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Funding: This work was supported by a grant from the Attorney General Prescriber and Consumer Education Grant Program, created as part of a 2004 settlement between Warner-Lambert, a division of Pfizer, and the Attorneys General of 50 States and the District of Columbia, to settle allegations that Warner-Lambert conducted an unlawful marketing campaign for the drug Neurontin (gabapentin) that violated state consumer protection laws.
Competing Interests: Shahram Ahari is a former pharmaceutical sales representative for Eli Lilly, and the primary findings of this paper summarize points he made in testimony as a paid expert witness on the defendant’s side in litigation against a New Hampshire law prohibiting the sale of prescription data. Adriane Fugh-Berman has accepted payment as an expert witness on the plaintiff’s side in litigation regarding menopausal hormone therapy.
Citation: Fugh-Berman A, Ahari S (2007) Following the Script: How Drug Reps Make Friends and Influence Doctors. PLoS Med 4(4): e150 doi:10.1371/journal.pmed.0040150 Published: April 24, 2007
Copyright: © 2007 Fugh-Berman and Ahari. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abbreviations: AMA, American Medical Association
Adriane Fugh-Berman is an Associate Professor in the Department of Physiology and Biophysics, Georgetown University Medical Center, Washington, District of Columbia, United States of America. Shahram Ahari is with the School of Pharmacy, University of California San Francisco, San Francisco, California, United States of America.
* To whom correspondence should be addressed. E-mail: ajf29@georgetown.edu
It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently and for others it’s my attention and friendship…but at the most basic level, everything is for sale and everything is an exchange.
—Shahram Ahari
You are absolutely buying love.
—James Reidy [1]
In 2000, pharmaceutical companies spent more than 15.7 billion dollars on promoting prescription drugs in the United States [2]. More than 4.8 billion dollars was spent on detailing, the one-on-one promotion of drugs to doctors by pharmaceutical sales representatives, commonly called drug reps. The average sales force expenditure for pharmaceutical companies is $875 million annually [3].
Unlike the door-to-door vendors of cosmetics and vacuum cleaners, drug reps do not sell their product directly to buyers. Consumers pay for prescription drugs, but physicians control access. Drug reps increase drug sales by influencing physicians, and they do so with finely titrated doses of friendship. This article, which grew out of conversations between a former drug rep (SA) and a physician who researches pharmaceutical marketing (AFB), reveals the strategies used by reps to manipulate physician prescribing.
Better Than You Know Yourself
During training, I was told, when you’re out to dinner with a doctor, “The physician is eating with a friend. You are eating with a client.”
—Shahram Ahari
Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians’ personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician’s family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor’s office for objects—a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols—that can be used to establish a personal connection with the doctor.
Good details are dynamic; the best reps tailor their messages constantly according to their client’s reaction. A friendly physician makes the rep’s job easy, because the rep can use the “friendship” to request favors, in the form of prescriptions. Physicians who view the relationship as a straightforward goods-for-prescriptions exchange are dealt with in a businesslike manner. Skeptical doctors who favor evidence over charm are approached respectfully, supplied with reprints from the medical literature, and wooed as teachers. Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep’s messages.
(See Table 1 for specific tactics used to manipulate physicians.)
Table 1. Tactics for Manipulating Physicians
Table 1. Continued
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