The
Pill Pushers
By
Alex Roslin
When Shahram
Ahari went to work at a giant pharmaceutical company straight
out of college in New Jersey, he was hired to do a job that few
people know exists. Even the job title would be a mystery to most
people. Ahari was going to be a "detailer."
His job was to schmooze with doctors in
order to get them to prescribe the company's drugs. He was really
a salesman, but he was also much more. His tools included everything
from free drugs to offers of lucrative speaking engagements, even
trips.
He'd bring medical residents pizza for
lunch or invite a doctor to dinner at an exclusive restaurant.
He'd do anything to improve sales in his New York City district,
which meant a bigger bonus.
The first hint of the strange world Ahari
had entered came when he attended the company's intensive, six-week
boot camp for detailers. There, he met his fellow trainees. They
were hundreds of fellow college grads, mostly in their mid-20s,
perhaps two-thirds of them women, the vast majority beautiful.
"They were 200 or 300 of the most
attractive people I had ever seen. The physical appeal was only
part of it. They were vivacious, well-coiffed, well-dressed, engaging
people," Ahari told me for a cover
story in the Vancouver weekly The
Georgia Straight.
In the story, which won the 2008 Canadian
Association of Journalists prize in the magazine category, Ahari
took readers into the bizarre and questionable world of pharma
sales practices.
I first came across his
account in a paper published in the open-access journal PLoS
Medicine. His story really helped bring the sales practices
to life and served as a backbone for the article.
Ahari told me that his training was part
CIA, part Freud. He learned to scan a doctor's office to spot
anything that could be used to make a personal connection: golf
paraphernalia, photos of trips or kids, religious items. The information
would later be entered into the company's file on the doctor.
"You capitalize on sexual appeal,"
he said. "My more attractive colleagues would say, 'I'm going
to wear my short skirt today,' or 'I'm going to wear my low-cleavage
top. He [the doctor] seems to get a kick out of that.' "
The practice of detailing has come under
growing scrutiny in the U.S. and, to a lesser extent, Canada.
Two-thirds of doctors in British Columbia say drug reps visit
them at least once a month. Forty-two percent of general practitioners
are visited several times a week.
A B.C. Medical Association official and
the provincial health minister told me the visits and benefits
don't influence doctors. But studies show interactions with sales
reps cause doctors to prescribe costlier drugs that aren't necessarily
the best ones for patients. Those drugs have also burdened the
health system with exploding costs.
Doctors in some cases are influenced to
prescribe drugs for so-called "off-label" uses -- ones
not approved by Health Canada and other regulators.
The lobbying of doctors is virtually unregulated
in Canada and the U.S. Most provinces even allow pharmacies to
sell information on individual doctors' prescribing habits to
pharma research firms.
Detailers, in turn, use that data to reward
high-prescribing doctors with benefits like free samples, meals,
lucrative speaking contracts and consulting gigs -- and to cut
off those who prescribe less.
I learned that pharmaceutical companies
spent $57.5 billion on marketing in the U.S. in 2004-nearly double
the $32 billion spent on researching and developing drugs. The
marketing budget paid for an army of 100,000 detailers -- one
for every eight doctors.
Canada has
5,200 reps, one for each 11 doctors. The easiest way to cozy up
to doctors? Through their bellies. Pharma companies spent $2 billion
on 371,000 pharma-sponsored lunch and dinner meetings, conferences
and other events for U.S. doctors in 2004. "I sometimes saw
myself as a glorified caterer," Ahari told me.
"I would argue with doctors until
I was blue in the face [about a drug]. Then I'd take them out
to dinner and see their [prescription] numbers rise."
Ahari also didn't neglect the secretaries.
"I took great pains to make sure the staff were happy with
my lunches… How successful and delicious your lunch is has
a sway in terms of how quickly you can get meetings [with the
doctor]."
In many Canadian hospitals, I learned that
it's nothing unusual for a pharma rep to provide food for doctors
at a weekly "lunch round" -- a meeting over a meal to
discuss a medical topic. Some hospital departments have daily
pharma-sponsored rounds. And then there are monthly "grand
rounds" and "journal clubs" -- again, often sponsored
by pharma reps.
A few U.S. states have reacted by restricting
benefits doctors may receive or requiring them to declare gifts.
Despite the denials from doctors and authorities,
I found lots of research that shows the visits and benefits have
a huge impact on prescribing behaviour. One of the most comprehensive
studies found that accepting a free trip led doctors to prescribe
a company's drugs 80 to 190 percent more.
Doctors who had heard a sales rep at a
talk recommended inappropriate treatment to patients more often.
Doctors who attended pharma-sponsored meals were 14 times more
likely to request the sponsor's drug be added to a hospital formulary.
And especially alarming, doctors say detailers
are the single-biggest factor in influencing their prescription
choice, cited 39 percent of the time -- far more than concern
about a drug's side effects (17 percent) or prescribing guidelines
developed by the medical community (15 percent).
This story wouldn't have been possible
without the support of two fine editors at The Georgia Straight,
Charlie Smith and Martin Dunphy, and intrepid owner-publisher
Dan McLeod. They are three of the great, unsung heroes of investigative
journalism in this country. Their team never fails to support
a good story, to devote the resources this kind of work needs
and to subject it to meticulous editing of the highest standards.
Under their wing, The Georgia Straight
is one of the few genuine remaining outposts of investigative
journalism in Canada, and I love them for it. Thanks, guys.
Alex Roslin is vice-president of the
Canadian Centre for Investigative Reporting. He also blogs about
investigative journalism at http://albloggedup.blogspot.com/.
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