Drug reps: Understanding the hand that feeds you

Dr. RosevearWe had Chinese on Tuesday. There was Mexican on Wednesday, but the best part of that meal was the dessert tray. It was a nice touch, as most reps don't bring dessert.

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I was sitting at my desk after lunch Wednesday waiting for my first patient to be roomed (and enjoying my second cookie of the day) when I started thinking about the modern relationship between drug reps and physicians. Our practice allows industry reps to visit, so you could argue that I have already formed an opinion on reps. But the stark contrast that exists between my experience in the real world and that of my residency program, where industry reps were not even allowed on campus, is enough to give me pause and make me consider their role in medicine today. 

As anyone who has read this blog before would guess, I started by researching the history of the drug rep industry to better understand how we got to where we are today. Drug reps (also called industry reps or "detail" reps for their ability to give details about a drug) have been around since the 1850s. The evolution of their job paralleled dramatic changes in medicine as a whole.

Originally, drugs were directly marketed to consumers and the drug rep concentrated on what would nowadays be considered direct-to-consumer advertising. In the early part of the 20th century, the American Medical Association started promoting the concept of an “ethical” drug company, defined as one that worked with a physician with no direct-to-consumer advertising. This moved the industry rep into the physician’s office, where his interaction with the physician was not only accepted but encouraged.

Later, especially after World War II, as the pharmaceutical industry became more complicated and as the number of marketed drugs dramatically increased, the role of the industry rep evolved into providing "details" about drugs directly to physicians. These hybrid salesman/pharmaceutical experts soon realized that doctors gave them more time if they came bearing gifts, in essence establishing a feeling of reciprocity.

It turns out that there is an entire social science showing that simply giving a gift, even a small one (remember when drug reps gave out pens?) increases the feeling of reciprocity between the physician and the rep. What is reciprocity? It is the tendency for most of us to be nice to someone if they are nice to us, and in this case it means that I am more likely to prescribe a drug if a rep has been nice to me.

By the 1980s, as some of my more experienced colleagues may remember, it was not uncommon for drug reps to give expensive gifts to physicians. This changed in 1990, when the FDA began to outlaw "gifts of substantial value." While this decreased the giving of gifts, it simply made gifts of meals and travel more common.

Next: Direct-to-consumer advertising

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The next major change was in 1997, when the FDA allowed for direct-to-consumer advertising of prescription drugs. This is worth noting because most young physicians probably don't remember a time before half of all commercials were for prescription drugs. This is also important because it created a second "lobby" group that a physician had to deal with, namely patients.

In 2002 (revised in 2008), under increasing pressure to curb some excessive gifts of travel to doctors, the Pharmaceutical Research and Manufacturers of America established a voluntary code that restricted gifts to those that were educationally related. Out went the all-expenses-paid trips to Cancun.

The next major development didn't occur until the passage of the Affordable Care Act, aka "Obamacare," which introduced the Physician Payment Sunshine Act, better known simply as the Sunshine Act. This law states that pharmaceutical and medical supply/equipment makers need to disclose to the government any gift over $10 and that this information will be published on an online database for anyone to access. Interestingly, even before this law was passed, many pharmaceutical companies were already releasing details of payments made to doctors for promotional talks and research. The Propublica site provides an online searchable database of that information.

With all of those laws in place, the simple question I asked myself is, why does the pharmaceutical industry spend billions each year on meals and such for doctors? The simple answer: because it works. A book by Jamie Reidy called "Hard Sell: The Evolution of a Viagra Salesman" (the basis of the 2010 movie, "Love and Other Drugs”) describes Reidy’s life as a Pfizer drug rep. In the book, Reidy says the foremost job of the pharmaceutical rep is to change a physician’s prescribing habits.

Next: How drug reps know my prescribing habits

How do these drug reps know my prescribing habits in the first place? The answer is, they buy that information. There are numerous companies (IMS Health is one of the largest) that purchase this information (without patient names but sorted by physician license number) directly from the pharmacy companies, repackage it, and then sell it to drug companies. Tracking physician prescribing habits does many things for drug reps. It allows them to target physicians who don't prescribe a certain drug, reward those who do prescribe drugs, and it helps drug rep supervisors gauge a rep's effectiveness.

In response to this, in 2006, the AMA started a program called the Prescribing Data Restriction Program. While it allows doctors to withhold this information from reps, the reps’ supervisors still have access to it. This problem has become so acute that New Hampshire passed a law forbidding pharmacies to sell this information. Remember, the next time a drug rep asks what you think of her medicine, she probably already knows not only how often you prescribed it this month but also how many times you prescribed competing drugs!

Armed with a vast amount of data about individual doctors’ prescribing habits, drug reps use interesting tactics to make us change those habits. A great article, “Following the Script: How Drug Reps Make Friends and Influence Doctors” by Adriane Fugh-Berman and Shahram Ahari, includes a wonderful table describing different types of physicians and how reps approach them. I was amazed that not only was I well described in one the table’s categories but it also correctly stated how most of the reps who visit my clinic interact with me.

Given the information above, does this mean I should close my door to industry reps? I don’t think so, anymore than we should go back to outlawing direct-to-consumer drug advertising. The simple fact is that the goal of a drug rep is to get me to prescribe more drugs, so certainly they are trying to influence me. But that observation alone does not require me to avoid them.

Rather, I believe what matters is that we as a physician community are aware of the tools and techniques that industry reps use in their efforts to influence us so that when we evaluate their products we can make a decision that is best for our patients. If in the process, a drug rep wants to provide lunch for my staff and me, I have no problem with that. I only ask that they bring dessert.

As always, my goal with this blog is to help other urologists avoid the mistakes I have made so that they have more time to spend with their families and friends. If anyone has a different opinion about the role of the industry rep in medicine, please write me.

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