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Drug Reps at Our Doors

Do They Influence Our Prescriptions?

Avitzur, Orly, MD

doi: 10.1097/01.NT.0000298564.57025.46
IN PRACTICE

Ask a group of doctors whether they see drug reps and you're likely to hit a nerve. Responses range from being defensive to dogmatic, with the strongest debate focusing on the strength of their influence on our prescribing choices. One thing most physicians seem to agree upon is that we have less time, and with it, a growing intolerance to intrusion by sales calls.

This comes as no surprise to the drug company reps. A recent survey of the pharmaceutical industry revealed that access to physicians is the number one problem for drug companies, according to a report, “Pharmaceutical Sales Management 2008,” by the market research firm Cutting Edge Information.

With limited access to doctors and restrictions on how they can sell their products, it is not surprising, the report suggests, that companies are scrambling to develop new and innovative sales tactics to stand out in a crowded market. And in the battle to gain favor with prescribing physicians, top reps tailor their selling techniques to each individual doctor.

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CAN WE BE MANIPULATED?

The subject of influence cuts to the heart of the matter: as neurologists, we think of ourselves as incisive thinkers with sharp analytical skills. Many of us simply do not accept the criticism that we need to be manipulated by salespeople.

Glen R. Finney, MD, clinical assistant professor at the University of Florida Memory and Cognitive Disorders Program, for one, does not have a problem speaking with drug reps. “I find it useful to hear what their corporations have in the pipeline, and to have them forward my questions about medications to their parent organizations,” he said.

Dr. Finney also does not object to their funding education. “They seek to raise the image of their corporations in this way, and gain some name recognition in return,” he explained. “I'm protected from corruption by my native ingratitude,” quipped Dr. Finney. “Just because they provided pens or a lunch or supported an educational activity has no relevance to me as to what I will prescribe for my patients. I do what I believe to be in the best interests of my patients, regardless of what some drug rep or company wants me to do.”

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RESPONSE TO SALES CALLS: PROS AND CONS

But Stephen T. Mernoff, MD, clinical assistant professor of neurology at the Warren Alpert Medical School of Brown University, disagrees. With rare exceptions — such when there is a new product without competition or an old product with new administration issues — he refuses to see drug reps in his office because he feels that it's a waste of time. “The information provided is inherently biased and I don't want my decisions to be affected by such influences,” Dr. Mernoff explained. “If I am going to spend valuable time learning more about available therapies, I'll do so at an unbiased continuing medical education activity.”

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When discussing this issue with colleagues over the years, Dr. Mernoff has heard four types of comments: “How can you keep them out of your office? They come all the time, and the staff likes the food they bring.” His reply: “Just say no. Physicians have absolutely no obligation to see them and it interferes with patient care. It takes time away from patients who hate seeing these interactions in their doctor's office.”

Others say: “The patients save money by getting samples.” His reply: “The companies are not losing money by giving samples. I'm sure their cost is factored in when determining the cost of prescription meds. I do admit that the sample packs are convenient and patients can depend on them at first with out-of-pocket savings, but I've found that the drug reps are more than willing to drop off samples without having face-to-face time with physicians.”

To those who say: “That's how I learn about medications,” Dr. Mernoff responds: “That one's really scary. Docs should be learning about medications from other docs, or PhDs, or pharmacists, not from drug reps who get intensive training on how to get docs to prescribe the one or two meds they are trained to know.”

And finally, to those who claim that the reps “provide useful information which does not bias or jeopardize their making independent prescribing decisions,” he replies: “Pharmaceutical companies would not spend so much money on marketing to physicians if it did not work. The industry has ways of determining which tactics are successful and which are not.”

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PEGGING PITCHES TO DOCTORS

Indeed, in “Following the Script: How Drug Reps Make Friends and Influence Doctors” (PLoS Med 2007:4(4):e150), a former drug rep reveals that detailers peg physicians into one of several categories and customize their pitches accordingly. The friendly and outgoing doctor gets offerings of friendship — office lunches, free samples, and flattery — and rarely hears mention of drugs.

The aloof and skeptical doctor is met with journal articles to counter previous objections to their use. Mercenary docs are offered favors based on expectation, and fawning attempts to make personal connections are bestowed upon high prescribers. Physicians who prefer competing drugs are lavished with attention and badgered until they're worn down.

But the relationship is not always so calculating. While child neurologist Deborah Lee, MD, PhD, was in practice at Tulane, she rarely met with the sales reps because most of their products were for adult patients. However, she did experience one beneficial interaction. When a ten-year old patient was diagnosed with seizures and was upset because she could not find anything in the library to read about her illness, the child's mother suggested that her daughter write her own publication. The young girl's writing was so impressive that Dr. Lee added a medical section designed for a pre-adolescent.

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Because the patient had mentioned her drug in the pamphlet, when it came time to look for funding, Dr. Lee was able to secure a $1,000 educational grant allowing Tulane to print and distribute the pamphlet. “It was of great use in my practice and gave both parents and children peace of mind,” she said.

Dr. Lee currently works in the pharmaceutical industry; she teaches drug reps about safety issues and advises them on how to speak about the subject with doctors. “The training allows them to report safety problems mentioned by doctors in the office who may be too busy to report them,” she said.

Whatever one's inclination toward reps, stricter guidelines regulating pharmaceutical industry contacts with patients have prompted private medical offices and academic centers to re-evaluate policies.

Barbara Scherokman, MD, chair of the AAN General Neurology Section, has been a neurologist with Kaiser in the Mid-Atlantic Permanente Medical Group in North Virginia for the past fifteen years. Although she did see drug reps in the office at one time, physicians were never allowed to accept samples of drugs.

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“Now, in light of the OIG [Office of Inspector General] guidelines, Kaiser does not allow drug representatives to promote drugs in our medical centers,” she said. [The final guidelines, issued by the OIG in April 2003, prohibit pharmaceutical companies from offering doctors and health plans incentives to encourage or reward prescribing or purchasing drugs.] Although drug companies had sponsored CME dinners in previous years, Dr. Scherokman said that since June 2003, when the new policies were created, these dinners have been banned, as well. Unrestricted educational grants go through a formal CME process, she said.

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WHAT DRUG REPS KNOW ABOUT PRESCRIBING HABITS

About a year ago, a drug rep complained to Jon Olson, MD, a Baton Rouge, LA, neurologist, that if sales didn't pick up, he'd lose his job. “He then mentioned that I wasn't prescribing his drug much,” said Dr. Olson. Dr. Olson was stunned to learn that the pharmaceutical company knew what he was and was not prescribing.

Drug reps enter our offices armed with each doctor's prescribing data: which medications and how much. Pharma companies contract with data mining companies to track which prescriptions physicians write. This information allows sales reps to customize their pitch.

Last year, the AMA, which sells access to a physician database, began to offer the Physician Data Restriction Program allowing doctors to “opt out” (refuse disclosure of their data). For more about the program, see www.ama-assn.org/ama/pub/category/12054.html.

“I opted out electronically after that experience and think more physicians should, as well,” he said. “I would actually prefer if it were the other way around: an “opt in” option, in which only doctors who wished to reveal their information would need to sign up,” he suggested.

Also in 2006, New Hampshire became the first state to try to make doctors' prescription writing practices confidential, but a district judge ruled the law unconstitutional. More than a dozen other states have similar prescription privacy laws in the works. Maine and Vermont recently amended their laws allowing physicians choice in the matter.

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REFERENCE

• Fugh-Berman A, Ahari S. Following the script: How drug reps make friends and influence doctors. PLoS Med 2007;4(4):e150.
    ©2007 American Academy of Neurology