Smart, sophisiticated, intelligent, clinically proficient, and highly respected. These were once terms that described the American pharmaceutical sales representative. Over many years, these reps have lost credibility through marketing practices that included paying prescribers exhorbitant amounts of money to speak or author studies, trials, and testimonials that painted the pharmaceutical company and it’s products in a favorable light. Sharply, we have seen a consumer, government, physician, and even industry crackdown that has halted these practices. So strict are current guidelines with HIPPA, Sunshine Act, and Pharma Code that reps may not even offer a pen with a legitimate dosing reminder attached.

Fear of impropriety has resulted in two camps. In one, there is a notion that we must create a nanny state in which our physicians are protected from the potential that they will prescribe based on having received a shiny pen or enjoyed a sandwich while a rep provided details on a medication’s pharmacokinetic profile. This camp eludes to the idea that physician’s, in spite of having passed med school, are incapable of the professionalism that enables them to filter industry provided information so that they may prescribe based on scientific evidence and appropriate clinical experience. In the other camp, there is a backlash in which physician’s resent increasing oversight and feel the threat to their autonomy as clinical professionals. This second camp is not unfounded. Lower Medicare reimbursements, HMO’s dictating which medications receive reimbursement, ACO’s, and now administrators telling them which drug reps they may or may not engage with and all of their interactions being bound by increasing scrutiny and threat of intervention by authorites or lawyers. Certainly a lot for a medical doctor to consider, isn’t there?

Lets examine the portion regarding the physician to drug rep interaction. We previously covered the high regard to which the pharmaceutical industry was once held. It was thought of as a vital source of new information and innovation to support the practice of medicine. The fault of the rep’s image decline does not fall solely on the reps, the administrators, or the physicians. For years, pharmaceutical companies pumped out scores of reps armed with the same literature, same samples, and the same message. Reps were told to extend their reach and frequency and it was thought that this high activity would increase sales. It did, until it didn’t.

Quickly, office staff as well as the physician customers became annoyed by constant interference by reps who were no longer engaging, but rather were regurgitating the same message as the rep that was by earlier in the day. Even the reps began to complain because they knew they were no longer bringing value to aid their target list in procuring the most effective medication for the patient population since their pod (a group of reps working on the same targets) all did the same thing over and over. The result has been reduced access as clinic’s limited the number of drug rep visits or even eliminated them altogether.

Industry has now recoiled with massive layoffs of the once prominent faces of their companies. Long standing relationships that reps had with physicians have been demolished in favor of contract or temp reps who can be easily reassigned. Even amongst those employed directly, there is recurring reorganization of sales teams such that a rep cannot count on being in any given territory calling on particular physicians for long. Those with tenured pharma sales backgrounds now find themselves in a sea of changing tide. Today’s call on a doctor may involve nothing more than a sample drop and a signature capture.

The dynamic of a modern sales call is not simply because physicians do not want to engage and learn about the products, some do. However, the rep is in the middle of two coins. On one hand, offices have restricted access with the belief that “the rep can’t provide value so they don’t need to see our providers”. On the other hand, reps are so limited in their messaging that they are prohibited from discussing or alluding to any off-label use even if that is the type of use that is most common with the medication and the company has studies to support the off-label use. As an ex-rep, it always irked me that a product could be known to have virtually no side-effects and even be more effective than current therapies yet I was not permitted to provide the data we had because “if the doctors already prescribe then it is not cost effective to do the studies required to get the indication”.

Now we have the Sunshine Act to deal with. One rep reported that she could not discuss insurance coverage for her products and efficacy on the same call because that is how her company was interpreting the new rules. Even the staple of rep access, lunches, are now feared because they could be seen as improper gifting in order to increase prscribing of a given medication. Of course, lunches increase prescribing! Lunches provide opportunity for reps to discuss treatment algorithms and present clinical evidence that supports using a given medication with a specific patient population. This causes the doctors to identify patients that may be better served by varying their treatment protocols. Personally, I like the idea of someone shaking (not literally) my doctor on occasion to check in and see if they’re up to speed on the latest treatments, don’t you?

The world we are left with is this. Pharmaceutical reps are not being given the complete information about their products so that their organizations can control the messaging. Physicians are unable to get direct questions answered on the spot unless the answer can be read from the package insert which they can do for themselves. Instead, doctors must be directed to a clinical science liaison that relays the clinical info at a later date. Value from reps has diminished such that many reps are now apothetic about their roles and find it satisfactory to drop samples with no discussion at all. Companies are even employing customer service sample droppers who are not trained to discuss medical info and work at half the cost. While rep opportunities still exist, the career path is no longer clear. Those with highly decorated success are being pushed out in favor of newbie reps with lower pay requirements and no recollection of the genuine clinical discussions of times past. The very tenured reps are hanging on in fear of layoffs with mouths closed and the hope of riding this out until retirement. Actually, I cross my fingers for them too. Highest paid tends to be the first to go when the companies hire an outside company to make “unbiased” layoff decisions.

In this author’s opinion, doctors are generally highly competent with a high degree of ability to discern viable information to guide their decisions. Each year, physicians are working harder and longer hours to prevent income decline. They are more demanded upon than ever and many do not have the time or energy to seek out every bit of relevant data regarding treatment options. The professional pharmaceutical sales rep (not the sample droppers) was and can still be a valuable filter that highlights the most important relevant data so that the physician does not need to dig. They also provide fast updates on discount programs, patient assistance programs, processing prior authorizations to see that medications are accessible, and they can even do the leg work of finding out where the info doctor needs resides. On top of all of this, the rep still knows what your competitor is doing and may have immeasurable knowledge about the market you serve if you ask them the right questions. I’d encourage any doctor to probe their reps to see what they really do know; identify the ones that bring value and please feel free to limit the rest but let them back in from time to time to see what has changed.