The Drug Pushers - The Atlantic
`
`https://www.theatlantic.com/magazine/archive/2006/04/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
`
`CARL ELLIOTT | APRIL 2006 ISSUE |
`
`TECHNOLOGY
`
`Want to receive exclusive insights from The Atlantic—while supporting a sustainable future for
`independent journalism? Join our new membership program, The Masthead.
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`ACRUX DDS PTY LTD. et al.
`
`EXHIBIT 1621
`
`IPR Petition for
`
`U.S. Patent No. 7,214,506
`
`

`

`The Drug Pushers - The Atlantic
`
`https://www.theatlantic.com/magazine/archive/2006/04/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
`
`CARL ELLIOTT | APRIL 2006 ISSUE |
`
`TECHNOLOGY
`
`Want to receive exclusive insights from The Atlantic—while supporting a sustainable future for
`independent journalism? Join our new membership program, The Masthead.
`
`1 of 23
`
`10/30/2017, 4:33 PM
`
`Page 1 of 23
`
`

`

`The Drug Pushers - The Atlantic
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`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers...
`
`sometimes very smart. Many give off a kind of glow, as if they had just emerged
`from a spa or salon. And they are always, hands down, the best-dressed people in
`the hospital.
`
`Drug reps have been calling on doctors since the mid-nineteenth century, but
`during the past decade or so their numbers have increased dramatically. From
`1996 to 2001 the pharmaceutical sales force in America doubled, to a total of
`90,000 reps. One reason is simple: good reps move product. Detailing is
`expensive, but almost all practicing doctors see reps at least occasionally, and
`many doctors say they find reps useful. One study found that for drugs
`introduced after 1997 with revenues exceeding $200 million a year, the average
`return for each dollar spent on detailing was $10.2 9. That is an impressive
`figure. It is almost twice the return on investment in medical-journal advertising,
`and more than seven times the return on direct-to-consumer advertising.
`
`But the relationship between doctors and drug reps has never been
`uncomplicated, for reasons that should be obvious. The first duty of doctors, at
`least in theory, is to their patients. Doctors must make prescribing decisions
`based on medical evidence and their own clinical judgment. Drug reps, in
`contrast, are salespeople. They swear no oaths, take care of no patients, and
`profess no high-minded ethical duties. Their job is to persuade doctors to
`prescribe their drugs. If reps are lucky, their drugs are good, the studies are clear,
`and their job is easy. But sometimes reps must persuade doctors to prescribe
`drugs that are marginally effective, exorbitantly expensive, difficult to
`administer, or even dangerously toxic. Reps that succeed are rewarded with
`bonuses or commissions. Reps that fail may find themselves unemployed.
`
`Most people who work in health care, if they give drug reps any thought at all,
`regard them with mixed feelings. A handful avoid reps as if they were vampires,
`backing out of the room when they see one approaching. In their view, the best
`that can be said about reps is that they are a necessary by-product of a market
`economy. They view reps much as NBA players used to view Michael Jordan: as
`an awesome, powerful force that you can never really stop, only hope to control.
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`The Drug Pushers - The Atlantic
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`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers...
`
`Yet many reps are so friendly, so easygoing, so much fun to flirt with that it is
`virtually impossible to demonize them. How can you demonize someone who
`brings you lunch and touches your arm and remembers your birthday and knows
`the names of all your children? After awhile even the most steel-willed doctors
`may look forward to visits by a rep, if only in the self-interested way that they
`look forward to the UPS truck pulling up in their driveway. A rep at the door
`means a delivery has arrived: take-out for the staff, trinkets for the kids, and,
`most indispensably, drug samples on the house. Although samples are the single
`largest marketing expense for the drug industry, they pay handsome dividends:
`doctors who accept samples of a drug are far more likely to prescribe that drug
`later on.
`
`Drug reps may well have more influence on prescriptions than anyone in
`America other than doctors themselves, but to most people outside the drug
`industry their jobs are mysterious. What exactly do they do every day? Where do
`they get their information? What do they say about doctors when the doctors are
`not around? Reps can be found in hospitals, waiting rooms, and conference halls
`all over the country, yet they barely register on the collective medical
`consciousness. Many doctors notice them only in the casual, utilitarian way that
`one might notice a waitress or a bartender. Some doctors look down on them on
`ethical grounds. "Little Willy Lomans," they say, "only in it for the money."
`When I asked my friends and colleagues in medicine to suggest some reps I
`could talk to about detailing, most could not come up with a single name.
`
`These doctors may be right about reps. It is true that selling pharmaceuticals can
`be a highly lucrative job. But in a market-based medical system, are reps really so
`different from doctors? Most doctors in the United States now work, directly or
`indirectly, for large corporations. Like reps, many doctors must answer to
`managers and bureaucrats. They are overwhelmed by paperwork and red tape.
`Unlike my father, who would have sooner walked to Charleston barefoot than
`take out an ad for his practice, many doctors now tout their services on roadside
`billboards. My medical-school alumni magazine recently featured the Class of
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`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers...
`
`1988 valedictorian, who has written a diet book, started her own consulting
`firm, and become the national spokesperson for a restaurant chain. For better or
`worse, America has turned its health-care system over to the same market forces
`that transformed the village hardware store into Home Depot and the corner
`pharmacy into a strip-mall CVS. Its doctors are moving to the same medical
`suburb where drug reps have lived for the past 150 years. If they want to know
`what life is like there, perhaps they should talk to their neighbors.
`
`The King ofHappyHour
`
`Gene Carbona was almost a criminal. I know this because, thirty minutes into
`our first telephone conversation, he told me, "Carl, I was almost a criminal." I
`have heard ex-drug reps speak bluntly about their former jobs, but never quite so
`cheerfully and openly. These days Carbona works for The Medical Letter, a highly
`respected nonprofit publication (Carbona stresses that he is speaking only for
`himself), but he was telling me about his twelve years working for Merck and
`then Astra Merck, a firm initially set up to market the Sweden-based Astra's
`drugs in the United States. Carbona began training as a rep in 1988, when he
`was only eleven days out of college. He detailed two drugs for Astra Merck. One
`was a calcium-channel blocker he calls "a dog." The other was the heartburn
`medication Prilosec, which at the time was available by prescription only.
`
`Prilosec is the kind of drug most reps can only dream about. The industry usually
`considers a drug to be a blockbuster if it reaches a billion dollars a year in sales.
`In 1998 Prilosec became the first drug in America to reach $5 billion a year. In
`2000 it made $6 billion. Prilosec's success was not the result of a massive
`heartburn epidemic. It was based on the same principle that drove the success of
`many other 1990s blockbusters, from Vioxx to Viagra: the restoration of an
`ordinary biological function that time and circumstance had eroded. In the case
`of Prilosec, the function was digestion. Many people discovered that the drug
`allowed them to eat the burritos and curries that their gastrointestinal systems
`had placed off-limits. So what if Prilosec was $4 a pill, compared with a quarter
`or so for a Tagamet? Patients still begged for it. Prilosec was their savior. Astra
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`Merck marketed Prilosec as the "purple pill," but, according to Carbona, many
`patients called it "purple Jesus."
`
`How did Astra Merck do it? Prilosec was the first proton pump inhibitor (a drug
`that inhibits the production of stomach acid) approved by the Food and Drug
`Administration, and thus the first drug available in its class. By definition this
`gave it a considerable head start on the competition. In the late 1990s Astra
`Merck mounted a huge direct-to-consumer campaign; ads for the purple pill
`were ubiquitous. But consumer advertising can do only so much for a drug,
`because doctors, not patients, write the prescriptions. This is where reps become
`indispensable.
`
`Many reps can tell stories about occasions when, in order to move their product,
`they pushed the envelope of what is ethically permissible. I have heard reps talk
`about scoring sports tickets for their favorite doctors, buying televisions for
`waiting rooms, and arranging junkets to tropical resorts. One rep told me he set
`up a putting green in a hospital and gave a putter to any doctor who made a hole(cid:173)
`in-one. A former rep told me about a colleague who somehow managed to
`persuade a pharmacist to let him secretly write the prescribing protocol for
`antibiotic use at a local hospital.
`
`But Carbona was in a class of his own. He had access to so much money for
`doctors that he had trouble spending it all. He took residents out to bars. He
`distributed "unrestricted educational grants." He arranged to buy lunch for the
`staff of certain private practices every day for a year. Often he would invite a
`group of doctors and their guests to a high-end restaurant, buy them drinks and a
`lavish meal, open up the club in back, and party until4:00 a.m. "The more
`money I spent," Carbona says, "the more money I made." If he came back to the
`restaurant later that week with his wife, everything would be on the house. "My
`money was no good at restaurants," he told me, "because I was the King of
`Happy Hour."
`
`My favorite Carbona story, the one that left me shaking my head in admiration,
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`took place in Tallahassee. One of the more important clinics Carbona called on
`was a practice there consisting of about fifty doctors. Although the practice had
`plenty of patients, it was struggling. This problem was not uncommon. When the
`movement toward corporate-style medicine got under way, in the 19 80s and
`1990s, many doctors found themselves ill-equipped to run a business; they
`didn't know much about how to actually make money. ("That's why doctors are
`such great targets for Ponzi schemes and real-estate scams," Carbona helpfully
`points out.) Carbona was detailing this practice twice a week and had gotten to
`know some of the clinicians pretty well. At one point a group of them asked him
`for help. "Gene, you work for a successful business," Carbona recalls them
`saying. "Is there any advice you could give us to help us turn the practice
`around?" At this point he knew he had stumbled upon an extraordinary
`opportunity.
`
`Carbona decided that the clinic needed a "practice- management consultant."
`And he and his colleagues at Astra Merck knew just the man: a financial planner
`and accountant with whom they were very friendly. They wrote up a contract.
`They agreed to pay the consultant a flat fee of about $50,000 to advise the clinic.
`But they also gave him another incentive. Carbona says, "We told him that if he
`was successful there would be more business for him in the future, and by
`'successful,' we meant a rise in prescriptions for our drugs."
`
`The consultant did an extremely thorough job. He spent eleven or twelve hours a
`day at the clinic for months. He talked to every employee, from the secretaries to
`the nurses to the doctors. He thought carefully about every aspect of the
`practice, from the most mundane administrative details to big-picture matters
`such as bill collection and financial strategy. He turned the practice into a
`profitable, smoothly running financial machine. And prescriptions for Astra
`Merck drugs soared.
`
`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
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`
`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
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`
`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 yearin 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. Mter 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
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`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
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`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers...
`
`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 oflike 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,
`until1998.
`
`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(cid:173)
`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
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`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
`compames.
`
`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
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`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
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`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(cid:173)
`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.
`
`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
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`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers...
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`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
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`give." When Oldani found a pharmacist who liked to play the market, he gave
`him stock options. When he w