Drug rep creates stir with details on tricks of his trade

Drug reps come to physicians' offices bearing not just samples, gifts and meals, but an armamentarium of psychological and sales techniques aimed at changing prescribing habits, says a former Eli Lilly and Co. detailer.

Shahram Ahari, MPH, quit his detailing job in 2000 after a year and a half because of ethical concerns about the work. In an April article in PLoS Medicine, a peer-reviewed, open-access journal, Ahari writes that drug reps are trained to profile physicians by personality type and tailor their detailing approaches accordingly. It's a technique similar to what is done in other industries that involve sales. But other drug reps said Ahari's account distorts the truth, and drugmakers said detailers are professionals whose visits focus on education, not sales.

In an interview, Ahari said many physicians still are unaware of how much information detailers gather about the doctors they visit. Material ranges from up-to-date prescribing data to any personal details physicians might mention. Moreover, he said, drug reps' personality styles are assessed in training so that they can understand how best to form friendships with physicians and use those friendships to change prescribing behavior.

"A lot of physicians feel a sense of invulnerability to the marketing techniques that industry representatives use," said Ahari, a health researcher at the University of California, San Francisco. "That's really a false sense of security and one cultivated by drug reps themselves. They want to lure physicians into thinking they can't possibly influence their prescribing habits, when in the face of the facts -- and the salaries drug reps get paid -- it's clearly the opposite."

The journal article is part of an effort by PharmedOut, a project funded by a $400,000 grant from the Warner-Lambert settlement over allegations of deceptive off-label marketing of Neurontin (gabapentin). The project aims to persuade physicians to steer clear of drugmaker-provided information about pharmaceuticals.

Adriane Fugh-Berman, MD, who co-authored the article with Ahari, also is PharmedOut's principal investigator and an associate professor at the Georgetown University School of Medicine's master's program in complementary and alternative medicine.

She said one of the techniques Ahari outlined -- asking skeptical physicians to act as teacher and discuss shortcomings in journal articles supporting a detailer's drug -- shows the diversity of approaches drug reps employ.

"For me, flattery wouldn't work [as a sales technique], but asking me to teach you would work. If someone comes to me and says, 'Teach me,' how could I say no to that?" Dr. Fugh-Berman asked. "Physicians think they can extract useful information out of what's being provided by drug reps, but we're not trained in resisting psychological manipulation. We can't win this game."

Drug industry response

Drugmakers and other drug reps challenged such criticisms. "Pharmaceutical marketing is one of several important ways for health care providers to receive the information they need to make sure medicines are used properly and patients are safely and effectively treated," Pharmaceutical Research and Manufacturers of America Senior Vice President Ken Johnson said in a statement.

Johnson added that PhRMA's ethics code governs physician-drugmaker relationships and that information drug reps provide to doctors must comply with Food and Drug Administration marketing rules.

Sarah Taylor, a former Merck & Co. drug rep and author of The Secrets of Successful Pharmaceutical Salespeople, would not discuss the PLoS Medicine article at length but said, "My experience wasn't anything like that."

Pam Marinko, another former drug rep, agreed. Ahari "cherry-picked" prevailing practices and "served it all up in a negative light," she said.

Ahari's article "is the very kind of thing that gives drug reps such a bad reputation," said Marinko, CEO of Wilmington, N.C.-based drug rep-training firm Proficient Learning LLC. Marinko is so convinced of detailers' value in delivering the latest clinical information to time-squeezed doctors that for her personal medical needs she won't see a physician who has a no-drug-reps policy.

Drug reps do take extensive personality tests, she said, but noted that the pharmaceutical industry is far from unique in this regard. Critics of drug reps underestimate physicians' ability to discern "what's a pitch and what's not a pitch," Marinko said. The notion that "friendship sells, is demeaning and belittles the physician. It's absurd to suggest that a physician would make a prescribing decision based on whether he liked a drug rep."

But a medical ethics expert disagreed. Howard A. Brody, MD, director of the University of Texas Medical Branch's Institute for Medical Humanities, said physicians who spend all day with demanding patients may see friendly drug reps as a bright spot in the day.

"This [drug rep] is making you feel better about the world rather than being one more drain on you," said Dr. Brody, author of Hooked: Ethics, the Medical Profession, and the Pharmaceutical Industry. He said detailers use whatever tool proves most effective in changing a physician's prescribing behavior.

"The relationship of the average physician and drug rep depends on mutual denial that this is about selling," Dr. Brody said. "It could be about friendship, education, information -- everything but sales. But the drug rep's job really is to push all the physician's buttons and pretend they're not pushing the buttons."

The AMA has extensive ethical policy and guidelines on gifts from industry and says gifts primarily should benefit patients and be worth $100 or less. More information is online (link).