How do pharmaceutical reps make their money and what exactly do physicians/quasi-physician-psychiatrists get out of it? The answer is both exactly what you think and something entirely different, something bordering on perversion.

First, I’ll show you the money. Here’s how pharmaceutical reps earn their livings: “Every company determines their own method of how to assess growth and this can change every 6 months -– so don’t get too comfortable! For example, some pharmaceutical sales companies track the # of new scripts coming in and your goal will be set in reference to that measure. Other companies may determine bonus by measuring the total # of scripts.” That’s from a pharmaceutical rep “education” company inventively called Pharmaceutical-Rep.com.

But how to do reps make the sell? Logos…lots and lots of logos. According to the Markkula Center for Applied Ethics (apparently no one informed Santa Clara University that applied ethics long ago died in the business world, if they ever existed), “Many prescribers receive pens, notepads, and coffee mugs, all items kept close at hand, ensuring that a targeted drug’s name stays uppermost in a physician’s subconscious mind. High prescribers receive higher-end presents, for example, silk ties or golf bags… This kind of advertising is crucial to sales. A doctor is not going to prescribe something he or she has never heard of, and it’s the drug representative’s job to get the products’ names in front of the physicians… It’s a way to get in the door so that your information rather than somebody else’s reaches the doctor’s brain.”

If that’s not insidious enough, here’s more from PLoS Medicine’s Following the Script: How Drug Reps Make Friends and Influence Doctors, which begins with a quote from one of its authors, Shahram Ahari, an ex-drug rep: “It’s my job to figure out what a physician’s price is. For some it’s dinner at the finest restaurants, for others it’s enough convincing data to let them prescribe confidently and for others it’s my attention and friendship…but at the most basic level, everything is for sale and everything is an exchange.”

Ahari and co-author Adriane Fugh-Berman expand upon this process: “Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians’ personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician’s family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor’s office for objects — a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols — that can be used to establish a personal connection with the doctor” [my italics].

From all of this, I can only conclude that physicians/quasi-physician-psychiatrists are amongst the loneliest people on earth. I’ve often entered a quasi-physician-psychiatrist’s office just as a drug rep leaves. Couldn’t the “doctor” have spent that time calling his wife? Alternatively, couldn’t she have read a monthly journal describing immediately-available new psychotropic drugs and their uses and side effects? Wouldn’t that take less time and at least approach professionalism? As it stands, the wise patient will reference prescribing information online, since it’s almost never provided prior to The Writing of the Scripts. Why a psychiatrist is paid at all remains a mystery. A better job title and one deserving minimum wage: “Treadmill Technician.”

I suppose if I asked physicians/quasi-physician-psychiatrists why they spend so much time with pharmaceutical reps, they might respond, “Thanks to insurance costs, I can’t afford pens, Post-It notes and coffee cups; I need those things, goddamn it.” Next, they’d stalk out of the office and weep upon the steering wheels of their BMWs, then call the kinds of prostitutes who don’t visit offices with suitcases full of samples and logoized potpourri.

kurt suicide scene

A despairing friend called late one night to say that he was looking at a photo of himself as a toddler holding his father’s rifle.

“I have an appointment with that rifle,” he told me. “I’ve always known I was going to end my life with it.”

He’s fine now, thank God, but his remark brought to mind a journal entry I made as a teenager, in which I said that I was sure I was going to kill myself one day; it was only a matter of how and when.