How doctors and pharmaceutical sales representatives interact and communicate
The promotion of medications to doctors by the pharmaceutical industry is the subject of recurring criticism in media, medical, political, union, and academic spheres. Research literature on the subject usually sets out to identify the place of medication marketing among the many sources of information that doctors have on medications, and to understand its impact (as well as that of indirect remunerations such as gifts) on the prescriptions they write.[note 1]The article by Norris et al. (2005) is an important review of the literature produced essentially by doctors. Kremer et al. (2008) survey the work of marketing researchers on the question of the impact of pharmaceutical promotion on prescriptions.
To understand this important part of a medication’s ‘life course’ – its promotion and marketing – researchers usually base their study among doctors. The observation by Van der Geest et al. (1996), about the absence of anthropological attention for pharmaceutical sales representatives (hereafter frequently referred to as ‘representatives’) remains true today, with few exceptions (Kamat 1997, Greene 2004, Martin 2006). Because access to pharmaceutical businesses is not easy, representatives’ interactions with doctors are almost always described by former representatives, in the form of romanticized accounts (Ménin 1981, Reidy 2005) and rarely in scientific articles (but see, Oldani 2002, 2004, Fugh-Berman and Ahari 2007).[note 2]Other approaches developed by doctors involve the recording and analysis of a limited number of interactions, centred on the discourse about products (Maire et al. 1998, Somerset et al. 2001).
In this article I highlight these interactions, in order to understand their modalities, power relations, and how they function.
Doctors dominate the interaction with representatives. This relationship may be qualified as a one of solicitation of a dominant professional, with a primary objective: a doctors’ favourable disposition in writing prescriptions. Comparing characteristics of the doctor/representative relationship with those of Goffman’s ‘service relations’ (1961) allows the illustration of an imbalance in favour of doctors. This relation, I argue, differs from service relations which puts ‘specialized professions’ in relation with ‘clients’ (the doctor-patient relationship, for example). The ‘client’ – the doctor – is at his or her workplace and is not explicitly seeking a relationship. Pharmaceutical representatives are not at liberty to withdraw from the relationship if its conditions are unsatisfactory, because their employer requires that a minimum number of doctors be solicited daily. They endeavour to increase the quantity of products sold in their sector to reach the objectives set by their management. Also contrary to service relations, representatives’ technical competence is not always recognized by the client-doctors, who consider themselves to be the legitimate holders of therapeutic knowledge. Finally, the ‘contract’ part of the relationship rewarding the ‘specialized professional’ (the representative) – in this case corresponding with an engagement to prescribe – is often evaded.
In the social structure, “the distribution of waiting time coincides with the distribution of power” (Schwartz 1974: 841). This proposal leads us to consider doctors’ hold over pharmaceutical representatives’ time, over the long and short term, as indicators of doctors’ domination. How does the imbalance of positions in this relationship, reinforced by gaps in socio-economic capital (between professional groups and between individuals), manifest itself in doctors’ mastery of interactional conditions, notably that of time? In examining the mechanisms which determine the frequency of visits, waiting time, and the duration of visits, I show how doctors control the conditions of interaction, and which means are employed by pharmaceutical representatives to act on these conditions in return.[note 3]This study is based on observations I conducted in France during 2006-2007 in a large multinational pharmaceutical group. I was able to follow fifteen pharmaceutical representatives during their rounds, spending two days with each, as they visited generalist and specialist doctors as well as hospitals. I observed 150 contact encounters with doctors. These observations were completed by interviews with pharmaceutical representatives and doctors.
Controlled access to doctors
Doctors define the rules for receiving pharmaceutical representatives, whether at their offices or the hospital. Doctors want the upper hand in time management in this economic sector where representatives are numerous and their visits recurrent.
The frequency with which doctors receive representatives varies, but some factors correlate with their allowing a higher visit frequency: being a generalist, permitting only very short visits, considering representatives as a valuable source of information, lunching together, and having a flexible reception system (Nabarette et al. 2009). The doctor may receive representatives by appointment or not, during a fixed day and/or time slot, or in limited numbers per day or week. Because doctors who require appointments consequently see fewer pharmaceutical representatives, the significant increase in doctors adopting this practice [note 4]From 25% in the early 1980s to 75% today (FADIM 1985; Nabarette et al. 2009). This change in attitude may be explained by the significant increase in the number of pharmaceutical representatives per doctor during this period.
can be understood as a way for doctors to resist the flood of representatives and to keep control over their time management. Medical secretaries also participate in the respect of the rules of receiving by scheduling meetings, taking complaints from representatives, and selectively helping meetings to take place.
Pharmaceutical representatives spend a lot of energy conforming to doctors’ demands, and they are expected to know the doctors’ rules for reception. When sent to a new sector, they are expected to first and foremost acquire the ‘doctor sheets’ outlining these rules from their colleagues or the local association, or if need be, to gather the information from doctors themselves. This knowledge, regularly updated, allows them to plan their daily rounds and to rapidly adjust to the unexpected. One important aspect of the work of representatives is thus managing their appointments. Good organization is necessary in order to construct coherent sales rounds well ahead of time, since appointments must be made in advance (often by several months). Because of limits on the number of how many pharmaceutical representatives a doctor will see per day, the best way to be assured of being seen by the doctor is to arrive before the doctor arrives.
All these rules can be worked around when a pharmaceutical representative is already well established in the sector and knows the doctor well enough. Yves, an experienced representative, proudly claims part of the control in interactions with doctors, which allows him to reduce waiting time – and thus his working time – and to facilitate his rounds. He explained the system of ‘rights of passage’ for me:
Yves: If you have the right of passage, it’s outside regular hours [for sales visits]. […] [In the sector where I have seniority] I stop where I want [and when I want], except for maybe a few doctors. […] After that, you need to know how to manage [these rights]. […] Rights of passage are friendly, so you aren’t there to give the doctor the whole routine and be a drag […] But still you’ve gotta make him swallow the pill. And the better you know your sector, the nicer the doctors are to you, you like them, you’ve invited them [to do something], they know you, they trust you… The more you get into the rights of passage circuit, the harder it gets to talk about your products […]. You still have to keep asking for their prescriptions.
These possibilities for bypassing the rules partly explain why pharmaceutical representatives have a difficult time changing sectors, especially since rights of passage had allowed them to free themselves from the long waits to which salespersons are usually submitted.
Making them wait
The wait endured by pharmaceutical representatives varies considerably depending on the doctor and his or her reception system, and represents a significant part of their work time.[note 5]Waiting time represents 30% of the work time of pharmaceutical representatives practicing in town, as opposed to 18% for those working in hospitals (DAFSA 2004a; 2004b).
It is a source of boredom and humiliation, as well as anxiety when it stretches out and puts the day’s schedule at risk. Pharmaceutical representatives organize their rounds so as to limit time spent waiting, ultimately knowing the hours which are more or less favourable for each doctor. Some doctors set fixed hours just for representatives, while others see them as they do patients, first-come, first-served or by appointment. At hospitals, representatives usually have to intercept doctors in the hallways. They try to convince doctors to grant them a little time, in the hall if need be, or in a more quiet room if possible.
Waiting situations clearly illustrate the importance of doctors’ power in their relationships with pharmaceutical representatives. This domination is first manifest in the attitude of permanent availability of representatives while they wait. One handbook for representatives advises thus: “Seated or standing up, well located so as to be seen from the entry, the medical representative is ready to work. No slouching posture in an armchair. No chit-chatting with colleagues. He should stop all reading and he will not change places after having been seen” (Desblé 1976; translation JR). Doctors may inflict little humiliations on representatives during these waiting situations:
Amélie had reserved her slot with a doctor having a strong potential for prescription and many patients for this afternoon. She wants to be there early, to be ahead of the patients. When we arrive, around 13:15, there are already two ‘colleagues’ waiting in the building’s entry. […] After five minutes, the saleswomen decide to go upstairs. It’s better to go on up to avoid being passed by a patient, even if the entry hall is much more pleasant. We find ourselves in a narrow, rather dark hallway. […] Amélie tells us that recently a dermatologist had given her an appointment between 15:00 and 16:00. When she arrived at 15:00, the secretary tells her that the doctor will only arrive at 16:00. Amélie resolves herself to wait. But the dermatologist takes a patient for 30 minutes. The dermatologist sees her in the waiting room: “X Laboratories?” Amélie says “yes,” rising. The dermatologist: “No, no, wait.” And she takes a second patient. At 17:00, Amélie left without having seen her. Amélie said, turning to me, “You see, it’s disrespectful!” [then, whispering] “Honestly, you have the impression of being complete shit.” Even more so because the dermatologist should know the product inside out: it shouldn’t have taken her more than a minute to see Amélie. […] Later, one of the colleagues suggests going into the office. The other saleswoman points out that it’s only 13:58. So they decide to wait a little more […] At 14:00 they ring at the office door. (Fieldnotes, June 2006).
This extract shows that waiting is a matter of constant preoccupation which feeds conversation among pharmaceutical representatives. The wait is seldom so long as to attain an ‘insulting period’ (beyond the established rules), and the uses of time in representative/doctor relationships are everyday symbols of the silent domination of doctors (Hall 1959). While the first respects appointment times, often arriving early, and notifies if the appointment cannot be kept, the second does the opposite. Doctors may even turn away representatives after they have waited.
There are two characteristics of doctors which correlate with lengthy waiting times: a high patient volume and a doctor who is high in the hierarchy. It is easier to see interns, whose status is low in the hospital doctor hierarchy and who are less likely to dare to refuse a meeting. Claire, an intern doctor in a hospital, tells of the difficulty of escaping solicitations:
Sometimes there is a waiting room with three of four salespersons. And as soon as I step out of my office, bam, they jump on me saying “Do you have five minutes?” […] Once I was in a hurry and I really didn’t want to see them, but it’s really hard to refuse because they’re kind of insistent and it’s always “Yes, I’ll just take a second” and in the end you can’t get rid of them. […] Once I was with one of my externists who’s really burly. I took off my badge so their eyes wouldn’t be drawn to the red internist’s badge, and we left running, me hidden behind my externist!
Pharmaceutical representatives may adopt strategies to circumvent the rules and limit waiting times. These strategies allow the relationship of power between doctors and representatives to balance out. It is often a question of rushing the encounter, either by exploiting good relations with the doctor or by promising a short visit, even if it means staying in the hallway. As for the frequency of visits, waiting time can also be modulated by the good relations that may exist between representatives and doctors; the same also applies to the length of visits.
The duration of visits in tension
In France, the duration of interactions between pharmaceutical representatives and doctors is variable, averaging twelve minutes for generalists (Nabarette et al. 2009). In this short time representatives are expected to present two or three products, sometimes more. They should not make doctors waste time pointlessly, even if visits are not always rushed. Representatives are studied in this sense: they keep their jackets on, ready to leave the room quickly; they organize their bag so they can rapidly find the necessary documents, which they sometimes already have in hand.
These strategies are designed to avoid provoking impatience in the doctor. Representatives are sensitive to the signs of impatience: the more there are, the more quickly a representative cut short the visit. For their part, doctors strategize for short visits, too, often assuming a disinterested air, opening the mail or using the computer, nodding distractedly. Another widespread strategy is to always agree, implying the doctor already knows the content of the presentation and inciting the representative to go faster. The absence of questions or interventions from the doctor is also a way to limit the visit duration. Sometimes the doctor does not limit himself to surreptitious signs and interrupts the encounter.
Pierre had recently changed sectors. He doesn’t yet know this doctor (D) well, hasn’t seen him for five months; we await his return from his morning visits for over half an hour. The doctor first takes a patient, then takes us. Pierre presents his first product, Prostom, and after ten minutes goes on to his second product.
Pierre: Next, I have a product called Thrombix. […] Do you know it?
D: Maybe let’s stop there because I have patients to see, too.
Pierre: [a bit disconcerted] Alright, OK.
D: [justifying himself] You dwelt on Prostom so…
Pierre: Yes, I did dwell on that…
D: [to lessen the rudeness of his interruption] Thrombix, it’s for what indication?
Pierre: It’s the new antithrombotic where there are no platelets to do. Do you remember?
D: Ah yes, alright.
Pierre: I’ll just leave you the info sheet and I won’t talk about it.
D: Next time. [looking at the sheet] Oh yes, right!
Pierre: There it is. So the appeal, it’s the same effectiveness, same effectiveness, same tolerance as [competing products]. Yes, really, to be quick, it’s a synthetic molecule.
D: Um, yes.
Pierre: Yeah, which is entirely synthetic. The appeal, it’s that it doesn’t act on platelets. So with Thrombix, you don’t have to watch the platelets since there’s no type-2 thrombopenia.
D: Um, alright.
Pierre: That there is the big advantage. [He quickly outlines the dosage.] I’ve given the important parts. [We stand]
D: Good, thanks. Very good, that was… it’s … We’ll talk about it again. [Then, to show he remembered the first product] So, for the prostate, still Prostom.
Pierre leaves this visit frustrated, thinking the doctor could have made an effort to give him more time. (Field notes, May 2006)
I have never seen a pharmaceutical representative openly contest the interruption of a visit. On the other hand, they often try to quickly interject a few key ideas. They often play on doctors’ difficulty in abruptly cutting off a social exchange, craftily announcing the end of the visit even as they continue to rapidly evoke the advantages of their products. With experience, representatives end up becoming familiar with the little habits and preferences of their clients. They can give the ‘whole spiel’ to some doctors, something to be avoided with those who impose a quick visit. This sometimes leads to perfunctory statements about health products which are reputed to be scientifically quite complex.
Face-to-face situations may offer representatives more control of the duration of visits than is possible for waiting time or visit frequency. They will be even less inclined to give in to the doctors’ will if they have waited a long time in the waiting room. In this case they think they have the right to more time, having ‘paid’ with their wait.
By controlling the duration and frequency of pharmaceutical industry sales’ visits, doctors try to control the quantity of solicitation – and thus publicity – to which they are subjected. This mastery is imperfect, partly because it depends on more global factors such as pharmaceutical company marketing strategies (which doctors to target, for example), state regulation of pharmaceutical promotion, and the inertia of the medical profession’s habits when faced with this promotion. Their control is also incomplete because of their interlocutors’ own determination to keep some control over the duration and frequency of their visits. Developing a ‘good relationship,’ for example, allows easier access to doctor-clients and some attenuation of the effects of their domination. On the other hand, this may prevent representatives from rigorously presenting the sales pitch or from “continuing to ask for prescriptions,” especially if doctors know the products well. This observation could explain why certain pharmaceutical companies do not seem to take the relationships formed with clients into account when reorganizing their sales departments.
The literature rarely examines the interactions between representatives and doctors (except Oldani 2004; 2006), and it has not previously engaged with an important question about this relationship: what makes this relationship functional within the everyday life of doctors, since they are the dominant professionals with most power in the situation? Under what conditions would they grant an hour per week to listen to the product marketing of the pharmaceutical industry? Observation of the interactions between representatives and doctors reveals that doctors are probably more inclined to receive pharmaceutical representatives if they feel they control the face-to-face relationship and its timing, and if it is compatible with the time management of their medical activity. These are part of the conditions for their interactions with representatives being sanctioned. Doctors who have the feeling of losing control over these interactions may thus stop receiving representatives. But why do the majority of doctors even accept seeing representatives from the pharmaceutical industry at all? Doctors draw a certain number of benefits from their relations with representatives, beyond frequent flattering and pleasant representatives. Some doctors may use the visits as an economical and convenient form of continuing education. Additionally, pharmaceutical representatives furnish a number of services and advantages, especially useful to doctors in reinforcing their professional network (for example, logistical and financial aid for various types of medical conferences) or their career at the hospital (financing of clinical studies, travel to conventions). Finally, advantages in the form of gifts persist, although regulated since 1946 (Greffion 2011). With pharmaceutical prices fixed by the state, the industry arranges wide access to urban and hospital-based doctors, thus giving priority to the volume of sales of its products.
Jérôme Greffion is a doctoral candidate at the Centre Maurice Halbwachs in Paris. Email: email@example.com. The text was translated from French by Juliette Rogers. He is grateful for extensive comments by two anonymous reviewers and the editors.
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