‘Doctor, one prescription please…’
‘Doctor, one prescription please…’
India has more than six lakh medical representatives. They are described as the interface between doctors and pharma. Traditionally graduates from a variety of backgrounds took up this job but recently pharmacy and management graduates are preferred
Sanjay Nagral
August 7, 2023, Hindustan Times
A doctor’s life involves interactions with a wide variety of people. One such group is representatives of the pharma industry. They always seem eager, pleasing and polite. Perhaps it’s their job. Pharma sales representatives have the task of influencing drug prescriptions. Through sales talk and information. As far as scientific interaction goes, the bar is low. Maybe because over the years both parties have set it low.
Last week, I had a troubling experience with a young pharma rep. He had met me multiple times in the weeks prior to promote a new drug. This time after he had extolled the virtues of the drug, he asked, “Doctor do you have anything against the drug? Why are you not prescribing it?” It was obvious that my prescriptions were being tracked. Just as I was about to express my resentment, he added with a distressed look, “Could you please give me at least one prescription per week? Or else my job is on the line.” I have heard that request for ‘one prescription’ before. But it was disturbing to hear about the job. I asked him about his background, explained to him why I didn’t prescribe the drug and that I had nothing against him or his company. I expressed my displeasure at what he said. I also suggested that he contacts his union if his job was indeed threatened. He was profusely apologetic. But, looking back, I was blaming the victim. And shooting the messenger.
India has more than six lakh medical representatives. They are described as the interface between doctors and pharma. Traditionally graduates from a variety of backgrounds took up this job but recently pharmacy and management graduates are preferred. You may have noticed them milling around doctors’ clinics. Young men and women in smart western attires with backpacks. Standing. Often for hours. Waiting patiently for the doctor. Making polite conversations with the secretary or attendant. Repeatedly requesting to be let in. For a few minutes to regurgitate promotional material about their product to a harried doctor. Only to repeat this ritual. Working long hours often late into the night. Making daily visits to chemists and hospitals to push products. Uploading reports every night to their boss. How many doctors did they meet? At the end of the month, tracking prescriptions. Outcomes measured against pre-set targets; incentives calculated. You may say this is standard sales protocol in all industries. What’s so special here?
Doctors in India largely learn about new drugs through pharma. Hundreds of such drugs are launched very year. Including the peculiar Indian drug combinations. There is no unbiased alternative mechanism. Many countries have national guidelines, protocols and formularies which are binding on prescription practices. No such thing here. As a result pharma can influence practice rather easily. Many well-done prescription audits show that irrational drugs are commonly prescribed. And drugs under a cloud or banned continue to be marketed. Chemists substitute brands. It’s largely a free-for-all. Have you forgotten Covid?
Prescription drugs account for a large share of India’s ₹80,000-crore pharmaceuticals market. Companies have to sell their brand among intense competition. The doctor controls prescriptions. The rep’s job is to convince the doctor to prescribe their brand. It’s a tough task. To hold the doctor’s interest, to try to push the false idea that the company brand is better than others. A legitimate way is to provide quality information. And explain why it should be preferred. That is not easy because there is nothing special about the product. How does one then prod the doctor? There is a wide spectrum from the legitimate, obfuscation, personal requests to the plainly dubious.
Finally, the time-tested policy of influencing the doctor with gifts and freebies is ubiquitous. The stories of pharma’s dubious relationship with doctors are complicated and almost stale. It’s a global problem.
Whilst it’s somewhat facile for me to speak on behalf of pharma reps, I have often wondered what they feel about us. We make them wait endlessly, give very little time and are often not listening with the attention they deserve. In meetings and conferences, we are complicit in making them run errands, make travel arrangements and even oversee hospitality. I suspect that besides finding us patronising they have a rather low opinion of our self-respect as it’s obvious that we can be manipulated easily.
Globally and in India, attempts have been made to create marketing codes of ethics both for pharma as well as the medical profession. The union of pharma reps in India has supported the move. The professionalisation of both industries demands such boundaries. But this is not about just any other industry practice being regulated. Drug prescriptions impact everyday lives. Medicines are consumed with trust and hope. Society therefore has every right to control perverse incentives, coercion and gaming. This needs a neutral umpire. That clearly can only be the state. To be fair, the Indian government has been trying to cajole Indian doctors to prescribe drugs with generic names without much success. There are efforts to rein in both industries. But pharma and the medical lobbies are too powerful for any meaningful intervention to work.
People will need drugs, pharma will make them and doctors will prescribe them. The competition and market are growing. But what are young graduates fresh out of college who wait endless hours, spout rapid predictable lines to bored doctors with their jobs at stake to do? The next time you visit a doctor’s clinic you may notice them more. And admire them for doing a tough job.