“Dr. Dave either you are a no-talent doc-in-the-box hack with time between "patients" or you are sitting out your time on suspension for writing too many scripts for "hillbilly heroin". There is a saying we have in the Pharma industry. "you know what you call the guy who finished last in his class in Med School?....Doctor.”
-Anonymous poster, Cafepharma Darkened Sample Closet
Drug reps and doctors have a lot in common. We have tough jobs with high expectations. We often feel that our overseers and regulators have lost touch with the work and how we have to do it. Most of us try to present ourselves as courteous and sincere, and the exceptions generate stereotypes unfair to the majority. However, just shy of eleven years ago, I had a cyberspace eyeopener on my side of the drug lunch table.
In May, 2006, as often happens on the internet, I was surfing stream-of-consciousness style and stumbled onto a must-see site I did not know existed: Cafepharma(CP). CP is devoted to the pharmaceutical industry and caters largely to field representatives, those who work in the trenches like me. After reading a few comments, I was hooked. Funny how the split-second whim to click on a hyperlink can affect your next decade.
The content was massive. There were general discussion boards, regional boards, company specific boards, and even veterinary boards to name a few. The topics ran the gamut from how to break into the industry to complete disillusionment with it and every possible topic in between. I did not explore most of the boards because there were just way too many of them, but the lack of censorship and no-holds-barred commentary which would be considered vulgar and offensive to many (including myself and possibly the late, great George Carlin) strangely drew me in. Despite the trolling (a term I learned there) and open hostility, nuggets of truth I had never seen were buried not-so-deeply within.
I have been fascinated with pharmaceutical marketing since my residency days in the mid-nineties. Certainly CP enthusiasts would be very interested in the perspective of a physician with this interest, I reasoned. In fact, they may not realize how much we have in common. I’ll register and begin posting my insightful viewpoints for all to enjoy! In hindsight, my naivete was astounding.
Not long after signing up, I found a thread entitled “Sales Techniques We Doctors Hate” in a board called the Darkened Sample Closet, a space for registered and anonymous posters to speak their minds about all things pharma. The thread was started by an individual who stated that s/he was a physician and offered a list of – any guesses? – sales techniques s/he hated. Perfect!
I have pretty thick skin, but something of a traumatic experience ensued. Although I went to great lengths to be very respectful to the other participants, my presence was not welcomed by all. Some contended I was lying about being a doctor. Others believed that if were a doctor, I must be an unemployed quack in the middle of some sort of legal suspension from practice if I were spending my time on CP. I can’t remember for sure if anyone replied to any of my comments with a “f___ you,” but, as I recall, most counterpoints weren’t as politely constructed as that.
I was sticking with the conversation, accepting insults and even sabotage - one or more posters knew a way to replicate my comments multiple times in succession, thus rendering the dialogue near impossible to follow - until a contributor made what I considered a very tasteless joke, the premise of which was a rep’s molesting my daughter. I assume the poster had no way of knowing I had three daughters, but, in an unfortunate coincidence, my wife read this post over my shoulder. On Mother’s Day.
Oh, well, I thought, it seems like CP is not the place for me. I was disappointed but not angry. As a believer in free speech, I accepted the risk of being offended and considered my right in this situation to leave the conversation, not to demand that the website change its policies. Before I called it quits, though, I did want to verify that this style of discourse was considered standard and acceptable by those who own the site.
After doing some investigating, it appeared that as a registered user (as opposed to an anonymous guest) I did have some protection under CP rules against personal attacks. I contacted the webmaster and explained that I was fascinated by the site and enjoyed the discussion, just not the aggression and hostility directed at me personally. As the saying goes, one thing led to another, and she offered me the opportunity to have a board of my own, sort of, entitled “Ask Dr. Dave.”
I was concerned about the responses that such a forum might generate given my past experience, but the administrators had a simple solution. To maintain a basic level of decorum, moderators reviewed posts to the forum before they went live. Also, I received no payment (in the spirit of the Sunshine Act: I did usually get a very nice Harry and David gift box from CP around the holidays), and even my own posts were reviewed before they appeared.
I later corresponded with Michael Bryan, one of the founders of CP. He relayed the following general administrative perspective on the site:
“Our original vision for Cafepharma.com included several facets. The primary mission was (and still is) to provide a place where reps could communicate in a safe environment about all of their experiences in the field. We also wanted to provide information relevant to the profession (including: job listings, company research, etc).
It has been my experience and the experience of the other founders that the majority of good ideas and good information comes from the field. This includes ideas about how to promote the products and ideas/information about what is going on in our companies. We thought that a site for pharmaceutical sales professionals would be an ideal place for reps to freely and safely communicate about their experiences with their jobs, their companies, the industry, etc. As you can imagine, most corporations attempt to put the most optimistic spin on virtually every move they make. A few knowledgeable employees can often provide a more realistic view.
While we did not envision Cafepharma as solely a place for employees to complain, we did think that it would be a place for upper management to learn about employees' concerns and the issues that they were dealing with in the field. There is a lot of pressure on employees to give only positive feedback to management. This pressure is felt at all levels below top company leadership. The result is that company leaders rarely get unvarnished feedback about what is happening in the field. This is true of marketing initiatives, benefits changes, etc. I think one of the most important aspects of Cafepharma is that it gives upper management insight into what is going on in the field that would very difficult, if not impossible, to achieve by other means.”
Reps who called on me around the time of the inception of the Dr. Dave forum told me that they were discouraged by their companies to look at CP, much less participate. On the surface, I could understand. I’m sure no company would want to be associated with some of the claims and criticisms posted there, nor the behavior of various participants. Nevertheless, the “unvarnished feedback” of which Michael Bryan speaks indeed seems valuable. It’s like being able to eavesdrop on water cooler conversations of not only your own employees, but also the employees of your competitors. I speculated, but of course could not prove, that the admonition to avoid CP is a savvy reverse psychology ploy.
The experience I had, though, was even better (or worse depending on how you look at it) than eavesdropping. Forum participants openly conversed with me about experiences they had with my colleagues – not necessarily physicians I knew, but those who represented the profession of medicine day-to-day as I did. Some of those early posts included:
“As a teaching hospital rep, I have to provide lunches (although I am not crazy about it). Anyway, at a clinic staff request, I had lunch delivered and the prima dona [sic], hot shot, grant receiving MD did not like it and began a ranting and raving episode in the building for all to hear (yes, even the patients). After he chewed on the nurses, he looked at me and said he would have me fired.”
“I had a big prescriber, that I had been calling on for 3 years tell me, straight faced and point blank that he would not write a drug my company had just acquired because I would not pay him to speak for us. I confirmed he was serious and then laid a quarter on the counter. He chuckled but seriously said that was not enough. So I collected my quarter and left. You don't have to have a red light in your window to be one...”
“A Dr complained that I would not provide his sons football team with hats and shirts ..It is actually in my perf [performance?] review complaint from Dr for not providing him with hats and I was being argumentative. BTW there were no company issued hats to provide…”
“Dr complained that there was one tuna sandwich amongst the 24 sandwiches I provided for his staff of 10..(.who always lie about the count). He did not like Tuna and did not care to see one on the platter. I assured him there was plenty and no one would have to eat tuna. He said it should not be on the platter…”
“Had a well known doc give me a wish list that included a set of new golf clubs. All the reps got one, we were supposed to pick one. I don't know why he didn’t just register with Cabelas and the proshop.”
Unfortunately, I could go on for pages, but I’ll close with this one that really got me.
“I have been in this industry for 10 years. I have had the pleasure of watching it go from "which big pharma company can outspend the other" to the tightly-controlled spending rules we have in place today. I must say, I don't miss the days of having to spend my evening after working all day taking docs to sporting events or concerts just to compete. It was getting out of control. High volume docs knew their worth and demanded to be compensated for their prescriptions. The pharma companies may have spent too much in entertaining, but it was fueled by the greed of the doctors. No one forced them to go to these events or accept the televisions [certain] reps "donated" for their waiting rooms. I never went that far, but docs asked for everything under the sun and usually got it from some big pharma rep. Even recently, a doc asked me to buy him a new stethescope [sic]-which I declined. In my years I have been groped, kissed on the lips, held hostage in a doc's car while he said he'd take me home after we "hugged for a while" after a carpool to a dinner and all other kinds of inappropriate behavior! I am an intelligent woman who knows her stuff and can go head to head with any doc out there and hold my own on disease state and product knowledge. Most doctors respect this and act appropriately, but there are still many who still cross the line.”
I have known since the first day of medical school that doctors can be dysfunctional folks, but reading some of the unvarnished feedback about my colleagues shocked me. What pharmaceutical reps had to say about physicians was more disturbing than anything I had to say about pharmaceutical reps. (To be fair and balanced, in high school I was voted Most Unlikely To Be Groped, but still.) The initial backlash I received in the Darkened Sample Closet made a whole lot more sense.
Were all doctors like those described above when interacting with pharmaceutical representatives? Of course not, and even the last victimized poster agrees with me on that. Doctors like this are simply memorable, much like the aggressive, discourteous reps that break the rules. Both generate negative stereotypes that affect the whole group. On the physician side, however, such behavior involves a hypocrisy that is egregious.
To be sure, since May, 2006, the pharmaceutical industry and its marketing has changed considerably, and, in my opinion, for the better. Yet, when I think about those early posts on Ask Dr. Dave, I wonder if the doctors have changed. I hope so, meaning that I hope that there are fewer “memorable” doctors. Sure, the opportunities for swag have decreased immensely, but an opportunity is only that. Removing an opportunity does not alter one’s values.
The times have changed, and I feel sure that no one forces doctors to see pharmaceutical representatives nowadays, as though they ever did. Consequently, much like CP administrators and I concurred in the beginning of our Ask Dr. Dave collaboration, we should establish a basic level of decorum in physician-rep conversation. Simply, we should not treat individuals with whom we choose to interact with contempt, scorn and disrespect.
Furthermore, doctors should not be thinking of the pharmaceutical industry as good or evil but rather with the wisdom of W. C. Fields – you can’t cheat an honest man. As we look back on the much-criticized sales techniques of the last thirty years, some of which we allegedly hated, they all required one thing to succeed: doctors who bought in. If our collective moral compass is sound, we will not likely be manipulated or exploited by any entity, including the pharmaceutical industry. If not, to paraphrase the great Chris Rock, we are only as ethical as our options.