Adriane Fugh-Berman*, Shahram Ahari
Following the Script: How Drug Reps Make Friends and Influence Doctors, Fugh-Berman A, Ahari S. PLoS Medicine 4(4): e150 (doi:10.1371/journal.pmed.0040150).
Dated: April 24, 2007
Copyright: Fugh-Berman and Ahari, 2007. This is an open-access article licensed under the Creative Commons Attribution License, which allows for free use, distribution, and reproduction in any form as long as the original author and source are credited.
Funding: This work was made possible by a grant from the Attorney General Prescriber and Consumer Education Grant Program, which was established as part of a 2004 settlement between Warner-Lambert, a division of Pfizer, and the Attorneys General of the 50 states and the District of Columbia to settle allegations that Warner-Lambert engaged in an unlawful marketing campaign for the drug Neurontin (gabapentin) that violated state consumer protection laws.
Competing interests: Shahram Ahari is a former Eli Lilly pharmaceutical sales agent, and the principal findings of this research synthesize statements he made as a paid expert witness for the defendant in litigation against a New Hampshire legislation restricting the selling of prescription data. Adriane Fugh-Berman has taken remuneration as an expert witness on the plaintiff’s side of a menopausal hormone therapy lawsuit.
AMA stands for American Medical Association.
* To whom correspondence should be addressed. E-mail:firstname.lastname@example.org
Adriane Fugh-Berman is an Associate Professor in the Department of Physiology and Biophysics at Georgetown University Medical Center in Washington, DC, USA. Shahram Ahari works at the University of California San Francisco School of Pharmacy in San Francisco, California, USA.
It’s my job to figure out how much a doctor costs. Dinner at the finest restaurants for some, enough convincing data to allow them to prescribe confidently for others, and my attention and friendship for others… At the most fundamental level, however, everything is for sale and everything is an exchange.
You are unquestionably purchasing love.
—James Reidy 
Pharmaceutical companies spent more than $15.7 billion on prescription drug promotion in the United States in 2000. . Detailing, or the one-on-one promotion of drugs to doctors by pharmaceutical sales representatives, also known as drug reps, cost more than 4.8 billion dollars. Pharmaceutical companies spend an average of $875 million per year on sales force. .
Drug representatives, unlike door-to-door vendors of cosmetics and vacuum cleaners, do not sell directly to buyers. Prescription medications are paid for by consumers, but access is controlled by physicians. Drug representatives improve drug sales by influencing doctors, and they do so with carefully calibrated doses of friendliness. The techniques employed by reps to affect physician prescription are revealed in this paper, which came out of conversations between a former drug rep (SA) and a physician who studies pharmaceutical marketing (AFB).
You know yourself better than you know yourself. Top
During training, I was told that when you go out to dinner with a doctor, “the physician is eating with a buddy.” You’re eating with a client.”
Reps may be truly nice, but they are not genuine friends. Drug reps are chosen for their presentability and outgoing personalities, and they are trained to be observant, pleasant, and helpful. They are also educated to assess physicians’ personalities, practice methods, and preferences and to convey this information back to the organization. Personal information may be more essential than prescription preferences. Reps inquire about and remember specifics about a physician’s personal life, professional interests, and recreational activities. A photo on a desk provides an opportunity to inquire about family members and memorize whatever information is provided (including names, birthdays, and interests); these are frequently recorded into a database following the interaction. Reps scan a doctor’s office for objects—a tennis racquet, Russian literature, 1970s rock music, fashion magazines, travel mementos, or ethnic or religious symbols—that might be exploited to develop a personal connection with the doctor.
Good details are dynamic; the greatest representatives constantly adjust their messaging based on their clients’ reactions. A friendly physician makes the rep’s job easier because the rep can exploit the “relationship” to obtain favors, such as prescriptions. Physicians who perceive the connection as a simple trade of commodities for prescriptions are treated professionally. Skeptical doctors who choose evidence over charm are treated with respect, given reprints from the medical literature, and wooed as teachers. Physicians who refuse to visit reps are detailed through proxy; their staff is entertained and petted in the hopes that they would function as messengers for a rep’s messages. (See Table 1 for specific tactics used to manipulate physicians.)
Gifts elicit both anticipation and obligation. “The importance of developing loyalty through gifting cannot be overstated,” anthropologist and former drug rep Michael Oldani writes. . Pharmaceutical gifting, on the other hand, necessitates carefully controlled generosity. Many prescribers receive pens, notepads, and coffee mugs, all of which are kept close at hand, ensuring that the name of a targeted drug remains prominent in a physician’s subconscious mind. High-level prescribers are given more expensive gifts, such as silk ties or golf bags. “The core of pharmaceutical gifting…is ‘bribes that aren’t deemed bribes,” says Oldani. .
Reps also recruit and audition “thought leaders” (physicians who are well-regarded by their peers) for the speaking circuit. Physicians who are invited and compensated by a representative to speak to their peers may express their appreciation through increased prescriptions. (see Table 1). Anything that improves the rep’s relationship with the client usually leads to increased market share.
Script Tracking Top
A pharmaceutical sales rep’s formal job description would be: Provide health-care professionals with product information, answer questions about product use, and provide product samples. Change physicians’ prescribing patterns, according to an unofficial and more accurate description.
—James Reidy 
Prescription tracking allows pharmaceutical companies to track the return on investment of detailed and other promotional initiatives. Prescription records are purchased from pharmacies by information distribution businesses, often known as health information organizations (including IMS Health, Dendrite, Verispan, and Wolters Kluwer). The vast majority of pharmacies sell these records; IMS Health, the world’s largest information distribution organization, obtains records for approximately 70% of prescriptions filled in community pharmacies. Patient names are not included, and physicians can only be identified by their state license number, DEA number, or a pharmacy-specific identity . Data that merely identify physicians by numbers are linked to physician names via licensing agreements with the American Medical Association (AMA), which maintains the Physician Masterfile, a database including demographic information on all physicians in the United States (living or dead, member or non-member, licensed or non-licensed). The AMA received more than $44 million in 2005 through database product sales, which included an undisclosed amount from licensing Masterfile information. .
Pharmaceutical companies are the key customers for prescribing data, which is used to identify “high-prescribers” as well as track the effectiveness of promotional campaigns. Physicians are ranked from one to ten based on the number of prescriptions they write. Reps shower attention, gifts, and limitless “educational” subsidies on high-prescribers. (Table 1).
Cardiologists and other specialists write very few prescriptions, yet they are targeted because primary care physicians keep specialized prescriptions for years, hurting market share.
Reps use prescribing data to determine how many of a physician’s patients receive specific pharmaceuticals, how many prescriptions are written for targeted and competitor drugs, and how a physician’s prescribing practices evolve over time. An “individual market share report for each physician…identifies a prescriber’s current habits” and is “used to identify which products are now in favor with the physician in order to design a strategy to turn those prescriptions into Merck prescriptions,” according to one training handbook..
According to a Pharmaceutical Executive article, “a physician’s prescribing value is a function of the opportunity to prescribe, as well as his or her attitude toward prescribing, as well as external influences.” By incorporating these various dimensions into physician profiles, it is possible to comprehend the “why” behind the “what” and “how” of their behavior.”  Some businesses do this by combining data sources. Medical Marketing Service, for example, “enhances the AMA Masterfile with non-AMA data from a variety of sources to include not only demographic selections, but also behavioral and psychographic selections that help you better target your perfect prospects.” .
The goal of this demographic segmentation is to identify physicians who are most vulnerable to marketing efforts. According to one industry publication, physicians should be classified as “hidden gems”: “Initially regarded as ‘low value’ due to their low prescribing rates, these physicians can change their prescribing habits after targeted, effective marketing.” “Growers” are “Physicians who are brand early adopters.” Pharmaceutical firms use retention strategies to reinforce their growth behavior.” Physicians are regarded as “low value” because of their “low category share and prescribing level.” .
Fred Marshall, president of Quantum Learning, explained in an interview with Pharmaceutical Representative, “… One type might be called ‘the spreader,’ who uses a little bit of everyone’s product.” The second type is a ‘loyalist,’ who is very loyal to one product and uses it for the majority of patient types. Another doctor could be a ‘niche’ doctor who only prescribes our product to a very specific patient group. And the idea behind physician segmentation is to have a unique messaging strategy for each of those physician segments.”.
IMS Consulting’s Ron Brand writes in Pharmaceutical Executive, “…integrated segmentation analyzes individual prescribing behaviors, demographics, and psychographics (attitudes, beliefs, and values) to fine-tune sales targets.” For a specific product, for example, one segment may consist of price-sensitive physicians, another of doctors loyal to a specific manufacturer’s brand, and a third of those hostile to sales representatives.” .
Script tracking has become well-known among physicians in recent years, much to their chagrin. The AMA launched the Prescribing Data Restriction Program in July 2006. (see http://www.ama-assn.org/ama/pub/category/12054.html), which allows physicians to withhold the majority of prescribing information from reps and their supervisors According to a Pharmaceutical Executive article, “reps and direct managers can view the physician’s prescribing volume quantiled at the therapeutic class level,” as well as aggregated or segmented data that includes “categories into which the prescriber falls, such as an early-adopter of drugs, for example.” . The pharmaceutical industry supports the Prescribing Data Restriction Program, which is considered as a less onerous alternative to, say, New Hampshire state legislation prohibiting the sale of prescription data to commercial groups. .
The Value of Samples Top
The goal of providing drug samples is to gain access to doctors’ offices and to train doctors to prescribe targeted drugs. Physicians value samples because they can be used to begin therapy right away, test tolerance to a new drug, or reduce the total cost of a prescription. Even doctors who refuse to see drug reps usually want samples (these doctors are derisively referred to as “sample-grabbers”). Patients appreciate samples as well; it’s nice to receive a small gift from the doctor. Samples can also be used as unacknowledged gifts for doctors and their staff. The ease of use of an in-house pharmacy increases loyalty to both the sales representatives and the drugs they represent.
Some doctors use samples to give drugs to poor patients.[14,15]. Pharmaceutical companies despise using samples for an entire course of treatment because it “cannibalizes” sales. One industry sample-tracking program’s goals include “reallocating samples to high-opportunity prescribers most receptive to sampling as a promotional vehicle” and “identifying oversampled prescribers and taking corrective action immediately.” .
Several studies have found that sample size influences prescribing decisions. [14,15,17]. Reps only give out samples of the most advertised, and usually most expensive, drugs, and patients who receive a sample as part of a course of treatment almost always get a prescription for the same drug.
Funding Friendship Top
While it is the doctors’ responsibility to treat patients rather than justify their actions, it is my responsibility to constantly persuade the doctors. It’s a job for which I’ve been paid and trained. Doctors are neither trained nor compensated to bargain. Most of the time, they aren’t even aware of what they are doing…
Drug costs now account for 10.7% of total health-care expenditures in the United States. . Prescription drug spending was $188.5 billion in 2004, nearly five times what it was in 1990. . Between 1995 and 2005, the number of drug sales representatives in the United States increased from 38,000 to 100,000. , approximately one in every six physicians The actual ratio is around one pharma rep for every 2.5 targeted doctors. , because not all doctors practice, and not all doctors who practice are detailed Drug reps overlook low-prescribers.
Drug information offered by reps is viewed by physicians as a convenient, if not fully reliable, educational service. According to an industry survey, more than half of “high-prescribing” doctors mention drug salespeople as their primary source of knowledge about new treatments. . Another study found that three-quarters of 2,608 practicing physicians found the information provided by reps to be “very useful” (15%) or “somewhat useful” (59%). . However, only 9% said the information was “very accurate,” 72% said it was “somewhat accurate,” and 14% said it was “not very” or “not at all” accurate.
Whether or not physicians believe the information presented is accurate, detailing is extraordinarily effective at influencing prescribing behavior, which is why it is worth the significant cost. A drug rep’s yearly pay is $81,700, which includes a base salary of $62,400 plus bonuses of $19,300. It is estimated that the average cost of finding, employing, and training a new salesperson is $89,000. . When expenses, income, and training are factored in, pharmaceutical companies spend $150,000 per primary care sales representative and $330,000 per specialty sales representative per year. . According to one industry publication, “the pharmaceutical industry averages $31.9 million in annual sales spending per primary-care drug… “Across the industry, sales spending for specialty drugs that treat a specific population segment average $25.3 million per product.” 
The notion that reps provide critical services to physicians and patients is a lie, as one of us (SA) explained in testimony in the dispute over New Hampshire’s new ban on the commercial selling of prescription data. Pharmaceutical firms spend billions of dollars each year to ensure that the most susceptible physicians prescribe the most expensive, most marketed treatments to the greatest number of individuals feasible. This power is built on a sales team of 100,000 drug salespeople who deliver rationed doses of samples, gifts, services, and flattery to a select group of physicians. If detailing were an instructional service, it would be available to all physicians, not only those whose market share is affected.
Because they are busy, swamped with knowledge and paperwork, and feel underappreciated, physicians are vulnerable to corporate influence. Drug salespeople, cheerful and charming, with food and presents, provide respite and sympathy; they understand how difficult doctors’ lives are and appear to desire merely to alleviate their problems. However, as SA’s New Hampshire testimony demonstrates, every phrase, every kindness, every gift, and every piece of information supplied is meticulously crafted to gain market share for targeted pharmaceuticals, not to benefit doctors or patients. (see Table 1). Physicians must reject the false friendship offered by reps in the interests of their patients. Physicians must rely on unconstrained drug information and seek friends among those who are not paid to be friends.
Note Added in Proof Top
Reference 26 Because it was added while the article was in proof, it is cited out of order in the article.
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