Pharmaceutical company representatives (PCRs) are as ubiquitous in otolaryngologists’ offices as seasonal allergies and ear infections. Their job during their marketing visits, commonly referred to as “detailing,” is to get physicians to write more prescriptions for their products. But there is more to friendly PCR visits than meets the eye, as Sridhar Narayanan, PhD, an assistant professor of marketing at Stanford University’s Graduate School of Business, has shown. Several studies of the marketing of second-generation antihistamines to both physicians and consumers have demonstrated that pharmaceutical companies, assisted by health care information organizations (HIOs), use marketing tools fashioned from massaging databases of individual physician prescribing data to get them to expand demand for drug categories.
Among Professor Narayanan’s more intriguing findings on marketing second-generation antihistamines is that “fast learning” doctors increase the number of prescriptions written after only two or three visits from PCRs, whereas the “slow learners” take 17 or 18 visits to catch on. “Drug companies rely on HIO data to detect the fast and slow learners because physician surveys about prescribing tend to be problematic. Data on prescribing patterns coupled with detailing visits geared to differences in physician learning rates often spells the difference between heavy and light prescribers,” says Prof. Narayanan. It’s all part of the $8.5 billion that pharmaceutical companies spend annually marketing to consumers and physicians.
For John Krouse, MD, PhD, professor and vice-chair, director of Rhinology/Allergy in Detroit-based Wayne State University’s Department of Otolaryngology–Head and Neck Surgery, the data-driven approach may account for the canned spiels that aggressive PCRs use to steer the conversation their way. “I prefer PCRs who act professionally, are well educated, and want a good ongoing relationship with the physicians. It doesn’t take long to figure out which PCRs are only pushing product and which are the ones who can build a relationship on trust and comfort,” he says.
Prof. Narayanan’s research also indicates that some managers, having front-loaded both direct-to-consumer advertising (DTCA) and detailing months before a product’s launch and in the year immediately following increased revenues by 4 to 14%, a strategy that other pharmaceutical companies should have followed to achieve similar results. Dr. Krouse counters that seasoned otolaryngologists are familiar with drugs in the pipeline and would like a collegial conversation with PCRs rather than a hard-sell about the new product. Prof. Narayanan also found in subsequent research that detailing and DTCA have long-term effects on revenues that are four to seven times the current-period effects. Apparently, persistence pays off in pharmaceutical marketing, encouraging PCRs to keep hammering away at physicians to keep their prescription-writing pens busy.
The determined pursuit of physicians by PCRs is unsurprising to Brad Marple, MD, of the University of Texas Southwestern Medical School in Dallas. Dr. Marple is an otolaryngologist and AAOA board member (as well as an editorial board member of ENToday). Busy with his clinical practice and students, Dr. Marple has little time for face-to-face visits with PCRs, who frequently visit his office to leave samples. Occasionally, PCRs will leave a peer-reviewed journal article or a chart summarizing a journal article pertinent to an otolaryngology practice. “That is in line with my preferred method of getting information about clinical developments and new medications, which is through peer-reviewed journal articles,” he says. “I approach PCR visits with a jaundiced eye because their job is marketing. Peer-reviewed sources and CME are more regulated,” he adds. He attends professional conferences sponsored by pharmaceutical companies as long as they disclose their interests, checking with the Chicago-based Accreditation Council for Continuing Medical Education (ACCME) if he has questions about a conference’s sponsorship or intent. As for being a “slow” or “fast” learner, Dr. Marple was surprised that companies track physicians in those terms: “For some companies I must be seen as a slow learner and a fast learner by others because the variables by which I’m judging medications are different than what they think is important.”
Dr. Krouse dismisses the notion that prescribing patterns have anything to do with how fast or slow physicians are on the uptake. Rather, he sees colleagues with different prescribing styles: some jump on a new product, some wait for reviews of clinical results, whereas others stick with familiar drugs.
Fortunately, physicians have official allies in keeping PCR behavior and the pharmaceutical industry in check. According to Karen Mahoney, the US Food and Drug Administration’s (FDA’s) trade press liaison, regulations on pharmaceutical sales representatives’ promotions to physicians “should not be false, not be misleading, and should include material facts such as risk information about a prescription.” FDA regulations do not address data collected on prescribing patterns or what gifts may be offered to physicians. Ms. Mahoney suggests that if a physician has a concern about the content of promotion, he or she should contact the FDA’s Division of Drug Marketing, Advertising, and Communications.
That’s what Dr. Krouse recommends for colleagues who have had unpleasant dealings with PCRs and whose complaints to the PCRs’ supervisors haven’t brought about disciplinary action. “Alerting the FDA when a PCR’s message is off label or who makes claims not supported by the label is the right channel for a physician to pursue in such cases,” he says.
The American Medical Association, responding to its members’ concerns about the increasingly sophisticated information culled by PCRs from databases on individual physician prescribing patterns, introduced new procedures in July 2006 to give doctors some control over data access. Through the Prescribing Data Restriction Program (PDRP), individual physicians who enroll can stop PCRs and their direct supervisors from having access to their prescribing patterns. However, such data will still be available to pharmaceutical companies for marketing, compensation, and research. For starters, the PDRP allows the pharmaceutical industry to police itself. Physicians can also contact their state legislatures to sound the alarms.
Despite the pharmaceutical industry’s unwavering focus on getting physicians to prescribe their products at the highest possible levels, and the doctors’ need to keep them at arm’s length, the two groups are linked. Dr. Krouse points out that the pharmaceutical industry has “cleaned up its act in the last few years, doing away with inappropriate gifts and other egregious lapses.” The industry recently funded 13 unrestricted grants for American Academy of Otolaryngic Allergy medical residents, allowing young physicians to explore academic medicine. Continually refining the relationship between the drug industry and physicians to keep it mutually beneficial is an ongoing challenge.
Teaching Medical Students to Handle PCRs
To help third-year medical students become aware of PCR influence on physician prescribing habits and professional behavior, professors at Wake Forest University teach a mandatory course for these students and other physicians covering:
- Typical physician–PCR interactions
- Appropriate uses of samples and gifts
- Validity and legal boundaries of PCR information
- Role plays
Prior to the course, 57% of the students were unaware that guidelines regarding interactions with PCRs exist, and 28% thought that there should be no restrictions on gifts including lunches, stethoscopes, textbooks, educational CD-ROMs, and sporting events.
At the course’s conclusion, both practicing physicians and students said they knew more about dealing with PCRs. Students surveyed indicated increased understanding of PCR–MD interactions, from 17.7% before the course to 43.2% after. For practicing physicians, 40.5% said they better understand such interactions after the course, whereas only 22.1% said so pre-course.
Source: Wofford JL, Ohi CA. Teaching appropriate interactions with pharmaceutical company representatives: the impact of an innovative workshop on student attitudes. BMC Med Educ 2005 Feb 8;5(1):5.
©2006 The Triological Society