went on to explain that drug companies, especially smaller ones, train their reps to treat doctors as if they were gods. And they seem to have a disproportionately large reserve of attractive reps. The whole effort is coordinated with military precision. Every self-respecting rep has access to a database that tells them exactly what each doctor has prescribed over the last quarter (both that company’s drugs as well as their competitors’). The reps also make it their business to know what kind of food each doctor and their office staff likes, what time of day they are most likely to see reps, and also which type of rep gets the most face time with the doctors. If the doctor is noted to spend more time with a certain female rep, they may adjust that rep’s rotation so that she can spend more time in that office. If the doctor is a fan of the military, they’ll send him a veteran. The reps also make it a point to be agreeable with the doctor’s outer circles, so when the rep arrives they start by handing out candy and other small gifts to the nurses and the front desk, securing themselves in everyone’s good graces from the get-go.
One particularly interesting practice is the “dine-and-dash,” where, in the name of education, doctors can simply pull up at prespecified take-out restaurants and pick up whatever they want. Even medical students and trainees are pulled into some schemes. One particularly creative example of this strategy was the famous black mug. A black mug with the company’s logo was handed out to doctors and residents, and the company arranged it such that a doctor could take this mug to any location of a local coffee chain (which shall go unnamed) and get as much espresso or cappuccino as he or she wanted. The clamor for this mug was so great that it became a status symbol among students and trainees. As these practices became more extravagant, there was also more regulation from hospitals and the American Medical Association, limiting the use of these aggressive marketing tactics. Of course, as the regulations become more stringent, pharma reps continue to search for new and innovative approaches to influence physicians. And the arms race continues …*
A FEW YEARS AGO, my colleague Janet Schwartz (a professor at Tulane University) and I invited some pharmaceutical reps to dinner. We basically tried the pharma reps at their own game; we took them to a nice restaurant and kept the wine flowing. Once we had them feeling happily lubricated, they were ready to tell us the tricks of their trade. And what we learned was fairly shocking.
Picture one of those pharma reps, an attractive, charming man in his early twenties. Not the kind of guy who would have any trouble finding a date. He told us how he had once persuaded a reluctant female physician to attend an informational seminar about a medication he was promoting—by agreeing to escort her to a ballroom dancing class. It was an unstated quid pro quo: the rep did a personal favor for the doctor, and the doctor took his free drug samples and promoted the product to her patients.
Another common practice, the reps told us, was to take fancy meals to the entire doctor’s office (one of the perks of being a nurse or receptionist, I suppose). One doctor’s office even required alternating days of steak and lobster for lunch if the reps wanted access to the doctors. Even more shocking, we found out that physicians sometimes called the reps into the examination room (as an “expert”) to directly inform patients about the way certain drugs work.
Hearing stories from the reps who sold medical devices was even more disturbing. We learned that it’s common practice for device reps to peddle their medical devices in the operating room in real time and while a surgery is under way.
Janet and I were surprised at how well the pharmaceutical reps understood classic psychological persuasion strategies and how they employed them in a sophisticated and intuitive manner. Another clever tactic that they told us about involved hiring physicians to give a brief lecture to other doctors about a drug they were trying to promote. Now, the pharma reps really didn’t care about what the audience took from the lecture—what they were actually interested in was the effect that giving the lecture had on the speaker. They found that after giving a short lecture about the benefits of a certain drug, the speaker would begin to believe his own words and soon prescribe accordingly. Psychological studies show that we quickly and easily start believing whatever comes out of our own mouths, even when the original reason for expressing the opinion is no longer relevant (in the doctors’ case, that they were paid to say it). This is cognitive dissonance at play; doctors reason that if they are telling others about a drug, it must be good—and so their own beliefs change to correspond to their speech, and they start prescribing accordingly.
The reps told us that they employed other tricks too, turning into chameleons—switching various accents, personalities, and political affiliations on and off. They prided themselves on their ability to put doctors at ease. Sometimes a collegial relationship expanded into the territory of social friendship—some reps would go deep-sea fishing or play basketball with the doctors as friends. Such shared experiences allowed the physicians to more happily write prescriptions that benefited their “buddies.” The physicians, of course, did not see that they were compromising their values when they were out fishing or shooting hoops with the drug reps; they were just taking a well-deserved break with a friend with whom they just happened to do business. Of course, in many cases the doctors probably didn’t realize that they were being manipulated—but there is no doubt that they were.
DISGUISED FAVORS ARE one thing, but there are many cases when conflicts of interest are more easily recognizable. Sometimes a drug maker pays a doctor thousands of dollars in consulting fees. Sometimes the company donates a building or gives an endowment to a medical researcher’s department in the hope of influencing his views. This type of action creates immense conflicts of interest—especially at medical schools, where pharmaceutical bias can be passed from the medical professor to medical students and along to patients.
Duff Wilson, a reporter for
Fudging the Numbers
If you think that the world of medicine is rife with conflicts of interest, let’s consider another profession in which these conflicts may be even more widespread. Yes, I’m talking about the wonderland of financial services.
Say it’s 2007, and you’ve just accepted a fantastic banking job on Wall Street. Your bonus could be in the neighborhood of $5 million a year, but only if you view mortgage-backed securities (or some other new financial instrument) in a positive light. You’re being paid a lot of money to maintain a distorted view of reality, but you don’t notice the tricks that your big bonus plays on your perception of reality. Instead, you are quickly convinced that mortgage-backed securities are every bit as solid as you want to believe they are.
Once you’ve accepted that mortgage-backed securities are the wave of the future, you’re at least partially blind to their risks. On top of that, it’s notoriously hard to evaluate how much securities are really worth. As you sit there with your large and complex Excel spreadsheet full of parameters and equations, you try to figure out the real value of the securities. You change one of the discount parameters from 0.934 to 0.936, and right off the bat you see how the value of the securities jumps up. You continue to play around with the numbers, searching for parameters that provide the best representation of “reality,” but with one eye you also see the consequences of your parameter choices for your personal financial future. You continue to play with the numbers for a while longer, until you are convinced that the numbers truly represent the ideal way to evaluate mortgage-backed securities. You don’t feel
