Dr Strangelove

Have you ever wondered how your doctor decides which drug to prescribe you? Sean Naughton enters the world of pharmaceutical marketing.Like most people, you probably just assume that there is one drug out there that will sort out your blood pressure, restless legs or expanding bald patch and that’s the one you will be prescribed. I assure you, your doctor wishes it were that simple.With a host of new medicines coming out all the time, most are neither silver bullets nor travelling medicine show tonics, but lie somewhere in between. This grey area is a messy and complex world of drug trials, statistics, and complex scientific journal publications.Fortunately, pharmaceutical companies have decided to come to the rescue of doctors who are in danger of being injured by falling piles of trial data, drug licensing information and patient follow-up reports and have decided to send out sales representatives, or drug reps, equipped with all the pertinent data on their latest developments, to inform and educate.This is where things start to get interesting. Drug companies, like most organisations in competitive industries, realised that there were a few things they could do to give themselves and their products an edge.The United States leads the way in aggressive pharmaceutical marketing. Companies spend more than $15 billion each year promoting prescription drugs in the US. One third of that amount is spent on detailing an industry term for drug company representatives’ one-on-one promotion to doctors. It used to be commonplace for doctors to be offered dinners, golf outings and speaking fees in exchange for some of their time, but now government crackdowns and the industry's self policing have curtailed those gifts.In the absence of these financial inducements, face-to-face rapport has taken on a more central role. Dr. Thomas Carli of the University of Michigan says: “There’s a saying that you’ll never meet an ugly drug rep.”In Ireland, drug reps still often have scientific backgrounds so they are in a position to talk to doctors about their product. However, in the US, the trend is well established towards hiring attractive presenters, with ex-cheerleaders being a particular favourite.  The demand has even resulted in the creation of an employment firm called Spirited Sales Leaders in Memphis, which maintains a database of thousands of potential candidates. Some industry critics view the influx of sexy drug representatives as a variation on the seductive financial incentives of old.Jamie Reidy is a former drug representative who was fired by Eli Lilly this year after publishing his book ‘Hard Sell: The Evolution of a Viagra Salesman’. In his book, he recalls a sales call with an attractive female colleague. At first, he said, the doctor gave ten reasons not to use one of their drugs. However, after “she gave a little hair toss and a tug on his sleeve and said, ‘come on, doctor, I need the scrips,’ he said, ‘okay, how do I dose that thing?’”Certainly there is nothing new about companies using attractive people to sell products and on its own; it could be considered relatively innocuous. More troubling however is when it is the actual data that gets dressed up.Gwen Olsen, an ex-sales rep that wrote Confessions of an Rx Drug Pusher about her experience of the industry, details how reps were often trained to minimise negative results in consultations with physicians. For example, if reps were reporting that certain information in the promotional materials were causing concern to doctors such as a bar chart which showed a particularly high number of central nervous system side effects, the materials would be reprinted, with the central nervous system effects separated out into components, like dizziness, headaches et cetera so they would be visually less likely to draw attention.How to Read a Paper is a book by Professor Patricia Greenhalgh in which she humorously points out her top ten tips for the pharmaceutical industry on how to show their product in the best light. Some of the points include blurring the distinction between absolute and relative risk and the use of surrogate end points in studies – for example, abstract indices like the pH of the stomach rather than clinical end points that have real meaning for patients.Dr Garrett Igoe, a GP, writes in the Irish Medical Times that when he gently pointed out to a drug rep who had called in on his surgery that she was using nearly all the tricks of the trade as described in Professor Greenhalgh’s book, she smiled amicably, leaned forward and simply said “you’re gas”!Where the line is drawn between simply putting your best foot forward and being wilfully misleading is by no means a clear cut one and it is ultimately up to doctors themselves to make the final decision as to which drug they prescribe.As in many areas, it seems likely that Ireland might follow America’s lead and with money only getting scarcer in the health system, drug reps will be under even more pressure to justify their latest wonder drugs. Perhaps it’s only a matter of time before Ireland’s drugs reps are turning up to doctor’s offices with drug samples in one hand and a pom-pom in the other.