Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, December 19, 2006

Just Saying "No" to Drug Reps

Stop the presses! DB and I agree on something.

The good Dr. Bob has not one but two posts about the perniciousness of drug reps pushing their wares. Frankly I have been saying the same thing for years; to their faces, though not on a blog.

Here's my take on it -- freely shared with reps who call on me:
  1. Everything they say is propaganda.
  2. They are better at it than I am (that is, even if I listen "criticallly" and "skeptically" they will compensate accordingly and therefore something will get through, whether I want it to or not.)
Here are my rules for reps (and only between 12:00 and 2:00 pm):
  • I only take samples for drugs I already write for (comes in handy to hold folks over when their mail order is delayed)
  • I will not accept *any* gifts. No pens/pads/kleenex/candy (even though it kills me to pass up chocolate) nor will I participate in any dinners or programs, no matter how "educational" you try to spin it. (See #1 above)
  • If I have time, I will happily listen to stories of (or check out pictures of) your kids/pets/weddings/etc.
  • I will not listen to any of your drug spiel (to the point of putting my hands over my ears and chanting "na-na-na I'm not LIStening".)
  • If you keep on trying (or slip studies onto my desk while I'm in with patients) I won't let you back into my office.
Over the years I've made actual friendships with some of the reps. They've learned to "leave the rep in the car" and just enjoy their visit. (No, they tend not to bring their managers. Unless said managers are a real PITA and they want them taken down a peg. Then I'm happy to oblige.)

One rep's twins are growing *so* fast it's unbelievable. Another rep never fails to get down on the floor with my doggie and rub her tummy (the dog's, that is.) One guy's son is in my son's scout troop; we're planning to get together for dinner one Sunday night. Another rep with kids the same age as mine kept crossing paths with me at school sports events. Despite the fact that I haven't written his drug for years, he's a real friend. And another's black lab puppy is *too* cute. One of my best rep friends left to become a nurse; she's going to be an awesome one. Another married her med student fiance and moved to DC for his surgical residency; I went to her baby shower a few months ago, and just sent a baby present to her new daughter.

While I don't resent the reps as people, I don't feel their profession should exist. When you stop to think about it, I neither buy nor use their product. Nevertheless, I'm the one they must "sell" on it. I can't think of a worse reason to prescribe a given drug than, "The rep is a nice guy." Five of the six "weapons of influence" quoted by DB are routine for them. Drugs should not be *sold*.

DB's commenters disagree.

One points out our "responsiblity to listen [to drug reps] critically." See #2 above. We do not have the information readily at hand to counteract the spin they have been carefully trained to deliver. Studies have shown that even when we think we are listening critically, our behavior (ie, prescribing patterns) are still affected.

Another laments that he is "not as virtuous" as DB (or me, for that matter) for not finding out about new drugs and pharmaceutical developments on our own; independently of reps. I don't think it's a question of virtue, but of responsibility. I agree that listening to drug reps as a primary source of new drug information is risky at best and foolhardy at worst. In addition to Vioxx and Celebrex, they were pushing Ketek like there was no tomorrow. I admit to being quite proud of my status as a "late adopter" when it comes to most drugs.

Now, as soon as DB recognizes the absurdity of his arguments for so-called "patient responsibility," we'll all be just ducky.

Update: DB's commenters continue to elaborate on all the above points.


At Tue Dec 19, 09:19:00 PM, Anonymous Anonymous said...

I will not accept *any* gifts.

Not even anatomical models/patient edu aids/physcian & compliance aids/tools? There are giveaways that are actually useful in clinical settings, not just the junky mug/pens/pads...

At Tue Dec 19, 09:25:00 PM, Blogger Janet said...

Hello, Dinosaur Doctor from a Dinosaur Nurse. I'm 29 years past a hospital-based diploma program and have recently discovered your blog.

I agree with you about drug reps. They make my skin crawl when they are on the job. Away from work they can be decent people.

At Tue Dec 19, 10:20:00 PM, Blogger Bo... said...

I can understand your point of view. (But I'll admit that I love the free Post-Its, heh!)

At Wed Dec 20, 08:02:00 AM, Blogger MedStudentGod (MSG) said...

Hate 'em. If there's a lunch being provided I will wait until they leave before I eat - or I'll leave as they're trying to "educate" medical students on why drug X is so much better for your patient(s).

I don't know any outside of their job roles so I can't come to any conclusions about their overall demeanor. But when they're in the clinic or hospital I avoid them at all cost. As far as I'm concerned they don't belong anywhere on patient wards or clinics. They interfere with real medicine and their information is incredibly biased and one sided.

As far as Anon's comment: ANY gifts are used to sell the drug regardless of their usefulness. There are ALWAYS advertisements located on those free give aways to not only help the doc *remember* to Rx that drug, but also get the patient interested and ask about it. A doctor's office is no place for marketing - only good medicine.

At Wed Dec 20, 09:18:00 AM, Blogger Big Lebowski Store said...

No one gets a free pass here. When drug reps give me the spiel, I challenge them. As a result, I'm detailed infrequently if at all. As a result I have almost no free formula to give away to families in a pinch.



At Wed Dec 20, 11:49:00 PM, Anonymous Anonymous said...

Now I know why my doc insisted on writing a prescription for Nexium when I was adamant that I wanted to stay with Priloc OTC.
He wanted more pens and pads.
ps: did I fill the script? No

At Thu Dec 21, 01:28:00 AM, Blogger Sid Schwab said...

1) I refused to see reps throughout my career.

1) Eventually, the clinic in which I worked put in place a policy prohibiting them from seeing all the docs (over 200 at last count.

At Thu Dec 21, 02:32:00 PM, Blogger Richard A Schoor MD FACS said...

I can think of 3 "good" services that drug reps and pharma supplies:
1: samples to patients, which can save the patients money
2: Sponsoring our national meetings, which makes it more affordable for us.
3: They can have their marketing departments think up new diseases for us to treat with new medications (sorry, couldn't think of a 3rd).

At Wed Jan 10, 02:14:00 AM, Anonymous Anonymous said...

Jeez dude, if I didn't see the drug reps I would have to buy my wifes Advair ($150/mo.) and Fosamax ($100/mo.)

At Sat Jun 16, 04:43:00 PM, Blogger Vitum Medicinus said...

As a med student who’s just starting to observe the drugrep/md relationship in my Family Practice observership, I’m approaching it with a lot of scepticism and caution even this early in the game. I’ve read a few interesting articles about it and discussed my impressions on my blog.

As a result, finding your post on this topic – and your personal policies – was an interesting addition to my readings on the topic, especially considering that your behaviour of considering drug reps as people is surprisingly new to me.

I’ve enjoyed reading your blog over the past while – Please let me know if you object to me adding you to my blogroll!

At Thu Oct 18, 11:33:00 AM, Anonymous Anonymous said...

We currently have appointments available for Drug Reps.

Dr. Christine B Lafferman, Medical Doctor-- Open schedule October 15, 2007 through October 15, 2007 (These appoinments can take place in the office or at an open forum)

Dr. Jeffrey A. Lafferman, MD- Geriatric Psychiatrist-- open schedule from january 14, 2008 through December 14, 2008(These appoinments can take place in the office or at Linwood Restaurant)

Feel free to call and or stop by the office to book an appoinment.

At Wed Apr 23, 02:40:00 PM, Anonymous Anonymous said...

Hi! I find it rather funny that majority of you have dissmissed medical reps like there scum.
However, isnt it funny that your paid on the number of patients you see? Additonally doctors are more bussiness like then any drug rep..they too have targets(aka their patients)!
I have been to my local doctor numerous times (over 6 years) and all she does is pass me on to a specialest. So do tell me what do GPs do aprat from throwing you off to another doctor?
I am totally digusted with how the NHS is run, and more seriosuly i dont trust any doctors or medical reps! Where have all the good doctors gone?
How desprately unfortuante is that?

At Thu Jun 19, 07:40:00 PM, Anonymous Anonymous said...

You Have Now Been Sampled

While the pharmaceutical industry’s image and reputation has and appears to continue to suffer, added damage has expressed itself with costly patent expirations. Yet the big pharma task forces still insist that reps provide incredible value, and the more the better, as the drug reps are the givers of gifts, and reciprocity in the form of prescriptions just has to occur.
As a big pharma ex drug rep for over a decade, which during that period the number of drug reps actually tripled, the drug rep’s vocation has become more ridiculous, and possibly void of any true sense of accomplishment due to their customers preventing them from interaction or even presence in order for the drug reps to follow directives of the health care givers, and not their own employers, which is to influence their prescribing habits via direct dialogue along with the giving of gifts. The job has become nothing more than doing lunches and leaving samples at offices, for the most part. My perception formed from my own analysis of how drug reps operate in today’s environment in the medical community has led me to draw such conclusions, which I believe to be accurate.
So they may be named at times in different ways, these promoters will be referred to now only as drug reps, which number close to 100,000 in the U.S. presently to influence close to 1 million prescribers in this country, it is believed, yet is probably less now due to big pharma cutting thousands of reps recently. The cost to the pharmaceutical industry of these drug reps is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes and set their own hours, which I understand is much less than 8 hours a day.
The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value that are not gifts, but bribes, by definition. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples. Yet I want to be clear on what I am saying: drug reps are some of the smartest people you will meet that do in fact have great paying jobs with great benefits. Most importantly and my opinion, I believe most reps really WANT to do well for their employers, yet are prohibited from doing so now because of how their employers are now viewed in their medical community.
Many years ago, drug reps have used their persuasive, yet ethical, abilities to influence the prescribing habits of doctors in an honest and ethical manner, as they focused on the benefits for the doctor’s patients with a particular drug that the detailer may promote to such a doctor. However presently, most health care providers now simply prevent drug reps to speak with them- now this is especially true when they are in clinic treating and assessing patients. More and more medical establishments are completely banning drug reps from their locations, and I speculate that this is occurring for many reasons, which may include the following:
The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are an incredible waste of their time. Yet they will accept your samples still. The credibility you possibly have thought you had and were perceived as such by doctors as a drug rep is no longer viewed to exist to any noticeable degree by the prescriber. For example and this is based on my experience and my colleagues, doctors view any information you may provide to them as biased and embellished. In my opinion, based on information and belief, their view regarding their assessment of you as a drug rep is accurate due to the statistical gymnastics the employers of drug reps engage in, which effectively and ultimately is permitting and encouraging the drug reps to lie to the doctor and likely are unaware of the statements stated by them are misleading. Doctors by their very nature seek answers objectively. And doctors do in fact find out about drugs through other methods besides the representative of the drug’s maker, such as the internet and experience with certain medications. Most drug reps in this country in particular mostly hire drug reps based on such qualities as the candidate’s looks as well as their personality, overall. Furthermore, it is possible that pharmaceutical companies desire their drug reps to be obedient and to not question what is asked of them. Upon speculation, this can be possibly determined by the background of the candidate, which may indicate they seek popularity as well as are money driven. In addition, most drug reps do not have degrees remotely related to any aspect of anything of a scientific or clinical nature.
During my decade as a drug rep, I would encounter on very rare occasion another rep that may have been a nurse or researcher, and this is concerning that others do not have similar backgrounds because the type of training necessary is rare for a drug rep. In fact, based on my opinion, many do not particularly care to acquire education related to such medical or clinical topics. They learn the basics in order to sell their promoted products. Yet anyone who has ever worked with doctors in a clinical setting, or in a hospital working in a clinical nature, likely they would agree that a drug rep should want to and seek all related to the complexities involved in the restoration of another’s health.
Many drug reps, it is believed, are void of any complete interest in medicine completely, and I believe this to be necessary. In addition, ethical considerations due to their possible deliberate ignorance created by the necessity of what they are required to say or do by their employers may be viewed as a disturbing fallacy as well. This allows them with the encouragement and coercion of their employer to embellish the benefits of their promoted products at times in addition to offering inducements to doctors in various ways- most of all of which are rather covert, yet performed and issued to select prescribers upon instruction of their employer. Examples may be creating a check from your company to a certain supporting doctor and handing this check to thank a doctor for supporting your company’s products for doing little if anything for your employer to justify this check. Or tangible items are given to such prescribers, such as TVs or DVDs which may or may not be utilized in a particular doctor’s office. It happens often, such activities.
From the drug rep’s perspective, it is unlikely they will even consider the possibility to question their pharmaceutical employer due to the great risk of losing income and benefits that they are unlikely to acquire at another place of employment. Because of their consistent and conscious effort to keep their high-paying jobs, the drug reps always appear overtly anxious to please their superiors- regardless of any ethics or legalities regarding any activity they may be required to perform. With big pharma in particular, each drug rep is given a variety of budgets, such as a chunk of cash for doctor office lunches that they are required to spend in a certain period of time. Another chunk of cash may be assigned to a rep to pay assigned or registered speakers of their employer to speak to other prescribers about a disease state related to the drug rep’s promoted product. These activities, in my time with big pharma, were never monitored or questioned by managers or superiors. What I did notice is that my annual raises were greater than others according to the amount I spent for that particular year, as this, according to a big pharma company, was a very objective and noticeable variable with securing and keeping your employment in big pharma.
While legally risky, the drug companies continue to dispense to their reps these large budgets their drug reps are in effect coerced to dispense with complete autonomy and possibly the spending can be fabricated, which is too complicated to fully explain. This design perhaps is why there are now various state and federal disclosure laws that are presently being considered to mandate the release of all funds dispensed from pharmaceutical companies as far as why a company’s funds were spent and for what reason or method. Because, according to the lobbyists of pharma companies, they consistently insist that whatever they spend always is for the benefit of public health. As mentioned earlier, presently such activities are quite covert. Yet if such laws are mandated, it is likely the accounting of pharma companies will become rather creative and incomplete. In summary, as a big pharma drug rep, my budgets were unlimited, and I typically spent more than I made though the activities I have mentioned so far. And this is not an isolated case.
Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies or pharmacies, by providing others identifying numbers of a particular doctor, such as a state license number or DEA number, which allows them to track the scripts a doctor writes not far from real time availability. This data shows the volume of scripts of a particular doctor and what the doctor has been prescribing for the doctor’s patient for their disease state, and this data reveals competitor products to the drug rep as well. Aside from being deceiving and dishonest, the data allows a pharma company to ‘reward’ those doctors who support their products, while treating the other doctors with ‘neglect’, which means the non-supporters of a pharma company will not receive any inducement or remuneration from a particular pharma company. The data, by the way, only reflects numbers linked with particular products, and fortunately is free of patient names- this data that is provided to all drug reps. What has been described is the method typical with all big pharma companies, in my opinion, and I worked for three of them. It appears to be manipulative in a psychological paradigm- a combination of Pavlovian responses combined with positive and negative reinforcement.
So such methods create a toxic culture required to be absorbed by those members of such a pharma company. Furthermore, the tactics implemented by pharma companies vacuum the judgment of prescribers, which may prevent patients from receiving objective treatment. Yet on the most basic level, it is the samples left with prescribers that ultimately determine their prescribing habits- with various inducements to some doctors running close in second place. Yet remarkably, prescribers are prescribing more and more generics, which typically are not sampled to prescribers. I find this comforting that the manipulation efforts of the pharma industry are not as effective as they believe they are in a rather delusional way. Yet what is happening now in regards of branded meds vs. generic meds, insurance companies are flat out paying doctors to switch patients to a generic if one is available, as well as initiating generic medication treatment for their patients. I speculate they are paying doctors for this as a response of what pharma has been doing for quite a long time. From a clinical paradigm, if a medication is providing desired treatment and good tolerability for a particular patient, one could argue it would be unethical to switch treatment for financial gain, further complicated by the fact that most patients are aware that insurance company payments to doctors for this even occur.
It is likely and I believe that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment. In other words, the drug reps have compromised their integrity, ultimately.
It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Because it is obvious that internal controls with such corporations exist on paper often, but clearly are discouraged to be enforced. It is possible that these pharma companies falsely believe that being an ethical company would make them a company without excess profit. One can only speculate on their true motives. Yet it appears that overt greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative. Perhaps most frightening is that most drug reps fail to dig deep enough to realize that what they do at times may damage public health.

“What you don’t do can be a destructive force.” --- Eleanor Roosevelt

Dan Abshear

Author’s note: What has been written was based upon information and belief.

At Mon Jan 12, 03:36:00 PM, Blogger PH said...

I enjoyed this post.

I work in a medical office, and it's been so nice lately because a lot of the local reps have been scaled back. I don't miss the smarm!

At Tue Jul 28, 05:02:00 PM, Anonymous Mike S. said...

Thank you for your wonderful site. I respect your "just say no to drug reps/drug dealers/ etc.... greed has certainly replaced ethics and integrity. I trained at a Harvard teaching hospital and drug dealers were BANNED from the hospital with police action if necessary. What does steak dinners, luxury box seating, horse racing tote tickets, spa days have to do with pharmacotherapeutics????? Again, thank you for having the ovaries and integrity to do what's right for medicine and our patients; we have enough sheeple in this world, refreshing to find someone with some guts to stand up to the drug establishment and their bottom line greed.

At Thu Jul 30, 12:17:00 PM, Anonymous Anonymous said...

You know, I can agree with what you have all said about how allowing drug reps in your practices can be disruptive and an unpleasant experience.

However, as a drug rep, I go in day in and day out and get treated TERRIBLY as a person by providers and staff. I respect practice policies, don't monopolize the time I am given and sure as hell don't give out steak dinners/luxury boxes/tickets/etc.

I came into this industry thinking I would be able to learn about medicine, healthcare and and industry that perhaps helped people, but I can tell you it leaves me with nothing but anger that people can't at least treat me and other reps like a human being. I AM interested in your practice and how I can help your patients. I'm not asking you what you think just because. I actually care and want to learn.

And as far as getting "bribes?" How are those any different than being rewarded for writing a generic as opposed to a branded drug?

I imagine you all, like me, went into this industry to help people feel better both on a mental a physical level. When I am laughed at, yelled at, treated like a disease, you might as well forget about your mission in life to make people feel better, because you're making a lot of people feel a lot worse. Do doctors need to cut reps down and make them cry? What good does that do? Do nurses need to give reps snide remarks? I'm not a particularly sensitive person, but after the same treatment over and over again it begins to hurt and I can tell you I am certainly not the only rep in the world that feels like this.

Isn't it possible for us to work together and have some respect? Please?


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