Thursday, March 27, 2008

A Drug Rep Tells All

Shahram Ahari, former Eli Lilly drug rep, recently spoke to the Tufts Progressive Medical Students Organization. It was a fascinating talk, because Ahari told us about how he and his colleagues used every trick of salesmanship in the book to increase prescriptions of Prozac and Zyprexa and therefore to maximize their bonuses.
The key criteria of employment as a drug rep, he said, are being good looking and mastering the art of small talk. No huge surprise here, but it’s helpful to remember that drug reps do not come to doctors to educate, but rather to persuade.

"Gift giving is the key," he said. "You are programmed as a human to reciprocate. You feel obliged to return the favor. As a matter of fact, the smaller the gift, the greater the sense of obligation."

Do you consider samples to be a part of the company’s civic duty? Think again. "Samples are a marketing tool. They always have strings attached. Typically, we would provide two weeks worth of samples, which worked out wonderfully. Just like a drug dealer, the first one is free, and then you’re hooked."

A member of the audience who had once been a consultant to industry made an interesting comment about samples. His job was to track doctors’ prescribing behavior in response to sampling practices, and to provide physician-specific "response curves" to companies. Using these curves, reps determined how to maximize their "return" on sampling. If you "hit" Doctor Smith 10 times per year with samples, he might prescribe more product than Doctor Jones, who might require less sampling. To drug companies, doctors are pawns in a game of cost-benefit analysis.

Ahari recalls well that food makes doctors more receptive to the message. "We took painstaking efforts to determine what you like. We had a $60,000 budget for food, and we used this to make ourselves seem a necessity to clinics who wanted to make their staff happy."

But food pales compared to what Ahari called "the most sinister tool in our armamentarium: our computer." He was referring, of course, to prescription data-mining. "We knew all your prescribing data, and we used it fine-tune our pitch."

Do you think drug reps are there to provide you with crucial medical information? Fuggedabout it! "I was in your office in order to influence you to prescribe Prozac or Zyprexa. We focussed on providing information to manipulate your prescribing, not to teach you how to treat your patients. Mostly, we wanted to build a good relationship, so that you’d like us. We are the one spot of sunshine in your day, a person who steps in the door and is actually interested in how you’re doing. We’re fun, witty, attractive, and we come bearing gifts. No wonder we’re accepted into your offices."


Anonymous said...

Is any of this a surprise? That's what one would expect a profit driven company to do.

The real indictment are the doctors who willingly take the bribes and then say they aren't affected by the pitch. For educated people, they're incredibly naive.

Anonymous said...

As a different anonymous, I just want to repeat what I said on a different posting:

This process feeds in an evil manner on the concept of reciprocity. As the above posting says, doctors are incredibly naive.

I would go one comment further:
doctors are stupid and have abandoned one of their key principles: do no harm. This behavior in accepting what reps do is reprehensible, and every day it goes on unaddressed by the majority of physicians, the integrity of the field is not just tarnished, but trashed.

Again, evil thrives when good men stay silent. What an indictment!!

Anonymous said...

I now use rep visits as a way to market my website,, to the drug companies. I want them to be aware that such consumer-driven, ground-up information resources exist.
The reps usually have some news from their company--if they don't, they are politely shown the door. I am always interested in hearing if they have a new indication, or if there's a new phase III trial out.
Anything else, I get bored pretty quick. I throw away their slick brochures--they're packed with lies and manipulations too subtle for my clinical eyes.
I think every drug company would like a free "shout-out" on my website, credible since it doesn't take ads. If the product is good, and helps my patients, I will give a favorable profile, not for money, but to have content that drives traffic and helps other docs and patients.
The search engines love this content, and drive additional hits to these stories.
The reps don't "get it" yet, but they will come around. I see Genentech coming around every time I post an Avastin article.
I think a little "counterdetailing" for my website throws the reps off guard just enough to dismantle the structure of their visit.
I think we doctors cannot avoid having a relationship with industry anymore than we can avoid seeing commercials on TV. The trick is to use industry for what we need it for: new drug introductions. The drug information part should be provided by us, to each other, for free.
I can buy my own sandwich, thank you very much. I tell the girls I would gladly rather buy them lunch than have some rep come in and hustle on lunch hour, and I do. It's expensive, but worth it.
I tell the patient that I'm sorry their drug is so expensive. We need profit motive to motivate the introduction of new drugs. What we don't need is a lot of fancy lunches and dinners, so now I don't feel guilty about contributing to the high cost of drugs.
I recognize that I'm susceptible to marketing messages. They're very effective. I think I'm making progress controlling rep-doctor interactions.

Anonymous said...

Wow. It doesn't say much for the physicians who fall for this crap.

James M. La Rossa Jr. said...

I think Interact MD's strategy is a good one, as long as he remains aware of his self-admitted gullibility.

Supremacy Claus said something recently that is worthy of noting again: "There is no greater scientific validity than simultaneous confirmation of a benefit by 1000's of independent practitioners. They have not spoken to each other. No bribe can induce
these docs to endure the negative consequences of continuing an ineffective or harmful treatment. They have been rewarded by the relief they experienced from patient improvement."

If can forward independent communication between practitioners, drug reps would do well to heed opinions expressed on these and like-minded sites.

Anonymous said...

Dr. Carlat,
I placed this post, "A Drug Rep Tells All", on our Honorable Mention list at I comb through many medical blogs on a daily basis. At the end of the week I choose a Scrubby Award winner (who receives a set of red scrubs) and a short list of honorable mentions.

We appreciate your dedication to the medical blogging community, and try to give what recognition we can to those that make a contribution.

Dr. Incognito

Daniel Carlat said...

Thanks, Dr. incongnito!

Supremacy Claus said...

Congratulations, Dan.

Your award:


Anonymous said...

It's interesting that this posting is of such importance that Dr Incognito offers to honor it with his Scrubby award mention, yet we are all still blogging about on a prior posting. I just want to go on record as saying this posting will get further recognition if people will share it with colleagues outside the internet. I forwarded it to my peers at work and so far some people have shared with me their disgust with the detailing process.

So, if this disgust is more widespread than admitted, what do we as honest and invested physicians do with this revelation? Expose it to any and all interested!

Dragonfly said...

Not surprising, either the intent or how well thought out the marketing strategies are. There is a big difference between recognising the game being played while chowing down on a free lunch and not playing the game and bringing your own sandwiches.

Anonymous said...

Anybody else barf inside a little when he said, "We are the one spot of sunshine in your day"?

No, the spots of sunshine are when:

- my patients are getting better and are happy to see me

- my 2 year old runs up to greet me with a hug when I get home

Perhaps he was being a little hyperbolic on purpose, as he is trying to make a point, but I didn't get much sense of tongue being in cheek, so I feel I can safely say, "Wow, dude, get over yourself!"

Most reps I see do not seem to realize how much of an annoyance they can be. Or if they do, they're choosing to ignore it and trudge onward. My practice partner calls one the FemBot because of this. There are some good ones, though, that are in tune with how busy I am and will quickly get me to sign for samples with a few friendly words.

Unknown said...

Even having a coffee cup or pad or pen with the drug name is good, and subtle, advertising for the doctor's presecription behavior.

Anonymous said...

the points by the above anonymous and gary greenberg are well appreciated. Today I read in the news that 2 of the newer statin agents are getting less than a supportive evaluation, and yet you read further in the article how Merck, company of one of the drug in question, is focused on how to downplay these findings. They will send out their reps to do damage control, and there will be a sizeable percentage of docs who will buy it.

How many of you were told by Lilly reps back around 2000 that Zyprexa first did not have a weight gain issue unique to the drug, then be told about 6-9 months later it was a class effect, then later, there were medication management options to control it, interestingly enough involving one of their other products, and finally we learn in responsible, unbiased literature that in fact Zyprexa causes siginificant weight gain issues in and of itself.

WHEN further poisons of other atypical antipsychotics come out, will you believe what the press and psychiatric literature have to say, or what your "spot of sunshine" will blind you with?

Barf is an understatement for me. I just wait for the solar eclipse.

While it is in Dr C's posting for today, the 31st, I sense his being named to this APA committee will possibly have some deleterious effect on his ongoing reporting of this issues. My cynacism may jade me too much at times, but, I do not believe the APA is an ally to this independent oversight on his part. I hope impartiality will win out on this alleged effort by the APA. Sometimes though, hopes can be dashed. Good luck, DR C!

Anonymous said...

The Damage of Legalized Lying

Amazingly, with the pharmaceutical industry, the amount spent by them on marketing is far greater than the amount spent on research and innovation, as it approaches 30 billion annually spent on their marketing efforts, as this presently takes priority over the research and development, so it seems. This includes 5 billion that is spent on drug reps, who implement the tactics of their marketing departments.
Marketing in some form exists with every business regardless of the industry of the business and its purpose. Essentially, marketing in itself is a complex activity- consisting of many specialty elements of various areas and levels, typically of an aggressive nature. However, with the pharmaceutical industry, marketing needs to become more specialized and altered due to the delicate nature of health care in order to prevent harm and ensure quality health care for all. Tactics that ignore such caution and consideration possibly could cause harm to patients in a number of ways, as this occurs presently. And recently, the marketing exposure of the drug industry has become an unfortunate issue for this industry for many reasons that remain a reality aside from what drug PR firms may try and tell us, as presently it seems as if the pharmaceutical industry, once viewed as very ethical, are now viewed as motivated by profit and greed. Such unwise and irresponsible methods include:

1. Advertising directly to the consumer. This method of bypassing what should entirely be decided by the heath care provider, as disregarding the determining factor of the heath care provider can possibly lead to inappropriate prescribing of certain advertised meds due to the demands of an unqualified patient who believed the content of such an advertisement that suggests that they are a candidate for a particular drug involved in the advertisement. Furthermore, it potentially removes the discretion of the provider regarding the best treatment for the patient through such frequent methods of marketing to potential consumers by such advertisements directly to consumers. Assessment of a patient by a health care provider is required and necessary, most believe, in order to determine the best treatment for a patient, as well as the provider considering their medical history as well as other variables necessary to consider the best course of the patient’s treatment. Ignoring this premise could be damaging to the patient seeking treatment through this possible inaccuracies through efforts provided by the marketing departments of drug companies.
2. Clinical evidence is the ultimate determining factor for treatment selection, after drug sample availability, and this evidence should be utilized by the provider entirely absent of any marketing technique implemented by a drug maker, which may include embellishments and lack of necessary evaluation of such patients. Analysis of such evidence is very necessary for the ultimate benefit of the patient.
3. People take issue with the use of celebrities who are paid greatly by some drug companies, possibly to attempt to expand or create a certain medical condition, so the celebrity will discuss a certain disease state determined by who paid such a celebrity. Many examples of this occurring have been noted by others, and can lead to both inappropriate prescribing and over-prescribing of these meds so often promoted to consumers. This may be appropriate if one is attempting to sell a car, but health care is more of an important topic of concern.
4. Education not only trough sponsored doctors of the drug company, but also statements from various medical groups sponsored as well by the industry for purposes of endorsement have been considered inappropriate for the welfare of public health through awareness techniques such as these methods initiated by marketing departments lacking thorough clinical evaluation that is necessarily for the best treatment of patients seeking care or concern of their health. As an ex seasoned big pharma drug rep, I can assure you that education is not the purpose of a pharmaceutical company.
5. The over-saturation of drug company sales reps who in the past have initiated questionable tactics upon the direction of their marketing department of their drug company employer, regardless of the validity or legality of such tactics that are normally not questioned or known by the drug reps in the first place. Such forms of manipulation include for some time questionable inducements for the health care providers. This is allowed to happen regardless of whether or not it is legal. As a result, many medical establishments are progressively prohibiting the activity or presence of drug reps at their locations. With the pharmaceutical company, sales reps are required by their employers to follow the direction of their marketing departments without exception. And the questioning of these directives is not tolerated by their employers. Because of this, the drug company’s image becomes more damaged as a result. To further illustrate this drug rep description, their employers require them to spend huge amounts of money annually to spend for doctors or to doctors that is void of any benefit for the patients.
In the past, the pharmaceutical industry was viewed as research-driven, innovative, and patient focused- entirely for the benefit of patient heath. This is why the industry was at a time viewed as an ethical one. Clearly, this is not the case today. Instead, many view this industry as one with their primary goal is to initiate market-driven profiteering, regardless of the attempts of the industry to convince the public otherwise, as stated previously by the industry’s supporters, who have attempted to place value to the medical community as the goal of the pharmaceutical company. So the view by the public of drug companies has been damaging to what should be a concerning degree because of their tactics and deception. So the pharma industry seems to be in great need of repair and re-evaluation of their purpose. This should performed by action instead of empty statements by the industry. It is the author’s opinion that actions by this industry for the sole benefit for the patients are displaced if they exist, unless my interpretation and perception are flawed greatly. The repair can only be done by the refocus of the industry towards convincing the public of the industry’s concern of their restoration of the patient’s health in several ways. One way is to always make the medical community aware and with conviction that their products are solely for the benefit of the patients, which is rarely discussed in full detail with such people. Fortunately, medications historically have been for this reason and are often necessary for the restoration or benefit of the health of those in medical need. The need should be more clearly defined by those who determine this, and these are the health care providers, who are caregivers, and not marketers. In summary, the medicines now available to us are for the benefit of the patients, and not the developers.

“Marketing is the act of making something seem better than it really is” --- Suso Banderas
Dan Abshear

Clint said...

I am no longer in the pharma industry but was in it for 14 years as a drug rep, product manager and sales manager. In my view, doctors are educated folks and if drug reps went in with a lousy product, it won't be successful. As for the education issue, it depends on the drug rep and company. In my 14 years in the industry, I've had countless number of doctors who told me they appreciated the info I passed onto them. Of course, they will balanced it with other info they got too. If one thinks about it, the pharma industry does a better job providing useful info than many other industries.

Anonymous said...

Sharam did a good thing, and has been sharing relevant information from the perspective of an insider that is accurate and free of embellishments.

Yet I can assure you, he does not 'tell all'. He has just scratched the surface.

Reps play a small role in the corruption of this industry. I say this as an ex big pharma rep myself, who did this game for a full decade.

Anonymous said...

I don't know where you guys are but we don't see "fancy" lunches unless you consider Subway and Pizza Hut to be "fancy." I can buy my own lunch too. But, I do appreciate lunches because it gives my staff a chance to have lunch and stay in the clinic. And, I don't have the means to pay my staff as much as they deserve, and it is helpful to them. Also, it helps the local businesses in my town. I know how to practice medicine, and meals and relationships don't have much influence. It is important to do your own research on drugs. If you don't like drug reps then don't see them, and DO NOT accept their samples. Samples are one of the biggest expenses for companies, and I admit I use them for patients that fall in the cracks and need help with affording drugs. Seventy five percent of scripts written are generic so how much influence do reps really have? It is funny that pharma gets such a bad wrap when the generic companies make millions of dollars without one cent in research. Why don't we complain about them? They break patents, etc... Sales people in any other industry do not have rules like not allowing someone to take a client to dinner or giving out a pen. Maybe there should be restrictions on all industries? Lobbyist for one.

Anonymous said...

Oh Shahram. You're just doing this to make some $$. You're just as bad as those "evil drug reps." I was in the industry for a LONG time. YOU, my dear, have twisted so many of the facts about the pharma industry so that you can get your 15 seconds. LAME. Reps provide valuable info- managed care updates, new indications, patient education, etc. We're not trying to persuade someone with a donut, we're simply trying to get some time with the physician. You're probably just bitter because none of your doctors liked you. You were the type of rep doctors ran from.