The plight of the drug rep in the doctor’s office

I have been to four or five talks at my academic medical center about the perils of physicians accepting handouts from the pharmaceutical industry. It was beaten into my head: doctors who take samples are more likely to prescribe irresponsibly. Doctors are wooed by drug reps, who are specifically trained to manipulate doctors into buying more drugs. There are plenty of great books about the ulterior motives of pharmaceutical marketing, a couple of which I’ve read.

There is no doubt that drug reps are highly trained with specific goals in mind. For example, here is a picture that Merck gives to drug reps-in-training on how to direct a conversation with a physician to the drug they are selling:

From: Overdosed in America

From: Overdosed in America

But I had never worked at a practice that accepted drug reps. Until recently.

I showed up at the office around 8:30 AM. A couple of patients were already in the waiting room. The medical assistants were chatting with a man in a suit, who I didn’t realize was a drug rep until he left a few papers for the doctor and a small armament of samples. He wasn’t the only one.  There were five or six who came in regularly, with coffee, pastries, or paid for lunch—of which I never partook, except for a few pita chips on the last day—who were really friendly and thicks as thieves with the office.

I learned why it was so helpful for my doctor, who worked part-time in solo practice with a couple of medical assistants to see at least twenty patients per day, to get visits and dinners from the drug reps. They provided a welcome respite from the grind of the work day. They were fresh, charming, and really knew their drug like no one else. One drug rep, who supplied suboxone to the clinic, explained in gritty, biochemical detail how to catch patients who falsified their urine samples. They explained the ins and outs of their drugs the way some people talk about their antique cars, and it felt educational, as well as gratifying to talk to another human being who wasn’t a patient.

But ultimately, I ended up feeling bad for the drug reps. Their paychecks teetered on the decisions that the doctors, their clients, made, which were often based on emotions, mood, and what was for lunch. One time, a drug rep messed up the lunch order for the office, so no one ate until 2 PM. The panic in her eyes was almost unhinged. I’ve also heard stories about drug reps who have quotas unfairly raised on them as soon as they meet their goals, who have to drive between states to make sales, and who have to deal with the egos and personalities of some more ornery docs.

So that’s the problem: theoretically, as physicians, we know it’s Bad Practice to accept the drug reps blindly. After all, it is a business relationship. However, the realities of a small private practice, or even if you’ve got a really hectic schedule and haven’t had time to catch up on CME (most of which is funded by drug companies, anyway), do not allow you to say no to gifts. Plus, it is actually pretty hard on the reps. And so the cycle continues.

As Carl Elliott writes in the Atlantic, “Doctors know a lot more about medicine, and drug reps dress a lot better, but these days both are Organization Men, small cogs in a vast health-care machine.” Perhaps, no matter what interactions are like on an individual level, this is the sad, sad truth.

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