Healthy Skepticism Library item: 2008

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

Publication type: news

Zuger A.
Fever Pitch: Getting Doctors To Prescribe Is Big Business
New York Times 1999 Jan 11

Full text:

On a recent Tuesday afternoon, Dr. Spartaco Bellomo took a few minutes before office hours began in his Jersey City suite to attend to one of the few traditions of medical practice to survive almost unchanged from the mid-19th century.

It involved leaning back in his chair, listening, nodding, asking a question or two and murmuring a few reassuring words. In the chair opposite Dr. Bellomo, however, sat not a patient but Marie Atkinson, a sales representative from Du Pont Pharmaceuticals, plugging the company’s newest product.

‘‘How are your patients doing on Sustiva, Doctor?’‘ Ms. Atkinson asked, her lap piled high with literature about the drug. One of Dr. Bellomo’s patients was doing very well indeed, and Ms. Atkinson beamed. ‘‘Excellent,’‘ she said, rising to go. ‘‘Doctor, you’ve made my day.’‘

It was in 1850 that a drug detail man first knocked on an American doctor’s door to take up just a few moments of his time, and the dialogue has not stopped. But it grows louder. Since an overhaul of health care system fizzled four years ago, the pharmaceutical sales force has exploded, from about 35,000 full-time sales representatives and supervisors in the top 40 pharmaceutical companies in 1994 to more than 56,000 in 1998, according to the Scott-Levin consulting firm in Pennsylvania. An additional 6,000 people are employed by independent marketing agencies.

Scott-Levin estimates that pharmaceutical companies in the United States spent $5.3 billion in the first 11 months of last year sending representatives into doctors’ offices and hospitals, and $1 billion more holding marketing events for doctors.

That translates into nearly one drug salesperson and almost $100, for every 11 practicing physicians in the United States, a class size and budget that might be the envy of any educational venture. But the relationship between the pharmaceutical sales force and the doctors it plies with information has been fraught with tension for years, and many doctors say that the new numbers are only making it worse.

National spending for prescription drugs has more than doubled in the last decade, to $78.9 billion in 1997 from $37.7 billion in 1990, according to IMS Health Inc., which collects health-related information. A recent analysis in The New England Journal of Medicine noted that the percentage of the personal health care dollar spent on drugs was growing faster than any other part, including doctor and hospital bills, partly because prescription drug costs have risen on average 17 percent a year in the last few years.

The same industry pressures thought to be responsible for these soaring costs have helped bump up the sales force. Developing drugs remains a huge uncovered expense for the industry. Pharmaceutical Research and Manufacturers of America, an industry group, has calculated that only 3 in 10 brand-name drugs make enough money to cover the average research and development costs. Meanwhile, the organization says that generic drugs are accounting for an increasing percentage of prescriptions, taking business away from brand-name pharmaceutical companies. It estimates that 44 percent of prescriptions were filled with generic drugs in 1997, up from 27 percent in 1996.

And as the Food and Drug Administration speeds its approval of new drugs, more and more unfamiliar — and expensive — brands must be introduced to prescribing doctors, while at the same time more medically similar drugs are clamoring for their allegiance.

Against this background, the sales force performs a vital educational role for the industry, said Michele Robinson, a spokeswoman for the National Pharmaceutical Council, an association of pharmaceutical companies. Sales representatives introduce doctors to new families of brand-name drugs and update them on using the older ones.

‘‘The drug companies still view the physician as their primary client,’‘ she said.

Putting a Pill In a Pretty Package

But in the drug representatives’ patter, the usual questions of accuracy and reliability that dog all highly competitive advertising ventures apply.

Over the last 20 years, studies have repeatedly shown that doctors say they rely a great deal on information supplied by pharmaceutical representatives instead of medical journals tend to have more expensive prescribing habits than other doctors, and are somewhat less likely to choose the best drugs for a given job. One study, published in The Journal of the American Medical Association in 1995, found a dozen errors of fact in tape recordings of 13 presentations made by drug representatives to doctors, errors that invariably favored the presenter’s own drug over the competition.

Other issues compound the problem. Given three medically equivalent brand-name drugs, is a harried doctor more likely to write a prescription for the one featured in the small print of an obscure medical journal, or the one endorsed in a few pithy words by the sales representative who just left a stack of colorful brochures in the office? Or might the doctor choose over either of them the brand whose logo is embossed on the expensive fountain pen another salesman pressed into his hand at an elegant dinner the night before? No one knows.

Despite significant changes in medical advertising and medical practice this decade, face-to-face drug promotion remains an invaluable marketing tool.

‘‘Personal selling is still the most effective and certainly the most expensive way of selling prescription medications,’‘ said Dr. Mickey C. Smith, professor of pharmaceutical administration at the University of Mississippi in Oxford and an authority on drug marketing.

The profile of sales jobs has changed slightly over the decade, Dr. Smith said. In addition to calling on doctors, drug representatives now make calls on executives and pharmacists who supervise the formularies of hospitals and insurers. Sophisticated prescription tracking systems can identify which doctors are prescribing medications and let representatives tailor their presentations, encouraging the reluctant prescribers and complimenting the enthusiastic. But even with a growing percentage of advertising budgets dedicated to introducing drugs directly to consumers, the industry has realized that the doctor ultimately makes the prescribing decisions.

And so in private offices and hospital corridors alike, traditional sales representatives energetically chat up the staff. Unlike the salesmen of years past, many now have a strong background in science or health care (Ms. Atkinson of Du Pont is a nurse), specialize in only one drug or group of drugs and get to know their field of medicine very well. Some become so expert that they begin to blend into the health care team. Salesmen who sell surgical devices have long been present at operations to guide doctors using new equipment; in a widely publicized case in New York City in November 1997, Beth Israel Medical Center was accused of allowing a salesman to operate a piece of surgical equipment while doctors performed a procedure on a young woman who later died.

For representatives who sell drugs rather than equipment, the Food and Drug Administration tries to forestall the practice of medicine without a license with guidelines that strictly limit what the representatives may and may not discuss with doctors. Representatives are limited to passing on only the most basic information about a drug; they cannot discuss studies in progress or observations the drug agency has not yet screened for distribution.

Drawing the Line At Chocolate Mousse?

But the Food and Drug Administration cannot stop representatives from sweetening their presentations with little extras. These range from reprints of pertinent articles and colorful charts to hang in the office, to ballpoint pens and pocket calendars bearing product or company logos, to trays of cookies, bagel breakfasts and pizza lunches. Many representatives routinely lug cartons of drug samples with them to keep office cabinets stocked with their product.

And often the extras take on another dimension entirely, always in the name of education. Some representatives buy expensive textbooks or pay for trips to conferences for a doctor or the doctor’s trainees. Others sponsor golfing outings, river cruises or lavish dinners at expensive local restaurants where an after-dinner speaker discusses the state-of-the-art treatment of a given condition and, inevitably, the place therein of the sponsor’s drug.

Doctors have long debated where, in the spectrum of pharmaceutical-sponsored information, pens, books, white wine and chocolate mousse, comes the ethical place to draw the line.

For some doctors, keeping an open door for the sales representatives is an educational imperative made more essential by the glut of new products.

Dr. Bellomo of Jersey City, for instance, may see a half-dozen or more representatives a week, usually by appointment, spending as long as a half-hour with each. The information they provide him is valuable ‘‘at least 90 percent of the time,’‘ he said. One passed on a new safety warning about a drug a few months ago, Dr. Bellomo said, and the official warning still has not arrived. ‘‘That person is welcome in my office anytime,’‘ he said.

For other doctors, there is persuasive evidence for giving the representatives a wide berth.

‘‘I basically do not go to them for information,’‘ said Dr. Allan S. Brett, director of the division of general internal medicine at the University of South Carolina School of Medicine in Columbia. ‘‘When a new drug is coming out, I tell the representative, ‘I’m really not interested in what you have to say. I’m glad you told me it’s coming out, but I’m going to get my information from somewhere else.’ ‘’

Dr. Bellomo sees drug samples as a handy way to start a patient on treatment at night after the drugstores are closed, and a way to ease the cost of treatment. But for Dr. Brett they are an insidious way to hook doctors and patients on new, expensive drugs, when older, cheaper, safer alternatives might easily suffice.

The issue of gifts also divides doctors. Some agree with the official policy of the American Medical Association that pens and other items of negligible value are permissible, as are gifts like textbooks that have an educational value that might indirectly benefit the doctor’s patients (whose prescription dollars are, after all, directly paying for the gifts).

But for other doctors, even trinkets are troubling. ‘‘The fact that you can walk down the hall here and every pad, every pen, every little magnet on the door for messages has a drug company’s name on it,’‘ Dr. Brett said, ‘‘that bothers me. I think there’s a cumulative ethos that’s bad.’‘

Dr. Allen F. Shaughnessy, director of research in the Family Practice Residency in Harrisburg Hospital in Harrisburg, Pa., said, ‘‘I can buy my own pens and sticky pads.’‘ Like other medical educators, Dr. Shaughnessy is increasingly concerned with what kind of limits, if any, he and his colleagues should place on the contact between the residents training in his program and drug sales representatives.

Roaming the Hallways, Or Kept at Bay

Hospital policies vary. Some ban drug representatives from busy patient care areas or confine them to a room at the end of a hall; others confine sales pitches to specific activities on specific days, while others issue sales representatives identification tags and allow them to roam.

And on teaching hospital wards the representatives — friendly, well-dressed, bearing gifts and food — are invariably popular visitors. Dr. Shaughnessy said he once found residents actually presenting cases to a pharmaceutical representative for treatment advice, apparently finding him more pleasant and accessible than their supervising physicians.

‘‘My zealous approach was, throw the bums out,’‘ Dr. Shaughnessy said. ‘‘But then I thought, no, we’re really throwing out a useful information source for a lot of people.’‘ He now invites sales representatives to a twice-monthly seminar on ‘‘information management,’‘ where his residents critique their sales presentations for logic and usefulness.

Even so, Dr. Shaughnessy is seeing a difference in his trainees. ‘‘I’ve been doing this for a long time,’‘ he said. ‘‘It seems like 10 years ago there used to be more moral outrage among the residents,’‘ he said, about receiving biased information disguised as education. ‘‘Business is a big part of medicine now,’‘ he said. ‘‘It’s easier for the drug reps to sneak in under the radar.’‘

Ms. Atkinson of Du Pont said that only a single doctor among the 385 she visits in her territory has told her that he has a policy of not speaking to pharmaceutical representatives. But Ms. Atkinson still leaves information in the lobby for him, she said, and Du Pont’s prescription tracking service lets her monitor his prescribing habits. And ‘‘he’s writing,’‘ Ms. Atkinson said. ‘‘He’s writing.’‘