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SOLD ON DRUGS / WOOING THE GATEKEEPER

Doctor, just a little something for you

Complex sales strategies go way beyond freebies.

August 06, 2007|Melissa Healy | Times Staff Writer

As guardians of the nation's prescription pads, doctors are the gatekeepers that stand between American patients and the pharmaceutical companies that have drugs to sell them.

Physicians' choices -- whether to medicate, with which medication, generic vs. brand-name drug, and for how long -- profoundly affect sales of a drug company's products. So pharmaceutical manufacturers focus the bulk of their marketing budgets to influence those choices. The drug companies' promotional efforts reach into physicians' offices, pervade their medical specialty organizations and often shape the messages that doctors receive in educational settings.

"There is a big bucket of money sitting in every office" a drug representative visits, said an AstraZeneca marketing director in a widely circulated newsletter interview. "Every time you go in, you reach your hand in the bucket and grab a handful," said Mike Zubillaga, who was fired after his blunt comments made their way onto the Internet last April.

Each day in the United States, an army of roughly 100,000 pharmaceutical company sales reps storms the waiting rooms and offices of the nation's 311,000 office-based physicians. Called "detailers" -- and earning, on average, $81,700 per year -- they are the smiling, well-dressed men and women often seen in a physicians' waiting room toting a cavernous briefcase and making small-talk with the receptionists. Their ranks have more than doubled in the last 10 years.

Sales reps say they want nothing more than to drop off drug samples that doctors can dispense at no cost to their patients, and to brief physicians on the FDA-approved benefits and risks of the prescription drugs their companies make. That's an accurate job description. But it doesn't nearly capture the sophistication of their efforts or the complex web of relationships that marketing departments cultivate with physicians. In recent years, drug-company insiders have come forward to detail the enticements, persuasive techniques and market-tracking systems that their organizations use to nudge doctors' prescribing decisions to boost sales. The picture they provide is of an industry in hot pursuit of physicians' hearts and minds.

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Relationships with drug reps

The inducements that doctors accept are more than just pads, pens and gadgets such as the Viagra calculator that stands up on its base when the "on" button is pushed. A national survey of doctors published in the April 2007 New England Journal of Medicine found that 94% of physicians in the six specialties studied reported some type of relationship with pharmaceutical companies' representatives. Most (83%) received food in their workplace, or accepted drug samples (78%) proffered by visiting representatives. Thirty-five percent reported that drug companies had reimbursed them for the cost of attending professional meetings or company-sponsored sessions that satisfied a physician's "continuing medical education" requirement. And 28% received payments for consulting with a drug company, giving lectures or enrolling patients in trials.

The American Medical Assn. and the pharmaceutical industry group PhRMA adopted non-mandatory codes of conduct in 2002 that discourage the offering or acceptance of items that bring only "personal benefit" to a physician. Shahram Ahari, a former drug rep with Eli Lilly, says that in many cases, those guidelines have given the practice of gift-giving "a nice veneer of respectability."

But the practice's impact is often unaltered -- and may even be greater than when drug reps were permitted to offer extravagant gifts such as theater tickets and golf bags. That is because psychologists have shown consistently that a small token or gesture of friendship often inspires a sharper sense of obligation in the recipient than does a showy gift, for which reciprocation is impossible.

Moreover, Ahari says, "the amount of money invested in gifts hasn't changed. In the past, I could spend $100 on a golf club and give it to you. Now, I can spend $100 on a textbook you need so you can spend your own $100 on that golf club."

Sales reps bear many gifts, but none is more important than the prescription drug samples they bring to doctors. In 2003, the pharmaceutical industry distributed $16.4 million worth of them to doctors, according to PhRMA, the industry's most important trade group.

"For me, that's access," Ahari says. "The doctors are first grateful that you're giving them samples, because it makes them seem like a hero to patients . . . and when they feel that sense of gratitude, they feel obliged to spend some time with the drug rep delivering them." But in the end, it is the patient who often will pay more, because even a short course of sample use builds customer loyalty to a brand-name drug, even when a generic or a cheaper, older drug might be just as effective.

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