From THE ATLANTIC magazine
The Drug Pushers
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As America turns its health-care system over to the market, pharmaceutical reps are wielding more and more influence—and the line between them and doctors is beginning to blur
By CARL ELLIOTT
Back in the old days, long before drug companies started making headlines in the business pages, doctors were routinely called upon by company representatives known as “detail men.” To “detail” a doctor is to give that doctor information about a company’s new drugs, with the aim of persuading the doctor to prescribe them. When I was growing up, in South Carolina in the 1970s, I would occasionally see detail men sitting patiently in the waiting room outside the office of my father, a family doctor. They were pretty easy to spot. Detail men were usually sober, conservatively dressed gentlemen who would not have looked out of place at the Presbyterian church across the street. Instead of Bibles or hymn books, though, they carried detail bags, which were filled with journal articles, drug samples, and branded knickknacks for the office.
Today detail men are officially known as “pharmaceutical sales representatives,” but everyone I know calls them “drug reps.” Drug reps are still easy to spot in a clinic or hospital, but for slightly different reasons. The most obvious is their appearance. It is probably fair to say that doctors, pharmacists, and medical-school professors are not generally admired for their good looks and fashion sense. Against this backdrop, the average drug rep looks like a supermodel, or maybe an A-list movie star. Drug reps today are often young, well groomed, and strikingly good-looking. Many are women. They are usually affable and sometimes very smart. Many give off a kind of glow, as if they had just emerged from a spa or salon. And they are always, hands down, the best-dressed people in the hospital.
Drug reps have been calling on doctors since the mid-nineteenth century, but during the past decade or so their numbers have increased dramatically. From 1996 to 2001 the pharmaceutical sales force in America doubled, to a total of 90,000 reps. One reason is simple: good reps move product. Detailing is expensive, but almost all practicing doctors see reps at least occasionally, and many doctors say they find reps useful. One study found that for drugs introduced after 1997 with revenues exceeding $200 million a year, the average return for each dollar spent on detailing was $10.29. That is an impressive figure. It is almost twice the return on investment in medical-journal advertising, and more than seven times the return on direct-to-consumer advertising.
But the relationship between doctors and drug reps has never been uncomplicated, for reasons that should be obvious. The first duty of doctors, at least in theory, is to their patients. Doctors must make prescribing decisions based on medical evidence and their own clinical judgment. Drug reps, in contrast, are salespeople. They swear no oaths, take care of no patients, and profess no high-minded ethical duties. Their job is to persuade doctors to prescribe their drugs. If reps are lucky, their drugs are good, the studies are clear, and their job is easy. But sometimes reps must persuade doctors to prescribe drugs that are marginally effective, exorbitantly expensive, difficult to administer, or even dangerously toxic. Reps that succeed are rewarded with bonuses or commissions. Reps that fail may find themselves unemployed.
Most people who work in health care, if they give drug reps any thought at all, regard them with mixed feelings. A handful avoid reps as if they were vampires, backing out of the room when they see one approaching. In their view, the best that can be said about reps is that they are a necessary by-product of a market economy. They view reps much as NBA players used to view Michael Jordan: as an awesome, powerful force that you can never really stop, only hope to control.
Yet many reps are so friendly, so easygoing, so much fun to flirt with that it is virtually impossible to demonize them. How can you demonize someone who brings you lunch and touches your arm and remembers your birthday and knows the names of all your children? After awhile even the most steel-willed doctors may look forward to visits by a rep, if only in the self-interested way that they look forward to the UPS truck pulling up in their driveway. A rep at the door means a delivery has arrived: take-out for the staff, trinkets for the kids, and, most indispensably, drug samples on the house. Although samples are the single largest marketing expense for the drug industry, they pay handsome dividends: doctors who accept samples of a drug are far more likely to prescribe that drug later on...."
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