More than a decade ago, the job of the pharmaceutical rep was enviable. Direct-to-consumer advertising pre-sold many drugs so doctors already knew about them. Medical offices welcomed the reps who were usually physically attractive and brought lunch. In fact, reps sometimes had their own reception rooms in medical offices.

By 2011 thanks to drug safety scandals and new methods of marketing, the bloom had fallen off the pharma reps’ roses. The number of prescribers willing to see most reps fell almost 20 percent, the number refusing to see all reps increased by half, and eight million sales calls “could not be completed” at all, reported ZS Associates.

Some doctors did not hide their antipathy. Salt Lake City family doctor Ross Brunetti estimated six reps called on his office every morning and six more in the afternoon. “In a week, I might see three people trying to sell me the same thing,” he complained. “There are more drug reps than patients. It’s like a minefield.”

While some medical offices tolerated reps for the drug samples they left behind, even that began to change. The samples began to be viewed as nothing but inducements to prescribe more expensive drugs. Nor were they usually going to needy patients but rather to staff members themselves and their families and a move to refuse free samples started.

In fact, even before the Affordable Health Care Act’s “Sunshine Law” requiring payments to doctors be reported, the ethics of drug marketing were under scrutiny. Three years before the Act, In 2007, the 62,000-member American Medical Student Association (AMSA) rolled out a “scorecard” program that graded the nation’s 150 medical schools on their policies toward Pharma gifts, consulting and speaker fees and their financial disclosures.

“The scorecard program has changed the landscape because medical schools really understand grades,” said Nitin Roper, MD an AMSA member. “Schools which originally wouldn’t give us their policies suddenly thought their grades were unfair. In a revealing turn of the tables, one medical school contacted our student organization to request its D grade be changed to a C+.”

Medical schools also began acknowledging rep pressures. At the UIC College of Pharmacy, former sales reps were used to demonstrate to students how one-on-one encounters can become psychologically coercive in an elective and how to fight back.

“Refusal skills” were also being taught for overzealous patients. Writing a prescription may seem quicker but “explaining to a patient why a highly advertised drug might not be appropriate only takes three minutes,” said Richard Pinckney, MD, professor at the University of Vermont College of Medicine where such a program existed. “The insurance savings could pay for programs like these,” he said.

The Vermont project included “secret shoppers” who asked doctors for an expensive brand name drug they had seen on TV after the refusal training.

“Doctors have a hard time saying no if a drug is effective, even if it is expensive,” said Audiey Kao, MD, vice president of ethics at the American Medical Association at a 2010 conference. Doctors are “nervous” that rebuffed patients will go elsewhere, agreed Dr. Pinckney.

After the Vytorin scandal in 2008 in which the expensive drug was found to work no better than the lower priced Zocor, there was an especially big cloud over pharmaceutical reps.

“Got my a*s chewed,” wrote a rep on the website Cafepharma who had been selling Vytorin. The doctor asked “if I knew … when was I going to give him the head’s up” and said he “looks like an a*s in front of his patients. I just nodded and said that I got the information just about the same time he did and that I’m heartsick over it,” wrote the rep. “I got thrown out.”

Since Vytorin, the drugs Darvon, Bextra, Vioxx and Meridia have been withdrawn. There are heated battles over the five digit prices of new medications like hep C drugs and drug companies trying to incorporate overseas to flee taxes. It is not a great time to be a pharmaceutical rep.

Martha Rosenberg is an investigative reporter whose work has appeared in the British Medical Journal (BMJ), Consumer Reports, Public Citizen, the Center for Health Journalism at USC Annenberg, the Nieman Foundation for Journalism at Harvard University, and other outlets. She studied at Rush Medical School and writes on health care, food, medicine, and public policy.

Rosenberg’s reporting has been cited by Memorial Sloan Kettering Cancer Center, Mayo Clinic Proceedings, Public Library of Science Biology, ScienceDirect, the Journal of Pain & Palliative Care Pharmacotherapy, the Journal of Trauma & Dissociation, Britannica, National Geographic, Hastings Law Journal, and Wikipedia. She is the author of several books, including Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians, Born With a Junk Food Deficiency, Big Food, Big Pharma, Big Lies, and Food, Clothes, Men, Gas and Other Problems. She publishes on Substack, OpEdNews, and her Amazon author page.

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