All Things Considered

How To Win Doctors And Influence Prescriptions

By Alix Spiegel
October 21, 2010, 4:11 PM

NPR and ProPublica

Mathew Webb left a sales job in menswear for a sales job in pharmaceutical drugs 10 years ago and suddenly found himself surrounded by money.

As a sales representative for a major drug company, he was expected to entertain doctors two or three nights a week. There were seats in elaborate sporting events in private stadium suites at major games and dinners at five-star restaurants.

At that point, openly using gifts and money to influence doctors was considered standard practice.

The hard reality about doctor speaking is that though doctors believe that they are recruited to speak in order to persuade a room of their peers to consider a drug, one of the primary targets of speaking, if not the primary target, is the speaker himself.

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But much of that came to a crashing halt after July 2002. That's when the pharmaceutical industry's trade group, known as PhRMA, published its Code on Interactions with Healthcare Professionals -- voluntary guidelines that substantially changed the game for reps like Webb.

The free tickets were pulled, the tropical vacations abandoned, even branded trinkets were banished. But the practice of trying to influence doctors with money didn't disappear -- it shifted.

Today when a rep like Webb wants to get a doctor to write prescriptions for his drug, there's still one almost foolproof way to get that task accomplished.

Do the doctors who do the speaking know that their prescribing habits have changed? If they do know, then in a sense they're being bought. If they don't, then they're unwittingly being played.

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To get a doctor to write more prescriptions, Webb asks the doctor to become a speaker.

Earlier this week the investigative news organization ProPublica published a searchable database of doctors who have taken money from seven drug companies in the past two years. The database features over 17,000 doctors, many of whom are paid substantial sums of money to act as speakers for drug companies. But because only these seven drug companies have publicly reported the payments they give to physicians, those doctors represent only a small fraction of the doctors who actually speak for pharmaceutical companies in the U.S. Most estimates place the number of physician speakers somewhere in excess of 100,000.

Differing Views: Education Vs. Profit

I perceive myself as always prescribing in the best interest of my patient, and even unconsciously if I was unduly influenced, that would really bother me. I usually pride myself on keeping up my guard to prevent undue influence.

–Dr. James Dickie, endocrinologist, Westminster, Md.

On the surface, the act of speaking is a very straightforward transaction. The drug company gives the doctor a series of slides, sometimes some training in speaking, and then a date is set at a popular upscale restaurant where a roomful of other doctors gather over dinner and wine to listen to him talk.

The speaker is supposed to educate those other doctors about a drug's benefits and drawbacks, in the hope that they might prescribe the drug for their patients.

That, anyway, is how many of the doctors who do this speaking, see it.

"I'm going out there and trying to educate other doctors about how to treat ADHD appropriately and safely," says Lance Clawson, a child and adolescent psychiatrist in Maryland, who is in ProPublica's database.

Clawson's view of what he's doing is pretty typical. He says that though the money is nice, fundamentally he feels that he is doing a good deed by speaking. He points out that there are fewer than 9,000 child psychiatrists in America today, which means that children who struggle with problems like ADHD are mostly being treated by doctors who have no specialized training. "The fact that children are being treated for ADHD inappropriately is a really bad thing," Clawson says. "So I'm going out there and trying to teach people how to do a good job."

But the practice of doctor speaking looks much different from the other side of the fence, the side occupied by drug representatives. For the past month, NPR has talked to former and current representatives, 18 in all, and two are quoted in this story.

The representative we call Mathew Webb recently left the drug business and doesn't want us to use his real name out of fear of financial repercussions. Another representative we interview extensively, Angie Maher, left the industry two years ago after becoming a whistle-blower in a lawsuit.

The Role Of The 'Thought Leader'

According to Webb and Maher, Clawson's view that speaking is educational is not at all accidental. Drug companies train representatives to approach a narrow set of doctors in a very specific way, using language that deliberately fosters this idea that the doctors who speak are educators, and not just educators, but the smartest of the smart.

For example, every drug representative interviewed for this story used the exact same phrase when approaching a doctor with a pitch to become a speaker: Each doctor approached to speak was told that he was being recruited to serve as a "thought leader."

This phrase, Webb says, seems to have incredible psychological power.

"When you do say 'thought leader' I think it's a huge ego boost for the physicians," Webb says. "It's like a feather in their cap. They get a lot from it."

This is because most doctors have a very specific idea in mind when you ask them what constitutes a thought leader. Most doctors, including Clawson, cite two important qualifications. "First, the other doctors in the community respect that person's opinion," Clawson says. "And the other way to become a 'thought leader' is to become an academic researcher and try to push the bounds of science further, and then by definition you're a thought leader."

But some drug representatives, like Maher, have a more cynical view of why drug companies choose the doctors they choose. It's not about how well respected the doctor is, according to Maher; it's about how many prescriptions he writes.

"I think nowadays a thought leader is defined as a physician with a large patient population who can write a lot of pharmaceutical drugs. Period," she says.

This doesn't mean that every doctor recruited is not a high-quality doctor. Many are. But every representative NPR spoke to had a stable of stories about profoundly unimpressive doctors that they'd recruited as thought leaders essentially for the same reason that a robber robs a bank: because that's where the money is.

The fact is that the top 20 doctors in a representative's territory prescribe the vast majority of the medication. According to Webb, the top 20 percent prescribe as much as the lower 80.

So if you want to sell more of your product, and every representative is required to sell more, those are the physicians to target.

Which brings us to the hard reality about doctor speaking: Although doctors believe that they are recruited to speak in order to persuade a room of their peers to consider a drug, one of the primary targets of speaking, if not the primary target, is the speaker himself.

That's where reps look for a real increase in prescriptions -- after a speech.

Following The Money

Here's how the money works out, at least for Webb. It's hard to know whether he's typical because there haven't been any published studies of this subject. But according to Webb, he would give a high-prescribing doctor about $1,500 to speak. And following that speech, Webb would see the speaking doctor write an additional $100,000 to $200,000 in prescriptions of his company's drug.

Webb points out that the people recruited to speak are almost always high prescribers with incredibly high patient populations. "That much money, easily," he says. "So yeah, it was a good return on investment."

To calculate return on investment, companies look at how much money was spent on a doctor compared with how much the company made from him in prescriptions. According to Maher and Webb, this is something companies monitor very closely.

"Whether it's a lunch, a dinner program -- paying a physician to speak is tracked," Maher says.

Drug companies buy the doctors' prescription data from firms like IMS Health that use pharmacy records to track the prescriptions of almost every doctor in the U.S.

"So the way we could get to tell honestly if a speaker event was productive is you could look at their four-week data and see how many prescriptions more he wrote than he used to write," Webb says. "That's how we knew."

Do Doctors Know Their Prescribing Habits Change?

All of this raises a very thorny moral question: Do the doctors who do the speaking know that their prescribing habits have changed?

If they do know, then in a sense they're being bought -- they are taking money to write prescriptions. If they don't, then they're unwittingly being played.

Dr. James Dickie, an endocrinologist in Westminster, Md., was very clear that his prescription-writing was unaffected by speaking. "Absolutely not. The physicians who are in the audience may notice it if they have been educated to that drug and the benefits of that drug -- they may see an increase in writing. But specifically in my own? I don't believe so."

When NPR told Dickie about the findings learned from drug reps like Maher and Webb, he seemed genuinely surprised and disturbed and began to wonder out loud if he was, in fact, affected.

"It would really bother me," Dickie says. "Because I perceive myself as always prescribing in the best interest of my patient, and even unconsciously if I was unduly influenced, that would really bother me. I usually pride myself on keeping up my guard to prevent undue influence."

But Maher says it's almost impossible for a doctor to keep up his guard. She points out that before doctors speak to their peers about a drug, they review slides provided by the company and talk to the company medical officers. And this process, she says, focuses the doctor on the most positive aspects of a drug.

"What is happening is that you are being manipulated to talk about the drug out loud," Maher says. "Kind of like talking themselves into knowing that what they were saying, were actually believing. And if they believed what they were saying, then they would write more drug."

Are Physicians Impervious?

David Switzer, a doctor in Virginia, writes about the interaction between doctors and reps on a popular website called cafepharma. As someone who has thought a lot about these issues, he says that he does not believe that most of the doctors who speak are conscious that their prescription-writing changes.

"The majority of doctors, I think, would honestly say, 'Oh that stuff doesn't work on me,' " Switzer says.

This attitude, he says is essentially programmed into them in medical school, where they're taught to think critically, and they're also taught that they have been taught to think critically. Which, in a way, Switzer says, handicaps them when it comes to drug reps.

"They come to the table with the belief that because they have gone through this rigorous academic training that they are somehow impervious," Switzer says. "I don't think that we're as good at that as we think that we are."

For his part, drug rep Webb says he can see the effects of this system, even in his own family. "My father has diabetes and I know one of his biggest complaints is that every time he goes to the doctor, it's: 'You know, let's try this medication this time. Let's try this medication this time.' And his diabetes is controlled -- everything is working fine," Webb says. "But his doctor's constantly changing him around, and he is a speaker -- for several companies in our metropolitan area."

The drug industry's trade group, PhRMA, says that in its view, the current rules on speaking are "sufficient," and a spokesman for the group said the group was unaware of any direct evidence that paying a doctor to speak influences his prescribing habits.

Even so, a growing number of universities and hospitals no longer allow doctors who work on their staff to speak on behalf of drug companies. And under the new health law, by 2013, every doctor who takes money from a pharmaceutical company will be listed on a government website.