2/21/2018
`
`The Drug Pushers - The Atlantic
`
`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
`
`Like The Atlantic? Subscribe to The Atlantic Daily , our free weekday email newsletter.
`
`Email
`
`SIGN UP
`
`Back in the old days, long before drug companies started making headlines in the
`business pages, doctors were routinely called upon by company representatives
`known as “detail men.” To “detail” a doctor is to give that doctor information about
`a company’s new drugs, with the aim of persuading the doctor to prescribe them.
`When I was growing up, in South Carolina in the 1970s, I would occasionally see
`detail men sitting patiently in the waiting room outside the office of my father, a
`family doctor. They were pretty easy to spot. Detail men were usually sober,
`conservatively dressed gentlemen who would not have looked out of place at the
`Presbyterian church across the street. Instead of Bibles or hymn books, though,
`they carried detail bags, which were filled with journal articles, drug samples, and
`branded knickknacks for the office.
`
`Today detail men are officially known as “pharmaceutical sales representatives,”
`but everyone I know calls them “drug reps.” Drug reps are still easy to spot in a
`clinic or hospital, but for slightly different reasons. The most obvious is their
`appearance. It is probably fair to say that doctors, pharmacists, and medical-school
`professors are not generally admired for their good looks and fashion sense.
`Against this backdrop, the average drug rep looks like a supermodel, or maybe an
`A-list movie star. Drug reps today are often young, well groomed, and strikingly
`good-looking. Many are women. They are usually affable and sometimes very
`Exhibit 1099
`IPR2017-00807
`ARGENTUM
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`1/22
`
`000001
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 $10.29. 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.
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`2/22
`
`000002
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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
`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,
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`3/22
`
`000003
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 of Happy Hour
`
`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 Merck marketed Prilosec as the
`“purple pill,” but, according to Carbona, many patients called it “purple Jesus.”
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`4/22
`
`000004
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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-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 until 4:00 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,
`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 1980s and
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`5/22
`
`000005
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 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
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`6/22
`
`000006
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 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
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`7/22
`
`000007
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 year in 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. After 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
`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
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`8/22
`
`000008
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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
`
`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 of like the
`Mafia,” Oldani told me. “They made me an offer I couldn’t refuse.” At the time, he
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`9/22
`
`000009
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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, until 1998.
`
`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-
`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
`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
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`10/22
`
`000010
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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
`companies.
`
`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 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
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`11/22
`
`000011
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 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-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,
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`12/22
`
`000012
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 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 halearted, 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.
`
`https://www.theatlantic.com/magazine/archive/2006/04/the-drug-pushers/304714/
`
`13/22
`
`000013
`
`

`

`2/21/2018
`
`The Drug Pushers - The Atlantic
`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 o