Sean Daly's Top 10 John Williams themes We
gave music critic Sean Daly a simple task: Give us your Top 10 Williams
themes of all time. Little did we realize that his choices would leave
us shaking our heads and wondering, "How could he leave off...?"
The transformation of a Jacksonville psychiatrist from a skeptic on
Seroquel into a super-prescriber was marked by months of gentle
pestering, generous $1,500 speaking engagements and giveaways of
everything from a plastic brain to gourmet chocolates.
A neurologist in Tampa joked with Seroquel sales reps that
she doled out so much of the powerful antipsychotic drug for migraines
that they probably thought she was a psychiatrist. She was rewarded
with free trips to Scotland and Spain. "I want to go too ! =)" her
Seroquel rep wrote.
A busy Panama City physician had no problem leaving patients
to stew in the waiting room while he listened to a pitch about Seroquel
from a persistent saleswoman.
"Dr had 3 pat (patients) waiting and did sit down w (with)
me," the rep wrote after a series of snubs at the front desk. "You
never know what you will get w/dr b."
Every day, legions of drug reps troop into doctors' offices,
then scoot back to their cars and enter notes about their encounters
into laptops or handheld devices. They include reminders about
everything from medical questions to the doctor's new Nissan 350Z or
his kid's Eagle Scout badge.
The notes are uploaded to a secure database at company
headquarters and used by the drug rep, her partners and managers as the
company refines its sales spiel.
Thanks to thousands of lawsuits pending against Seroquel,
AstraZeneca's best-selling antipsychotic, hundreds of pages of call
notes concerning several Florida doctors recently were made public.
Though specific to Seroquel, the salespeople's notes reflect
industrywide practices. They give insights into what happens behind
closed doors while patients cool their heels.
It's not a pretty picture, with sales reps laying on the swag
and doctors complaining about late honoraria and angling to get on the
AstraZeneca "advisory board."
Company spokesman Tony Jewell said the drugmaker's philosophy
is that "any interaction with health care providers should be about
providing information that helps them decide on the right medicines,
for the right patients, at the right time."
But notes from the company's emissaries reflect two different
goals: Get the doctor to prescribe the drug. Then push him to boost the
A sales rep in Jacksonville was ecstatic when a nurse
practitioner prescribed Seroquel at twice the dosage used by the
psychiatrist in the same practice.
"Gave him goodies," the rep wrote. "Biggest user of Seroquel in the office!"
• • •
AstraZeneca's sales reps have worked wonders. Though approved
only for schizophrenia and bipolar disorder, Seroquel has been one of
the world's best sellers. Last year sales reached $4.5 billion.
But Seroquel's widespread use for everything from insomnia to
anxiety has also triggered lawsuits alleging the drug caused weight
gain, diabetes and other health problems. AstraZeneca, whose corporate
headquarters are in London, denies the charges, noting that the FDA has
repeatedly upheld the safety of Seroquel.
It also has denied that its salespeople illegally promoted
unapproved, or off-label, uses of the drugs to doctors. Sales reps "are
trained to ensure that every product promotion discussion with (a)
health care provider conforms to the FDA-approved prescribing
information," Jewell said.
Company lawyers vigorously opposed unsealing sales reps'
notes, saying they contained confidential, proprietary information. But
at a recent hearing in Orlando's federal court, AstraZeneca agreed to
release call notes from before January 2004, when Seroquel received FDA
approval for bipolar mania.
Heavily redacted, the notes comprise what the company's
commercial brand leader, Alfred Paulson, described as sales reps'
"continuous conversation" with a half-dozen Florida health care
providers who prescribed Seroquel to plaintiffs in pending lawsuits.
Depicting sales pitches, on which millions of dollars of
revenue hinge, as simple "conversations" is an apt description for
what, in the end, comes down to the chemistry between two people.
Shahram Ahari, a drug rep for competitor Eli Lilly & Co. in 1999
and 2000, now lectures physicians on how to avoid being manipulated by
well-trained marketing reps.
"As much as doctors want to think the relationship with a
salesperson is about the transfer of knowledge, it's the affinity
between two people that's the big money-maker for the drug company,"
said Ahari, who is part of Pharmedout.org, a physician-education group
in Washington. "That's why drug companies hire former cheerleaders and
athletes as drug reps instead of scientists. It's a question of how
gregarious and engaging you can be."
While AstraZeneca declined to comment on its employees'
compensation, industry data show drug reps earn an average of nearly
$100,000 a year, including bonuses based on sales.
They learn sales techniques more often associated with
door-to-door soliciting than medical offices. Doctor too busy to see
you? Send in several sales people, daily if necessary, until you get a
sit-down. Show up on rainy days when patients cancel. And even highly
paid physicians find it hard to resist a free lunch.
In 1999, Seroquel sales reps tried to waylay Dr. Maria Carmen Wilson, the Tampa neurologist, four times before hitting gold.
"We were able to speak to her at lunch that we brought for the office," a rep wrote.
Wilson moved from free food to free trips to medical meetings
in Spain and Scotland. By early 2002, a drug rep noted that Wilson was
using a "ton of Seroquel" for patients with migraines.
Wilson, who says she was surprised to learn that drug reps
recorded their interactions with her, denies that she was ever a big
Seroquel prescriber. Despite her initial hopes, she says the drug did
not turn out to be effective against chronic headaches.
"I still use it in low doses for people with intractable
insomnia," said Wilson, an associate professor at the University of
South Florida. "But I make sure patients are acutely aware of the
potential for weight gain, especially if they have a predisposition to
Wilson says the industry-funded jaunts to Europe did not unduly influence her.
"I went because I want to be up-to-date and learn," she said of
the seminars, which she did not report, as required, to USF officials.
"But frankly, I'd prefer they were in Orlando."
• • •
The call notes show that massaging doctors' egos consumed an inordinate amount of a drug rep's time.
Saleswomen in Miami quickly honed in on psychiatrist Heriberto
Cabada's need for extra schmoozing. "Would not pay attention, all about
him," wrote one frustrated sales rep in 2001. So the line worker pulled
in a "customer solutions" specialist who offered to redo the doctor's
patient history forms with a personalized logo.
She agreed to Cabada's demands for multiple revisions, "one
side only and … marbled type paper." More attention was funneled his
way through a "preceptorship," in which a sales rep shadows the doctor
for the day and pays for the honor.
In a few months, Cabada went from prescribing what he called
"chicken dosages" of Seroquel to higher doses. Soon after his
conversion, Cabada closed his practice and moved to Spain, where he now
lives. He did not respond to an e-mail seeking comment.
Drug reps are taught to use free samples as a strategic
weapon: Parcel them out sparingly, even if there are box loads in the
"It makes the doctor even more grateful," said former Lilly
rep Ahari. "And when he gives a freebie to the patient, the doctor
feels like a hero."
Dribbling samples out in small caches, and requiring the
doctor's signature each time, also gives the rep another chance at
valuable face time.
"Samples are key to access," wrote a sales rep who was routinely brushed off by Dr. John Roy Billingsley in Panama City.
AstraZeneca said it has voluntarily banned many of its
"reminder" giveaways to doctors — free pens, pads and hand wash
emblazoned with drug names. But the company declined to say how such
changes have affected its spending on physicians.
Ahari said he doubts drug companies have pared back their
marketing budgets. "The money going to influence physicians is exactly
the same,'' he said.
"There's absolutely no enforcement of these voluntary
guidelines. All the incentives are still in place to wine and dine
doctors at Hooters if he needs to."
The reason: It works.
Case in point: Dr. Mohamed O. Saleh, a Jacksonville
psychiatrist who was involved in early clinical studies of Seroquel. In
1998, he was telling AstraZeneca reps that their product wasn't
effective and two years later he was still dodging sales reps.
By 2003, however, a rep was crowing that Saleh "really loves
seroquel for elderly … said that he would — dose of 800 (mg) and even
higher if necessary!"
Saleh and his nurse practitioner, Richard Daniel Malcolm,
were wooed with everything from holiday treats ("Left pumpkin candy
baskets … put seroquel labels on them") to a video of Saleh for his use
during a visit to Africa in 2002.
AstraZeneca also furnished Saleh with freebies for the trip.
The payoff: The doctor told the drug rep he would put a picture on his
Web site showing "African healthcare workers holding the Seroquel bags
filled with (a textbook) and pens/etc. Appreciated our support."
Saleh, who said in July that he is still receiving $10,000 to
$15,000 a year as a speaker for Seroquel, seemed aware of the
persuasive power of drug company payola. In October 2003, he told
AstraZeneca reps that he was concerned about his nurse practitioner,
who had taken a fishing trip with the Seroquel rep and was pushing for
his own speaking gigs.
"Concerned about payments to Dan (Malcolm) and can be
inducement for scripts b/c paying so much," wrote one of the two reps
assigned to Saleh's office.
Malcolm joined Saleh's office in June 2001, four months after
he was disciplined by the Florida Board of Medicine for pleading guilty
to charges of domestic battery, driving with a suspended license and
fraud in obtaining a medicinal drug.
Neither Saleh nor Malcolm returned calls or e-mails seeking comment.
• • •
When doctors complained that patients were ballooning up on
Seroquel, sales reps often handed them a study by Chicago psychiatrist
Michael J. Reinstein. Its startling message: "Use of S (Seroquel) to reduce weight and reduce risk," according to a sales rep who visited Panama City's Billingsley.
Back at headquarters, however, company executives had serious
questions about the validity of Reinstein's findings. "Our clinical
colleagues have significant and numerous issues in the past with the
quality of research that this group has produced," a note from
Seroquel's brand manager said in 2001.
While sales reps were not allowed to explicitly promote
Seroquel for anything other than schizophrenia prior to 2004, the notes
reflect a not-so-subtle, broad-based push.
In early 2000, Billingsley's sales rep wrote, "S best in new Schizo's, kids, adolescents, bi-pols, blacks and asians."
Dr. Guido Nodal Jr., a psychiatrist in Hialeah, at first was
cautious about Seroquel, fearing potential links to cataracts. In late
2001, he told a male sales rep he would keep the drug in mind only for
"smoking sciz pts."
Two months later, however, a female rep wrote that Nodal
"LOVES SER. FOR ELDERLY." By year's end he had 15 nursing home patients
on the drug. (Later the Food and Drug Administration made all
antipsychotics warn that use in elderly with dementia could cause
"Claims that he is switching patients from Risperdal to
Seroquel at the nursing homes," a sales rep wrote in 2003. "Writing as
much as he can to all patients."
Notes show that in the interim, Nodal received a textbook,
mug, penlights ("Using lots"), payment for a preceptorship and dinner
at Ruth's Chris Steak House. He denies the giveaways influenced his
"If drug companies stopped marketing, I think prescribing
(patterns) would be more or less the same as they are now,'' said
Nodal, who said he tried to become a Seroquel speaker but was not
accepted. "It didn't affect me at all."
Nodal closed his private practice last year and now works for
the state's Department of Corrections in Florida City. The agency does
not allow drug reps to lobby its physicians.
Times researcher Carolyn Edds contributed to this report. Kris Hundley can be reached at firstname.lastname@example.org or (727) 892-2996.
By the numbers
Amount drug industry spent on marketing directly to doctors (2004)
FDA budget (FY 2008)
Drug industry's research & development budget compared with marketing budget
1 to 2.5
Ratio of drug reps to doctors in the United States
Median annual total cash compensation for a drug rep (2008)
Favorable change in a doctor's prescribing habits after less than 1 minute with a sales rep
Prescribing change seen after 3 minutes with a sales rep