How Drug Reps Make Friends and Influence Doctors

This article, which grew out of conversations between a former drug rep and a physician who researches pharmaceutical marketing, reveals the strategies used by reps to manipulate physician prescribing.

The authors of the article are Adriane Fugh-Berman, an Associate Professor in the Department of Physiology and Biophysics, Georgetown University Medical Center, Washington, District of Columbia, United States of America and Shahram Ahari who is with the School of Pharmacy, University of California San Francisco, San Francisco, California, United States of America.

Shahram Ahari is a former pharmaceutical sales representative for Eli Lilly, and the primary findings 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.

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 Pfizer, 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.

SEE: Neurontin Used for Pain: Doctors Influenced by Drug Reps

It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently 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.

Table 1. Tactics for Manipulating Physicians
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You are absolutely buying love. – James Reidy. (Elliott C (2006) The drug pushers. Atlantic Monthly (April) 2–13).

In 2000, pharmaceutical companies spent more than 15.7 billion dollars on promoting prescription drugs in the United States. 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. (Med Ad News 24: 1).

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 influencing physicians, and they do so with finely titrated doses of friendship.

This article, which grew out of conversations between a former drug rep (Shahram Ahari) and a physician who researches pharmaceutical marketing (Adriane Fugh-Berman), 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, 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 office 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, and wooed as teachers.

Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep’s messages. (See Table 1 for specific tactics used to manipulate physicians.)

Table 1.
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Table 1. Continued
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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. (Med Anthropol Q 18: 328–356).

Pharmaceutical gifting, however, involves carefully calibrated generosity. Many prescribers receive pens, notepads, and coffee mugs, all 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”. (Elliott C (2006) The drug pushers. Atlantic Monthly (April) 2–13).

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. Anything that improves the relationship between the rep and the client usually leads to improved market share.

Script Tracking

An official 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 unofficial, and more accurate, description would have been: Change the prescribing habits of physicians. – James Reidy.

Pharmaceutical companies monitor the return on investment of detailing (the one-on-one promotion of drugs to doctors by pharmaceutical sales representatives) – 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 filled in community pharmacies. Patient names are not included, and physicians may be identified only by state license number, Drug Enforcement Administration number, or a pharmacy-specific identifier. (New Engl J Med 354: 2745–2747).

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 Masterfile, 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 Masterfile information, provided more than $44 million to the AMA. (Steinbrook R (2006) For sale: Physicians’ prescribing data. New Engl J Med 354: 2745–2747).

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 specific 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 in order to develop a strategy to change those prescriptions into Merck prescriptions”. (Merck (2002) Basic training participant guide).

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 influences. By building these multiple dimensions into physicians’ profiles, it is possible to understand the ‘why’ behind the ‘what’ and ‘how’ of their behavior.” (Pharmaceutical Executive).

To this end, some companies combine data sources. For example, Medical Marketing Service “enhances the AMA Masterfile 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”. (Medical Marketing Services (2007) American Medical Association list).

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”. (Jason J. Hogg, (2006) Marketing to professionals: Diagnosing MD behaviour, Pharmaceutical Executive).

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 defined patient type. And the idea in physician segmentation would be to have a different messaging strategy for each of those physician segments”. (George Hradecky, (2004) Breaking point. Pharmaceutical Representative).

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Main article Citation: Fugh-Berman A, Ahari S (2007) Following the Script: How Drug Reps Make Friends and Influence 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

Other references:
Reidy J (2005) Hard sell: The evolution of a Viagra salesman Kansas City: Andrews McMeel Publishing. 210. p.

Merck (2002) Basic training participant guide. Available: http://oversight.house.gov/features/vioxx/documents.asp. Accessed 23 March 2007.

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.

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.

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.

Hradecky G (2004) Breaking point. Pharmaceutical Representative. Available: http://www.pharmrep.com/pharmrep/article/articleDetail.jsp?id=102324. Accessed 23 March 2007.

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.

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