A New Paradigm for Drug Reps, or, "M-I-C...K-E-Y..."

Jonathan D. Rockoff wrote a little while ago in the Wall Street Journal online:
http://online.wsj.com/article/SB10001424052970204331304577142763014776148.html
--that while people like me were paying attention to other issues at the medicine-Pharma interface, and ignoring our old friends the drug reps, a paradigm shift may have begun to occur in that field.

First off, Rockoff updates us on a trend that was just beginning at the time HOOKED came out, that from a peak in 2007 of 105,000 drug reps in the US, industry has been trimming steadily down to a present force of about 72,000. The firms had decided that too many reps were tripping over each other and duplicating effort.

But the real paradigm shift is what these reps are now supposed to do, at least according to the picture Rockoff paints (focusing on a particular Eli Lilly rep who peddles neurological and psychiatric drugs in North Carolina). Instead of the old hard sell where reps were trained to "close the sale" and push their docs to promise that they'd write the next 5-10 prescriptions in that class for the company's drug, reps are being urged to use a softer and friendlier technique, do more listening, and try harder to find out what the physicians think and want and better meet their needs.

Hence my subtitle--as Rockoff reported, "Lilly's most recent national sales meeting, held at Disney's business training institute in Florida in February, was devoted to customer service, not product training. Sales representatives watched how Animal Kingdom workers greeted families at the gate and answered questions around the attractions."

Now, here's the most serious aspect of the paradigm shift: "In the wake of costly settlements by other drug makers over illegal marketing practices, British drug giant GalxoSmithKline PLC stopped evaluating salespeople based on the number of prescriptions written. Instead, companies are considering how well physicians rate their representatives." Whoa-- bonuses for reps no longer based on sales volume pure and simple? That's huge.

Not, you understand, that companies have changed how they see the rep's job--just that you can catch more of the proverbial flies with proverbial honey: "'Increasing physician satisfaction, it turns out, is a much better way to promote a pharmaceutical agent than simply telling them to write more prescriptions or what the benefits' are, said David Ricks, president of Lilly's global business unit."

The new generation rep, says Rockoff, is more ready to admit the downside of the company's drug and give docs useful information about side effects. For example, the "new" rep Rockoff profiles, Michaelene Greenly, helped one of her physicians troubled by a patient's weight gain on the Lilly antipsychotic Zyprexa, recommending a special Lilly-sponsored nutrition program. (What drugs the patient might have been switched to besides an antipsychotic appears not to have been part of the conversation.)

As an example of how this goes over with the physicians, Rockoff tells us about Dr. Carey Cottle, Jr., a psychiatrist on Ms. Greenly's circuit:

Before the change in tactics, psychiatrist Carey Cottle Jr. says he was more likely to write prescriptions for a competing antidepressant like Pfizer Inc.'s Effexor over Cymbalta, because Lilly representatives had a "high-pressure, car sales-type approach, and it was just not appropriate." Fed up several years ago, Dr. Cottle called their Lilly manager and complained that the reps' visits were "wasting our time."

Now, Ms. Greenly's service has lifted the bias he had against prescribing Lilly medicines, Dr. Cottle says. When he had a patient who was breast-feeding, she supported his conclusion that it would be safer if the woman took the antipsychotic Risperdal instead of Lilly's Zyprexa because Risperdal had more safety data on that point.

Let's talk about this for a minute. First, it's a great step forward that the rep would actually suggest a rival company's drug due to a safety issue--even though, once again, one has to ask whether the patient truly needed an antipsychotic, given how much evidence we have of massive overprescribing of psychoactive drugs.

On the other hand, personally, as a patient, I would not want to be treated by a physician who used not to prescribe a certain company's drugs because he did not like their rep, and now prescribes that company's drugs because the rep is nicer. Whatever happened to the quaint idea of prescribing the drug that you think, based on the available scientific evidence, is really best for this particular patient? Or are you really saying that the choice of a drug is like Tweedledum and Tweedledee, and that you might as well toss a coin anyway based on the scientific data, so why not go with the company that sent their reps to Disney? Somehow I don't think that's what even the "new" reps tell the physicians, even though in many drug categories it's probably true.

So in some ways the paradigm seems really to be shifting, but in the most basic way, it hasn't. The challenge to docs is still: do you want to get your information about drugs from a person who was sent to your office specifically with one mission, which is to represent a company and try to maximize their sales?