Fool Me Once, Shame on You, Fool Me Twice, Shame on Me: Drug Reps' Gifts and Fake Friendships

An important article in PLoS Medicine on how drug representatives "detail" doctors has already gotten a lot of attention. [Fugh-Berman A, Ahari S. Following the script: how drug reps make friends and influence doctors. PLoS Med 4(4): e150 doi:10.1371/journal.pmed.0040150] Note that one of the authors (Ahari) is described as "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."

The most important points in this very interesting article are:

The Detailing Relationship is Built on False Friendship - The key, deliberate tactic is for the drug representive to convince the individual physician that the rep is the physician's friend. Thus the relationship can be inherently dishonest. To quote the article,

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.

And the article concludes,

Physicians are susceptible to corporate influence because they are overworked, overwhelmed with information and paperwork, and feel underappreciated. Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctor's lives are, and seem only to want to ease their burdens. But, as SA's New Hampshire testimony reflects, 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.... In the interests of patients, physicians must reject the false friendship provided by reps.

Drug Reps Try to Buy Physicians' Friendship - The article emphasizes that giving gifts to physicians is meant to buy friendship and make the physician feel obligated.

Gifts create both expectation and obligation. 'The importance of developing loyalty through gifting cannot be overstated,' writes Michael Oldani, an anthropologist and former drug rep. Pharmaceutical gifting, however, involves carefully calibrated generosity. Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug's name stays uppermost in a physician's subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags. As Oldani states, 'The essence of pharmaceutical gifting‥is ‘bribes that aren't considered bribes’'.

There are those who belittle the article as merely showing that pharmaceutical companies employ aggressive marketing tactics. Aggressive marketing is prevalent in the developed world, so why should physicians moan about being subject to it? For example, see these comments by the anonymous "Industry Veteran" in the Health Care Blog, (whether the Veteran is real or a constructed persona playing devil's advocate is not clear).

What the hell, are physicians such delicate flowers that they must not be subjected to the lures of salesmanship?

The fact remains that drugs are discovered and distributed everywhere in the world through a competitive market system. Personal sales serves as one of the main spokes of that marketing wheel. Why do some people buy into the chauvinistic ideology of physicians that they must never serve as targets for marketing?

This might be fairer criticism if the marketing was only meant to persuade physicians to purchase products themselves.

But the ethical issue here is that the physicians are making decisions about what drugs their patients will receive. Patients cannot purchase prescription drugs without a prescription. Physicians (and other health professionals with prescribing authority, who are also detailed by drug reps) are the only ones who can write prescriptions.

So if physicians let these decisions be influenced by the phony friendship of drug reps and the gifts they provide, they are compromising their primary duty to the welfare of their patient. This duty would only be fulfilled if the physicians were to make prescribing decisions based on balancing the possible benefits and harms of the treatment, and their value to the patient.

As others have argued, it may be psychologically very difficult for physicians to prevent themselves from being influenced by gifts given them to market drugs. Thus, there is an argument to ban such gifts. (See our post here on this argument made by Brennan et al.) And before such a ban becomes policy, for physicians to fulfull their obligation to put the welfare of individual patients first, they ought not to accept such gifts.

It probably is just as difficult for physicians to prevent themselves from being influenced by drug reps' feigned "friendship." What to do about this on a policy level is not so clear. But physicians ought to consider simply avoiding drug reps. This may seem harsh, but remember, it is likely that one's apparent drug rep "friends" were only programmed to act that way.

Shame on physicians, though, (myself included) for falling for this. We may be overworked, distracted, and tired, but we should not have been so gullible, or so eager for gifts and new "friends."

Finally, more shame on the pharmaceutical companies for trying to influence physicians' decisions for patients with gifts and fake friendships. Just because many physicians have been too gullible and eager for more gifts and new "friends" to resist these practics does not make them ethical.

One wonders how many drug reps feel contempt for the physicians who really believe the reps are their "friends?" But how do the drug reps feel about themselves for fooling the gullible physicans?