March/April 1999 Vol 17 No 3/4 ISSN 1321-571X

Memoirs of Methods Used to Sell Drugs

Insight into the inner workings of drug companies is valuable and difficult to obtain. This MaLAM edition presents the memoirs of a former drug company employee regarding the methods he saw being used to sell drugs. He worked in the medical departments of three drug companies. We will not disclose his name or the names of the companies and countries where he worked. The amounts of money mentioned have been converted to the equivalents in US $.

Profiling

I must confess to being quite amazed at the amount of information that is collected by representatives and drug companies on individual doctors. When a representative leaves employment, the diary and profile dossier is forwarded on to the successor. Doctors’ profiles will contain minutiae, from the names of their family members to their golf-handicap, to the foods they like or dislike, to the clothes that they wear!

Most companies have their own classification of the doctor’s personality type. One schema is that of the eagle-owl-dove-peacock, where the eagle is egotistical and domineering, the owl wants information and is very analytical, the dove is a friendly sort who gets on well with everyone and the peacock is a social butterfly / extrovert.

The companies hire specialised professional agencies to teach the representatives about their own personalties using the same classification. This helps the representative to plan and adapt their selling styles based both on the doctors’ styles and their own. For example, a conservative doctor and a flamboyant representative may not gel, so the representatives would modify their styles to be less flamboyant and more technically oriented so as to be in alignment with what such doctors wanted to hear. The agency providing the training would administer personality tests and then teach representatives how to modify their styles. This would be taught using video taped role-plays. The drug company that used that classification system also used it for selecting staff. They preferred to employ peacocks or eagles to be representatives.

Many doctors are also categorised according to how they prescribe. For example, A for high volume prescribers of the company products down to C for those doctors not worth targeting. This is based on the principal that 80% of the market for your product comes from 20% of prescribers. Those classified as A need to be kept on this level and so are targeted by the representatives to attend meetings etc. The B group are those targeted with a view to converting them to A types. So how does one obtain prescribing information about a particular doctor? From IMS and STATIM data, but even these methods are not that specific for a product. Representatives use the local pharmacies, or obtain the information from doctors directly using such schemes as SCRIPTRACK eg doctors are required to fill in paperwork providing information regarding their prescribing preferences etc in return for small prizes, lottery tickets, etc. The companies go to great lengths to obtain this information.

Detail Aids

Detail aids are glossy eye-catching colourful displays of data, which are used by representatives as a selling tools. Some are designed to be left behind with the health care professional as an aide memoir. Others are not. It is the latter which are more likely to be used to convey misleading claims because doctors can not examine them carefully or compare them with other information sources or get a second opinion on them. Like any promotional item, detail aids are supposedly vetted by the company’s medical department to ensue that no misleading or false claims are made, and that the data represented is a fair reflection of the literature.

Medical Departments

Many companies are very "marketing driven". By this I mean to say that the structure and function of the medical department is often either token or designed to assist the marketeers in what may be construed as ‘unethical practice’. For example, some marketeers will think of an idea that will be appealing to the recipient health care professional or consumer. They will then approach the medical department to find out if there is any data to support their claim, regardless of whether that evidence is weak or unrepresentative of the current body of knowledge. For those companies that consider themselves as ‘very competitive’, the promotional items are often allowed to pass through a proverbial net of scientific scrutiny with little or none of the modifications that would be required to avoid misleading doctors.

Give-Aways

Similarly to Detail Aids, the typical Give-Aways include such things as pens, post-it pads, torch lights, anti-stress balls, golf balls, chocolates. These are essentially brand name reminders that lead to the promoted drug being remembered more quickly than the alternatives. They are also designed to affect the subconscious mind of prescribers so that they will prefer the promoted drug. The value of any gift or give-away has to be perceived to be of relatively low monetary value eg USD $40. Consequently, companies (in association with their advertising companies) think of ingenious ways to produce materials that are appealing to the recipient without appearing expensive. For example cookie jars, which are filled up each time a company representative passes by a doctor’s surgery, are aimed primarily at the doctor’s secretarial and support staff, to assist the representative in acquiring ready access to the doctor. It must be stressed that although the final give-away product may not look expensive, the real costs involved in producing that product may vastly exceed the nominal USD $40 cited by the industry associations.

Competitions

In recent years the costs of prizes have had to be reduced from the days when drug companies used to offer videos and TVs and the like. However prizes are still a useful way to attract doctors to a particular product or company. For instance, between plenary sessions at a conference, attendees were invited to partake of some "fun and games" at a trade display. The prizes on this occasion included soft toys and some good quality wines. Hundreds of attendees entered the competition which was to be drawn on the final day of the conference. Who drew the winners? I was flabbergasted to see one of the company’s product managers sit down in a quiet place and sift through all the entrants, then select three key doctors that the company wanted to influence. On challenging the ethics of such a manoeuvre I was told that it was a common practice across the industry!

Inter-company agreements

Since the rise of "self-regulation" in some countries, there have been remarkably few inter-company complaints that have progressed to the stage of fines or corrective advertising. Indeed, in most countries relying on self-regulation no member company has ever been suspended or expelled. Proponents of self-regulation would argue that this is a successful formula that has a proven track record. This may be true, although I have some reservations on the matter. In 1994, whilst joining a large multi-national company’s medical department I was surprised to hear that my company and a leading competitor company had entered into an agreement whereby neither company would challenge each other’s claims. Without knowing the specific details, I can not say whether or not this agreement was unethical in this instance. However, if companies enter such agreements then perhaps misleading claims will go unchecked in the marketplace with possibly catastrophic consequences for patients. Although this is only one experience, it does make one wonder just how much of this type of thing actually occurs.

Training for Medical representatives

The manufacturers’ association has gone a long way to improve the professional image of the medical representative. Each representative has to undertake the association’s diploma for representatives. This involves submitting written assignments within defined time periods, in other words, distance-learning. There can be no question that the subject material and course material is pertinent to a medical representative, however, to the best of my knowledge, no studies have been undertaken to assess the effectiveness of introduction of the diploma. I have seen many representatives go through the diploma process. It is viewed by a great many as a chore, even an inconvenience. They do not see it as useful or important. They are aware that obtaining the diploma makes them more attractive and marketable as a seller of medicines. However, the nature of someone who choses to work in sales is to focus on gaining a competitive edge over rivals in the same company as well as inter-company competition. Knowledge of ethics and therapeutic areas doesn’t automatically translate into ethical selling; no such association has been established.

Incentives

Representatives are given incentives, bonuses, trips etc on the basis of their market share, projected growth estimates, achieving targets, etc. They are wined and dined by the management and the marketing department, and are actively encouraged to become competitive and ‘push to the limits’ to achieve their targets. This is where ethical selling vs achieving your sales targets may clash. That’s not to say that all representatives are unethical. Many honestly convey the beliefs that their companies have given them (see indoctrination below) and have rapport established from many years of servicing health care professionals. However I did hear senior management of one company tell the representatives to say anything to the customer if it portrayed the product in a good light, but do not write it down, because it could be used against you!

Selection of Medical representatives

Sales teams are primarily comprised of people from health care backgrounds who fundamentally care about people because such people are more effective at achieving higher sales. Selection of personnel usually involves psychometric testing, presentation skills and multiple interviews, to obtain a particular ‘type of person’ that fits with the corporate image the company wants to portray.

Indoctrination of Medical representatives

Sales teams are nurtured and fed positive information about the product so that they develop a strong genuine belief in the product and in the company so that they will have no problem about selling that product, which they feel will benefit patients. I remember my brief on introducing technical data to some representatives. I was not allowed to say anything negative about the product, or if I did, then I was to handle it by converting the negative into a benefit. (eg the adverse effect of sedation would be presented as "therapy for anxiety and insomnia", nausea would be presented as "helps patients to loose weight.")

The Sale

One training technique that representatives utilise is role-play (on audiotape or videotape). This role-play often uses a written script which the representatives have learnt verbatim, yet can adapt to different circumstances eg restricted time limits, personality type of recipient and so on.

Representatives usually do not just "drop in" to see a health care professional but have an agenda, with defined objectives. Most representatives push for a commitment from the prescriber. This is called "The Close" and is the most important part of the visit. For example: "Will you prescribe this product for the next 3 patients you see?"

If hitting an obstacle or difficult doctor the representative will ask the doctor about how they would manage a particular patient scenario. Then they can go away and discuss with other company staff to decide what is the best approach to get the doctor on side the next time around.

For a new representative, it’s essential just to be visible and friendly for up to the first 8 visits to doctors, gradually winning them over with gratuitous behaviour and a shining persona. All the time that representative is profiling the doctor, assimilating information regarding the type of person that the doctor is etc so that this information can be added to the company’s file on that doctor.

Pharmacy aspects

Much information is obtained from the local pharmacies pertaining to a doctor’s prescribing habits. Most representative visits are ‘drop ins’ whereby they monitor the prescribing habits of their doctors. Many pharmacies are happy to allow the representatives to view the items dispensed for a particular doctor in return for a few samples or give-aways. If representatives discover that they are not making headway with particular doctors then the representatives will know that they need to attempt other strategies to influence those doctors. However if representatives discover that a strategy has been successful then they will use it again.

Product Familiarisation Programs

Product Familiarisation Programs (PFP) are often done immediately after the Govt regulatory body has approved the Product Information for a product but before the drug is officially launched onto the marketplace. The aim is to expose key prescribers to the product and to form a patient base before the launch. PFPs are sometimes disguised as a type of post marketing study. It is my recollection that these programs can take place for about a year before launch of the product. This enables companies to get around the restriction against using the word 'new' only during the first 12 months of its general marketing. Delaying the launch enables representatives to use the word 'new' with the PFP doctors for an extra year. This may seem trivial, but the word 'new' is a powerful marketing tool. More importantly, the promotional material utilised by the drug company to influence the doctors in the PFP, is not readily accessible by competitor companies, and can hence be used for potentially misleading promotional practices without detection. Doctors are chosen specifically on the criteria that they are absolutely supportive and loyal to the company. Doctors are hand-picked after much analysis of their prescribing habits and assessment of their ‘profiles’. In combination with the promotional material used and the expenditure the company goes to win these doctors over, PFPs almost make the doctors putty in the company's hands. This gives the company a supply of Specialists and GP facilitators to call upon for use in promotion to other doctors.

On one occasion I was asked to oversee a PFP disguised as a post marketing study. The doctors were given the use of state-of-the-art fax machines for the duration of the study (1 year), had fax lines installed and even had the rental paid for by the company. These doctors were wined and dined by the sales representatives on a regular basis, given gifts and invited to a lavish launch meeting for the product with key company-friendly speakers.

Use of Clinical papers

In the medical information department I was called upon many times to support a representative’s claims with scientific papers. Only those papers that placed the product in a good light were chosen, not necessarily those that reflected the body of knowledge at that time. The company was only interested in gaining evidence to support its claims, and was not interested in me spending time delving deeper into the relevant literature to determine whether or not the claim was really justified or not. I had wanted to provide a good scientific perspective on the available evidence, to utilise my skills and professionalism, yet in reality my skills were utilised to maximise the selling of the product irrespective of the scientific merit of the claims...not much job satisfaction there!

Representative’s knowledge of epidemiological and biostatistical methodology is generally poor. I have known companies to base promotion on a small series of case reports, when other sources provided a higher level of evidence, but such sources did not give the same message/s as the case reports did.

Some drug companies have an extremely wide sphere of influence. For example, one company that I worked for promoted a meta-analysis of data regarding its antibiotic, published by an "independent" drug information company. Unknown to most people the main author of this publication was the sole paid medical consultant to that company at the time. He was formerly a medical director of the drug company and has since returned to that position. In another instance, the same company had another publication produced by the same "independent" drug information company. This time the author was married to a Product Manager in the drug company.

Weekend meetings

These are an integral part of many doctor’s Continuing Medical Education (CME) programs. Typically, for GPs, a meeting will be arranged in a location that is meant to appeal to the recipients eg ski fields, wineries, grand hotels with views and so on. There will be plenty of good food and entertainment eg theatre, dinners, arranged around the company sponsored education programs, typically run by specialists and / or GP facilitators. That these programs attract CME points is a pre-requisite for hosting the meetings by the drug companies; because CME points convey endorsement by the colleges and that leaves the doctors off their guard. A lot of work goes into these meetings behind the scenes. It shouldn’t come as a surprise to hear that both the GP facilitators and Specialists are specifically chosen for having a bent or loyalty towards the sponsoring company. They are briefed by the drug company in advance of the meetings. During these briefs, the company directs the speakers and facilitators to the key messages that they wish to have endorsed during the meetings. These key messages often portray a particular product in a positive light, even if the product is not specified by its name. The follow-up visit by the representative will usually build upon the key messages given by the speakers at the meeting, but this time the message will be linked to the actual product.

Sponsorship

It is vitally important for companies to get key people who are regarded as figure-heads or leaders in their fields, albeit GP or Specialists, on side to promote their products and corporate image. The process of acquiring that support usually takes time and invariably involves supporting research proposals and clinical trials of the product, and hence much contact time between these key people and hospital representatives and drug company clinical research departments. The key people are sponsored for their work, travel and conferences (local and international), and are usually accompanied by a representative from the company to maintain an image and influence the exchange of ideas that occur at such venues.

Sponsorship is used to gain loyal medical supporters that a company can call upon for support when needed. I know of a high ranking academic pharmacist who wrote in support of an advertisement, despite the fact that it was obviously unjustified. That pharmacist’s department was primarily running on a grant from the company that published the advertisement but that was not disclosed in the letter that he wrote.

Field Intelligence

It is an essential part of a sales representative’s job to find out what your competitors are doing and feed back up the chain of command immediately, so that counter-action can be designed and implemented without delay. On visiting a doctor, a representative will find out what the competitors are saying, and if any leave-behind literature is left, try to get it. If a representative happens upon a representative from another company in a doctor’s waiting room then he or she will try to obtain information about the other company’s products. I know of one occasion when a representative came out of the doctor’s office to find a competitor representative rummaging through the first representative’s briefcase!

Multi-field force

Many drug companies, especially the larger ones have many ‘divisions’ that generally either promote therapeutic classes of drugs eg respiratory, cardiovascular, or are classified according to target population eg pharmacy representatives, hospital representatives, specialist representatives, GP representatives. Some of these divisions have their own names which may not be obviously affiliated to the parent company. There are a number of companies that exceed six ‘types’ of company representative. If a doctor is unaware of the association, there is an enormous potential for a company to have a great influence. Many doctors operate an appointment system for representatives; if a particular company has three divisions then they can obtain three times as many appointments!!!

Co-marketing agreements

Essentially there are two main scenarios from my experience. First, two companies that have the same product may agree not to encroach upon each other’s business, or promote contradictory or potentially damaging claims for their product. The former can be carried out by, for example, not promoting the same product to the same doctor, although both companies may continue to promote the rest of their range of products quite freely. The second option is when one company's sales team is employed to promote a second company's product. For example, if one wants to promote an oral antibiotic to respiratory physicians, then one may consider employing a respiratory team from another company that has all of the contacts with the desired recipients.

Consumer education programs

It is my belief that these projects may play a useful role in patient education. I have been involved with one such project. However it is obvious that such projects are essentially there to nurture patient loyalty to the company’s products. Establishment of a core base of loyal customers is essential for the viability of a particular product, especially in a competitive marketplace, where your competitor products are of similar efficacy and cost, and you need to establish an advantage for your product. The aim is to further the commercial interests of the company regardless of whether or not the product being promoted is the best for the patient.

Cycle Meetings

Many companies work on promotional ‘cycles’, typically 2 or 3 per year. The Cycle Meetings are a time for motivating and getting representatives hyped up and enthused to get back out there on the road to sell, sell, sell. The company representatives meet at one location for about a week and learn about new products, role-play selling scenarios, learn about market-shares, play games and have lots of fun! Each representative has specific targets, eg for a particular product they may be given a % market share to be achieved. If that is achieved they may get a USD $ 4,000 bonus. Representatives are given a whole host of incentives to achieve certain goals eg recruit x number of doctors onto a program, y number of patients onto a product and so on. Each of these targets is rewarded, and those rewards are invariably given at the Cycle Meetings in front of the other representatives. These meetings are usually big fanfare events, leading to Representative of the Year awards etc.

The marketing departments typically introduce new material for the sales team to maintain motivation, to help representatives to approach doctors from different angles, etc. The life expectancy of such material is very short. Whilst it is true that successful material may continue to be used for a long time, often the material is replaced by the next cycle meeting. Built into this approach is the fact that if a complaint is made about any of the material, then that material will have been finished with before the complaint proceeds through the self-regulatory processes. So, essentially, the company can give the impression that self-regulation is working by agreeing to cease using misleading material, when in reality the material has already served its purpose, and so on to the next cycle’s promotional material!

Product Information

Often the Product Information (PI) is described as the ‘bread and butter’ of the product. A representative can safely claim anything that is within the PI, although (as mentioned above) I know of one field force that was told that they could say anything they wanted to sell the product so long as they don’t write anything down! The PI is a document that is approved by the government, so it immediately has credibility, or so it is perceived. It is a fact that all the data supplied with an application for registration of a product (truck loads of paperwork) is deemed "commercial in confidence" and is not available for external scrutiny. I have seen wordings in some product PIs that were deliberately placed there by marketeers as a marketing tool. Such inclusions include the words ‘significantly’ and ‘negligible’, or may present data in a misleading way eg presenting a single study quoting the point estimate as median rather than mean.

Unapproved Indications

If a doctor requests clinical papers regarding an indication for which the product is not approved then provision of such documents is acceptable practice. However, interest in unlicensed indications is often generated by representatives, with a view to altering prescribing habits. Representatives may sometimes gain a doctor’s support for unapproved indications to the extent that doctors will promote the unapproved indications to their peers.

Conclusion

From my experiences, both within and outside the industry, I feel that it is indisputable that the industry has a lot to offer health care professionals, including sponsorship, education, and the many quality products that they produce. The market place for medicines is an extremely competitive environment, which leaves companies no choice but to use aggressive marketing methods in order to gain an advantage over ‘me-too’ drugs.

It is hoped that the readers of this article will have gained a greater insight into some of the methods used by the drug industry to woo health care professionals over to their products. It is with such insight and the application of evidence-based principles that health care professionals can adopt a more positive approach to dealing with promotional activities carried out by the drug industry. Such healthy scepticism towards drug promotion should lead to a win-win situation for all parties concerned. The health care professional’s standing will be enhanced, which will hopefully enable the industry to use more ‘appropriate’ promotional activities, ultimately for the benefit of the patients we all serve.