the atlantic monthly
`
`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
`
`BY CARl ellIOTT
`
`Illustrations by Marcellus Hall
`. . . . .
`
`Back in the old days, long before drug companies
`
`started making headlines in the business pages, doc-
`tors were routinely called upon by company repre-
`sentatives 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 doc-
`tor. 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 “pharmaceuti-
`cal 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 gener-
`ally 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 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-
`19th century, but during the past decade or so their num-
`bers 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 prod-
`uct. Detailing is expensive, but almost all
`practicing doctors see reps at least occasion-
`ally, and many doctors say they find reps
`useful. One study found that for drugs intro-
`duced 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 obvi-
`ous. 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 commis-
`sions. 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
`byproduct 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.
`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
`Exhibit 1071
`ARGENTUM
`IPR2017-01053
`
`Carl Elliott teaches at the Center for Bio-
`ethics at the University of Minnesota and
`is the author of several books, including
`Better than Well: American Medicine
`Meets the American Dream (2003),
`and the co-editor of The last Physi-
`cian: Walker Percy and the Moral
`life of Medicine (1999). His article “A
`New Way to Be Mad” appeared in the
`December 2000 issue of The Atlantic.
`
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`

`the atlantic monthly
`
`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 mys-
`terious. 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, 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 con-
`versation, 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 ini-
`tially 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 Pri-
`losec, which at the time was available by prescription only.
`
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`Prilosec is the kind of drug most reps can only dream
`about. The industry usually considers a drug to be a block-
`buster 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 diges-
`tion. 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 mar-
`keted 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 stom-
`ach 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
`
`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 con-
`sisting of about fifty doctors. Although the practice had plenty
`of patients, it was struggling. This problem was not uncom-
`mon. When the movement toward corporate-style medicine
`got under way, in the 1980s 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 doc-
`tors 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
`
`Drug reps are easy to spot in a hospital or clinic. They are
`often young and strikingly good-looking. They are usually
`affable and sometimes very smart. and they are always,
`hands-down, the best-dressed people in the hospital.
`
`late 1990s Astra Merck mounted a huge direct-to-consumer
`campaign; ads for the purple pill were ubiquitous. But con-
`sumer 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 prescrib-
`ing 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 a group of doctors and their guests to a high-end res-
`taurant, 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
`
`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 ‘suc-
`cessful,’ 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 dramati-
`cally, 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 consul-
`tant 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 cour-
`tesy of Carbona. The strategy worked. “Those guys went
`
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`berserk for me,” Carbona says. Doctors at the newly vital-
`ized 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 osteo-
`arthritis?” 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-Moschau’s 2005 film about a fictional fledgling
`drug rep. Slattery-Moschau, 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 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-Moschau 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 hand-
`somely. 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 pharma-
`ceutical 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 lit-
`erature 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 man-
`aged this debate skillfully, pouring vast resources into gifts
`for doctors while simultaneously reassuring them that their
`integrity prevents them from being influenced. For exam-
`ple, 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 pri-
`vate, 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 19th
`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?
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`the drug pushers
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`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 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 anthropolo-
`gist 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
`
`Many companies started hitting for the fences, concen-
`trating on potential blockbuster drugs for chronic illnesses
`in huge populations: Claritin for allergies, Viagra for impo-
`tence, 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 busi-
`ness 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 appoint-
`ment 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
`
`in the 1990s, new technology made it easy for any rep
`to track any doctor’s prescriptions. The result was an arms
`race of pharmaceutical gift-giving. if gsK flew doctors
`to Palm springs for a conference, you flew them to Paris.
`
`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 under-
`going 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 mak-
`ing 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 televi-
`sion 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.
`
`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 recep-
`tionists, 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 pre-
`scriptions 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.
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`What they discovered was revela-
`tory. For one thing, they found that a
`lot of doctors were lying to them. Doc-
`tors might tell a rep that they were writ-
`ing prescriptions for, say, lipitor, when
`they weren’t. They were just being
`polite, or saying whatever they thought
`would get the rep off their back. Now
`reps could detect the deception imme-
`diately. (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 con-
`servative 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 presenta-
`tion 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 com-
`pany. 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 confer-
`ence, 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 relation-
`ship 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 owner-
`ship about prescriptions. If their doctors started writing more
`prescriptions for their drugs, the credit clearly belonged to
`them. However, more precise monitoring also invited micro-
`management 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 poten-
`tially 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 half-hearted, 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 Medi-
`cal 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
`a having a stroke.” In 2001 the AMA launched a campaign
`to educate doctors about the ethical perils of pharmaceutical
`
`the drug pushers
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`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 doc-
`tor 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
`
`she reached over his shoulder into his drug closet and picked
`up a couple of sample packages of Zoloft and Celexa. Waving
`them in the air, she asked, “Tell me, Doctor, do the Pfizer and
`Forest reps bring lunch to your office staff? ” A stony silence
`followed. Hal quietly ordered the rep out of the office and
`told her to never come back. She left in tears.
`It’s not hard to understand why Hal got so angry. The
`rep had broken the rules. like an abrasive tourist who has
`not caught on to the code of manners in a foreign country,
`she had said outright the one thing that, by custom and com-
`mon agreement, should never be said: that the lunches she
`
`Doctors insist that gifts and perks from reps have no
`real effect. studies in the medical literature indicate just
`the opposite. Doctors who take gifts from a company
`are more likely to prescribe that company’s drugs.
`
`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 t