From the Los Angeles Times
WOOING THE GATEKEEPER
Doctor, just a little something for you
Complex sales strategies go way beyond freebies.
By Melissa Healy
Los Angeles Times Staff Writer
August 6, 2007
AS guardians of the nation's prescription pads, doctors are the gatekeepers
that stand between American patients and the pharmaceutical companies that
have drugs to sell them.
Physicians' choices -- whether to medicate, with which medication, generic
vs. brand-name drug, and for how long -- profoundly affect sales of a drug
company's products. So pharmaceutical manufacturers focus the bulk of their
marketing budgets to influence those choices. The drug companies'
promotional efforts reach into physicians' offices, pervade their medical
specialty organizations and often shape the messages that doctors receive in
"There is a big bucket of money sitting in every office" a drug
representative visits, said an AstraZeneca marketing director in a widely
circulated newsletter interview. "Every time you go in, you reach your hand
in the bucket and grab a handful," said Mike Zubillaga, who was fired after
his blunt comments made their way onto the Internet last April.
Each day in the United States, an army of roughly 100,000 pharmaceutical
company sales reps storms the waiting rooms and offices of the nation's
311,000 office-based physicians. Called "detailers" -- and earning, on
average, $81,700 per year -- they are the smiling, well-dressed men and
women often seen in a physicians' waiting room toting a cavernous briefcase
and making small-talk with the receptionists. Their ranks have more than
doubled in the last 10 years.
Sales reps say they want nothing more than to drop off drug samples that
doctors can dispense at no cost to their patients, and to brief physicians
on the FDA-approved benefits and risks of the prescription drugs their
companies make. That's an accurate job description. But it doesn't nearly
capture the sophistication of their efforts or the complex web of
relationships that marketing departments cultivate with physicians. In
recent years, drug-company insiders have come forward to detail the
enticements, persuasive techniques and market-tracking systems that their
organizations use to nudge doctors' prescribing decisions to boost sales.
The picture they provide is of an industry in hot pursuit of physicians'
hearts and minds.
Relationships with drug reps
THE inducements that doctors accept are more than just pads, pens and
gadgets such as the Viagra calculator that stands up on its base when the
"on" button is pushed. A national survey of doctors published in the April
2007 New England Journal of Medicine found that 94% of physicians in the six
specialties studied reported some type of relationship with pharmaceutical
companies' representatives. Most (83%) received food in their workplace, or
accepted drug samples (78%) proffered by visiting representatives.
Thirty-five percent reported that drug companies had reimbursed them for the
cost of attending professional meetings or company-sponsored sessions that
satisfied a physician's "continuing medical education" requirement. And 28%
received payments for consulting with a drug company, giving lectures or
enrolling patients in trials.
The American Medical Assn. and the pharmaceutical industry group PhRMA
adopted non-mandatory codes of conduct in 2002 that discourage the offering
or acceptance of items that bring only "personal benefit" to a physician.
Shahram Ahari, a former drug rep with Eli Lilly, says that in many cases,
those guidelines have given the practice of gift-giving "a nice veneer of
But the practice's impact is often unaltered -- and may even be greater than
when drug reps were permitted to offer extravagant gifts such as theater
tickets and golf bags. That is because psychologists have shown consistently
that a small token or gesture of friendship often inspires a sharper sense
of obligation in the recipient than does a showy gift, for which
reciprocation is impossible.
Moreover, Ahari says, "the amount of money invested in gifts hasn't changed.
In the past, I could spend $100 on a golf club and give it to you. Now, I
can spend $100 on a textbook you need so you can spend your own $100 on that
Sales reps bear many gifts, but none is more important than the prescription
drug samples they bring to doctors. In 2003, the pharmaceutical industry
distributed $16.4 million worth of them to doctors, according to PhRMA, the
industry's most important trade group.
"For me, that's access," Ahari says. "The doctors are first grateful that
you're giving them samples, because it makes them seem like a hero to
patients . . . and when they feel that sense of gratitude, they feel obliged
to spend some time with the drug rep delivering them." But in the end, it is
the patient who often will pay more, because even a short course of sample
use builds customer loyalty to a brand-name drug, even when a generic or a
cheaper, older drug might be just as effective.
Among the not-so-well-kept secrets of the medical world is the physical
attractiveness of the men and women who make up the pharmaceutical sales-rep
force. "It seems pretty cynical," says UCLA internist Dr. Martin Shapiro. "I
mean, the people that do the detailing aren't your average-looking
Ahari laughs at the description. Pharmaceuticals' marketing departments look
to hire "young, attractive people, quite charismatic" -- and scientific
training is completely optional, says Ahari, now a researcher at the UC San
Francisco's School of Pharmacy, who describes his former profession on a
website ( www.Pharmedout.org) devoted to exposing drug company marketing
"They're looking for gender icons -- cheerleaders and ex-military types --
fun to be with, someone with whom you'd like to have a beer or watch a
game," Ahari says. To establish friendship and assure access to a physician,
a detailer "will scour a doctor's office for objects -- a tennis racquet,
Russian novels, '70s rock music," wrote Ahari and Adriane Fugh-Berman, a
Georgetown University physician, in an article published by the Public
Library of Medicine in April.
Small practices and family physicians are most intensively courted. And
doctors whose prescribing practices are not circumscribed by healthcare
companies or hospital formularies get extra attention as well. According to
the New England Journal of Medicine survey published last April, family
practitioners reported they met with pharmaceutical-company detailers, on
average, 18 times per month, more than four times the average for all
doctors that was reported in a 2000 study. Trailing not far behind them were
internists (10 meetings per month), cardiologists (nine) and pediatricians
Outside the confines of a doctor's office, pharmaceutical marketing efforts
become more extravagant.
At physicians' association meetings and at conferences and seminars that
provide "continuing medical education" for doctors, drug-company sponsorship
is substantial. Both have become important venues for courting physicians
over meals and in appealing venues. Both provide opportunities for drug
companies, indirectly, to pay speaking fees to favored physicians. And a
recent Senate Finance Committee report concluded that, in spite of efforts
to stem the practice, both are used by pharmaceutical companies to boost
physicians' prescribing of their products.
Sponsorship of seminars
AT a recent hearing of the Senate Committee on Aging, Dr. Jerome Kassirer of
Tufts University School of Medicine described meetings of medical societies
and associations as "mini-circuses, replete with enormous glittering
displays and hovering attractive personnel. Although couched as education,"
he added, "these marketing efforts are thinly disguised bribes."
UCLA internist Shapiro, who as president of the Society for General Internal
Medicine in 2002 sought to limit drug company sponsorship, calls it "the
walk of shame." At almost every major medical meeting he attends, he said,
"there are these opportunities to get free things that are questionable --
and that clearly are not intended to sharpen the rational decision-making
skills of a physician, but to have an impact . . . on how they prescribe
medications." It's not enough, he added, to close your eyes and walk past
them: Pharmaceutical company money has largely underwritten the programs
doctors will attend and the administration of the professional association
that organizes the event.
Medical societies "have become dependent on the infamous 'unrestricted
grant' from numerous pharmaceutical companies," Dr. J. Gregory Rosenthal, a
Toledo, Ohio-based retinal surgeon, told the Senate Committee on Aging in
June. "In this context, 'unrestricted' means, 'Use this for whatever you
want, but if you ever want another, don't displease us.' "
Physicians' "continuing medical education" requirements also have provided
drug companies ripe marketing opportunities, experts say. In 2005, drug
companies spent $1.12 billion to fund sessions that physicians attend to
maintain their license to practice.
In recent years, new guidelines have sought to distance those grants from
companies' marketing departments. Still, the Senate report noted, "drug
companies routinely fund educational grants to support programs that
favorably discuss the companies' newer and more lucrative products, thereby
encouraging physicians to prescribe these products and, ultimately, driving
sales." Where doctors are typically a skeptical audience for direct pitches,
"when the favorable message is delivered in the context of education -- even
if corporate sponsorship is disclosed -- there is an imprimatur
ofcredibility and independence," investigators noted.
Some of those programs appear to have been forums for pushing "off-label"
uses for prescription drugs, a back-door means of expanding its market.
About one-fifth of prescriptions that doctors write are for off-label uses
-- to treat a condition other than that for which FDA has found a drug safe
and effective. Although it's legal for doctors to write off-label
prescriptions, it is illegal for a drug manufacturer to market its drugs for
In 2004, Warner-Lambert (now a division of Pfizer Inc.) paid $430 million to
settle claims that it was using continuing education grants to promote
off-label uses of Neurontin, an epilepsy drug. In 2005, Serono Laboratories
paid $704 million to settle claims in a case that alleged it was using
educational programs to boost sales of the AIDS drug Serostim for off-label
The 50 state attorneys general who accepted the settlement of the Neurontin
case have used $21 million to establish the Consumer and Prescriber Grant
Program, www.ohsu.edu/cpgp/, designed to provide healthcare professionals
and consumers information related to prescription drugs and their marketing.