How the Pharmaceutical Industry Influences Doctors
In 2007, Shahram Ahari (former pharmaceutical sales representative for Eli Lilly and Company) and Adriane Fugh-Berman reported how the pharmaceutical industry influences doctors in an article in the Public Library of Science journal titled 'Following the Script: How Drug Reps Make Friends and Influence Doctors'.
Physicians may often view drug information provided by reps as a convenient educational service. However, as this report states, 'the concept that reps provide necessary services to physicians and patients is a fiction. Pharmaceutical companies spend billions of dollars annually to ensure that physicians most susceptible to marketing prescribe the most expensive, most promoted drugs to the most people possible'. If the reps truly did provide an educational service, then it would be provided to all physicians, not just those who affect the companies market share. 'Every word, every courtesy, every gift, and every piece of information provided is carefully crafted, not to assist doctors or patients, but to increase market share for targeted drugs'
- 'An official job description for a pharmaceutical sales rep would read: Provide health-care professionals with product information, answer their questions on the use of products, and deliver product samples. An unofficial, and more accurate, description would have been: Change the prescribing habits of physicians'.
As Ahari states, as a pharmaceutical sales rep...
- 'It's my job to figure out what a physician's price is. For some it's dinner at the finest restaurants, for others it's enough convincing data to let them prescribe confidently and for others it's my attention and friendship...but at the most basic level, everything is for sale and everything is an exchange'.
The one-on-one promotion of drugs to doctors by pharmaceutical sales representatives (drug reps) is known as 'detailing' and for the year 2000, more than 4.8 billion dollars was spent by pharmaceutical companies in the U.S. in this area. Between 1995 and 2005, the number of drug reps in the U.S. increased from 38,000 to 100,000. This works out at about one for every six physicians (or 1 for every 2.5 physicians when physicians that do not practice or who are not 'detailed' are excluded).
As Ahari points out, drug reps are...
- 'trained to assess physicians' personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician's family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor's office for objects—a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols—that can be used to establish a personal connection with the doctor'.
'Good details are dynamic; the best reps tailor their messages constantly according to their client's reaction. A friendly physician makes the rep's job easy, because the rep can use the “friendship” to request favors, in the form of prescriptions'.
'During training, I was told, when you're out to dinner with a doctor, “The physician is eating with a friend. You are eating with a client.”' - Ahari
One of the primary tools of a drugs rep is their ability to make friends with doctors, but they are not genuine friends. 'Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful'. After winning the doctors confidence and 'when the time is right' they lean on their friendship to persuade the doctor to prescribe more of the company's drugs. Saying things like 'it will help meet my quota', 'it will impress my manager', or 'its crucial for my career', when in fact they are simply doing their job.
Aloof and Skeptical
For doctors who refuse to see reps, they are 'detailed by proxy'. The reps target the doctors staff who are 'dined and flattered in hopes that they will act as emissaries for a rep's messages'. As Ahari states, 'Even though they're on the doc's side for the most part, its amazing how much trouble one can rile up when the staff are lavished with food and gifts during a credible sounding presentation...'
This has the added impact for 'while a message delivered by a rep gets discounted, a detail delivered by a co-worker slips undetected and unfiltered under the guise of a conversation'.
Drug reps also target doctors who do not prescribe their drugs by scheduling 20 minute appointments 'so the doc can't escape' where they bring along articles that counter the doctors perceptions of the drug they're trying to push (in other words articles in favour of the company's products). The reps then 'play dumb' and have the doctor explain the significance of the article. As Ahari says, 'The only thing that remains for me to do is be just aggressive enough to ask the doc to try my drug in situations that wouldn't have been considered before'.
Drug reps also play on a mercenary nature. These are normally considered as doctors found 'further down the prescribing power scale'. The rep plays on their desire for attention and works to make them feel special. Playing on a 'projected demand on limited resources' and normally followed by statements such as 'so doc, you'll choose drug X for the next 5 patients who are depressed and with low energy? oh, and don't forget dinner at the Nobu next month. I'd love to met your wife'.
Doctors who prefer to prescribe a competing drug
In this situations drug reps 'force the doctors to constantly explain their prescribing rationale, which is tiresome. Our intention is to engage in discourse but also to wear down the doc until he or she simply agrees to try the product...'
Doctors may simply agree with what the rep says in order to avoid confrontation but without the intention of changing their habits. The doctor may think that they can end the encounter quickly and receive their offered gifts. However as the report states 'nothing could be further from the truth... there's no such thing as a free lunch'. Reps are trained to frame every conversation in order to derive commitments from their clients. Pharmaceutical companies analyse data on prescription habits (see Monitoring Prescription Habits below) and can tell if the doctor has not changed their practice as desired. In this case the rep then becomes a 'badgering nuisance'.
Gifts to create expectations and obligations
'The importance of developing loyalty through gifting cannot be overstated'.
Pharmaceutical companies gifts range from pens, mugs, lunches and dinners, to 'higher-end presents' (for high prescribing doctors) such as silk ties, golf bags or perhaps even 'unrestricted "educational" grants so loosely restricted that they were the equivilent of a cash gift'.
Reps may present themselves as generous, however giving 'involves carefully calibrated generosity'. Items with the companies logo are designed to be kept close at hand and thus ensure 'that a targeted drug's name stays uppermost in a physician's subconscious mind'. High prescribers receive higher-end presents, for example, silk ties, golf bags or 'grants'. As Oldani states, 'The essence of pharmaceutical gifting... is bribes that aren't considered bribes'.
- 'Gifts are used to enhance guilt and social pressure. Reps know that gifts create a subconcious obligation to reciprocate... Of course most of these doctors think themselves immune to such influence. This is an illusion reps try to maintain'.
Reps also recruit and audition 'thought leaders'. These are physicians who are respected by their peers. They are then groomed for the speaking circuit, where they are invited as 'speakers' to influence their peers. As Ahari states, Physicians who are paid by a rep 'may express their gratitude in increased prescriptions. Anything that improves the relationship between the rep and the client usually leads to improved market share'.
Monitoring prescriptions habits
Pharmaceutical companies monitor the returns on their investment in drug reps (and other forms of marketing) through what is known as 'prescription tracking' (or 'script tracking'). Information about the prescription habits of doctors is obtained through 'information distribution companies' (also known as health information organizations) such as IMS Health, Dendrite, Verispan and Wolters Kluwer.
Information distribution companies purchase prescription records from pharmacies which are then sold on to companies. The data is then used 'to see how many of a physician's patients receive specific drugs, how many prescriptions the physician writes for targeted and competing drugs, and how a physician's prescribing habits change over time'. This enables reps to build a profile and aid their targeting. In doing so, they analyse individual prescribing behaviours, demographics and psychographics (such as attitudes, beliefs, and values).
- 'The goal of this demographic slicing and dicing is to identify physicians who are most susceptible to marketing efforts'.
The Prescribing Data Restriction Program was launched in 2006 (see Physician Data Restriction Program). This allows physicians the opportunity to withhold most prescribing information from reps and their supervisors. However anyone above that level has full access to all data and similar data can still be accessed in other ways.
The supply of samples is reported to be in order to 'gain entry into doctors' offices, and to habituate physicians to prescribing targeted drugs'. This in turn increases loyalty to both the reps and the drugs they represent. According to the report, studies consistently show that samples influence prescribing choices. Reps only provide samples for the most promoted (and usually most expensive) drugs and samples given to patients are normally for only part of the course of treatment (with the remaining always requiring a prescription for the same drug).
In March 2008, Senate President Therese Murray proposed to ban (in Massachusets) all gifts and 'freebies' to doctors from drug companies. Such 'perks' have helped drive up medical costs and the move is proposed as an attempt to help to control healthcare costs.
- American Medical Association Physician Data Restriction Program
- Public Library of Science Following the Script: How Drug Reps Make Friends and Influence Doctors Accessed 28th March 2008