, and the company announced a "Dear Doctor" letter
would be sent to all physicians that day addressing "new complications"
associated with Suprol®, primarily flank pain. Nearly twenty-five percent of
the patients affected had required hospitalization. Flank pain is a very
serious side effect because it indicates the possibility of kidney damage.
Little did I know at the time, one of the doctors who had reported an
adverse event, which eventually resulted in death due to dialysis
complications, was in my territory. I was later contacted and instructed by
management to have my doctor complete an Adverse Drug Reaction (ADR) report.
Much to my surprise, the doctor referenced in my instructions was the Late
Adopter/Skeptic, who had promised me his "most difficult patient" against
his better judgment. Even more startling would be the discovery that the
patient had been his very own mother. Of course, I didn't find that out
until I visited him to do the ADR. (By the way, the ADR was a daunting ream
of paperwork that appeared to be designed to discourage busy doctors from
reporting. That reporting process has since been streamlined online with
MedWatch.) I will never forget the betrayed look on his face or his terse
remark to me that "the company's marketing strategy had obviously been more
thoroughly tested than our drug!"; I was devastated and riddled with guilt. I
didn't call on his office again for nearly six months. I didn't have the
nerve!
Suprol® was eventually recalled in 1987 after it had first been banned in
Europe. I found myself back pedaling in offices, embarrassed as I picked up
samples. Reps were instructed to take a proactive stance with providers by
pointing out the swift, decisive action taken by the company to remove the
product once the adverse events surfaced. What reps were not told was that
Public Citizen, Ralph Nader's consumer activist organization, had actually
sued the FDA in order to protect consumers and have Suprol® pulled from the
market.
So, I was somewhat surprised later on to discover that not all of my
pharmaceutical cohorts in the marketing and sales departments subscribed to
the medical Hippocratic Oath: "First, do no harm."; Marketing strategies were
designed to do one thing: maximize profits. If information could have a
negative impact on the bottom line, reps were instructed to downplay it. The
opposite was true of even the most ridiculous perceived benefit. Patent
extensions were sought for minute enhancements, and tons of marketing hoopla
would tout the "new and improved" products.
Over the years as my knowledge base grew from the specialized training I
received, I started to better understand the drugs and the effect they had
on the body systems. I also became more adept at interpreting clinical trial
data and laboratory results. I realized that drugs which were nominally
effective were touted as phenomenal progress. I observed drugs being over
utilized, overdosed, and improperly promoted "off label"; for indications
that were yet untested and/or unapproved. I watched as year after year the
FDA approved dangerous drugs that were later removed from the market. I
observed the defensive cover-ups and posturing employed by the industry to
save those ill-fated products. But most importantly, I witnessed the demise
of fair-balanced education in medicine.
A series of haunting images ingrained themselves in my memory
banks-disturbing experiences that would completely alter my perception of
medicine and the institutio |