This week’s three articles continue our investigation of the effects that marketing and pressure from the sales-driven pharmaceutical sector have upon healthcare and physicians’ abilities to attend to their ‘primary duties’ of providing patient care. Each provides a closer investigation of the relationships between drug companies’ representatives and physicians, as the former seem to provide, through carefully calculated interactions, the main link between the business and professional sides of medicine.
In the first article, Oldani proposes that a close ethnographic study of the activities of drug reps can illuminate how exactly their relations work to generate immense profit for pharmaceutical companies, and to examine the effects these relations have upon both patients and health care in general. We have seen how these reps, via their financial backing and forging of social relations with medical professionals, have gained immense influence over prescriptions (and thus the money made by drug companies), but Oldani also demonstrates their effects upon the ‘feedback loops’ between doctors, companies, and patients which are a key component to companies’ marketing and sales tactics. He then seeks to examine the ramifications of these three-way cycles of interaction combining with new technology available to sales reps, and the resultant acceleration of pharmaceutical exchanges.
In this investigation the sales-oriented mentality of drug companies becomes apparent, their task clearly appearing to be merely maximizing the number of prescriptions sold, rendering patients mere consumers who are to be manipulated via physicians and marketing in order to generate the most profit, and the goal of drug development to create drugs which will be prescribed at high levels. Drug reps being the actors who influence physicians’ prescriptions, it is no surprise when Oldani mentions that 46% of drug companies’ budgets were spent on detailing in 1984.
Most of drugs reps’ tactics revolve around the relationships they create with physicians, which are generated by the calculated and repetitive practice of gift-giving (never involving actual business transactions, but investments of money, time, goods, and effort supposed to foster a spirit of reciprocity). Indeed, Oldani demonstrates how both drug reps and physicians are indoctrinated into the culture of gift-giving from the very beginning of their training or education. The life cycle of a drug which he identifies demonstrates the way a gift is turned into profit: the gift itself from the rep brings the drug to doctors, who prescribe the drug to patients, who consume the drug, after which its yield is received by pharmaceutical companies and reps. The dual and paradoxical role of gifts is to mask the fact that ‘drug pushing’ and profit are the goals behind the gifts themselves, but the fact that this nature is concealed also conceals the risks of side effects in patients who are generalized or haphazardly prescribed these ‘one-size-fits-all’ blockbuster drugs. Profits of a drug are greatly influences by its success immediately upon arriving on the market, so companies tend to focus on hyping them up immensely and less on their potential results or consequences, but clinical trial results are unable to provide accurate information for drugs prescribed at the high rates successful drug reps create.
This accelerated prescription process has been further exacerbated by new technology which made available ‘script tracking’, which allowed drug reps across companies to focus their energies exclusively on high-prescribing physicians, and created competition which caused the size of gifts required to win their favour to escalate exponentially. Oldani argues that this combination of traditional detailing methods of personal interaction with what such technology has allowed has caused a “pharmaceutical involution” in recent decades, resulting in an immense number of pharmaceutical transactions and increase in the money spent (both by consumers and companies) on drugs, and yet no real healthcare progress as shown by a lack of decline in hospitalizations or illness levels. The increasing complexity of these systems as a result of the myriad (mainly market) causes of pressure and demand seems to be changing things in a way which is may not necessarily equate improvement.
Elliott’s article proposes that these recent changes in the tactics and influence of drug sales representatives, parallels and highlights the greater transition the health-care system appears to have undergone from being a profession to an industry, which has rendered it so increasingly subject to market forces. This is examined in the article through the changing roles of drug reps, professional organizations, educational systems and doctor-patient relationships. The naturally ensuing conflict between doctors’ primary duties to their patients is shown to be becoming increasingly difficult to keep free of interference from sales reps, marketing, and self-interest.
Although “detailing” and drug reps have been around, as Elliott says, since the mid-nineteenth century, their tactics and influence have changed dramatically during this recent transitory phase for medicine; as Elliott says, the mentality of which has gone from that of “the country-club establishment to the aggressive, new-money entrepreneur”. Where traditional drug ‘detailers’ presented themselves as purveyors of information respectful of doctors’ duties, practices of gift-giving from pharmaceutical companies have become increasingly removed from this supposed purpose and focus largely on entertaining and befriending physicians in order to establish a relationship and the ensuing reciprocity from them, in the form of biased prescription-writing. Drug reps with backgrounds in sales are now favoured over those with relevant knowledge, and the sheer number of reps alone has doubled since 1996 as the pharmaceutical industry rose to become the most profitable in the American business sector. New technology which allows reps to track doctors’ prescriptions online has further allowed them to aggressively target doctors who are most likely to be influenced by their tactics. Elliot decrees the efforts of professional organizations to prevent this market influence upon physicians and patients alike as “halfhearted”, with the AMA funding its promotions of ethical practice with money from pharmaceutical companies and the FDA accepting money in exchange for faster drug approval rates.
Despite these changes towards a more obvious business culture, Elliott emphasizes the importance of reps maintaining the unspoken nature of bribery that lies behind the gifts, characterizing their relationships with doctors as “a delicate ritual of pretence and self-deception”. He shows how this has led to increasing attempts of drug companies to hire doctors as “thought leaders” or fund educational conferences, a more subtle tactic which makes doctors reluctant to interact with reps seem to feel far more comfortable (or unaware that they are) acquiring information spun in their favour. This further step to blurring of the lines between having duties as a doctor and interests in a pharmaceutical company is one of the most telling signs of the parallel shift the medical system is undergoing as its ethos becomes increasingly businesslike. Elliott’s article brings up the question of whether in a capitalist system, such a large and lucrative sector such as that of medicine can ever truly be free of the market forces which drive these perverting pressures upon its integrity. Further, it demonstrates our endless faith in the market and belief that these pressures will, courtesy of the “invisible hand”, provide us with an effective healthcare system, quality drugs, and skilled physicians (regardless of their motivations and priorities).
The final article by Fugh-Berman and Ahari provides some further investigation into the strategies used by pharmaceutical companies, through drug reps, to influence physicians and their prescriptions. It shows the extensive ways in which reps acquire information about doctors’ personal lives and preferences, attitudes towards drug reps and gifts, prescribing habits, and external influences, and use it to create detailed demographic profiles. Doctors are then categorized into these profiles, each of which reps have designed a specific tactical plan for in order to yield the most prescriptions from said group. Tactics reps consider and modify based on these profiles range from what attitude to approach the doctors with, how to provide them with their products and information, and above all how blatant to be about masking their ultimate goal of influencing or bribing. Though the previous articles focused on how ‘script tracking’ allowed reps to focus on the highest-prescribing physicians (and those most susceptible to influence), we see here that they also target ‘diamonds in the rough’ who they may be able to grow into loyal company supporters, or specialists whose few prescriptions will generate many in the long run. The dual purpose it also serves is allowing physicians to learn which tactics are most effective and continually modify their physician “segments” or profiles, making the role of reps a dynamic and ever-changing one. It also discusses the use of samples by reps for the first time, demonstrating how this perhaps subtler tactic has great influence as well, as their usefulness in practice is greater than most ‘gifts’, and even doctors reluctant to speak with reps generally desire samples for their patients.
We are provided with the paradoxical information that many physicians reportedly get most of their education about new drugs from reps, yet a significantly smaller number claim to have faith in the truthfulness of the information they receive from them. This may reflect an attitude amongst at least some doctors that reps and marketing are simply an inevitable part of their profession, and to take the good they can provide with the bad. In its conclusion, however, the article points out the obvious fact that if there were truly any educational value in the information reps provide, it would be provided to all doctors and offices, not just those who are the most lucrative for companies. Backing this up is the example of New Hampshire, who the article claims to have “forbidden the sale of prescription data to commercial entities” altogether.
One of article’s final comments reflects upon the fact that the majority of doctors (who genuinely strive to fulfil their primary duties to benefit their patients and resist influence from other interests) are busy, overworked, and often feel underappreciated in their careers, and it is easy to see how a positive interaction with a charming, gift-bearing sales rep would be difficult not to welcome, particularly when their influence is so well-hidden. Though clearly important to hold doctors to a high professional and ethical standard, there may be much more that can be done to provide them with the resources to acquire the benefits of reps without the bias, such as making access to education and information from non-interested sources easier. That said, given the massive amounts of money involved in the healthcare and pharmaceutical industries, finding or creating a non-interested source is sure to be a challenge.