MUST READ: Following the Script: How Drug Reps Make Friends and Influence Doctors

[Sir Arthur]

MUST READ: Following the Script: How Drug Reps Make Friends and
Influence Doctors

On Sep 21, 8:01 am, Ilena Rose <B...@mundo.com> wrote:

- Hide quoted text -

> Note from Health Lover, Ilena Rosenthalhttp://ilenarose.blogspot.com

> Just one more way Pharma advertises & promotes & does PR for their
> high profit merchandise.

> www.BreastImplantAwareness.org/QuackWatchWatch.htmwww.BreastImplantAw...
> Quackwatch hunts down homeopathy companies and sues them and harasses
> them with smear campaigns ... why them and not the pharmaceutical
> companies ? $ ? $

> http://medicine.plosjournals.org/perlserv/?request=get-document&doi=1...

> Following the Script: How Drug Reps Make Friends and Influence Doctors

> Adriane Fugh-Berman*, Shahram Ahari

> 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 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.

> Competing Interests: 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.

> 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

> 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 influencing physicians, and they do so with finely
> 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, 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. Tactics for Manipulating Physicians
> Table 1. Continued

> 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 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 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 [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
> 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
> [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 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 [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 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” [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 influences. By
> building these multiple dimensions into physicians' profiles, 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 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” [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
> defined 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
> fine-tune sales targets. For a particular product, for example, one
> segment might consist of price-sensitive 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 (seehttp://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'
> offices, 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 influence 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 five 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.

> 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 fiction. 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 influence is a sales
> force of 100,000 drug reps that provides rationed doses of samples,
> gifts, services, and flattery 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 influence 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 reflects, 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 unconflicted sources, and seek
> friends among those who are not paid to be friends.
> (Photo: “Bitter Pills?” by net_efekt, athttp://www.flickr.com/photos/wheatfields/316337784/. Published under
> the Creative Commons Attribution License.)
> (Photo: “Pills” by Rodrigo Senna, athttp://www.flickr.com/photos/negativz/74267002/. Published under the
> Creative Commons Attribution License.)
> (Photo: “Pills” by Sugar Pond, athttp://www.flickr.com/photos/sugarpond/236235191/. Published under the
> Creative Commons Attribution License.)
> Note Added in Proof

> Reference 26 is cited out of order in the article because it was added
> while the article was in proof.
> References

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Brilliant, outstanding, a job well done. This will shut up the
ignorant skeptics.