by Gwen Olsen
As critics of DTC-advertising had already suspected, the authors found “antidepressant prescribing rates were highest for visits in which standardized patients made general requests for medication (76%), lowest for visits in which standardized patients made no requests for medication (31%), and intermediate for visits in which standardized patients the made brand-specific requests linked to DTC advertising (53%).” The results of this study “underscore the idea that patients have substantial influence on physicians and can be active agents in the production of quality,” wrote the authors. “The results also suggest that DTC advertising may have competing effects on quality, potentially averting underuse, while also promoting overuse.” Finally, they concluded, “The results of this trial sound a cautionary note for DTC advertising but also highlight opportunities for improving care of depression (and perhaps other chronic conditions) by using public media channels to expand patient involvement in care. [Here! Here!] Furthermore, physicians may require additional training to respond appropriately to patients’ requests in clinically ambiguous circumstances” (Kravitz).
The excessive use of these DTC ads that rely on emotional appeals rather than medical evaluation and supply very little health information further undermines the patient-doctor relationship and the provider’s clinical judgment about which drugs should or should not be used for the patient’s medical benefit. It increases risk along with cost. However, the pharmaceutical companies argue these ads help improve public health by informing consumers and raising awareness. Proponents of the ads claim DTC advertising serves as an educational tool; even though, most of these ads vaguely describe the drug benefits in qualitative terms and then rarely support their claims with any clinical evidence (Kravitz).
Just remember, there are many older, less expensive drugs that have been around awhile. They also have much safer side effect profiles than the newer, highly promoted products. One of the reasons that Americans pay, on average, more than seventy percent more for our drugs than consumers in Canada and other countries is that DTC advertising of prescription drugs is not allowed in most foreign countries. Billions of dollars are spent annually on the advertising to create markets for branded prescription drugs. Which leads one to wonder: Exactly how medically innovative are these new products if they require such a massive effort to market? For example, Merck spent more than $160 million dollars in 2000 on DTC ads for Vioxx alone. In 2003, industry spending on DTC advertising totaled $3.2 billion (Kravitz). Those advertising expenses were passed on to you, the consumer. That would perhaps explain why expenditures for prescription drugs over the past several years have been increasing seven times faster than the rate of inflation (Abramson 245).
Also, contrary to what people may think, the FDA does not review DTC ads for accuracy and false claims before they are aired or published. When a manufacturer is found to be in violation by misrepresenting product benefits or risks, it has historically taken the FDA as long as one year to get the ads pulled or revised. A proverbial slap on the wrist is all that the company usually receives. When fines are levied, they rarely equal the positive financial impact the misleading ad has made for the company. Apparently, the long arm of the law does not reach as deeply as some of the pockets in this industry do.
The Smoke Screen of R & D Costs
If there is a mantra shared among all drug manufacturers, it is the catchall excuse of the high cost of research and development (R & D). As predictable as a beauty contestant’s desire for world peace in any pageant interview, it is the automatic response each rep in the industry gives to exorbitant pricing complaints. In fact, they are almost smug about costs. “After all, you get what you pay for, right?” Of course, that statement would suggest to the doctor that the older products, now available generically, are in some way inferior to the newer, more costly products. “You do want cures to be found for cancer, AIDS, heart disease, and Alzheimer’s, don’t you? Well, who’s going to pay for that?”
The truth is, one way or another, you are! However, it probably won’t be through the outrageous prices you pay on prescription drugs. It will more than likely be through your tax dollars and the grants bestowed to the few tireless scientists and researchers who truly are in search of these cures as their mission in life. Moreover, the cures to our greatest medical fears probably won’t come from a pharmaceutical company’s laboratory either. Why? It does not benefit the pharmaceutical manufacturers to cure our diseases and restore our health and vitality. That’s why!
Pharmaceutical companies are not the great humanitarian organizations we might want to believe they are. These executives don’t rise to their morning coffee every day bursting with philanthropic desire to heal the world. They are businessmen who are accountable to stockholders and are basically motivated by bottom-line profits. Healthy profits! As my first regional sales manager pointedly told me in my final interview, “If it’s altruism that motivates you, kid, join the Peace Corps. But, if it is money that motivates you, let me show you how you can retire a millionaire with this job!”
Drug manufacturers maximize their profits by treating our symptoms. The more long-term the illness is, the more profitable the treatment with drugs.
Just What the Doctor Ordered
Most of us think of drug dealers as the seedy characters that hang out in our schoolyards and back alleys trying to lure our children into drug addiction or as the rich Colombian warlord who runs a cocaine empire with machine guns and cash payoffs. The truth is that some of the most lethal drug dealers wear suits and ties, drive company fleet vehicles, and live in your very own neighborhoods. More importantly, they are addicting you and your children to the drugs they sell via your most trusted relationships—those with your doctors!
For the most part, pharmaceutical reps are attractive, personable, engaging sales professionals. The industry boasts of spending nearly $100,000 initially to hire, train, and indoctrinate a new rep. Basic sales training classes are much like boot camp and are designed to weed out the faint of heart or easily intimidated. (Working with the egos of doctors can wear on even the strongest self-esteem!) Trainers push new recruits to the breaking point, often giving them long hours of homework assignments into the night and weekends, videotaping sales presentations, and testing medical product knowledge. The environment is highly competitive as most reps desire to excel in front of their colleagues and educators. Not surprisingly, large numbers of these new hires cannot endure the stress and do not complete all tiers of their training. Only the most tenacious and ambitious succeed in having long-term careers in the industry.
Unfortunately, many reps come from other sales backgrounds that have little or nothing to do with either health care or medicine. Take me for example. Before joining the pharmaceutical industry in 1985, I had not so much as taken a chemistry or biology course. My undergraduate degree is a bachelor of arts in foreign language, Portuguese and Spanish. Although I consider myself intelligent and a fast learner, I was at first unequipped with the knowledge I needed to have even a basic understanding of the disease states and physiology or pharmacology involved in the drugs I was selling. That meant I was completely reliant on the product managers and marketing department for the accuracy of the information I gave doctors.
We were instructed to promote our products in a given manner and with a particular focus. This was called marketing direction. Individual thinking and style was definitely discouraged. Sales literature and visual aids were all geared toward the promotional message, and they were utilized in role-plays until the presentations flowed naturally. Reps were taught to handle and minimize the objections physicians might have. They were given the specific wording that would best represent the company’s position. Often, these instructions came from the legal department who would review the sales documents for legal accuracy. If a visual aid initiated too many negative questions from physicians, the bar graph, product comparison, and so forth was reworked in a way that presented the information in a more favorable light. I had alread
y learned the manipulative advantage of semantics in language, and I soon learned the semantics of research were called statistics.
Most doctors would deny the influence that sales reps have on their prescribing behavior. However, the fact of human nature is that we tend to support people that we like and feel are supportive of us. The pharmaceutical industry knows this all too well, and it provides the means for busy doctors to be accommodated in their practices by helpful, attentive sales professionals. These reps not only provide samples, lunch, medical education, tools and devices, medical textbooks, calendars, scratch pads, and pens, but they also influence the doctors’ personal lives. Reps make generous contributions to office parties, fund-raisers, and golf tournaments. They provide tickets to local sporting events and entertainment venues, and they coordinate social events such as boating, fishing, and hunting expeditions disguised as CME opportunities.
For example, if one of my doctors was too busy for me to gain regular access to his practice, I would invite the doctor and his wife or family to dine with me and a key opinion leader (KOL) in the community (a supporter of mine, of course). One time, I remember leasing a private room at a four-star Italian restaurant. That afternoon, I sent a singing Italian waiter to the doctor’s office with a bottle of champagne as a reminder and an invitation to him, his son (who was also an HVP [high volume prescriber] with his own practice), and their wives to join my husband and me for dinner. I paid a local specialist, whom I knew to receive the majority of my HVP’s referrals, $1,000 to have dinner with us and initiate a round- table discussion about my product with the two family practitioners. The evening would more than pay for itself because both doctors increased their prescriptions more than twenty-five percent in the next three months. Prior to that, I had made very little impact on either lucrative practice. This practice of hiring KOLs to influence other doctors is quite common, and reps openly refer to these hired guns as prostitutes or drug whores because they are willing to sell their reputations to drug companies in this manner.
I have also known reps that joined a particular health club or church in order to gain casual access to a HVP who was difficult to access. One former colleague even babysat for a doctor’s children in order to win his favor. I have sent doctors singing telegrams from various entertainer look-alikes, and I once had a belly dancer snuck into a hospital cardiac cath lab for a cardiologist’s birthday. I was definitely a rep that was known as a goodie girl, and I never went anywhere empty-handed. I showered my giveaway items and promotional treasures on anyone and everyone in my path. For holidays and special events, I would make up goodie baskets around the theme of the occasion (for example, Easter, Halloween, or Christmas) and fill them with chocolates and gimmick items for office staff. On any given day or visit, there was always a trail of evidence from the latest marketing plan in my wake.
Why do some reps go to such great lengths to access and influence physicians? Pharmaceutical companies provide lucrative incentives for reps who reach sales quotas, and a rep stands to make several thousand dollars in one lump sum as a bonus in addition to his or her quarterly salary. Merchandise from catalogs and trip incentives are common as well. Over the years, I have won a Nikon 35mm camera, a Sony camcorder, a telescope, stereos, a set of luggage, a VCR, a Maytag washer and dryer, a daybed, company car upgrades, parasailing lessons, a weekend getaway package, and a trip to Hawaii with my spouse. I prided myself in my ingenuity, and I used creative, unique approaches to gain airtime with busy doctors and meet company sales goals. With my work ethic and enthusiasm, I advanced quickly in my career.
Legislative Attempts at Regulating Gift-Giving
At least twenty states have introduced bills in 2007-2008 that would require pharmaceutical sales reps to file reports with their companies that detail the gifts they give to physicians. Of course, manufacturers are opposing the bills. PhRMA spokeswoman Wanda Moebius said the bills require manufacturers to disclose “trade secrets.” She also claimed the laws are unnecessary because PhRMA already prohibits the practices lawmakers are attempting to curtail with its professional code of conduct (Robeznieks).
Most of the legislation restricts the reporting requirement to drug manufacturers, so medical societies have been reluctant to get involved because it will not affect the administrative responsibilities of doctors. According to the National Conference of State Legislatures*, bills have been introduced in Arizona, California, the District of Columbia, Hawaii, Illinois, Kansas, Louisiana, Maryland, Massachusetts, Mississippi, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Oklahoma, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Washington and Wisconsin. Legislation was passed in these five states and made into law: CA, DC, MA, NY and VT (National Conference of State Legislatures).*
*(www.ncsl.org/programs/health/drugbill08.htm)
Learning That Ingenuity Sells!
My most successful, self-initiated sales campaign (and a perfect example of what I am discussing here) was in 1991 during the Gulf War. My husband had been deployed to Saudi Arabia, and everyone was talking about the war. It was difficult to conduct business under the circumstances. Nobody wanted to talk about drugs! So, I devised a “GI safety campaign” around Naprosyn, my new enteric- coated product, and utilized the war as my theme. I made all of my visits dressed in my husband’s desert camouflage uniform and distributed miniature American flags and lapel pins everywhere I went. My lead-in to each sales presentation was the likening of a doctor’s battle with disease to war and the necessity of ensuring GI safety in order to win that battle. Thus, the enteric-coated benefit (GI safety from ulceration) of Naprosyn provided the perfect bridge and play on words. My close to each presentation was an appeal for the doctor’s support of my business while my husband supported our country abroad. My Naprosyn sales went through the roof after that! Less than one month after my husband returned home, I was promoted to an ob-gyn specialty rep’s position and relocated to Austin.
The majority of drug companies know just what the doctor ordered, primarily because they subscribe to prescription data service companies that provide their sales force with detailed information on what doctors are prescribing in their practices. Pharmacies sell the doctors’ prescription information, allowing companies to pinpoint who is supporting their product line and who is not. Reps frequently know more about a doctor’s prescribing habits than he does himself! This data often verifies what marketers already know, and that is, when detail activity or call averages are increased in a doctor’s office, the result is generally an increase in prescriptions for the products being promoted. The more memorable the presentation or information the doctor receives, the larger the assumed impact.
It would take many years and dozens of conscience-altering experiences before I really comprehended the scope of just how much my profession affected the medical industry and the contribution I had made to harming thousands of trusting people.
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Related Current Events
“Intelligence is our first line of defense.”
—Pres. George W. Bush
Recently, several investigative reporters have uncovered examples of questionable promotional strategies and incriminating documents distributed by pharmaceutical companies to their sales force. These documents instructed reps to dodge and/or minimize serious side effects or complications associated with their products. One such example appeared in the Primetime Live special on antidepressants (“Drug Company Investigation”) that I referenced previously. ABC obtained marketing instructions issued to Paxil reps to minimize withdrawal side effects of the drug to doctors. Another appeared in a 60 Minutes piece aired in November 2004. A paper trail uncovered by CBS revealed instructions for the intentional dissemination of misleading information in association with the Merck drug, Vioxx (“Prescription for Trouble”).
With annual sales of more than $2.5 billion before being pulled from the market on September 30, 2004, Vioxx was one of the most successful new drugs ever launched.
It was no small wonder considering the barrage of TV ads and unprecedented amount of direct-to-consumer advertising Merck employed (Appleby and Krantz).
Merck voluntarily pulled Vioxx after a new study showed the risk of heart attacks and strokes had doubled in the patients taking the drug. The document 60 Minutes obtained was a training manual entitled “Dodge Ball Vioxx.” It consisted of a twelve-page list of objections that could be posed by physicians. Among them was the objection, “I am concerned about the cardiovascular effects of Vioxx.” A former Merck rep was quoted in the interview as saying, “We were supposed to tell the physician that Vioxx did not cause cardiovascular events, that instead, in the studies, Naproxen has aspirin-like characteristics which made Naproxen a heart-protecting type of drug where Vioxx did not have that heart- protecting side” (“Prescription for Trouble”).
However, Naproxen has never been proven to have cardioprotective features like aspirin, and it has itself drawn negative attention in the same National Institutes of Health study that exposed the Cox-2 cardiovascular risks. At least two studies sponsored by Merck drew red flags early on to the cardiovascular and stroke event increases: the 1999 VIGOR (Vioxx Gastrointestinal Outcomes Research) study and the unpublished 1998 Study “090.” (It is not uncommon for drug companies to claim their studies are “proprietary information” of economic value, thereby keeping the outcomes a secret.) Both studies showed an alarming (as much as sixfold) increase in cardiovascular events, including heart attack and stroke.
