Industry-Sponsored Dissemination of Medical Knowledge
[T]hese tremendous R and D budgets and the entire flow of knowledge and information used to discover new products rests on the ability of the industry to convince those who can write a prescription, or a script (doctors, nurse practitioners, physician’s assistants, etc.), to write that script for their particular product.—Michael Oldani (2004: 329)
Publications address many audiences, but to pharmaceutical companies the most important audiences are generally made up of prescribing physicians. Simply by being published, articles may reach some physicians and researchers who influence physicians. But companies do not rely on this route and distribute their preferred knowledge directly to physicians by sales representatives, key opinion leaders (described below), and occasionally by direct mailings—the pharmaceutical company Merck is reported to have bought 900,000 copies of a New England Journal of Medicine article reporting a large trial of Vioxx (Smith 2006), an amount that suggests at least some mass mailings.
At the ground level, pharmaceutical sales representatives use reprints of publications for promotional purposes. Addressing an audience of publication planners at a large conference, a former sales representative, now an industry consultant, gives a bit of a pep talk: “Folks, they’re dying for your work, by the way. Field reps are dying every day for more of your work. You know that, right? Because that’s what doctors are going to see.” In the course of discussing legal developments around interactions between companies and physicians, she indicates how articles create opportunities for conversations. She imagines a situation in which she is not permitted to discuss science suggesting the off-label use (i.e., use not sanctioned by regulators) of drugs:
Those of you who’ve been a sales rep know how difficult that would be. First reprint I’ve gotten now in three years, and I’ve got it gripped, I’ve got it in my hand .... So now I’m now in an office and I’ve got this reprint and I think ‘Hi doc, good to see you today. By the way, and one more thing, here’s this reprint. Goodbye.’
This, she indicates, would be uncomfortable, unusual, and unproductive. For sales representatives, distributing reprint of scientific article is an opportunity to initiate discussions. Those discussions will invariably be of the article, but also about how to use its information—setting up possible prescriptions and sales.
Of course, pharmaceutical sales representatives do much more than transmit knowledge. Providing information about drugs is only one component of their jobs. Sales reps also provide samples, as gifts and to get physicians used to prescribing their products. Where these haven’t been made illegal, they provide other, larger, gifts to physicians (see Oldani 2004). Perhaps most commonly, they provide friendship (e.g., Fugh-Berman and Ahari 2007). Ultimately, though, it is the fact that sales reps provide information, whether in the form of scientific reprints or product information sheets, that legitimizes their presence in physicians’ offices. The transmission of medical knowledge is what allows sales reps to make their pitches, offer their friendship, and convince physicians to prescribe specific drugs.
But while sales representatives might be prominent vectors for the distribution of knowledge, their sales role makes them suspect. According to another former pharmaceutical sales representative, “[t]here are a lot of physicians who don’t believe what we as drug representatives say. If we have a KOL stand in front of them and say the same thing, they believe it” (Moynihan 2008). For this reason it is worth taking a detailed look at key opinion leaders.