To do this, the biggest of Big Pharma deploy an astonishingly large force of "sales reps" all across the country -- 90,000 of them! That's roughly one for every nine physicians, and they swarm non-stop into doctors' offices -- one Virginia physician says his office had to set a quota of three visits in the morning and three visits in the afternoon in order to get any doctoring done. They are highly trained in persuasive arts, motivated to make the sale at all costs, and alarmingly successful (a 2003 Blue Cross survey found that more than half of "high-prescribing" doctors relied on the reps as their main source of information about new drugs).
INTRIGUING QUESTION: What occupational sub-group of Americans
are, by far, the most heavily recruited to take jobs as drug reps? You
might think pharmacists, marketing consultants, or even used car
salesmen. All wrong.
THE SURPRISING ANSWER: College cheerleaders.
Hey, the point is to "make the sale," to entice this mostly male profession to switch from A to B. Solid scientific evidence is one thing, but winks apparently work, too -- and who's twinklier, prettier, more buffed, peppier, or more gregarious than cheerleaders? The University of Kentucky, which boasts champion-level cheerleading squads, has been one of the premier movers of talent from pompoms to Pharma. A UK "cheering advisor" notes that his perky collegians are naturals for sales rep positions: "Exaggerated motions, exaggerated smiles, exaggerated enthusiasm -- they learn those things, and they can get people to do what they want." He says he routinely receives calls from drugmakers seeking to hire his graduates. "They don't ask what the major is," he says.
The demand is so high that an executive of a business that runs cheerleading camps set up a specialized employment firm in 2004 called "Spirited Sales Leaders." Based in Memphis, it funnels hundreds of former cheerleaders into drug sales.
"There's a lot of sizzle" in being a sales rep, he explains, and these experienced sizzle-generators can earn six figures a year, counting bonuses, for pep-talking doctors into writing more prescriptions for their companies' medicines.
Not that these upstanding corporate citizens would stoop to hiring salespeople based on their sex appeal. No, no, explained a top executive of Bristol-Myers Squibb: "[It] has nothing to do with looks, it's the personality."
Sex appeal or not, the essence of the job is manipulation, and reps are highly trained and well armed to ingratiate themselves with each individual on their list of doctor-clients. Adriane Fugh-Berman, a doctor and professor at the Georgetown University Medical Center, is a drug company watchdog who has studied the doctor-sales rep relationship. In a 2007 article, she reported that the salespeople play to a doctor's feeling of being overworked and underappreciated: "Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctors' lives are and seem only to want to ease their burdens. But every word, every courtesy, every gift, and every piece of information provided is carefully crafted, not to assist doctors or patients, but to increase market share for targeted drugs." Here are key elements of the DTD operation:
The file. Each doctor is a mark, and drug reps are trained intelligence gatherers who build and constantly update a computerized corporate file on the doc's personality, preferences, interests, and any personal tidbits that might help them change his or her prescribing habits. The strategic goal of good reps is to become each doctor's trusted "friend" -- not unlike the relationship that lobbyists try to cultivate with lawmakers.
The data. How can pill peddlers know which ones your doctor is prescribing -- isn't that a private matter? Not in today's bluntly intrusive world of commercial data mining. A majority of pharmacies sell their records of every single prescription written by doctors doing business with them. This vast trove of computerized info is bought by such data hawkers as IMS Health, which procures prescriptions from about 70 percent of US pharmacies. While the names of patients are deleted, the name of the doctor who wrote each prescription is easily discernible, so pharmaceutical giants pay millions a year to buy, slice, and dice the electronic data on exactly which medicines each doctor has ordered and in what quantities. This is regularly fed to the laptops, iPads, and even smartphones of the sales reps on the ground -- allowing them to target their daily pitches, and to precisely and carefully track the slightest of changes in a doctor's prescribing habits.
The gift. Reps don't go to a physician's office empty-handed. Gourmet donuts and lunch treats for the entire staff are daily routines, and doctors and key staffers are treated to dinners at fine restaurants, holiday gift baskets, tickets to a game or show, and such nice personal presents as a silk tie or a monogrammed golf bag. A New York Times report in January of this year says that two-thirds of doctors accept such goodies. For the heavy prescribers of a drugmaker's concoctions, the gifts grow ever-larger -- a ski trip to Aspen, an invitation to make weekly paid "lunch and learn" presentations in other doctors' offices, an honorarium to make brief comments at a conference in some five-star resort (complete with an "educational grant" to cover the bar tabs and other incidentals), big-buck "consulting" contracts that require practically no work, and outright cash payments for prescribing particular drugs. The Times' January report found "that about a quarter of doctors take cash payments" and "that they are more willing to prescribe drugs in risky and unapproved ways."
The hoax. Few doctors are experts in the chemistry and biological impacts of particular medicines, so they rely on honest studies and tests (as reported in credible medical journals) to give them an un-hyped, non-sales-rep picture of the pluses and minuses of the drugs they choose to prescribe to you and me. Unfortunately, this process, too, has been corrupted -- drugmakers have regularly paid doctors and researchers to conduct studies and publish results without revealing their financial ties. Pfizer, however, sank this sales-over-science approach to new lows when it launched its anti-depressant, Zoloft, in the 1990s. It hired an advertising firm to fabricate "studies," write them up as salutary reports about the drug, pay some big-name psychiatrists a couple of thousand bucks each to put their names on the reports, and convince major journals (read by thousands of doctors) to publish the ghostwritten "findings." About half of the medical articles about Zoloft at that time were ad agency fakes. Journal editors, embarrassed by being scammed, have since imposed safeguards, but many doctors and observers say that up to 20 percent of major journal articles are still being ghosted.We can do better
DTC and DTD are just two surging branches of the central stream running through America's healthcare industry -- an out-of-control stream that should be labeled DTP -- "Direct-to-Profit." The very fact that healthcare, an essential human need, has been twisted into an "industry" -- a commercial activity for the purpose of maximizing profits -- is a damning measure of its moral bankruptcy.
As avaricious and monopolistic drug corporations have demonstrated again and again, "care" is treated, at best, as an externality to their real work of making money -- and at worst as an impediment to that corporate imperative. Thus, top executives and boards of directors constantly seek ever more sophisticated forms of deception and manipulation to, at all costs, make the sale. In this ethos, such loathsome products as blatant price gouging, artificial shortages of vital medicines, deliberate promotion of pills that kill, falsification of medical research, and routine corruption of doctors are not merely tolerated, but expected and accepted as normal.
Is this the best that this great, super-rich country can do? Of course not -- we Americans can, must, and will create a system that puts public need over private greed. This month's "Do Something" features some groups leading the way. I'll give the final word to Dr. Relman, the thoughtful, insistent, and unflagging voice for an ethical and sensible system of care built around the concept of "Medicare for all." A decade ago, he wrote that "our health policies have failed to meet national needs because they have been heavily influenced by the delusion that medical care is essentially a business ... A different kind of approach could solve our problems, but it would mean major reform of the entire system ... Since such a reform would threaten the financial interests of investors ... the short-term political prospects for such reform are not very good. But I am convinced that a complete overhaul is inevitable, because in the long run nothing else is likely to work."