AHMM, September 2007

by Dell Magazine Authors

  The guilty party was the one who had encouraged the doctor to prescribe the terbutaline pump. Dawna turned her attention to Nacere, which hadn't existed in 1993. The pump manufacturers warned off at that time by the FDA had disappeared in a flurry of mergers, consolidations, and reorganizations. Nacere had emerged from the ashes, the terbutaline pump one of a range of products included in their home health care programs for the management—conveniently—of respiratory disorders and high-risk pregnancies. Only one device out of a half dozen, Dawna noted, but at a cost to the patient of fifteen thousand dollars per month, the strap-on pump generated ten times more profit for Nacere than that earned by their uterine monitors and everything else combined.

  Which was why this final training session focused on it. Right now, Forrester was trying to extract reason number eight why Nacere's infusion pump was the world's best.

  Whitney's perfectly manicured hand waved eagerly. Fighting the cute-but-dumb ex-cheerleader stereotype, Whitney memorized every piece of information the company provided.

  Forrester's eyes crinkled as though he were sharing a great joke with the dozen trainees, and he gave Whitney the nod.

  "Dermatitis,” she announced triumphantly.

  "Very good, Whitney.” Forrester's smile widened a hair, approving her answer at the same time he seemed to bind her to him. “Our pumps don't cause rashes. We don't use nickel or acrylic needles. Our sharp-pointed Teflon cannula is a state-of-the-art skin-puncturing tool."

  He cupped a hand to his ear, and Dawna forced herself once again to join the class in chanting the mantra he demanded after each assertion: “Our competitors can't say that."

  Waving her hand for attention, Whitney wrinkled her forehead to demonstrate her puzzlement. “But aren't rashes a side effect of the drug?"

  "In rare cases.” Forrester's voice was pitched at just the right level to soothe Whitney's fears.

  Dawna couldn't help admiring his perfection. Playing basketball, she'd had to anticipate moves the other players would make. She'd learned to read people, and she'd honed that skill when she joined law enforcement. A cop also has to guess what witnesses aren't saying and what criminals will do next. She thought she was pretty good at it.

  Kyle Forrester was better. Plus, he'd turned his natural talent into an awesome sales tool. He'd taken his keen intuition and worked it into an invasive ability to assess people's needs. He was more than a born seller—he'd bulked up that ability to where he might be the best salesman on Earth. He could look at the way a person held her head or moved her hands and analyze instantly what ploy would work on her.

  He watched Whitney adjust her pleated plaid skirt over her muscular bare legs as he added, “The rash side effect is a problem for the pharmaceutical company, not us. We supply only the means of delivery. Our pump has no side effects."

  Dawna allowed herself a mental snort while she kept her admiring expression in place. Technically, maybe, the pump was clean. But giving the drug intravenously for more than a few days produced the most lethal side effects. Nacere's not-so-innocent device pumped the terbutaline right into the patient's veins, at regular intervals round-the-clock, typically for ten weeks or more.

  Dawna had seen that blatant disregard for the patient as a basis for criminal investigation. She knew the crime wasn't one that would automatically interest the FBI. Sure, the Bureau was the primary investigative agency in the fight against health care fraud, but FBI resources were directed at problems more significant nationally than potential illegal marketing by a medical equipment manufacturer in Dallas, Texas. Such a problem would ordinarily be of interest only to the local community, and addressing it left up to the Dallas field office.

  Between Dawna's in-house maneuverings and her daddy's calling in favors from fellow lawmen all over Texas, the Special-Agent-in-Charge of that office had been easily convinced to mount an operation. Dawna hadn't expected to work a case where her sister was the victim, but she emerged as the agent best suited for the job. She already had a half dozen successful undercover ops on her record. Plus, she came closer than any other agent to filling Nacere's requirements for salespeople: With her slender figure and curly blond hair, she was good looking and appeared to be under thirty years of age. Though she hadn't been a cheerleader, she had played college basketball where her commanding six foot three inches had made her a standout from her freshman year.

  The decisive factor, though, was that Dawna's favorite college cheerleader and former classmate Julie-Karen Linden now ran Rally Marketing Stars, an employment firm and recruiting pipeline that linked college cheerleaders and athletes to the pharmaceutical and medical supply industries. Nacere was a Rally client, eager to hire from their pool of wholesomely sexy salespeople.

  After talking with Dawna, Julie-Karen realized that if Nacere were engaged in illegal promotion, the new sales reps that she recruited for the company could end up taking the fall. Suddenly, it seemed ominous to her that Nacere screened out potential new hires who had science backgrounds or prior medical sales experience. College education wasn't even a prerequisite for employment. Why did the company want sales reps who knew only what Nacere taught them? Could it be that those new reps weren't being taught to stay on the right side of the law?

  Julie-Karen liked the young men and women she recruited. She didn't want any of them ending up in a federal penitentiary. On the other hand, if Nacere was clean, she didn't want to lose the company as a client. For that reason, she agreed to infiltrate only Dawna into the company. She didn't trust the FBI to protect her from repercussions, but back at UT, she'd led the cheers when Dawna scored. In Dawna she had faith, and the SAIC had been in Dallas long enough to understand that local ops worked best when they went down Texas-style. He sent Dawna undercover to Nacere.

  So now she sat in the sleek glass and concrete corporate headquarters near UT Southwestern Medical Center, one of a dozen new Nacere reps, bracketed by Whitney and Roc. Like Dawna, those two had been hired through Rally Marketing Stars, and both thought she was as eager to earn abundant sales commissions as they were.

  All Dawna wanted was to nail Kyle Forrester for the gigantic whopper his company had to be telling. But her testimony alone wouldn't be enough. She needed one more piece of evidence to seal the case against Nacere. The tiny but powerful digital recorder resting at the bottom of her deep trouser pocket had to capture the voice of the marketing chief instructing his sales force to tell obstetricians that using the terbutaline pump was an excellent way to prolong a high-risk pregnancy. Forrester was giving them the final pitch. He had to include the damning words.

  He stopped, plucked a vibrating cell phone from his shirt pocket, checked the digital display, and looked up at the class. “Sorry, have to take this call,” he said, heading for the door. “Have a break, I'll be back in five."

  Roc unfolded from the chair beside Dawna, rising on his toes and stretching his arms above his head. She stood and faced him, their eyes on the same level. “Want some coffee?” she asked, glancing down to include Whitney, who was a foot shorter.

  "No caffeine,” Whitney replied, bright eyed. “I'm already wired. I don't understand how you can doze off when Kyle's talking.” Her voice caressed the first name.

  Dawna's snort was audible. “Not my type."

  "And it shows.” Roc shook his head, reproving. “Bad move. You want to keep this job, you got to look like you're listening to the man. He's not exactly blown away by your sales talent."

  "She's not that bad,” Whitney said to Roc. She turned toward Dawna. “Just give it a little more oomph, know what I mean?"

  Dawna knew exactly what Whitney meant, it was the woman's rule for life: Anything worth doing is worth overdoing. To stop Whitney giving her more advice, Dawna said quickly, “Then coffee is exactly what I need."

  "Too late.” Roc nodded toward the opening door. “The man is back and you better look sharp."

  Forrester was talking as he came into the room. “Take your seats everyone. I'm going to
have to cut this session shorter than we planned. I've got to see the CEO at three o'clock. That gives us twenty minutes, so let's get going. Somebody, give me advantage number nine that makes our terbutaline pump better than the others."

  Roc pinched Dawna's upper arm. “Go for it,” he murmured.

  She shook her head. “All yours,” she whispered back.

  His disapproving head shake echoed hers, and his hand shot up. When Forrester nodded at him, Roc said, “Our infusion device is small, simple, and easy to use. The patient wears it while leading her normal life at home."

  Forrester fine-tuned his expression for Roc, giving a more manly attaboy breadth to his smile. “Exactly. Our pump keeps the patient ambulatory.” Forrester waved his hand like a conductor with a baton. The class chanted the correct response.

  "You guys are fantastic.” Forrester shook his head as though amazed. “Truly, I've never met with another group that showed such super potential. I'm looking forward to seeing the sales figures you generate. And as your reward, you can stop working so hard. I'll give you number ten on this list. But in a minute. First, I can see that a couple of you are sitting on questions, not answers. So spit them out, nobody has to leave here with less than perfect understanding of the company."

  Dawna met Forrester's gaze with an attempt to look as open and honest as he did. Not that he'd be misled for long, but she hoped he'd pick on someone else first. She needed a few more seconds to phrase her question. In her scramble through her brain, she kept tripping over all the wrong thoughts his last remarks had triggered.

  Luckily, before Forrester could call on anyone else, Whitney jumped in. “The portability of the pump is a big plus,” she said slowly. “But does it work?"

  "The pump?” Forrester raised an eyebrow. “It does what it was designed to do. It puts the drug into the body."

  Whitney blushed and gave an oh-silly-me toss of her hair. “Okay, I guess I'm back at the drug, again. Terbutaline. Effective in the treatment of asthma, I know that. But women in the home obstetrical management program use the terbutaline pump too. I can't tell from what I've read, if that really keeps a woman from going into labor before she should?"

  Forrester shrugged. “There are studies out there that are positive and studies out there that are negative. You all got copies of relevant journal articles to deliver to the doctors in your assigned area. It's up to the medical professionals to evaluate the literature. At Nacere, we're the middleman. We follow the doctor's orders."

  Dawna's lunch roiled in her stomach, and she could taste chili blowback from her bean burrito. She knew Forrester would pick up on her heat, her fury was too strong to conceal completely. Nacere was just following orders? That excuse hadn't worked last century at the Nuremburg trials, and it didn't work for Dawna now.

  Whitney wasn't soothed either. “But is it safe?"

  Forrester allowed an undertone of irritation to creep into his voice. “The pump is safe, of course. I can't comment on the medication. All we do is supply the pump and our nurse hooks up the patient and monitors her progress.” His face smoothed out and he let his voice return to the comforting syrup he'd used on Whitney before: “I've heard of no client who was seriously harmed."

  As if he'd sensed Dawna's long backbone going rigid, he turned toward her, sharpening his gaze and his tone. “How about you?” he asked her. “You have any comments on the pump's safety and effectiveness?"

  She was outraged by his lies and evasions, but Whitney'd given her enough extra seconds to get her act together. Time to play the card she'd brought, the one that would protect her later if Forrester tried to claim she'd used entrapment on him. She pulled a paper from the stack in front of her. “This is a letter from 1997. The FDA warned physicians against using terbutaline, especially administered intravenously over the long term. They claimed, and I quote, ‘At least one maternal death occurred during outpatient use of a continuous infusion of terbutaline sulfate by subcutaneous pump.’”

  Dawna paused so that Whitney's predictable gasp could be heard by everyone. She added, “One maternal death sounds like serious harm to me."

  Forrester laughed. “Come on, Dawna, that letter is ten years old. We don't know a damn thing about that alleged death.” He held up a hand. “No, wait, we know two things. The patient wasn't our client, and she wasn't using our pump. Nacere wasn't founded until 2000."

  "Is that what we tell doctors when they mention this letter?” Dawna tried to look innocent.

  "They won't.” Forrester let his fatherly look return. “That letter isn't news. Most doctors have put those concerns to rest years ago. The only thing they're going to ask is how quickly you can get our pump hooked up to their patient. And that's our job, giving the patient what the doctor decides the patient needs."

  He was a magician, floating the audience into the ether, while he shifted the ground from under them. She'd never met his match. White-hot expertise in a field not Dawna's own always got her attention. Not always her admiration, absolutely not in Forrester's case. She stared down at her hands, hoping he wouldn't pick up on her disgust.

  Out of the corner of her eye, she saw Whitney's head move in an approving nod. Ordinarily, Dawna would've been nodding along with her, though not because she was reassured by Forrester's spiel. No, she'd have concluded that Forrester was too slippery to catch in this one-woman operation. She'd have quietly let the training session run its course, turned in her recorder, and gone on to another job. A cost-effective solution, one the Bureau bean counters never faulted.

  But this operation wasn't ordinary. No way was Dawna giving up, not after what happened to her sister. She had to make one last try, a long shot from mid court.

  "I must be missing something,” Dawna began, pasting what she hoped was an apologetic yet perplexed expression on the face she raised to Forrester. “I'm having a hard time seeing how I talk an obstetrician into using this thing."

  Forrester blocked her shot effortlessly. “That brings me to the tenth reason why our device is the best.” He paused, tilting his head toward the opening door. On cue, a chunky grayhaired woman dressed in green surgical scrubs came through pushing a rolling two-tier aluminum tray. A white cloth covered the top and centered on it was a palm-size polished white rectangle. It was the latest model of Nacere's infusion pump.

  "Let's face it, Dawna, you're not a natural sales star. You have to work to get your skill level up. But you're an athlete, you know practice is vital. And with our products, your practice will pay off.” Forrester rubbed his hands, imitation glee. “Our pump is smarter than the most advanced Nikon digital camera, and as easy to use as a Kodak kiddie model. This baby sells itself."

  He pulled three chairs to the front of the room and beamed at Dawna and her seatmates. “Dawna, let's see you try to sell this pump to Roc and Whitney. You three come up here and act this out for the group. You run into trouble, Dawna, maybe we can give you some ideas."

  Dawna, Whitney, and Roc exchanged glances. Whitney's was charged with excitement. Performing, it was her life. Roc's glare was less happy and directed at Dawna. She read him easily: What the hell have you gotten us into?

  Dawna shrugged and rose, following an eager Whitney to the front of the room. Run the play, see what happens, that's how the game works. Roc tagged after her.

  Forrester extracted a stethoscope from the lower tray and dangled it toward Roc. “Let's face it, the majority of our prescribers are male, so why don't you play the doctor? You're a dedicated obstetrician, on top of the latest developments in your field.” He grinned at the four other men in the room. “You fellows pay close attention and figure out what advantages you might have when you're discussing this product with a female physician. Remember what you learned in your sessions dealing with the sales rep/prescriber interface. You can put the device on the doctor, but you can't stroke her thigh."

  Dawna remembered those training sessions clearly. The speakers warned that sales reps couldn't give doctors gifts, honorariums, free re
sort weekends, or sexual favors to persuade them to prescribe products. Stricter FDA guidelines and industry self-policing had eliminated all those thinly disguised bribes prevalent in the past. Dawna had also noted what was missing from that lecture. Ten straight days of training and no speaker nor printed handout included the information that promoting a product for off-label use was illegal.

  "Whitney,” Forrester continued, “you're our patient. Not because you look pregnant,” he added jovially, “but since you're wearing a skirt, it'll be easy for Dawna to demonstrate how the pump works, using your leg."

  Demonstrate the pump on Whitney's leg. Take this thing that had nearly killed her sister and stick it to another woman? Dawna felt as if cactus spines were pricking the back of her neck, and she tasted secondhand chili again. She was sure that Forrester was aware of her discomfort and exploiting it, though he was looking at the class, not her.

  "Here's the deal. Roc, Dr. Jefferson, she's your patient and she's carrying twins. With twelve weeks to go in her pregnancy, she came in for a routine checkup and you spotted signs of preterm labor. You sent her home with a prescription medicine, but she had six more contractions that night and ended up in the hospital where they gave her a stronger dose of the same medicine and got the contractions under control. You set her up with home uterine monitoring and she did fine for another month.

  "But now she's in her twenty-ninth week and started dilating again. She was hospitalized last night and got a muscle relaxant to stop the contractions and an IV to stop the labor. The risk of preterm labor is now so high you want to try the procedure described in the article that Dawna left with you last month."

  He glanced up at the class. “The relevant handout is in your packet. Research published last year in the Journal of Care Management."

  There was a shuffle of papers and murmurs from the class. Dawna remembered the article in question. It was one of eighteen concerning infusion pumps that she'd found on the Internet and the only one which claimed to prove the treatment was beneficial to women in preterm labor. Of the five authors, four worked in Nacere's department of clinical trials. Dawna doubted the research would stand close scrutiny, but giving copies of only that article to obstetricians was a legal sales practice. It was up to the doctors themselves to discover the opposing arguments.