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.”
Agree. Great read. As clinicians we are so busy it is impossible to keep up on every JAMA article. But I've learned reps are full of BS, so I took their countless wines & dines, & went pharma paid vacations for myself and family. But, I still did the ethical thing for my pts. too bad more MDs aren't like that. Never swayed me, but they did my colleagues.
I spent 3 x the time in the industry and can say if I paid for 10 lunches in 29 years I'll be surprised. There are always unethical people like this guy in any industry. I've heard of people with budgets in the 6 figures. I can say that was never my way of doing business, and we ended up owning AMI. Literally. And my old company had just as many unethical people, who seemed to skate along and never face the consequences of their actions. I'm glad I am now retired.
Old carboner... dude helped me make a ton of money in my territory. I went to med school and have been a general surgeon for about 10 years now. Pharma sales sure has changed. I don't get much from my reps. Still great looking chicks though.