by Dr.Harald Wiesendanger– Klartext
What the mainstream media is hiding
How do drug manufacturers manage to win over practicing physicians? Do they go to a lot of trouble with convincingly arguing letters? Are they using email ads that catch the eye? Do they send out brilliantly designed glossy brochures? Nothing like that. How many doctors would take the time to read something like this, especially when it arrives unsolicited from a sender with whom they have had little or no contact, let alone a personal one?
No, the pill industry knows far more effective tools that intertwine in a strategically sophisticated way. It undermines medical education and training. She inclines opinion leaders. She lures professional societies. It buys publishers and editors of relevant media. And she relies on on-site marketing – on face-to-face encounters.
To do this, she directs an army of pharmaceutical representatives. Around 20,000 of them are out in the field throughout Germany (1), primarily in medical practices and clinics, but also in pharmacies, home operators, health insurance companies, and associations. In the United States alone, their number increased from 38,000 to 100,000 between 1995 and 2005 (2)—that would be one for every six doctors there. If one excludes non-practicing physicians and “low prescribers,” who are economically ignored by pharmaceutical emissaries, the ratio would even be 1 to 2.5. And this indicates the most intensive care, in whatever form.
Such on-site marketing is obviously carried out to the greatest satisfaction of the client – why else does it take place, and why is it rewarded princely? In Germany, pharmaceutical representatives earn an average of EUR 35,000 as beginners, professionals EUR 60,000, and top people EUR 110,000, plus bonuses and company cars. (3) In the USA, the average income of a “Rep” – as the sales representative is called within the industry – was already 81,700 dollars per year in the noughties; a performance-based bonus of $19,300 is added to the base salary of $62,400. On average, drug companies spend another $89,000 to recruit, train, supervise, and evaluate their feedback. This results in total costs of around 170,000 dollars per year per Rep; for specialty reps and representatives for “special tasks,” it is even 330,000 dollars. (4)
Up to 35,000 euros – per doctor
And that means the bottom line? 416,000 doctors were practicing in Germany at the end of 2021; more than half of them work in hospitals, and 114,000 are in private practice. (Another 130,000 are out of work.) (5) Even if reps were to handle only a small fraction of these, their efforts result in huge expenses. Based on US figures, a German ground force of 20,000 pharmaceutical representatives alone would require an annual budget of three billion euros – but that would only be the personnel costs. In addition, there would be billions more for all sorts of ensnaring aids, which will be discussed shortly.
All in all, pharmaceutical companies spend between 8,000 and 35,000 euros annually on on-site marketing – mind you, per resident doctor. (6)
No matter how much: The industry can get over it. Ultimately, the health insurance community pays for any minuses in door-to-door cleaning and smearing anyway – through increased drug prices and health insurance contributions.
But there is no minus. For every euro that pharmaceutical companies put into on-site marketing, they get back EUR 1.96. (7)
But how could such an investment ever pay off? How do pharmaceutical representatives get the hang of it? How do they get there?
The pharmaceutical representative as a persuasive artist
Common stereotypes about this are ridiculous. Neither does a pharmaceutical representative carry a suitcase full of cash with him, nor does a female industry representative appeal to the baser instincts of male practice operators with short skirts and sultry perfume, non-slip buttocks on the desk. But what else is the secret of their success?
As Wikipedia tells us, the task of pharmaceutical representatives is to “inform and advise” – “professionally, critically and completely” – about “the latest research results, product development, new therapy, and care approaches.” (8) Are they simply excellent at fulfilling this function as a source of knowledge and mentor, which is why physicians greatly value their visit?
Technically, most pharmaceutical envoys can now keep up quite well. Gone are the days of clever lateral entrants who had already proven their suitability by selling rows and rows of luxury cars, extra insurance policies, and shabby capital investments. Today’s pharmaceutical representative must not appear as a bloody layman in front of the doctor; he should cut a reasonably good figure in technical discussions.
And this requires quite extensive medical and pharmaceutical knowledge. To acquire it, a rep now undergoes at least 1,000 hours of training, which he completes with an exam at the local Chamber of Commerce and Industry; Details have been regulated nationwide since 2007 by the “Regulation on the examination for the recognized qualification of a certified pharmaceutical representative” (PharmRefPrV). (9) The “pharmaceutical consultant” has recently been placed one educational level higher; it requires highly specialized expertise as well as legal knowledge. Increasingly, these are natural scientists and physicians, some with a doctorate. According to the Medicines Act (§ 75, paragraphs 1 to 3), a pharmaceutical consultant must be able to demonstrate a university degree in pharmacy, chemistry, biology, human medicine, or veterinary medicine but at least training as a technical assistant in pharmacy (PTA), who chemistry (CTA), biology (BTA), human (MTA) or veterinary medicine (VTA). (10)
Changing prescription habits: that’s all that matters.
But what does a pharmaceutical representative use his considerable expert knowledge for? To “inform” and “enlighten,” factually and neutrally? As a former rep for pharmaceutical giant Lilly, Shahram Ahari, his real mission is blunt: “Change the doctor’s prescribing habits!” – that’s all it’s about. (11) Get him to prescribe the expensive new instead of the old cheap one; an original instead of a generic; a drug from manufacturer XY, not that of a competing company; with more patients, with more clinical pictures than before, as early as possible, as often as possible, as long as possible.
With these goals in mind, the company representatives aim to establish a personal, as close and long-term relationship as possible with the doctor, to find out about his prescribing habits, personal attitudes, views, and preferences, to provide him with a comfortable additional salary in exchange for his services, to give him an understanding of “scientific evidence” that promotes sales, talk him out of concerns about side effects, make competitor products and chemical-free alternatives mad. He should become aware of how “old-fashioned” his prescriptions are, as long as he prefers a tried and tested drug to what is always a groundbreaking novelty, instead of expensive originals preferring to receive cheaper generics. Arznei-Telegramm, an information service for doctors and pharmacists, sees “a typical danger of discussions with representatives” in the “strategy of disinformation. The previous therapy of the doctor is presented as outdated, and the doctor is unsettled by the reference to the ‘expert’ XYZ’ in his therapeutic decisions to create a breach for the dissemination of a new preparation, usually a sham innovation.” (12) The more prescriptions the pharmaceutical representative ultimately initiates, the more lavish his commission will be (13) – a powerful motive for persistently exerting subtle pressure that ignores medical facts and necessities.
Lying friendship
And how do you get that? “Why,” the Arznei-Telegramm riddles, “do 80 to 95 percent of the (visited) doctors – despite the workload and cost pressure – allow pharmaceutical representatives to steal their time with product promotions that are questionable in terms of content and content?” (14)
The pharmaceutical representative uses a wide range of proven measures to do this. Which he prefers, in what dosage and combination, depends on what type of doctor he is dealing with and how the relationship with him develops. Whenever you visit the doctor’s office, the be-all and end-all is: “Make friends!” The primary goal is to gain the doctor’s trust. If that succeeds, you already have your patients in your pocket. Because “their trust in the doctor as a person automatically extends to trust in the medicines he prescribes for them. The efforts of the pharmaceutical industry are aimed at precisely this transfer of trust,” explains a former manager of several industry giants. (15)
To this end, the visited doctor is literally showered with niceties, attention, and signs of sincere interest in the whole person behind the white coat. “I give everything I do the appearance of friendship,” says a former Lilly rep from the sewing box. “If I give the doctor a present, it’s not because it’s my job, but because I really like him. I bring him an office lunch because, for me, an appointment with him is a pleasant change from what I experience with other docs. (…) During my training, I was drummed into it: When we have dinner together, the doctor eats with a friend. You are eating with a customer.” (16)
Also, with medical assistants and secretaries, important door openers to their boss, impeccable manners, good humor, and trained charm of the always well-dressed, extremely eloquent pharmaceutical envoys usually go down well. The Pfizer representative Jamie Randall in the US feature film “Love and Other Drugs” (2010), an impudent womanizer, represents the profession quite dignified.
A good friend leaves nothing unnoticed; he takes an interest in everything and everyone. “We are trained,” reveals the ex-pharmaceutical officer, “to assess the doctor’s personality, the way he runs his practice, and his preferences – and to report this information to the company. The personal can be more important than prescription preferences. Reps inquire and remember details of the doctor’s family life. They ask about his professional interests and how he spends his free time. Her trained eye scours the office for items that can serve to establish a personal connection with the Doc—a tennis racket, Russian novellas, a CD of 1970s rock music, a fashion magazine, holiday mementos, cultural or religious symbols, for example. A photo on the desk opens up an opportunity to find out about loved ones, including their names, birthdays, and idiosyncrasies. The Rep usually enters all of this into a database immediately after the encounter.” (17)
In the context of such a friendly relationship, it is usually sufficient to mention medicines in passing. “Physicians are susceptible to corporate influence because they are overworked, overwhelmed by information and paperwork, and feel undervalued. By bringing good humor, sympathy, and gifts, courteous reps give the doctor a breather. They appreciate what a rough existence he endures and seems only intent on lightening his burden. However, every word, favor, and gift is carefully planned – not to help doctors and patients, but to increase the market share of certain drugs.”
In retrospect, the remorseful Rep can only urge doctors to “make friends only among people who aren’t being paid to be friends.” (18)
Veracity: hardly expedient
In general, truthfulness in on-site marketing is not necessarily effective. According to a study by the Cologne Institute for Evidence-Based Medicine (DIeM), 90 percent of all statements in the advertising material that the pharmaceutical representative hands over are medically irrelevant, unproven, one-sided, or incorrect – from the product brochure to the reprint of a test report. Only eight percent of all medical and pharmacological information is documented and agrees with the source mentioned. (19) Despite this, more than 80 percent of those visited describe the pharmaceutical advisor or representative as the “most important source of information for their therapeutic work and prescriptions.” (20)
Gifts of all kinds prove to be helpful. Pharmaceutical consultants carry all sorts of fine gifts in their suitcases: from fine pens and pocket calculators to drug samples, brochures, and reprints of promising research reports to invitations to pharmaceutical-financed events with an exquisite leisure program. Depending on the service in return, high-quality electronics are sometimes donated, as a resident doctor reports from a visit by a pharmaceutical representative from Aventis Pasteur MSD: Get a cell phone for free.” (21)
Visitors can also come up with free installation CDs for high-quality practice software: no sooner has the doctor entered a patient’s symptoms than the “suitable” drug from the company that made the software gift flashes on the monitor. The program takes care of all work steps up to the printed recipe. (22)
One of the most popular gifts, which open practice doors particularly reliably, is “sample” medicines that are given in small quantities. These are always new, particularly expensive preparations. A small supply of it is designed to tempt the doctor to switch to the “innovation” and get used to prescribing it. And he is often happy to do so. Ready-to-hand samples are suitable for starting therapy immediately. Patients are also happy with such a gift. According to studies, most of them switch to the new preparation if they initially received samples of it. (23)
“We focus on the top prescribers.”
Do all resident doctors get such a visit? A Bayer sales manager explains that keeping tabs on so many doctors is a waste of money. Ultimately, “we focus on the 25 percent we can influence” — the top prescribers. “We make our money with them. We ignore everyone else.” (24)
(Harald Wiesendanger)
Remarks
Näheres in Harald Wiesendanger: Das GesundheitsUNwesen – Wie wir es durchschauen, überleben und verwandeln, Kap. 6: „Dressierte Halbgötter“ und Kap. 7 „Nimmersatte Mietmäuler“. 1 Nach Audimax: „Pharmaberater: Ein Beruf mit Zukunft“, www.audimax.de/ingenieur/branchen/medizin-pharma-chemie/pharmaberater-ein-beruf-mit-zukunft/, abgerufen am 29.5.2019.
2 M. Goldberg u.a.: “PE’s annual sales and marketing employment survey: The big squeeze, “Pharmaceutical Executive 24/2004, S. 40–45
3 Nach https://hitec-consult.de/de/firmenhistorie-hitec, abgerufen am 29.5.2019.
4 “Hard sell: As expanding the sales force becomes a less attractive option, pharmaceutical companies are reevaluating their sales strategies, “Med Ad News 23/2004, S. 1.
5 „Nachgezählt“, Der Spiegel Nr. 21, 21. Mai 2022, S. 19; nach Angaben der Bundesärztekammer, www.bundesaerztekammer.de/baek/ueber-uns/aerztestatistik/aerztestatistik-2021
6 www.kvpm.de/fakten/fakten zur psychiatrie, abgerufen am 22.10.2016; John Virapen: Nebenwirkung Tod, 7. Aufl. 2015, S. 49; Magnus Heier: „Wer soll das bezahlen, wer hat so viel Geld?“, Frankfurter Allgemeine Sonntagszeitung Nr. 48, 3.12.2006, www.faz.net/aktuell/wissen/medizin- ernaehrung/finanzierung-von-selbsthilfegruppen-wer-soll-das-bezahlen-wer-hat-so-viel-geld-1381620.html? printPagedArticle=true#pageIndex_2, abgerufen am 25.11.2016.
7 “Can I buy you a dinner? Pharmaceutical companies increasingly use doctors’ talks as sales pitches “, August 2004; www.worstpills.org.
8 Siehe die Wikipedia-Einträge „Pharmareferent“ und „Pharmaberater“; jeweils abgerufen am 22.5.2019.
9 Siehe www.bmbf.de/upload_filestore/upload/fvo_pdf/17_11_30_Pharmareferent.pdf, abgerufen am 29.5.2019.
10 Gesetz über den Verkehr mit Arzneimitteln (Arzneimittelgesetz – AMG) – Vierzehnter Abschnitt – Informationsbeauftragter, Pharmaberater – § 75 und § 76, siehe www.gesetze-im-internet.de/amg_1976/BJNR024480976.html#BJNR024480976BJNG001406310.
11 Adriane Fugh-Berman/Shahram Ahari: „Following the Script: How Drug Reps Make Friends and Influence Doctors“, PLoS Medicine 4 (4) 2007, S. 623, https://doi.org/10.1371/journal.pmed.0040150
12 Arznei-Telegramm 34/2003, S. 89-90: „Brauchen wir Pharmareferenten?“
13 Nach Angaben der früheren Pharmareferentin Kathleen Slattery-Moschkau, zit. nach Jeanne Lenzer: „What Can We Learn from Medical Whistleblowers?“, PLoS Medicine 2 (7) 2005.
14 Arznei-Telegramm 34/2003, S. 89-90: „Brauchen wir Pharmareferenten?“
15 Virapen: Nebenwirkung Tod, a.a.O., S. 58.
16 Fugh-Berman/Ahari, a.a.O., S. 621, 622.
17 Fugh-Berman/Ahari, a.a.O., S. 621.
18 Fugh-Berman/Ahari, a.a.O., S. 625.
19 T. Kaiser u.a.: „Sind die Aussagen medizinischer Werbeprospekte korrekt?“, arznei telegramm 35 (2) 2004, Sonderbeilage S. 21-23.
20 Nach Wikipedia: „Pharmareferent“, abgerufen am 29.5.2019.
21 Arznei-Telegramm 32/2001, S. 54: „Immer wieder Bestechungsversuche“
22 Virapen: Nebenwirkung Tod, a.a.O., S. 50-52.
23 L. D. Chew u.a.: “A physician survey of the effect of drug sample availability on physicians’ behavior, “Journal of General Internal Medicine 15/2000, S. 478–483; K. E. M. Groves u.a.: “Prescription drug samples—Does this marketing strategy counteract policies for quality use of medicines? “, Journal of Clinical Pharmacy and Therapeutics 28/2003, S. 259–271; R. F. Adair u.a.: “Do drug samples influence resident prescribing behavior? A randomized controlled trial “, American Journal of Medicine 118/2005, S. 881–884.
24 zit. nach Hans Weiss: Korrupte Medizin (2008), S. 34.
This text is part of a series of articles with the following additional contributions:
1) Trained demigods – How doctors become drug dealers
2) Visit from the Rep – Mendacious Friendship based on the script
4) Off-label – crossing borders as
5) Bought Observer- the doctor as a “researcher.”
6) Like Lubricated – When doctors let themselves be greased
7) “As you do to me, so do you” – reciprocity as the secret of success
8) Soft Rinsed – education and training as brainwashing
9) Insatiable Rented Mouths – The uncanny power of paid opinion leaders
10) Among Gorillas – Silverbacks call the shots
11) As KOL to the Golden Nose – Why “Key Opinion Leaders” have taken care of it
Pharma consultant, Pharma consultant, Rep, Harald Wiesendanger