This is how AMI sold:
The King of Happ y Hour Gene Carbona was almost a criminal. I know this
because, thirty minutes into our first telephone conversation,
he told me, “Carl, I was almost a criminal.”
I have heard ex-drug reps speak bluntly about their former
jobs, but never quite so cheerfully and openly. These days
Carbona works for The Medical Letter, a highly respected
nonprofit publication (Carbona stresses that he is speaking
only for himself), but he was telling me about his twelve
years working for Merck and then Astra Merck, a firm initially
set up to market the Sweden-based Astra’s drugs in
the United States. Carbona began training as a rep in 1988,
when he was only eleven days out of college. He detailed two
drugs for Astra Merck. One was a calcium-channel blocker
he calls “a dog.” The other was the heartburn medication Prilosec,
which at the time was available by prescription only.
The Atlantic Monthly april 2006
Prilosec is the kind of drug most reps can only dream
about. The industry usually considers a drug to be a blockbuster
if it reaches a billion dollars a year in sales. In 1998
Prilosec became the first drug in America to reach $5 billion
a year. In 2000 it made $6 billion. Prilosec’s success was not
the result of a massive heartburn epidemic. It was based
on the same principle that drove the success of many other
1990s blockbusters, from Vioxx to Viagra: the restoration of
an ordinary biological function that time and circumstance
had eroded. In the case of Prilosec, the function was digestion.
Many people discovered that the drug allowed them
to eat the burritos and curries that their gastrointestinal
systems had placed off-limits. So what if Prilosec was $4 a
pill, compared with a quarter or so for a Tagamet? Patients
still begged for it. Prilosec was their savior. Astra Merck marketed
Prilosec as the “purple pill,” but, according to Carbona,
many patients called it “purple Jesus.”
How did Astra Merck do it? Prilosec was the first proton
pump inhibitor (a drug that inhibits the production of stomach
acid) approved by the Food and Drug Administration,
and thus the first drug available in its class. By definition this
gave it a considerable head start on the competition. In the
late 1990s Astra Merck mounted a huge direct-to-consumer
campaign; ads for the purple pill were ubiquitous. But consumer
advertising can do only so much for a drug, because
doctors, not patients, write the prescriptions. This is where
reps become indispensable.
Many reps can tell stories about occasions when, in order
to move their product, they pushed the envelope of what is
ethically permissible. I have heard reps talk about scoring
sports tickets for their favorite doctors, buying televisions for
waiting rooms, and arranging junkets to tropical resorts. One
rep told me he set up a putting green in a hospital and gave
a putter to any doctor who made a hole-in-one. A former
rep told me about a colleague who somehow managed to
persuade a pharmacist to let him secretly write the prescribing
protocol for antibiotic use at a local hospital.
But Carbona was in a class of his own. He had access to so
much money for doctors that he had trouble spending it all.
He took residents out to bars. He distributed “unrestricted
educational grants.” He arranged to buy lunch for the staff of
certain private practices every day for a year. Often he would
invite a a group of doctors and their guests to a high-end restaurant,
buy them drinks and a lavish meal, open up the club
in back, and party until 4:00 a.m. “The more money I spent,”
Carbona says, “the more money I made.” If he came back to
the restaurant later that week with his wife, everything would
be on the house. “My money was no good at restaurants,” he
told me, “because I was the King of Happy Hour.”
My favorite Carbona story, the one that left me shaking my
head in admiration, took place in Tallahassee. One of the more
important clinics Carbona called on was a practice there consisting
of about fifty doctors. Although the practice had plenty
of patients, it was struggling. This problem was not uncommon.
When the movement toward corporate-style medicine
got under way, in the 1980s and 1990s, many doctors found
themselves ill-equipped to run a business; they didn’t know
much about how to actually make money. (“That’s why doctors
are such great targets for Ponzi schemes and real-estate
scams,” Carbona helpfully points out.) Carbona was detailing
this practice twice a week and had gotten to know some of the
clinicians pretty well. At one point a group of them asked him
for help. “Gene, you work for a successful business,” Carbona
recalls them saying. “Is there any advice you could give us to
help us turn the practice around?” At this point he knew he
had stumbled upon an extraordinary opportunity.
Carbona decided that the clinic needed a “practicemanagement
consultant.” And he and his colleagues at Astra
Merck knew just the man: a financial planner and accountant
with whom they were very friendly. They wrote up a contract.
They agreed to pay the consultant a flat fee of about $50,000
to advise the clinic. But they also gave him another incentive.
Carbona says, “We told him that if he was successful there
would be more business for him in the future, and by ‘successful,’
we meant a rise in prescriptions for our drugs.”
The consultant did an extremely thorough job. He spent
eleven or twelve hours a day at the clinic for months. He
talked to every employee, from the secretaries to the nurses
to the doctors. He thought carefully about every aspect of
the practice, from the most mundane administrative details
to big-picture matters such as bill collection and financial
strategy. He turned the practice into a profitable, smoothly
running financial machine. And prescriptions for Astra Merck
drugs soared.
When I asked Carbona how the consultant had increased
Astra Merck’s market share within the clinic so dramatically,
he said that the consultant never pressed the doctors
directly. Instead, he talked up Carbona. “Gene has put
his neck on the line for you guys,” he would tell them. “If
this thing doesn’t work, he might get fired.” The consultant
emphasized what a remarkable service the practice
was getting, how valuable the financial advice was, how
everything was going to turn around for them—all courtesy
of Carbona. The strategy worked. “Those guys went
Drug reps are easy to spot in a hospital or clinic. They are
often young and strikingly good-looking. They are usually
affable and sometimes very smart. And they are always,
hands-down, the best-dressed people in the hospital.
the drug pushers The Atlantic Monthly
berserk for me,” Carbona says. Doctors at the newly vitalized
practice prescribed so many Astra Merck drugs that
he got a $140,000 bonus. The scheme was so successful
that Carbona and his colleagues at Astra Merck decided
to duplicate it in other practices.
I got in touch with Carbona after I learned that he was
giving talks on the American Medical Student Association
lecture circuit about his experiences as a rep. At that point
I had read a fair bit of pharmaceutical sales literature, and
most of it had struck me as remarkably hokey and stilted.
Merck’s official training materials, for example, instruct reps
to say things like, “Doctor, based on the information we
discussed today, will you prescribe Vioxx for your patients
who need once-daily power to prevent pain due to osteoarthritis?”
So I was unprepared for a man with Carbona’s
charisma and forthright humor. I could see why he had
been such an excellent rep: he came off as a cross between
a genial con artist and a comedic character actor. After two
hours on the phone with him I probably would have bought
anything he was selling.
Most media accounts of the pharmaceutical industry
miss this side of drug reps. By focusing on scandals—the
kickbacks and the fraud and the lavish gifts—they lose sight
of the fact that many reps are genuinely likeable people. The
better ones have little use for the canned scripts they are
taught in training. For them, effective selling is all about
developing a relationship with a doctor. If a doctor likes a
rep, that doctor is going to feel bad about refusing to see
the rep, or about taking his lunches and samples but never
prescribing his drugs. As Jordan Katz, a rep for Schering-
Plough until two years ago, says, “A lot of doctors just write
for who they like.”
The King of Happ y Hour Gene Carbona was almost a criminal. I know this
because, thirty minutes into our first telephone conversation,
he told me, “Carl, I was almost a criminal.”
I have heard ex-drug reps speak bluntly about their former
jobs, but never quite so cheerfully and openly. These days
Carbona works for The Medical Letter, a highly respected
nonprofit publication (Carbona stresses that he is speaking
only for himself), but he was telling me about his twelve
years working for Merck and then Astra Merck, a firm initially
set up to market the Sweden-based Astra’s drugs in
the United States. Carbona began training as a rep in 1988,
when he was only eleven days out of college. He detailed two
drugs for Astra Merck. One was a calcium-channel blocker
he calls “a dog.” The other was the heartburn medication Prilosec,
which at the time was available by prescription only.
The Atlantic Monthly april 2006
Prilosec is the kind of drug most reps can only dream
about. The industry usually considers a drug to be a blockbuster
if it reaches a billion dollars a year in sales. In 1998
Prilosec became the first drug in America to reach $5 billion
a year. In 2000 it made $6 billion. Prilosec’s success was not
the result of a massive heartburn epidemic. It was based
on the same principle that drove the success of many other
1990s blockbusters, from Vioxx to Viagra: the restoration of
an ordinary biological function that time and circumstance
had eroded. In the case of Prilosec, the function was digestion.
Many people discovered that the drug allowed them
to eat the burritos and curries that their gastrointestinal
systems had placed off-limits. So what if Prilosec was $4 a
pill, compared with a quarter or so for a Tagamet? Patients
still begged for it. Prilosec was their savior. Astra Merck marketed
Prilosec as the “purple pill,” but, according to Carbona,
many patients called it “purple Jesus.”
How did Astra Merck do it? Prilosec was the first proton
pump inhibitor (a drug that inhibits the production of stomach
acid) approved by the Food and Drug Administration,
and thus the first drug available in its class. By definition this
gave it a considerable head start on the competition. In the
late 1990s Astra Merck mounted a huge direct-to-consumer
campaign; ads for the purple pill were ubiquitous. But consumer
advertising can do only so much for a drug, because
doctors, not patients, write the prescriptions. This is where
reps become indispensable.
Many reps can tell stories about occasions when, in order
to move their product, they pushed the envelope of what is
ethically permissible. I have heard reps talk about scoring
sports tickets for their favorite doctors, buying televisions for
waiting rooms, and arranging junkets to tropical resorts. One
rep told me he set up a putting green in a hospital and gave
a putter to any doctor who made a hole-in-one. A former
rep told me about a colleague who somehow managed to
persuade a pharmacist to let him secretly write the prescribing
protocol for antibiotic use at a local hospital.
But Carbona was in a class of his own. He had access to so
much money for doctors that he had trouble spending it all.
He took residents out to bars. He distributed “unrestricted
educational grants.” He arranged to buy lunch for the staff of
certain private practices every day for a year. Often he would
invite a a group of doctors and their guests to a high-end restaurant,
buy them drinks and a lavish meal, open up the club
in back, and party until 4:00 a.m. “The more money I spent,”
Carbona says, “the more money I made.” If he came back to
the restaurant later that week with his wife, everything would
be on the house. “My money was no good at restaurants,” he
told me, “because I was the King of Happy Hour.”
My favorite Carbona story, the one that left me shaking my
head in admiration, took place in Tallahassee. One of the more
important clinics Carbona called on was a practice there consisting
of about fifty doctors. Although the practice had plenty
of patients, it was struggling. This problem was not uncommon.
When the movement toward corporate-style medicine
got under way, in the 1980s and 1990s, many doctors found
themselves ill-equipped to run a business; they didn’t know
much about how to actually make money. (“That’s why doctors
are such great targets for Ponzi schemes and real-estate
scams,” Carbona helpfully points out.) Carbona was detailing
this practice twice a week and had gotten to know some of the
clinicians pretty well. At one point a group of them asked him
for help. “Gene, you work for a successful business,” Carbona
recalls them saying. “Is there any advice you could give us to
help us turn the practice around?” At this point he knew he
had stumbled upon an extraordinary opportunity.
Carbona decided that the clinic needed a “practicemanagement
consultant.” And he and his colleagues at Astra
Merck knew just the man: a financial planner and accountant
with whom they were very friendly. They wrote up a contract.
They agreed to pay the consultant a flat fee of about $50,000
to advise the clinic. But they also gave him another incentive.
Carbona says, “We told him that if he was successful there
would be more business for him in the future, and by ‘successful,’
we meant a rise in prescriptions for our drugs.”
The consultant did an extremely thorough job. He spent
eleven or twelve hours a day at the clinic for months. He
talked to every employee, from the secretaries to the nurses
to the doctors. He thought carefully about every aspect of
the practice, from the most mundane administrative details
to big-picture matters such as bill collection and financial
strategy. He turned the practice into a profitable, smoothly
running financial machine. And prescriptions for Astra Merck
drugs soared.
When I asked Carbona how the consultant had increased
Astra Merck’s market share within the clinic so dramatically,
he said that the consultant never pressed the doctors
directly. Instead, he talked up Carbona. “Gene has put
his neck on the line for you guys,” he would tell them. “If
this thing doesn’t work, he might get fired.” The consultant
emphasized what a remarkable service the practice
was getting, how valuable the financial advice was, how
everything was going to turn around for them—all courtesy
of Carbona. The strategy worked. “Those guys went
Drug reps are easy to spot in a hospital or clinic. They are
often young and strikingly good-looking. They are usually
affable and sometimes very smart. And they are always,
hands-down, the best-dressed people in the hospital.
the drug pushers The Atlantic Monthly
berserk for me,” Carbona says. Doctors at the newly vitalized
practice prescribed so many Astra Merck drugs that
he got a $140,000 bonus. The scheme was so successful
that Carbona and his colleagues at Astra Merck decided
to duplicate it in other practices.
I got in touch with Carbona after I learned that he was
giving talks on the American Medical Student Association
lecture circuit about his experiences as a rep. At that point
I had read a fair bit of pharmaceutical sales literature, and
most of it had struck me as remarkably hokey and stilted.
Merck’s official training materials, for example, instruct reps
to say things like, “Doctor, based on the information we
discussed today, will you prescribe Vioxx for your patients
who need once-daily power to prevent pain due to osteoarthritis?”
So I was unprepared for a man with Carbona’s
charisma and forthright humor. I could see why he had
been such an excellent rep: he came off as a cross between
a genial con artist and a comedic character actor. After two
hours on the phone with him I probably would have bought
anything he was selling.
Most media accounts of the pharmaceutical industry
miss this side of drug reps. By focusing on scandals—the
kickbacks and the fraud and the lavish gifts—they lose sight
of the fact that many reps are genuinely likeable people. The
better ones have little use for the canned scripts they are
taught in training. For them, effective selling is all about
developing a relationship with a doctor. If a doctor likes a
rep, that doctor is going to feel bad about refusing to see
the rep, or about taking his lunches and samples but never
prescribing his drugs. As Jordan Katz, a rep for Schering-
Plough until two years ago, says, “A lot of doctors just write
for who they like.”