Policy Forum
`
`Following the Script: How Drug Reps Make
`Friends and Infl uence Doctors
`
`Adriane Fugh-Berman*, Shahram Ahari
`
`It’s my job to fi gure out what a physician’s price
`is. For some it’s dinner at the fi nest restaurants,
`for others it’s enough convincing data to let
`them prescribe confi dently and for others it’s my
`attention and friendship...but at the most basic
`level, everything is for sale and everything is an
`exchange.
`
`—Shahram Ahari
`
`You are absolutely buying love.
`—James Reidy [1]
`
`In 2000, pharmaceutical companies
`
`spent more than 15.7 billion
`dollars on promoting prescription
`drugs in the United States [2]. More
`than 4.8 billion dollars was spent on
`detailing, the one-on-one promotion
`of drugs to doctors by pharmaceutical
`sales representatives, commonly
`called drug reps. The average sales
`force expenditure for pharmaceutical
`companies is $875 million annually [3].
`Unlike the door-to-door vendors
`of cosmetics and vacuum cleaners,
`drug reps do not sell their product
`directly to buyers. Consumers pay for
`prescription drugs, but physicians
`control access. Drug reps increase drug
`sales by infl uencing physicians, and
`they do so with fi nely titrated doses of
`friendship. This article, which grew
`out of conversations between a former
`drug rep (SA) and a physician who
`researches pharmaceutical marketing
`(AFB), reveals the strategies used
`by reps to manipulate physician
`prescribing.
`
`Better Than You Know Yourself
`During training, I was told, when you’re out to
`dinner with a doctor, “The physician is eating
`with a friend. You are eating with a client.”
`—Shahram Ahari
`
`Reps may be genuinely friendly, but
`they are not genuine friends. Drug reps
`are selected for their presentability
`and outgoing natures, and are
`trained to be observant, personable,
`
`The Policy Forum allows health policy makers around
`the world to discuss challenges and opportunities for
`improving health care in their societies.
`
`and helpful. They are also trained
`to assess physicians’ personalities,
`practice styles, and preferences, and
`to relay this information back to the
`company. Personal information may
`be more important than prescribing
`preferences. Reps ask for and
`remember details about a physician’s
`family life, professional interests, and
`recreational pursuits. A photo on a
`desk presents an opportunity to inquire
`about family members and memorize
`whatever tidbits are offered (including
`names, birthdays, and interests); these
`are usually typed into a database after
`the encounter. Reps scour a doctor’s
`offi ce for objects—a tennis racquet,
`Russian novels, seventies rock music,
`fashion magazines, travel mementos,
`or cultural or religious symbols—that
`can be used to establish a personal
`connection with the doctor.
`Good details are dynamic; the best
`reps tailor their messages constantly
`according to their client’s reaction.
`A friendly physician makes the rep’s
`job easy, because the rep can use
`the “friendship” to request favors, in
`the form of prescriptions. Physicians
`who view the relationship as a
`straightforward goods-for-prescriptions
`exchange are dealt with in a
`businesslike manner. Skeptical doctors
`who favor evidence over charm are
`approached respectfully, supplied with
`reprints from the medical literature,
`
`doi:10.1371/journal.pmed.0040150.g001
`
`(Photo: “Bitter Pills?” by net_efekt,
`at http://www.fl ickr.com/photos/
`wheatfi elds/316337784/. Published under the
`Creative Commons Attribution License.)
`
`and wooed as teachers. Physicians
`who refuse to see reps are detailed by
`proxy; their staff is dined and fl attered
`in hopes that they will act as emissaries
`for a rep’s messages. (See Table 1 for
`specifi c tactics used to manipulate
`physicians.)
`Gifts create both expectation
`and obligation. “The importance of
`developing loyalty through gifting
`cannot be overstated,” writes Michael
`Oldani, an anthropologist and former
`drug rep [26]. Pharmaceutical gifting,
`however, involves carefully calibrated
`generosity. Many prescribers receive
`pens, notepads, and coffee mugs, all
`
`Funding: This work was supported by a grant from
`the Attorney General Prescriber and Consumer
`Education Grant Program, created as part of a 2004
`settlement between Warner-Lambert, a division of
`Pfi zer, and the Attorneys General of 50 States and
`the District of Columbia, to settle allegations that
`Warner-Lambert conducted an unlawful marketing
`campaign for the drug Neurontin (gabapentin) that
`violated state consumer protection laws.
`
`doctors. PLoS Med 4(4): e150. doi:10.1371/journal.
`pmed.0040150
`
`Copyright: © 2007 Fugh-Berman and Ahari. This is
`an open-access article distributed under the terms
`of the Creative Commons Attribution License,
`which permits unrestricted use, distribution, and
`reproduction in any medium, provided the original
`author and source are credited.
`
`Competing Interests: Shahram Ahari is a former
`pharmaceutical sales representative for Eli Lilly, and
`the primary fi ndings of this paper summarize points
`he made in testimony as a paid expert witness on
`the defendant’s side in litigation against a New
`Hampshire law prohibiting the sale of prescription
`data. Adriane Fugh-Berman has accepted payment
`as an expert witness on the plaintiff’s side in litigation
`regarding menopausal hormone therapy.
`
`Abbreviations: AMA, American Medical Association
`
`Adriane Fugh-Berman is an Associate Professor
`in the Department of Physiology and Biophysics,
`Georgetown University Medical Center, Washington,
`District of Columbia, United States of America.
`Shahram Ahari is with the School of Pharmacy,
`University of California San Francisco, San Francisco,
`California, United States of America.
`
`Citation: Fugh-Berman A, Ahari S (2007) Following
`the script: How drug reps make friends and infl uence
`
`* To whom correspondence should be addressed.
`E-mail: ajf29@georgetown.edu
`
`PLoS Medicine | www.plosmedicine.org
`
`0621
`
`April 2007 | Volume 4 | Issue 4 | e150
`
`Exhibit 1083
`ARGENTUM
`IPR2017-01053
`
`000001
`
`

`

`Table 1. Tactics for Manipulating Physicians
`Physician Category
`Technique
`
`How It Sells Drugs
`
`Comments
`
`Friendly and outgoing
`
`Aloof and skeptical
`
`Mercenary
`
`High-prescribers
`
`Prefers a competing
`drug
`
`Acquiescent docs
`
`I frame everything as a gesture of friendship.
`I give them free samples not because it’s
`my job, but because I like them so much. I
`provide offi ce lunches because visiting them
`is such a pleasant relief from all the other
`docs. My drugs rarely get mentioned by me
`during our dinners.
`I visit the offi ce with journal articles that
`specifi cally counter the doctor’s perceptions
`of the shortcoming of my drug. Armed with
`the articles and having hopefully scheduled
`a 20 minute appointment (so the doc can’t
`escape), I play dumb and have the doc
`explain to me the signifi cance of my article.
`The best mercenary docs are typically
`found further down the prescribing power
`scale. There are plenty of 6’s, 7’s, and
`8’s [lower prescribing doctors] who are
`eagerly mercenary but simply don’t have
`the attention they desire fawned on them.
`I pick a handful out and make them feel
`special enough with an eye towards the
`projected demand on my limited resources
`in mind. Basically, the common motif to
`docs whom you want to “buy out” is to
`closely associate your resource expenditure
`with an expectation—e.g., “So, doc, you’ll
`choose Drug X for the next 5 patients who
`are depressed and with low energy? Oh, and
`don’t forget dinner at Nobu next month. I’d
`love to meet your wife.”
`I rely on making a strong personal
`connection to those docs, something to
`make me stand out from the crowd.
`
`The fi rst thing I want to understand is why
`they’re using another drug as opposed to
`mine. If it’s a question of attention, then
`I commit myself to lavishing them with it
`until they’re bought. If they are convinced
`that the competitor drug works better in
`some patient populations, I frame my drug
`to either capture another market niche
`or, if I feel my drug would fare well in a
`comparison, I hammer its superiority over
`the competing drug.
`
`Most docs think that if they simply agree
`with what the rep says, they’ll outsmart the
`rep by avoiding any confl ict or commitment,
`getting the samples and gifts they want, and
`fi nishing the encounter quickly. Nothing
`could be further from the truth. The old
`adage is true, especially in pharmaceutical
`sales: there is no such thing as a free lunch.
`
`Just being friends with most of my docs
`seemed to have some natural basic effect
`on their prescribing habits. When the time
`is ripe, I lean on my “friendship” to leverage
`more patients to my drugs...say, because it’ll
`help me meet quota or it will impress my
`manager, or it’s crucial for my career.
`The only thing that remains is for me to
`be just aggressive enough to ask the doc
`to try my drug in situations that wouldn’t
`have been considered before, based on the
`physician’s own explanation.
`
`Outgoing, friendly physicians are every rep’s
`favorite because cultivating friendship is a mutual
`aim. While this may be genuine behavior on the
`doctor’s side, it is usually calculated on the part of
`the rep.
`
`Humility is a common approach to physicians who
`pride themselves on practicing evidence-based
`medicine. These docs are tough to persuade but
`not impossible. Typically, attempts at geniality are
`only marginally effective.
`
`This is the closest drug-repping comes to
`a commercial exchange. Delivering such
`closely associated messages crudely would
`be deemed insulting for most docs so a rep
`really has to feel comfortable about their
`mercenary nature and have a natural tone
`when making such suggestions.
`
`Drug reps usually feel more camaraderie with
`competing reps than they do with their clients.
`Thus, when a doctor fails to fulfi ll their end of the
`prescriptions-for-dinners bargain, news gets around
`and other reps are less likely to invest resources in
`them.
`
` The highest prescribers receive better presents.
`Some reps said their 10’s might receive unrestricted
`“educational” grants so loosely restricted that they
`were the equivalent of a cash gift, although I did
`not personally provide any grants.
`
`For reps this is a core function of our job. We’re
`trained to do this in as benign a way as possible. No
`doc likes to be told their judgment is wrong so the
`latter method typically requires some discretion.
`
`Gifts are used to enhance guilt and social pressure.
`Reps know that gifts create a subconscious
`obligation to reciprocate. New reps who doubt
`this phenomenon need only see their doctors’
`prescribing data trending upwards to be convinced.
`Of course, most of these doctors think themselves
`immune to such infl uence. This is an illusion reps try
`to maintain.
`
`Friendship sells. The highest prescribers (9’s
`and 10’s) are every reps sugar mommies and
`daddies. It’s the equivalent of spitting in the
`ocean to try to buy these docs out because,
`chances are, every other rep is falling head
`over heels to do so.
`If, during the course of conversations, the
`doctors say something that may contradict
`their limited usage of our products, then
`the reps will badger them to justify that
`contradiction. This quickly transforms the
`rep from a welcomed reprieve to a nuisance,
`which can be useful in limited circumstances.
`We force the doctors to constantly explain
`their prescribing rationale, which is tiresome.
`Our intent is to engage in discourse but
`also to wear down the doc until he or she
`simply agrees to try the product for specifi c
`instances (we almost always argue for a
`specifi c patient profi le for our drugs).
`From the outset of my training, I’ve been
`taught to frame every conversation to
`ultimately derive commitments from
`my clients. With every acquiescent nod
`to statements of my drug’s superiority I
`build the case for them to increase their
`usage of my product. They may offer me
`false promises but I’ll know when they’re
`lying: the prescribing data is suffi ciently
`detailed in my computer to confi rm their
`behavior. Doctors who fail to honor their
`commitments, no matter how casually
`made, convert the rep into a badgering
`nuisance. The docs are often corralled into
`a conversational corner where they have to
`justify their previous acquiescence.
`
`PLoS Medicine | www.plosmedicine.org
`
`0622
`
`April 2007 | Volume 4 | Issue 4 | e150
`
`000002
`
`

`

`Table 1. Continued
`Physician Category
`
`Technique
`
`How It Sells Drugs
`
`Comments
`
`No-see/ No-time
`(hard-to-see docs)
`
`Thought leaders
`
`Occasionally docs refuse to see reps. Some
`do it for ethical reasons, but most simply lack
`the time. Even when I don’t manage to see
`the doctor, I can still make a successful call
`by detailing the staff. Although they’re on
`the doc’s side for the most part, it’s amazing
`how much trouble one can rile up when the
`staff are lavished with food and gifts during
`a credible sounding presentation and then
`asked to discuss the usage of a drug on their
`patients.
`
`As a rep, I was always in pursuit of friendly
`“thought leaders” to groom for the speaking
`circuit. Once selected, a physician would
`give lectures around the district. I would
`carefully watch for tell-tale signs of their
`allegiance. This includes how they handled
`questions that criticized our product, how
`their prescribing habits fl uctuated, or simply
`how eager they were to give their next
`lecture.
`
`It’s a victory for me just to learn from the
`staff about which drugs are preferred,
`and why. That info provides powerful
`ammunition to debate the docs with on
`the rare occasions that I might see them.
`However, it’s a greater success when the
`staff discusses my meds with the doc after I
`leave. Because while a message delivered by
`a rep gets discounted, a detail delivered by
`a co-worker slips undetected and unfi ltered
`under the guise of a conversation. And the
`response is usually better then what I might
`accomplish.
`The main target of these gatherings is
`the speaker, whose appreciation may be
`refl ected in increased prescribing of a
`company’s products. Local speaking gigs
`are also auditions. Speakers with charisma,
`credentials, and an aura of integrity
`were elevated to the national circuit
`and, occasionally, given satellite telecast
`programs that offered CMEs.
`
`One’s marketing success in a particular offi ce can
`be strongly correlated to one’s success in providing
`good food for the staff. Goodwill from the staff
`provides me with critical information, access, and
`an advocate for me and my drug when I’m not
`there.
`
`Subtle and tactful spokespersons were the ideal
`candidates. I politely dismissed doctors who would
`play cheerleader for any drug…at the right price,
`of course.
`
`These descriptions are based on SA’s experience working for Eli Lilly and testimony in IMS Heath Inc. v. Ayotte, US District Court, New Hampshire. Actual tactics may vary.
`doi:10.1371/journal.pmed.0040150.t001
`
`items kept close at hand, ensuring that
`a targeted drug’s name stays uppermost
`in a physician’s subconscious mind.
`High prescribers receive higher-end
`presents, for example, silk ties or golf
`bags. As Oldani states, “The essence of
`pharmaceutical gifting…is ‘bribes that
`aren’t considered bribes’” [1].
`Reps also recruit and audition
`“thought leaders” (physicians respected
`by their peers) to groom for the
`speaking circuit. Physicians invited and
`paid by a rep to speak to their peers
`may express their gratitude in increased
`prescriptions (see Table 1). Anything
`that improves the relationship between
`the rep and the client usually leads to
`improved market share.
`
`Script Tracking
`An offi cial job description for a pharmaceutical
`sales rep would read: Provide health-care
`professionals with product information, answer
`their questions on the use of products, and
`deliver product samples. An unoffi cial, and more
`accurate, description would have been: Change the
`prescribing habits of physicians.
`—James Reidy [4]
`
`Pharmaceutical companies monitor the
`return on investment of detailing—and
`all promotional efforts—by prescription
`tracking. Information distribution
`companies, also called health
`information organizations (including
`IMS Health, Dendrite, Verispan, and
`
`Wolters Kluwer), purchase prescription
`records from pharmacies. The majority
`of pharmacies sell these records;
`IMS Health, the largest information
`distribution company, procures records
`on about 70% of prescriptions fi lled
`in community pharmacies. Patient
`names are not included, and physicians
`may be identifi ed only by state
`license number, Drug Enforcement
`Administration number, or a pharmacy-
`specifi c identifi er [5]. Data that identify
`physicians only by numbers are linked
`to physician names through licensing
`agreements with the American Medical
`Association (AMA), which maintains
`the Physician Masterfi le, a database
`containing demographic information
`on all US. physicians (living or dead,
`member or non-member, licensed
`or non-licensed). In 2005, database
`product sales, including an unknown
`amount from licensing Masterfi le
`information, provided more than $44
`million to the AMA [5].
`Pharmaceutical companies are the
`primary customers for prescribing data,
`which are used both to identify “high-
`prescribers” and to track the effects of
`promotion. Physicians are ranked on
`a scale from one to ten based on how
`many prescriptions they write. Reps
`lavish high-prescribers with attention,
`gifts, and unrestricted “educational”
`grants (Table 1). Cardiologists and
`
`other specialists write relatively few
`prescriptions, but are targeted because
`specialist prescriptions are perpetuated
`for years by primary care physicians,
`thus affecting market share.
`Reps use prescribing data to see
`how many of a physician’s patients
`receive specifi c drugs, how many
`prescriptions the physician writes for
`targeted and competing drugs, and
`how a physician’s prescribing habits
`change over time. One training guide
`states that an “individual market share
`report for each physician…pinpoints
`a prescriber’s current habits” and is
`“used to identify which products are
`currently in favor with the physician
`
`doi:10.1371/journal.pmed.0040150.g002
`
`(Photo: “Pills” by Rodrigo Senna, at http://
`www.fl ickr.com/photos/negativz/74267002/.
`Published under the Creative Commons
`Attribution License.)
`
`PLoS Medicine | www.plosmedicine.org
`
`0623
`
`April 2007 | Volume 4 | Issue 4 | e150
`
`000003
`
`

`

`in order to develop a strategy to
`change those prescriptions into Merck
`prescriptions” [6].
`A Pharmaceutical Executive article
`states, “A physician’s prescribing
`value is a function of the opportunity
`to prescribe, plus his or her attitude
`toward prescribing, along with outside
`infl uences. By building these multiple
`dimensions into physicians’ profi les, it is
`possible to understand the ‘why’ behind
`the ‘what’ and ‘how’ of their behavior.”
`[7] To this end, some companies
`combine data sources. For example,
`Medical Marketing Service “enhances
`the AMA Masterfi le with non-AMA
`data from a variety of sources to not
`only include demographic selections,
`but also behavioral and psychographic
`selections that help you to better target
`your perfect prospects” [8].
`The goal of this demographic slicing
`and dicing is to identify physicians
`who are most susceptible to marketing
`efforts. One industry article suggests
`categorizing physicians as “hidden
`gems”: “Initially considered ‘low value’
`because they are low prescribers,
`these physicians can change their
`prescribing habits after targeted,
`effective marketing.” “Growers” are
`“Physicians who are early adopters of
`a brand. Pharmaceutical companies
`employ retention strategies to continue
`to reinforce their growth behavior.”
`Physicians are considered “low value”
`“due to low category share and
`prescribing level” [9].
`In an interview with Pharmaceutical
`Representative, Fred Marshall, president
`of Quantum Learning, explained, “…
`One type might be called ‘the spreader’
`who uses a little bit of everybody’s
`product. The second type might be
`a ‘loyalist’, who’s very loyal to one
`particular product and uses it for most
`patient types. Another physician might
`be a ‘niche’ physician, who reserves our
`product only for a very narrowly defi ned
`patient type. And the idea in physician
`segmentation would be to have a
`different messaging strategy for each of
`those physician segments ” [10].
`In Pharmaceutical Executive, Ron
`Brand of IMS Consulting writes
`“…integrated segmentation analyzes
`individual prescribing behaviors,
`demographics, and psychographics
`(attitudes, beliefs, and values) to fi ne-
`tune sales targets. For a particular
`product, for example, one segment
`might consist of price-sensitive
`
`doi:10.1371/journal.pmed.0040150.g003
`
`(Photo: “Pills” by Sugar Pond, at http://www.
`fl ickr.com/photos/sugarpond/236235191/.
`Published under the Creative Commons
`Attribution License.)
`
`physicians, another might include
`doctors loyal to a given manufacturers
`brand, and a third may include those
`unfriendly towards reps” [11].
`In recent years, physicians have
`become aware of—and dismayed
`by—script tracking. In July 2006,
`the AMA launched the Prescribing
`Data Restriction Program (see
`http:⁄⁄www.ama-assn.org/ama/pub/
`category/12054.html), which allows
`physicians the opportunity to withhold
`most prescribing information from
`reps and their supervisors (anyone
`above that level, however, has full
`access to all data). According to an
`article in Pharmaceutical Executive,
`“Reps and direct managers can view
`the physician’s prescribing volume
`quantiled at the therapeutic class
`level” and can still view aggregated or
`segmented data including “categories
`into which the prescriber falls, such
`as an early-adopter of drugs, for
`example….” [12]. The pharmaceutical
`industry supports the Prescribing Data
`Restriction Program, which is seen
`as a less onerous alternative to, for
`example, state legislation passed in
`New Hampshire forbidding the sale
`of prescription data to commercial
`entities [13].
`
`The Value of Samples
`The purpose of supplying drug
`samples is to gain entry into doctors’
`
`offi ces, and to habituate physicians to
`prescribing targeted drugs. Physicians
`appreciate samples, which can be
`used to start therapy immediately, test
`tolerance to a new drug, or reduce
`the total cost of a prescription. Even
`physicians who refuse to see drug
`reps usually want samples (these
`docs are denigrated as “sample-
`grabbers”). Patients like samples too;
`it’s nice to get a little present from
`the doctor. Samples also double as
`unacknowledged gifts to physicians
`and their staff. The convenience of an
`in-house pharmacy increases loyalty
`to both the reps and the drugs they
`represent.
`Some physicians use samples to
`provide drugs to indigent patients
`[14,15]. Using samples for an entire
`course of treatment is anathema to
`pharmaceutical companies because this
`“cannibalizes” sales. Among the aims of
`one industry sample-tracking program
`are to “reallocate samples to high-
`opportunity prescribers most receptive
`to sampling as a promotional vehicle”
`and “identify prescribers who were
`oversampled and take corrective action
`immediately” [16].
`Studies consistently show that
`samples infl uence prescribing choices
`[14,15,17]. Reps provide samples only
`of the most promoted, usually most
`expensive, drugs, and patients given a
`sample for part of a course of treatment
`almost always receive a prescription for
`the same drug.
`
`Funding Friendship
`While it’s the doctors’ job to treat patients and not
`to justify their actions, it’s my job to constantly
`sway the doctors. It’s a job I’m paid and trained
`to do. Doctors are neither trained nor paid to
`negotiate. Most of the time they don’t even realize
`that’s what they’re doing…
`
`—Shahram Ahari
`
`Drug costs now account for 10.7%
`of health-care expenditures in the
`US [18]. In 2004, spending for
`prescription drugs was $188.5 billion,
`almost fi ve times as much as what was
`spent in 1990 [19]. Between 1995 and
`2005, the number of drug reps in the
`US increased from 38,000 to 100,000
`[20], about one for every six physicians.
`The actual ratio is close to one drug
`rep per 2.5 targeted doctors [21],
`because not all physicians practice,
`and not all practicing physicians are
`detailed. Low-prescribers are ignored
`by drug reps.
`
`PLoS Medicine | www.plosmedicine.org
`
`0624
`
`April 2007 | Volume 4 | Issue 4 | e150
`
`000004
`
`

`

`Physicians view drug information
`provided by reps as a convenient,
`if not entirely reliable, educational
`service. An industry survey found that
`more than half of “high-prescribing”
`doctors cited drug reps as their main
`source of information about new
`drugs [22]. In another study, three
`quarters of 2,608 practicing physicians
`found information provided by reps
`“very useful” (15%) or “somewhat
`useful” (59%) [23]. However, only
`9% agreed that the information was
`“very accurate”; 72% thought the
`information was “somewhat accurate”;
`and 14% said that it was “not very” or
`“not at all” accurate.
`Whether or not physicians believe in
`the accuracy of information provided,
`detailing is extremely effective at
`changing prescribing behavior,
`which is why it is worth its substantial
`expense. The average annual income
`for a drug rep is $81,700, which
`includes $62,400 in base salary plus
`$19,300 in bonuses. The average cost
`of recruiting, hiring, and training a
`new rep is estimated to be $89,000
`[24]. When expenses are added to
`income and training, pharmaceutical
`companies spend $150,000 annually
`per primary care sales representative
`and $330,000 per specialty sales
`representative [25]. An industry article
`states, “The pharmaceutical industry
`averages $31.9 million in annual sales
`spending per primary-care drug…Sales
`spending for specialty drugs that treat a
`narrowed population segment average
`$25.3 million per product across the
`industry.” [25]
`
`Conclusion
`As one of us (SA) explained in
`testimony in the litigation over
`New Hampshire’s new ban on the
`commercial sale of prescription
`data, the concept that reps provide
`necessary services to physicians and
`patients is a fi ction. Pharmaceutical
`companies spend billions of dollars
`annually to ensure that physicians most
`susceptible to marketing prescribe
`the most expensive, most promoted
`drugs to the most people possible.
`The foundation of this infl uence is a
`sales force of 100,000 drug reps that
`provides rationed doses of samples,
`gifts, services, and fl attery to a subset
`of physicians. If detailing were an
`educational service, it would be
`provided to all physicians, not just
`
`those who affect market share.
`Physicians are susceptible to
`corporate infl uence because they
`are overworked, overwhelmed with
`information and paperwork, and
`feel underappreciated. Cheerful and
`charming, bearing food and gifts, drug
`reps provide respite and sympathy;
`they appreciate how hard doctor’s
`lives are, and seem only to want to
`ease their burdens. But, as SA’s New
`Hampshire testimony refl ects, every
`word, every courtesy, every gift, and
`every piece of information provided is
`carefully crafted, not to assist doctors
`or patients, but to increase market
`share for targeted drugs (see Table 1).
`In the interests of patients, physicians
`must reject the false friendship
`provided by reps. Physicians must
`rely on information on drugs from
`unconfl icted sources, and seek friends
`among those who are not paid to be
`friends. (cid:1)
`References
`1. Elliott C (2006) The drug pushers. Atlantic
`Monthly (April): 2–13.
`2. Rosenthal MB, Berndt ER, Donohue JM,
`Epstein AM, Frank RG (2003) Demand
`effects of recent changes in prescription drug
`promotion. Henry J Kaiser Family Foundation.
`Available: http:⁄⁄www.kff.org/rxdrugs/
`6085-index.cfm. Accessed 23 March 2007.
`3. Niles S (2005) Sales force effectiveness (the
`third in a series of articles that examine
`problems and solutions of detailing to
`physicians). Med Ad News 24: 1.
`4. Reidy J (2005) Hard sell: The evolution of a
`Viagra salesman. Kansas City: Andrews McMeel
`Publishing. 210 p.
`5. Steinbrook R (2006) For sale: Physicians’
`prescribing data. New Engl J Med 354: 2745–
`2747.
`6. Merck (2002) Basic training participant guide.
`Available: http:⁄⁄oversight.house.gov/features/
`vioxx/documents.asp. Accessed 23 March
`2007.
`7. Nickum C, Kelly T (2005) Missing the
`mark(et). Pharmaceutical Executive. Available:
`http:⁄⁄www.pharmexec.com/pharmexec/
`article/articleDetail.jsp?id=177968. Accessed 23
`March 2007.
`8. Medical Marketing Services (2007) American
`Medical Association list. Available: http:⁄⁄www.
`mmslists.com/category_drilldown.asp?nav=
`category&headingID=1&itemID=1. Accessed 23
`March 2007.
`9. Hogg JJ (2006) Marketing to professionals:
`Diagnosing MD behavior. Pharmaceutical
`Executive: 168. Available: http:⁄⁄www.
`pharmexec.com/pharmexec/article/
`articleDetail.jsp?id=162039. Accessed 23
`March 2007.
`10. Hradecky G (2004) Breaking point.
`Pharmaceutical Representative. Available:
`http:⁄⁄www.pharmrep.com/pharmrep/article/
`articleDetail.jsp?id=102324. Accessed 23 March
`2007.
`11. Brand R, Kumar P (2003) Detailing gets
`personal: Integrated segmentation may be
`pharma’s key to “repersonalizing” the selling
`process. Pharmaceutical Executive. Available:
`http:⁄⁄www.pharmexec.com/pharmexec/
`article/articleDetail.jsp?id=64071. Accessed 23
`March 2007.
`
`12. Alonso J, Menzies D (2006) Just what the
`doctor ordered. Pharmaceutical Executive:
`14–16. Available: http:⁄⁄www.pharmexec.com/
`pharmexec/article/articleDetail.jsp?id=323314.
`Accessed 23 March 2007.
`13. Remus PC (2006 November 10) First-
`in-the-nation law pits NH against drug
`industry. New Hampshire Business
`Review. Available: http:⁄⁄www.nh.com/
`apps/pbcs.dll/article?AID=/20061110/
`BUSINESSREVIEW05/61108030/-1/
`BUSINESSREVIEW. Accessed 23 March 2007.
`14. Chew LD, O’Young TS, Hazlet TK, Bradley
`KA, Maynard C,et al. (2000) A physician survey
`of the effect of drug sample availability on
`physicians’ behavior. J Gen Intern Med 15:
`478–483.
`15. Groves KEM, Sketris I, Tett SE (2003)
`Prescription drug samples—Does this
`marketing strategy counteract policies for
`quality use of medicines? J Clin Pharm Ther
`28: 259–271.
`16. Sadek H, Henderson Z (2004) It’s all in the
`details: Delivering the right information to the
`right rep at the right time can greatly increase
`sales force effectiveness. Pharmaceutical
`Executive. Available: http:⁄⁄www.pharmexec.
`com/pharmexec/article/articleDetail.
`jsp?id=129291. Accessed 23 March 2007.
`17. Adair RF, Holmgren LR (2005) Do drug
`samples infl uence resident prescribing
`behavior? A randomized controlled trial. Am J
`Med 118: 881–884.
`18. United States Government Accountability
`Offi ce (2006) Prescription drugs: Price
`trends for frequently used brand and generic
`drugs from 2000 through 2004. Available:
`http:⁄⁄www.gao.gov/new.items/d05779.pdf.
`Accessed 23 March 2007.
`19. Kaiser Family Foundation (2006) Prescription
`drug trends. Available: http:⁄⁄www.kff.org/
`rxdrugs/3057.cfm. Accessed 23 March 2007.
`20. Marshall PC (2005) Rep tide: Pulling back in
`magnitude, pushing forward effi ciency: Recent
`talk of pharma companies restructuring or
`even paring back their sales forces is the fi rst
`acknowledgement that effi ciency, and not
`noise, is the key to effective detailing. Med
`Market Media 40: 96.
`21. Goldberg M, Davenport B, Mortellito T (2004)
`PE’s annual sales and marketing employment
`survey: The big squeeze. Pharmaceutical
`Executive 24: 40–45. Available: http:⁄⁄www.
`pharmexec.com/pharmexec/article/
`articleDetail.jsp?id=80921. Accessed 23 March
`2007.
`22. Millenson ML (2003) Getting doctors to say
`yes to drugs: The cost and quality of impact
`of drug company marketing to physicians.
`Blue Cross Blue Shield Association. Available:
`http:⁄⁄www.bcbs.com/betterknowledge/cost/
`getting-doctors-to-say-yes.html. Accessed 23
`March 2007.
`23. Kaiser Family Foundation (2006) National
`survey of physicians. Available: http:⁄⁄www.kff.
`org/rxdrugs/upload/3057-05.pdf. Accessed 23
`March 2007.
`24. Goldberg M, Davenport B (2005) In sales we
`trust. Pharmaceutical Executive . Available:
`http:⁄⁄www.pharmexec.com/pharmexec/
`article/articleDetail.jsp?id=146596. Accessed 23
`March 2007.
`25. [No authors listed] (2004) Hard sell: As
`expanding the sales force becomes a less
`attractive option, pharmaceutical companies
`are reevaluating their sales strategies. Med Ad
`News 23: 1.
`
`Note Added in Proof
`Reference 26 is cited out of order in the article
`because it was added while the a