Attack of the Pharma Babes

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Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area

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It's the click of high heels that gets our attention. The hospital is a place of aching feet in wide, thick rubber-bottomed, stand-all-day-long shoes. And our good women thus shod can't compete; in the weary, unaesthetic world of sick people they work too hard at tasks that are too unglamorous. Those good women were the first to warn us about the young lovelies in high heels. But the pharma babes still get to us, and the good women just roll their eyes.

Younger and prettier — or at least better coiffed than anybody taking actual care of the sick — drug reps are a feature of medical life that few outsiders see. Known as "detail" people or (behind closed doors) "pharma babes," they are basically salespeople. They generally work on commission. Despite all the patient information confidentiality laws, they somehow find out which doctors write how many prescriptions for what.

Hired to " educate" us about the drugs and devices they sell, few reps have any education in pharmacology or bio-engineering. They do know the basics we need to use the products: how to dose the drugs, the common side effects and interactions, how to use the equipment, etc. But questions beyond basic ones are usually answered with "I'll have to get back to you on that." They encourage us, though, with smiles, samples and glossy cards with easy-to-understand graphics. Perhaps more encouraging are their compliments and the sheer confidence they exude in the fine, expensive products they sell.

On the record, most docs will say reps are just a minor distraction, that as professionals "we do our learning the old-fashioned way." The cheap pens and pads adorned with logos and drug names, and the occasional steak-house dinners are supposed to mean nothing to us. But 10 minutes of rapt attention from a smiling beauty is still 10 more minutes than usual. So what if she's talking about nausea, vomiting and diarrhea — we talk about that stuff too. Every doc I know thinks he or she is above truly being influenced by drug reps. Professing ourselves wise, though, we generally become fools; I eavesdropped on the medical marketing world when I repped medical devices for a summer job in college — the reps knew what suckers docs were and taught me to take advantage of the fact. It hasn't changed; just grab hold of that inflated medical ego and twist — over we go.

The business of medical repping, although infrequently scrutinized, is invariably seen as a negative in the public eye, somewhere between legislative logrolling and subsidizing Big Sugar. The unethical influencing of our prescribing, the corruption of the sacred relationship between doctor and patient, allegations of bribery, unnecessarily increasing the price of health-care — these are on the rep's rap sheet. Yet it's a perfectly legal profession. Here are three reasons why.

Unlike doctors, drug companies are truly and primarily businesses. They invest billions and come up with many great, new products which cannot be sold, whatsoever, without convincing doctors to prescribe them. Billion-dollar businesses will influence lawmaking in every kind of governmental system. Reps move product, making money for the companies and their millions of stockholders. Powerful people will make sure that process is allowed to continue.

Secondly, many doctors rely on reps for practical information. Someone has to show the doctors the new stuff they can prescribe, or the new procedures they can do using new medical equipment. "Well, that's why there are laws about continuing medical education (CME)," you might say. The problem is that the CME apparatus is ungainly and practically impossible to standardize. As an orthopedist, I can get all the CME I need listening to lectures on handwashing and diversity sensitivity — and then poison my next patient with the wrong dose of a new drug.

"But doesn't board certification guarantee my doctor knows everything already and doesn't need reps?" Most people know that doctors take something like the lawyers'bar exam, called specialty boards, to get certified. Since the mid-'80s certification is not even permanent; pass the bar and you're a lawyer for life, but get a great grade on your boards and guess what — you have to take them again 10 years later or lose your certification. And that's every 10 years until you quit or die. Board exams are really hard — they stress rare things and subtle differences that even a very good, very busy doctor would not automatically know from being "in the business." In other words, you have to study a lot to pass them. (Not something I look forward to doing, a fourth time, when I'm 60.) Unlike the immediately useful, practical and admittedly simple things a rep teaches us, the material we study for the exams does little to help us in our daily practices. And unlike the stony inquisitor's face of a board examiner trying eagerly to fail you, reps are friendly, flattering and they often bring donuts.

The third, most urgent reason we need our reps is that hospitals are low on trained staff these days. With the myriad parts and pieces it takes to do a spine fusion, knee replacement or robotic prostatectomy, operating room staffs need help keeping the trays and trays of little parts organized and ready for action. In community hospitals especially, with no layer of surgical-resident help to keep things organized, OR staffs rely on product reps to set up and get them through procedures smoothly. And as more and more of our nurses are immigrants from countries that don't have such amazing medical technology, the rep's job in the hospital has become even more essential.

Today's doctor is far less in-charge than was Marcus Welby. Patients tell us what to prescribe. They see prescription drugs advertised on TV. "Ask your doctor" means "go tell your doctor you want this pill." The tactic must work; I see more TV drug ads every time I turn the thing on.

HMOs tell us what to prescribe. They have lists of (cheap) drugs for which we don't have to spend hours filling out forms, and lists of (less cheap) drugs we can only get with forms, and lists of (not cheap) drugs they won't pay for no matter what.

Hospitals tell us what to prescribe. They have formulary lists, somewhat like the HMOs, and contracts with equipment suppliers whose implants they force us to use. It is perhaps because of these strong voices that the reps are more effective. While those stern voices tell, the friendly pharma babe, just asking, is often a more forceful persuader.