Guests or pests?

You may have seen them in and around doctors' offices. They're young, well-dressed, attractive and generally come bearing gifts.

They are pharmaceutical representatives, and for those who are sick and waiting to be seen, their presence can be aggravating and their presumed influence suspicious.

"I've often thought that some doctors push medications because they get influenced by drug reps," said Juanita Wyant of Cape Girardeau.

Others, though, say they're valuable for the benefits they bestow.

"I appreciate all the free samples they provide; it can really help get you started on a new medication," said Dorothy Mitchell of Cape Girardeau.

Britt Durham, senior sales consultant for Novartis pharmaceutical products, gave a short presentation of Enablex and Lamisil products along with some free samples for their patients at Cape Family Practice. Durham travels to about 10 doctors and two pharmacists a day.

Last year, 118 listed pharmaceutical representatives regularly did business in Cape Girardeau.

Their job is to ensure the drug they push maintains or increases its market share. To do it, reps go wherever prescriptions are written. Critics believe this proximity is purchased with gifts like pizza, pens or even baseball tickets. They point to a conflict of interest for physicians whose first responsibility is to their patients.

The reps counter that they provide vital information to busy doctors.

The University of Pennsylvania Hospital made headlines recently by announcing that beginning July 1 its staff will not be allowed to accept any gifts. Locally, physicians differ in the way they treat reps. Some welcome them, some listen to them with caveats, and some simply shun them.

Freely open

Dr. Anthony Keele of Cape Family Practice says he, for one, has arms wide open.

"We are basically freely open to drug reps," he said. "We don't have any kind of weird requirements that they can only come during certain hours or they have to stand in a certain spot or they need a special key or a card to get in. You'd be amazed what some other places do. In my opinion it's a bunch of nonsense because in the end, either you see them or you don't."

See them he does. Keele estimates he interacts with 20 reps per day but limits the time to a total of around 15 minutes snatched in between patients.

This, he said, is a courteous exchange for the benefits his practice receives. Largest among these is an estimated $4 million to $5 million of free drug samples per year given to the office.

"Patients think that drug reps monopolize a physician's time and contribute to waiting time, but when it's effective they don't significantly impact what is happening," Keele said.

"If any of them gripe about 'How come you're seeing the rep instead of me?,' I've never had a patient gripe about it when I give them $150 or $200 in free drugs, but that's how it works."

That's not the only interaction Keele has with reps. Like many other doctors, Keele allows the reps to provide free lunches to him and his staff in exchange for an open ear.

"Our lunch schedule is booked out for the next nine months," he said. "That's their favorite thing because while you eat your lunch they get more face time to go over products."

Keele also schedules a one-on-one dinner appointment with a rep every Friday night.

He has added his own flourish to the reciprocal relationship. He created what he believes to be a one-of-a-kind reward system: a "Drug Rep of the Month program."

Whichever rep has given the most benefits to him, his staff and his patients gets a certificate and a photograph displayed prominently in Keele's office.

"I started it a couple of years ago, and once I did it I got such an overwhelming response that I kept doing it. They're all just really motivated type A people, so they want to know whatever it is they can do to get on that wall."

Five years ago, 90,000 drug representatives were working nationwide. That figure was approximately double the total in 1996 and equals one industry rep for every 4.7 physicians.

If reps are abundant, it's because pharmaceutical companies have decided they're effective. One study by the Journal for the American Medical Association found that for certain newer drugs every dollar the drug company spends on reps nets a return of $10.29 in sales. That ratio far outpaces more standard types of advertising, including television commercials.

In 2002, drug companies spent $18.5 billion to promote their products to health-care workers, according to industry data.

Keele admits that all the attention pays off.

"I'd be lying if I said it didn't have some influence," he said. "My deal is within a drug class we have an idea what works. If there are three or four drugs within the same class and they work the same without any given benefit of one over the other, then I'm going to prescribe the one that has a rep who always makes sure that we have samples full and tries to do the extra stuff for the staff and the patients."

Different methods

Some may see the figures and the statements and conclude doctors can be bought.

But one local rep who says he's often frustrated with people in his industry who "just get in the way" and "don't realize they're guests in these offices" presents a different picture of the role reps can play.

Soft spoken and unassuming, Mark Carver is not a typical detail man (an industry term for reps). He can often be found patiently sitting in a waiting room until a doctor has a free moment and doesn't travel with the typical food and trinkets.

"This is all I take with me," said Carver, pointing to a black notebook filled with articles from medical journals and studies relating to his drug's efficiency. "I don't ask about their family, I don't ask how they're doing. Because they don't care about all that and we don't have time for that. We may get three, four or five minutes, and we've got to make every second of that count."

Carver works for UCB Pharmaceuticals specializing in the anti-seizure drug Keppra. Last year, he logged 85,000 miles in his car and visited an average of six physicians per day. He is responsible for seeing neurologists in Southeast Missouri, Southern Illinois, western Kentucky and southern Indiana.

Carver met with Dr. A. Basit Chaudhari of Southeast Missouri Hospital's Neurosciences Center on Thursday. In recent months, Chaudhari's staff said a "tidal wave" of drug reps had convinced them to switch to a system where reps are seen on an appointment-only basis.

The staff said they were simply fed up with the reps' presence, which they said was often loud and pushy.

"They're a necessary evil," said office manager Joyce Wunderlich. "The most insulting thing to a patient who's sitting in the lobby is when they see them bringing doughnuts and cakes to the window. It's clear as day that's how they get in the door."

Chaudhari no longer stocks drug samples in his office and rarely accepts lunch from reps. Instead, he says he's only hungry for the knowledge they can provide.

"Every doctor must read two to three hours per day to keep up. If not, he will lag behind," he said. "So the reps when they are good are a blessing because they can give us the information we need in a nutshell."

Carver says he tries to be that source. "It is overwhelming. There is a lot of data out there, and that's just within epilepsy. Neurologists are dealing with multiple sclerosis and Parkinson's disease and on and on and on," he said. "So I try to help educate them on all of the drugs in a given class, the good and bad, because they ultimately are going to make the choice on what to prescribe to the patient. I want them to have all the information available when they make that choice."

The bottom line

But the relationship is not always as generous as the one between Chaudhari and Carver. Like any good salesman, a rep expects a return on his or her investment. For the past decade, Internet tools have made it possible for them to track precisely how and where their drugs move in the market.

Companies like IMS Health specialize in collecting prescription data from pharmacies, hospitals, wholesalers and insurance companies. Reps can use this data to pinpoint exactly which doctors are prescribing which drugs.

It has succeeded in making doctors more accountable than ever to market forces, say those close to the business.

"The biggest thing is information. The information is worth more than the prescriptions themselves," said Ben Tally of Medicap Pharmacy. "And the wholesalers, the pharmacies and the insurance companies are just getting better and better at collecting and selling information because the detail man has to know how many are buying from his area, and he'll pay to know."

Tally said anyone participating in Medicare Part D can be certain that drug reps have data on the prescriptions they fill.

Keele agrees that the information age has changed the ballgame. "They've got a decent idea that Dr. Keele writes so many of this one and so many of that one," he said. "If they're the ones I'm writing for, then everything is hunky-dory, but if not, they try to give me a reason to change my mind. That's what their job is, to try to improve their market share."

tgreaney@semissourian.com

335-6611, extension 245