Kas087 006

Tales From The "Script": An Insider/Outside View Of
Pharmaceutical Sales Practices

Michael J. Oldani
The ultimate goal of the pharmaceutical industry is to make money...
The goal of medicine is curing people. One is self-interest, one is
altruism. It's an intersection of two different social systems. [Dr.
Erdem Cantekin, quoted in Crossen 1996:166]
What has come to differentiate one company's chances for
competitive success over others is . . . competency in externally
oriented activities, most notably marketing innovation. [Appelbaum
1998:327, emphasis added]
Introduction
Multinational corporations that manufacture and market pharmaceutical
products exist within a self-perpetuating ethical paradox. As biomedical research
driven institutions, pharmaceutical companies provide innumerable advances in
biomedical therapy for humankind. However, to satisfy shareholders with increases in
profit these companies must maximize their investment in research and development
(R&D) through aggressive sales and promotion of pharmaceutical products in the
health care marketplace. Salespersons working for these companies are engaged in a
variety of "externally oriented activities" and must perform at this intersection of the
profit motive and human health care. From 1989 to 1998, I was a pharmaceutical
salesperson for a multinational phannaceutical corporation, Company X.! As a "drug
rep" or a "detail man"2 my goal was to persuade, to influence, and ultimately to
convince physicians to write a prescription, a "script" in medical-industry jargon, for
one of Company X's products. Prescription generation is accomplished through a
variety of means, including multimedia advertising (print, Internet, television, etc.),
1
The company name, product names, and individual names have been changed for a variety of
reasons, including protection of individuals through anonymity and personal liability.
2Detail man is a phrase derived from the "detail" which is a central part of a pharmaceutical
salesperson's selling activity. The detail is the sales pitch (i.e. "Doctor, our antibiotic has a
broader spectrum of activity, is only once-a-day, and costs half the price of our competition.")
The pitch is verbal, however, almost all representatives carry a "detail book," which includes
company advertisements, clinical reprints of product efficacy and safety, and cost information.
The detail book was seen by my managers as a way of stressing particular selling points. The
information that is included or not included in the detail book is of central importance to this
paper.
148 Kroeber Anthropological Society Papers No. 87
participation in gift exchanges, and promotion ("detailing") of pharmaceutical

products (often "off-label").
During my last four and half years with Company X, while still actively
participating in the complicated social milieu of the pharmaceutical sales, I returned to
graduate school to study cultural anthropology, completed my Master's degree, and
eventually left the industry altogether to pursue doctoral studies. As part of my on-
going graduate training, I have scrutinized my pharmaceutical experiences
ethnographically. In this paper, I specifically explore salespersons' off-label
promotion of pharmaceutical products to healthcare providers. Products are sold "off-
label" when promoted to treat conditions outside of the current Food and Drug
Administration (FDA) approved package insert (PI) (e.g., promoting an anti-fungal
drug for fungal toenail infections when it is only "indicated" for oral thrush).3
Pharmaceutical salespersons not only ignored FDA policy at times, but also departed
from their own company's policy regarding product promotion by engaging in tactics
that were seen as contrary to official corporate policy.4 Despite breaking the "rules"
of the FDA or the company, pharmaceutical salespersons, including myself and others
within my circle of colleagues, liked to "cheat," or to be "creative" when promoting
our products; it became an everyday practice and was even encouraged by managers
and fellow workers.
3 The package insert ("PI") is included with pharmaceutical products sold to phanracies or
included in products given free to doctors. The "complete" package insert contains the FDA
approved list of indications for a product, side effects, drug interactions, dispensing
instructions, and other information related to the particular drug. Tanouye (1997) in the Wall
Street Journal provides both insight into the dollars behind off-label promotions for
pharmaceutical companies and the tactics used by companies to ensure off-label prescription
writing by doctors. In her example, Rhone-Poulenc Rorer's (RPR) drug Lovenox in 1996 did
$151 million in sales, 60 percent of which was from off-label use. (FDA indicated for
preventing blood clots in hip, knee, and abdominal surgery, the drug is used freely by doctors
for patients post-stroke or during heart operations when installing stents to keep arteries open.)
Legally, doctors can write for any product for any use. However, it is against FDA policy for
companies to promote their drugs for "unapproved" use. According to this investigation, RPR
encouraged representative to have doctors recommend off-label prescriptions. Tanouye also
discusses how four "former and current" employees of RPR were suing the company for
coercing them to promote products off-label and that they were harassed when they protested.
In my example that follows, I describe how I freely participated in off-label promotion of
Company X products, and after I finally protested against this type of activity, how I was
ignored and later "let go."
4For example, a rep might request for a doctor a medical department letter explaining off-label
uses for a Company X product - a good way to expand market share through official corporate
channels. Representatives could then ask the doctor for a copy and then make more copies and
hand these out to other doctors. This was a short cut and a way to increase "noise level" on a
particular product for uses outside of the FDA approved package insert.
Oldani Tales from the "Script" 149
My interest in how salespersons promoted pharmaceuticals stems from my

own involvement in a district-wide scandal the last year and a half of my employment
with Company X. I was caught "cheating" during a time when, according to
company gossip, the corporation was "cracking down" on maverick representatives5
who did not adhere to the company's new "zero tolerance" policy regarding product
promotion.6 We had begun to hear rumors in the "field" that representatives were
actually being fired for various types of cheating. Over coffee with my sales
colleagues, I can remember realizing that the company had suddenly become serious
about disciplining representatives for what had previously been routine everyday
actions. A Southern Region representative had been "let go" for distributing to
physicians embroidered baseball caps with the phrase "Prozac Sucks" (Prozac was a
key competitor to Company X's own successful antidepressant. These hats had been
spotted and confiscated by our competitors, sent to the FDA, and eventually Company
X was forced to take action against the employee. Considering how widespread this
type of activity was in my own district (personalized party-favors were quite
common), the story caught our attention. However, we laughed at this representatives
lack of good judgment. This was truly over the top in terms of product promotion.
My own activities eventually caught up with me (an event I will explain in
detail shortly), and I was "demoted" from a Senior Institutional Healthcare
Representative to a "trainee." Ironically, for the first time in eight years, Company X
had released me from the pressures of making quota (i.e., increasing prescriptions for
Company X's products).7 As a trainee I was put in pharmaceutical sales limbo and I
was free for over a year to begin my transition from detail man to anthropologist. My
final year with Company X was a strange mix of ethnographic observation, legal
s Throughout this paper, I employ the term "representatives" which is often abbreviated as
"reps" or "sales reps."
6
The stakes are particularly high in the SSRI antidepressant market. During my employment
with Paxil, Prozac, and Company X's own SSRI were dominating the market (each product
today is over $1 billion dollars in sales). Companies had begun to co-market their products
(i.e., 2 or 3 representatives for each company would call on the same doctor). What became
key to expanding market share was getting new indications. Paxil, for example, was gaining
on Company X's SSRI and received its obsessive compulsive disorder (OCD) indication first.
Rumrs in the field centered around how the FDA was punishing Company X for its unethical
activities in the field (i.e., promoting off-label) by "holding up" approval of any other
indications. In other words, we needed to publicly clean up our act - "zero-tolerance" thereby
became born as official Company X policy.
7Quota is a term to describe yearly increases the company would give for a particular product.
Forexample, in 1997 a representative may sell one million dollars of a product. The next year
the quota may be one million plus an additional ten percent, or $100,000.00, equaling
$1,100,000 in total sales. For 1998, the rep must beat the previous year plus the new quota.
The goal is always to finish over quota. At Company X all bonus dollar payouts at the end of
the year were contingent on making your yearly quota for each product sold (my portfolio
ranged from three products to five).
maneuverings, and psychological stress. My pharmaceutical sales career came to an

end after I was denied a transfer out of my trainee territory to join my wife, who had
accepted a job in another state. A Fed-Ex package arrived at our new home with a
letter of termination and a final paycheck. Looking back today, I realize how I could
never have freely walked away from the money and the material benefits of corporate
America. I needed to be pushed away, and my termination by the corporation finally
started me on the road to anthropology. This paper is about my ethnographic return to
Company X and a critical reassessment of my experiences there, as both insider and
outsider - first as salesperson and then as ethnographer.
To Cheat or not to Cheat?: A Personal History of Pharmaceutical Knowledge
Games
Detail-man's Oath: I do hereby solemnly swear that I will tell the
doctor the truth, the whole truth, and nothing but the truth; that I will
make no exaggerated claims of superiority or safety; that I will
always give adequate assurance and proof that no medication is 100%
effective in all patients and that even a placebo will cause distressing
side effects in some patients; and that the difference between the
product I am detailing and the product the doctor has been using is
much smaller in his eyes than in my own, and any exaggeration of
this difference will only serve to confrnm his previous prescription
writing habit. [Sutton 1960, quoted from Smith 1968]
During the late 1980s and early 1990s, Company X's salesforce was divided
into two divisions, "A" and "B", with different product portfolios. My division, B,
had historically been the less glamorous of the two; as my colleagues put it then "we
have to sell, they, Division A, don't." Division A had historically received better
products to promote. Division A introduced an important calcium channel blocker in
the late 1980s for the treatment of angina and hypertension that was a new
advancement for treatment. Physicians embraced this product-they wanted to see
sales representatives from Division A. Conversely, until the early 1990s, Division B
had sold products in the highly competitive antibiotic arena, where Company X's
antibiotics competed with products superior in terms of efficacy, ease of
administration, safety, and cost. I sold one antibiotic that was initially seen by
corporate headquarters as having low potential in sales revenue. However, this
product's annual rise in sales revenue represents the type of success Division B came
to be known for-an ability to sell marginal products through creative promotional
tactics. Pharmaceutical sales had shifted from a time where the "good old boys"' met
and participated in "truthful" exchanges of information into the era of "spin" selling8
and "guerrilla marketing."9
8
I have recently explored other examples of spin selling (e.g., Oldani 2001) and would like to
stress that the "spin" is now part of our everyday language and thought. The spin simply
In addition to this divisional schism, widely differing sales philosophies

prevailed among the marketing teams at the corporate headquarters in New York City
(busy developing "Madison Ave" product advertisement pamphlets) and the "field
forces" of salespersons that cover every geographic region of the United States. My
first manager clearly instilled in us the belief that Division A sold products the "New
York way," our division would follow a different strategy. Our district teams would
meet quarterly to discuss these strategies regarding product promotion. At these plan
of action (POA) meetings, which lasted for three to four days, representatives of a
district (usually ten to twelve reps working in a large metropolitan area or a less
populous state) would meet with their district manager (DM) and outline sales
strategies for the next three months. These strategies were then re-assessed at
subsequent quarterly POAs. These meetings were also a time for disseminating
marketing information from Company X's New York city corporate headquarters to
the field force.
As a new hire for Division B in 1989, I attended my first district meeting
begining my indoctrination into how my district sold Company X's products. There
were two competing ideologies for product promotion in Company X, the "New York
way" and the "Division B way." In 1989, the Division B way was based the principle
that corporate marketing teams in New York did not sell in the field (they relied on
market surveys) and therefore failed to realize what was necessary to say to doctors,
what information needed to be presented (visually and verbally) and what product
information needed to be omitted. We took care of this "problem" at the local level-
during district meetings and subsequently through everyday practice. Our district
manager embodied resistance to the New York way. His routine performance
involved standing in front of his team with newly designed product promotion pieces
from New York, making sarcastic comments about the effectiveness of New York
marketing, and then tossing them on the ground or in the garbage. His act garnered
means taking a negative thing and spinning it into a positive thing, something beneficial for
both parties involved. (Neil Rackhaam's 1996 book, The S.P.I.N. Selling Fieldbook: Practical
Tools, Methods, Exercises, and Resources was discussed at several POA meetings.) Doctors
might object to an antidepressant I sold by saying it "causes too much nausea." I would spin
this and retort: "This may be true in some patients, but you can tell these patients it's a sign the
drug is working and the nausea will fade over time." I could also remind the doctor that if a
patient tried to overdose on our drug it would cause so much nausea that the patient would
vomit - a nice built-in safety mechanism.(Oldani 2001:34, n.38).
9 "Guerrilla marketing" is a movement that originated in mid-1990s from a series of popular
books regarding sales techniques (Levinson and Rubin 1994 and Levinson et al. 1995). The
books stressed things such as "noise level" (i.e. the more times someone sees the name of a
product the more likely they will remember to use it) as a marketing strategy. My district used
"bulk mail" (hundreds of advertising pieces sent weekly to doctors in a sales territory) as a
strategy to increase noise level for products.
many laughs from all of us in attendance,'0 but he was also empowering us to defy
corporate policy. After we had "reviewed" these promotional pieces, our manager
would then hand out the real sales material for our detail book. This would often
include off-label clinical articles pertaining to our products and "cut-and-paste" visual
aids.
A pattern had been established in my district whereby many sales
representatives were led to believe the only real way to sell effectively and to expand
market share was to cheat by using one's own source material-or at the very least to
look skeptically at any and all information from New York. The district manager's
actions reflected this belief, and we were rewarded for creative presentations at POA
meetings (i.e. reps with the best "stuff' in the detail book were praised and usually
asked to share this good information). Moreover, we fully understood that the FDA
would only approve clinical articles and company visual aids that were seen as
"balanced," giving equal attention to efficacy, side effects and drug interactions.
FDA-approved clinical articles, such as randomized, double-blind studies, were seen
considered as the most challenging types of articles to use for promoting product
superiority. Therefore, most of the information used to sell and promote products
came from our own sources, such as unapproved clinical articles from JAMA and the
Archives of Internal Medicine or from non-peer-reviewed journals. "
There was a vast network of "underground" sharing and distribution of this
information and rep-generated material circulating between salespersons. District
managers would usually send information through inter-district mail or distribute
things at POA meetings. Sales reps would also share information through informal
gatherings. Even official corporate mailings would identify the best clinical articles
available for cheating by stamping them with the words: "DO NOT DETAIL." In this
case, material that was sent to reps varied from extremely positive articles regarding
the efficacy of a Company X product to extremely negative articles about our
competition (i.e. unwanted side effects, newly discovered drug to drug interactions,
recent deaths associated with a competitive product, etc.). The "DO NOT DETAIL"
company warning was an obvious liability avoidance strategy for the corporation, but
10
Occasionally, the regional manager (RM), the DM's immediate supervisor, would be on
hand at these POA meetings. On more than one occasion I can recall the regional manager
telling us that he was going to "act like I didn't see (or hear) that" and let the district manager
continue on with his presentation. In this specific case the DM (previously a RM himself) had
actually hired the then current regional manager.
11 As representatives, we were all aware of particular doctors who published favorable articles
pertaining to our products. These usually appeared in "throwaway journals" (non-peer
reviewed). These doctors would often be on the Company X "spealdng tour," and we would
bring them around our territories for dinner programs, grand rounds and continuing medical
education (CME) programs. We had to be careful because most physicians could easily spot a
"company whore." However, many of Company X's product supporters were very clever and
adept at selling our products without giving a blatant advertisement.
more importantly, identified to reps that, if in fact we are being told not to use it, this
material must be worth looking at and possibly incorporating into our sales
presentations. At the very least, representatives could incorporate this "DO NOT
DETAIL material into their verbal sales repertoire without leaving a "paper trail" of
unapproved product information. Later in my tenure, I would come to question the
motives of Company X regarding the "do not detail" material which clearly
contradicted the corporation's ability to maintain a "zero-tolerance" policy instituted
in the mid-1990s. Why give sales representatives on-going access to information that
creates legal liability both for the individual and the institution? One answer lies in
the company's own need to create the most "knowledgeable" representatives possible
in order to establish rapport with their key clients-physicians. The profitability of a
product hinges on the representative's ability to persuade doctors to write
prescriptions for their respective drugs. Knowledgable reps are a key link in
confidence building between industry and medicine, and can ensure both the long-
term success of a product and of a company.
Thus, representatives who could increase their overall knowledge about
diseases and products were at an extreme advantage. The quickest way to earn a
physician's trust was by demonstrating overall medical knowledge.'2 Once trust was
established, many physicians would defer to representatives regarding product
knowledge. It was not uncommon to be contacted by physicians who had questions
regarding one of Company X's products or even ask questions regarding a
competitor's product. Establishing rapport also allows for representatives to become
teachers for emerging new "illnesses," especially new and treatable mental health
disorders. In the early 1990's during POA's we talked about "educating" the family
practice physician on how to recofnize and treat depression before we could actually
sell them on using our new SSRI.1
12
A group of pulmonologists over lunch showed me a video from another pharmaceutical
manufacturer that they all found hilarious. This was a company training video (that was
probably not supposed to be handed out to physicians) that comically illustrated the
relationship between the doctor and the rep in terms of knowledge and information. It begins
with a representative trying to sell the doctor a particular antibiotic and the representative
mispronounces the names of bacteria. The video then went on to show the representative
going through a sort of medical jargon training Olympics. The video concluded with the
representative giving a flawless presentation packed full of medical terminology, all of which
was correctly pronounced. The problem was that now the physician could not understand the
rep!
13 We were told during our meetings and training sessions that prior to Prozac (the first SSRI),
family practice doctors appeared reluctant to talk about "depression" with their patients. One
of the most common treatment options at that time was to use a TCA (a tricyclic
antidepressant) for treating depression. The TCAs have a sedating effect so they could be
talked about as sleep aids, avoiding the stigmatizing language of depression and mental illness.
The TCAs are also toxic at higher doses and patients can ingest a fatal overdose. With Prozac
and the SSRIs, serious (i.e., fatal) side effects were no longer an issue. In terms of efficacy,
Gaining a doctor's trust could also involve "selling the competition first." For
example, a veteran sales representative taught me a valuable strategy early in my
career at Company X. Her "trick" with influential doctors was to build trust by
presenting or providing them with specific information (usually in the form of a
clinical article) that was related to their own research interests. I liked her strategy
and "targeted" an influential "no-see"'4 infectious disease doctor who treated serious
fungal infections, but first I needed to get an appointment from the "gatekeepers"-
the receptionists. This required a little "drug rep 101" (a phrase coined by my first
district manager) which simply means getting the office personnel on your side. This
took time and varied from case to case. At this infectious disease clinic I discovered
that a quiet persistence was rewarded with increasing empathy towards my efforts to
"just have a few minutes of DR. Z's time to discuss important information about my
product." The "quiet approach" combined with several hand-deliveries of strawberry
frozen custard shakes eventually persuaded the head nurse to schedule an
appointment. I arrived at the meeting with clinical information regarding the use of
inhalable amphotercin B (my competition) for the treatment of fungal lung infections.
I sold the competition first and Dr. Z's words to me were "I can really use this,
thanks." I did not mention my product for treatment of fungal infections at all during
this first meeting and only asked if it would be possible to schedule another
appointment "when I have good information regarding my product." He agreed.
By the time I left Company X, all three physicians in this clinic were seeing
me on a regular basis. I was allowed to support financially the local infectious disease
society through company "grants," and we did several speaker trade-offs (I cover
expenses for a speaker of their choice and they allow me to bring in one of my
"experts" at a later date.). My initial "trick" was rewarded with years of exchanges
that benefited both of our needs. Dr. Z and his colleagues were highly respected in
their field, and I was able to mention their names support of my products to other
doctors when detailing. In fact, Dr. Z influenced most of the use of anti-infectives at
the largest dollar volume hospital in the state (which reps coined "St. Lucratives") and
his eventual support of all of my products helped me to consistently achieve my
SSRIs work no better than TCAs; they simply are easy to use, especially for family practice.
Within several years everyone was talking about depression and we had helped to broker both
the everyday use of mental illness terms and the generation of billions of dollars in prescription
medication. I do not want to claim that reps were solely responsible for destigm ng
depression. However, while pharmaceutical corporations spent millions of dollars on
advertising "depression awareness" to the general public and helped to focus government
attention on mental health, on a daily basis thousands of representatives were not only talkdng
about depression, but handing out boxes of educational material, and stocking millions of
dollars worth of free samples in clinics.
14 The "no see" doctor is the physician who refuses to engage any type of interaction with the
pharmaceutical industry. They were a major challenge for representatives and required
relentless pursuit. Success in seeing a no-see doctor was recognized as a great achievement by
management.
yearly goals and helped to rank our district "number one" in 1997. My relationship
with Dr. Z became a district standard to try and achieve with other influential and
respected doctors and it all started with a bit of off-label information and custard
shakes. My various "successes" with Dr. Z. were always included in my weekly
report and held up by my manager at later district meetings as a model for my
colleagues to emulate.
Getting Caught at the "Game"
In my district there was no clear distinction made between both FDA and
corporate policies regarding the "tricks," "cheating," and "games" we used for gaining
physician trust and confidence in our products. As salespersons we were quite adept
at playing in the "gray area," and through the mid-1990s the corporation let us play.
However, for very clear reasons during the late 1990s, Company X began to initiate
very black and white policies regarding product promotion. Once a minor player in
the global pharmaceutical market, Company X had grown into a major force in
pharmaceutical sales by the end of the 1990s. A pharmaceutical product portfolio that
in the 1980s was made up of a few products approaching one hundred million dollars
in annual sales has grown into a portfolio that, after a recent acquisition of another
pharmaceutical manufacturer by Company X in 2000, will include seven products
with at least one billion dollars each in annual sales. The sales force has also
expanded greatly. In 1989 when I began with Company X the combined number of
sales representatives of the two divisions was a little under a thousand. Today,
Company X employs approximately 5,400 representatives in nine divisions. Part of
the Company X's current success can be tied directly to its investment in research and
development (R&D) in the 1970s and 1980s. Products being introduced to the market
in the 1990's were "blockbuster" type of products.'5 As Company X's profits
increased (total revenues increased by 284% in 1990s) and stock value soared (three
2-for-I splits and one 3-for-I split in the 1990s) the corporation became more and
more self conscious of its corporate image and more "black and white" regarding
product promotion-zero-tolerance policies focusing on product sales became a
corporate mantra. 16
15 "Blockbuster" is used by Wall Street investors to describe drugs that normally exceed a
billion dollars in sales during the first full-year of sales and marketing.
16
Simple math explains this incredible growth. If you had 1000 shares of Company X stock
that was purchased for 50 dollars a share, this would equal a cost of $50,000. Company X
began to split stock when it reached a price of roughly 150 a share. Your total now is
$150,000 - a nice profit. However, a two-for-one split means you now have 2,000 shares at
$75.00 a share (still $150,000). Yet, the stock continues to grow to $150 a share once again.
You now have (2,000 shares x $150) $300,000 worth of stock. Another two-for-one and
growth to $150 per share would equal ($4,000 x $150) $600,000, and so on. Company X
provided this kind of growth to stockholders (many of whom were employees thanks to a stock
option program where the initial buying price is actually lower than the current market price)
over a relatively short period of time, roughly 10 years - the decade of the 1990s.
Managers, and representatives, myself included, were operating in denial on

several levels. On one hand, our risky behavior was part of a machismo or bravado
that was constantly being displayed and reinforced;'7 most importantly we were
rewarded through increased sales. On the other hand, management and
representatives had always agreed to a policy of denial (i.e., simply lying to upper
management) if ever caught breaking official policy or questioned regarding any of
the types of activity described above. This was stressed at our POA district meetings
where, during discussions regarding the consequences of cheating, my second
manager with Company X, would trigger the familiar group-chant: "Deny! Deny!
Deny!" This secret policy of denial would be in operation until my last days with
Company X.
In 1996, my third district manager took over the reigns and actually
strengthened our local (district) resistance to corporate and FDA policies. Her agenda
fit well with my own. Intellectually, I was shifting away from sales and the corporate
world and more towards anthropology and academia. Yet, I had committed myself to
finishing my sales career on top. I saw 1997 as my fmal year with Company X and
deliberately "setup" my sales territory for success.'8 The missing piece to ending my
career on a high note in terms of financial rewards was increasing the sales of
Company X's antidepressant, a selective serotonin reuptake inhibitor (SSRI) that
competes with Prozac, Paxil, and other antidepressants in one of the most highly
competitive markets in medicine. My third manager was very skilled at "noise level"
sales tactics. I made bi-weekly anonymous "mail blitzes" to a data bank of
17 As a Senior Institutional Healthcare Representative, I was seen as a leader and mentor to

many district members. My manager often asked me to give presentations regarding my own
strategies and to provide information for other district members. One of my last presentations
included an elaborate "cut-and-paste" visual aid and dosage card for Company X's antifungal,
which was all clearly against official policies as defined here. Most reps were eager to use the
material, some had reservations. Nevertheless, I was compensated with "bonus points" which
I could use to buy merchandise with at the end of the year.
18 My previous year was mediocre in terms of my quota so my last year I would have lower
quotas to make. I discouraged my hospital pha rmcies from buying any product in the last
several months of the previous year. Because I was a hospital representative I had large
volume hospital accounts and dealt directly with phannacy purchasers. "Saint Lucratives" had
a purchaser that would do quid pro quo transactions. He would buy huge amounts of product
and in return I would provide the pharmacy grants, gifts for fund raisers, dinners, lunches, etc.
In this particular year he requested a $6000 pharmacy paperwork-processing machine and in
return would buy over $300,000 in one product. I would be well over quota and maximze
bonus payout. The only way I could do this was to "write off" this money in the form of
dinner programs at $500 each. "OK" was given from my manager, and I informed all my co-
promoting Company X colleagues as to what was going on. Our district would finish "number
one" (largely impart from this transaction), and a co-promoting colleague was promoted during
the next year to a district manager. I never saw the bonus money from the increase in sales due
to my demotion.
physicians. The strategy operated under the logic that more often a physician "sees"
your product name the more familiar he becomes with it, and the more likely the
doctor will write a script. As a class of medications, SSRIs are indicated for the
treatment of major depression and their indications for uses in other areas were
expanding at the time into panic disorder, social anxiety, and obsessive compulsive
disorder ("OCD"). Company X's SSRI was lagging behind in getting approval from
the FDA for these indications. In the field we kept hearing from "corporate"
headquarters that we were close. However, as the competition received indications,
representatives began to adjust strategies and to use any information we could find
regarding the use of Company X's SSRI for these other, off-label, indications. The
process of distributing this information became easy, and my initial efforts had good
results. Sales numbers in key accounts were increasing, and physician comments
validated my covert efforts. I was being told more often that they (the doctor) had
recently read an article or "heard something" about using Company X's SSRI for
OCD, or for panic disorder, and they were going to give it a try. The "little bird" was
of course my anonymous mailings making it to their desk.
With my territory in "cruise control,"'9 I left town for a vacation and returned
to find my corporate demise in process. While I was gone, events were transpiring
that would forever change my pharmaceutical sales experience. A physician in our
district had turned into the FDA a computer-generated flyer she or he had received
from a Company X rep which described Company X's SSRI as the product that would
"lift the gray cloud of depression." When I returned home I received a call instructing
me to participate in the regional corporate ritual of denial. This normally involves a
handful of representatives being called into the regional manager's office where the
"illegal" visual aid is presented and being asked if we were responsible for its
creation. We all denied ever seeing the material or knowing who in fact created the
piece. (In this particular case most of us knew who the culprit was, but we kept it to
ourselves at the meeting and subsequent public forums.) We were all warned against
this type of activity.
At this particular regional meeting the events unfolded, however, with one
surprise. The regional manager had contacted several representatives from other sales
divisions within Company X to inquire about the origin of this illegal promotional
piece and had unintentionally turned up another. As he presented this to the group, I
realized it was my creation as did one of my colleagues. True to form, we all denied
ever having seen it, but as I left the conference room I had a sense that my career was
going to end on a low instead of a high. On the way home I discussed this with two
colleagues whom I trusted, and we convinced each other that I may have handed it out
at a POA meeting - sharing of "good material" was after all a common practice. The
next week, I was called down to the regional office with my district manager. I was
19
Cruise control is a term to describe a territory over quota on all products and increasing in
sales each month.
confronted with a file filled with each bi-weekly mailer I had sent. The regional
manager looked me in the eyes and said, "You're looking at the most being fired and
at the least losing your yearly bonus."
The story that unfolded was at first hard for me to believe, though I now
realize it was essentially true. A colleague of mine had transferred from our district to
become a "psychiatric specialist" for Company X. We had worked together on large
psychiatric accounts where the stakes are highest for drugs.20 While visiting the office
of a psychiatrist we had both called on, he was handed a cut-and-paste advertisement I
had created and mailed anonymously to all the doctors at his institution. The ad
reminded doctors to write more prescriptions for Company X's SSRI. My colleague
kept this document, and when interrogated by the regional manager concerning the
other off-label ad handed into the FDA, he faxed my cut-and-paste example to the
regional office probably thinking he had helped to solve a company "crime."21
By coincidence, a different psychiatrist at this institution, who shared a
secretary with the aforementioned doctor, was on sabbatical. My colleague and his
psychiatrist-friend were able to rummage through several months of his collected mail
and sent all of it into the regional office. When I was confronted with the evidence I
had mailed, I had no choice but to admit my guilt (my days of denial were clearly
over) and wait for corporte headquarters to hand down their decision regarding my
future employment with Company X.
I had misjudged the seriousness with which Company X now regarded the
enforcement of the new "zero tolerance" policies. They were now actually
disciplining representatives who were brealdng product promotion guidelines. While
waiting to hear about my fate, I was reassured by both managers and sales reps of the
corporation's historic "hand-slapping" policies. In fact, I found out through these
stories and general gossip that a good deal of current managers in my division had
actually lost many bonus checks as punishment for similar activities, but never their
jobs or their current positions. Most recently, my own manager had been reprimanded
20 Pharmaceutical companies are very much aware that prescribing "habits" begin durng
resident training. Many times, for example, a staff surgeon will dictate which antibiotics will
be used by surgical residents throughout the residency, thus forning a prescribing habit for
residents that is hard for phannaceutical reps to break. Staff surgeons are extremely hard to
meet with and rarely change their own habits. If you had a staff doctor that loved your product
Evou were lucky - reinforcing this with the residents was easy.
My colleague and this psychiatrist were very close. At the time they probably had a 20-year
relationship of eating, drinking, and golfing together. This rep was very protective of the
institution as well (he had called on it off and on for 25 years). We had actually agreed that
this doctor was "off-limits" for my daily sales calls. The problem was that this rep was not
promoting our drugs at the institution. He was more concerned with talkdng to his "old
fiiends," usually about arcane issues. So I used the mail to get around this - to do some selling.
He later denied having anything to do with my demotion at Company.
for a questionable form of product promoting and had confided in me while she was
being scrutinized by upper management.22
Days, weeks and months passed as I awaited my fate. I began to realize that I
was left alone to deal with a powerful corporation. I waited for my manager to step
forward and admit to encouraging and "incentivizing" representatives to cheat. This
never happened. I waited for the representative who had created the "gray cloud"
piece sent to the FDA to come forward. This representative never did. I was
confident that other reps in my district who werefriends, and who looked up to me as
a mentor, and who all participated in the same types of activity, would step forward
and admit wrong-doing in hopes that our shared guilt would lessen my punishment.
Of course, this never occurred either.
Instead, I was isolated, forced to deal with Company X by myself. My lonely
experience culminated in a trip to Company X's corporate headquarters in New York
City. I was questioned and given a chance to tell my side of things. Looking back I
appreciate the amount of stress I was under.23 My meeting with the Vice President of
Division B, the Vice President of the entire United States pharmaceutical group, two
company lawyers and one human resources person, all clearly positioned to intimidate
me with their fast and formal questions. After exchange we exchanged greetings, I
received their apologies for the long plane ride and lack of sleep. A "good-cop, bad-
cop" interrogation followed with the VP of my division demanding answers regarding
all of my activities as well as the activities of others, including mangers. He wanted
names. The VP of Company X's pharmaceutical group consoled me at times and
even offered me a soft drink. I stayed loyal to my district "teammates" and named no
one. I raised some issues regarding the history of this activity and the fact that my
division had always played with the "gray area" of product promotion. In a previous
22 My manager had only been on the job a few months when a manager from another division
at Company X turned in a "cut-and-paste" flyer that he had received from a concemed
physician. My manager had created and used this piece while still working as a sales rep. She
was promoted in large part do to her outstanding "numbers" for Company X's antifungal. One
way she had exceeded quota was to do weekly mailings to physicians providing information
for the use of our antifungal for fungal toe nail infections - a growing market for oral
antifungals. She engaged in questionable tactics of pulling different efficacy rates from
different sources and comparing them together on the same page. Our product clearly looked
superior. As a manager she gave us this one page summary and we all began to hand it out. In
fact, the day we spoke on the phone regarding her investigation, I had just handed the flyer out
to a group of dermatologists. I had to run back to the clinic and collect all the paper evidence
andthrow it away. Nothing ever happened to my manager.
23 Today, I find it somewhat humorous that on the plane ride to New York City I had a panic
attack - with the classic symptoms of increased heart rate, nausea, and sweating. This is
slighdy ironic considering I was being punished for promoting Company X's SSRI off-label,
which included copying medical department information discussing the use of our SSRI for the
treatment of panic disorder.
"letter of mercy" sent to these superiors I had implied that my first manager (now
retired and thus a good scapegoat) had encouraged us to use "creative" selling
techniques, and I mentioned that my practices were common everyday events. My
interrogators, especially the two VP's, reacted to my remarks regarding company-
wide rule-breaking with continual surprise, insisted on names, and wanted to know if
my current manager encouraged us to sell in this manner. She did, but I protected her.
After twenty-five minutes, we reached an impasse, shook hands and parted company.
I flew home and, two weeks later, I was demoted to a "trainee."24 I was assured by my
regional manager that this was a temporary, one year, demotion. I would be back on
track soon after. He assured me that my colleagues would see me as a powerful
"example" regarding the consequences of breaking company policy. All was
forgiven. We could finally move on.
From Scapegoat to Ethnographer
My first act as a demoted representative was to stand before my district
"teammates" at our Summer POA meeting and inform them of my demotion. Rumors
had been floating around that I was in "trouble," and for weeks I had done a
reasonably good job of remaining calm and in a good frame of mind. My emotions
and the humiliation of the spectacle got the better of me during my telling of the
ordeal to my district teammates and, after several attempts, I finally regained
composure enough to tell them all I had been demoted and reassigned as a trainee
within our district. I pleaded with them to think twice before breaking the zero-
tolerance policies of Company X - the consequences were serious this time. An
assistant to the Vice President of Division B was on hand taking notes, and he left
(without introductions) soon after my confession, which was followed by tears, hugs,
and shocked stares from my colleagues.25 After an awkward day of meetings, we
played a round of golf, participated in alcohol-induced "company bashing" and even
smoked a sort of anti-victory cigar-all the while being constantly reassured that I still
had my health, and most importantly my high salary. The next day we resumed our
POA meeting and within twenty-four hours it was business as usual, except with a
twist. The district representatives and our manager were on their best behavior during
this first post-demotion meeting. In a show of solidarity, we threw out all unapproved
24 Probably the only thing to save me from being fired was my number one ranking amongst
Institutional Healthcare Representatives in the Midwest region. The "Goal Achievement
Report" (GAR) had only been release with my number ranking the week before my demotion.
I was having a "great year" and it saved me. As a trainee you have no territory (you help other
reps in their own) and no quota. You receive full pay, but no chance for bonus. Its sort of a
liminal state where you await a new teritory, or you simply can decide if you want to stay on
with the company.
25 I later received cards and notes from colleagues. A note stated: "thanks for talking one for
the team." And a personal card was signed: "tis could have happened to any of us."
material that was in our detail books and swore to adhere to zero-tolerance policies in
the future.
By the fall POA meeting, I had begun to commit myself to anthropology full-
time, finishing course work for my Masters, and applying to doctoral programs. With
the responsibility of making quota removed, I was able to fully participate
academically in graduate studies - research, writing, and teaching. During the Fall
semester of 1997, I enrolled in an ethnographic methods class and began to analyze
and write about the pharmaceutical industry. 26 My own experiences and later
developments in my district began to fuel my ethnographic research.
One thing I learned as a salesperson was that successful habits die hard-
quotas only increase-and beginning with the Fall POA meetings, management and
representatives began to show signs of returning to previous product promotional
techniques. During the meeting our manager had begun to ask us to "alter" the
package insert (PI) of Company X's SSRI and the PI's of Prozac and Paxil, our
competition. At first I was truly dumbfounded by this obvious breech of zero-
tolerance policy. However, I was awakened from my stupor by objections to this
strategy being raised by my replacement, who subsequently became the moral
barometer for the district.27 We had worked together on my old accounts and he knew
my story intimately. He would have nothing to do with playing in the gray area of
product promotion. The district manager and other reps did not quite know how to
26 The paper that resulted from this research methods class has inforned certain aspects of this
current paper. However, my original project (Oldani 1997) was covert in nature. I took notes
after meetings, recorded voice mail transmissions, interviewed my district members
informally, and asked questions in a way to get salespersons to talk about ethics and cheating.
In addition to this, I analyzed how the company advertised both inside the corporation to its
employees and outside to the consumers (patients and doctors). My information gathering and
analysis had a dual purpose. Aside from a research project, I was trying to collect information
for my lawyers for a legal suit that never materialized. After the project was completed
however, my instructor and I decided against pursuing this type of covert social science
research. There was no informed consent from Company X or my colleagues, and with full
disclosure to informants and human subjects a basic tenant of research for the American
Anthropological Association, we felt this research, if possible, should go in another direction.
My current efforts have moved more towards auto-ethnography, which does limit the
perspective to a "mono-view," but considering the circumstances this method seems most
appropriate at this time.
2 My replacement and I have stayed in contact. In 2000 he accepted a "buyout" from
Company X (after a merger with another phannaceutical company created an excess of
salespersons in the same territory) and went back to school with the hopes of being a teacher.
He decided however to try pharmaceuticals again, explaining to me through email exchanges
that perhaps it was Company X that was strange. He was quickly hired by the competition but
only lasted two months. He commented to me: "they all are the same" (in terms of promoting
products).
react to his resistance (this was a new phenomena for our district), yet the meeting
continued on, albeit awkwardly.
Apparently, some representatives throughout our Midwest region were having
success promoting Company X's SSRI by comparing the PI's while detailing
physicians (i.e. highlighting and pasting key phrases of Company X's PI together on
one page with our competition's PI sections to maximize the visual presentation while
comparing products). This new technique had diffused over to our district. I started
to look around the room at my colleagues who were all watching me. Their faces
seemed to ask the same question: How could we be asked to do this after what
happened to you? There was some confusion and the meeting was on the brink of
falling apart when my manager asked me, "How do you feel about this, Mike." At
that moment, all my bottled up anger, all my past rationalizations came pouring out of
me. I knocked over a chair, mumbled some obscenities, and stormed out of the
meeting room followed only by the manager asking me to come back. My district
manager joined my outside and kept telling me she was "sorry" and asking me what
should be done to make people more relaxed. We eventually walked back into the
meeting together and she suggested we all take a break. When the meeting
reconvened the district manager made a brief announcement in which she repeated an
older mantra regarding how we were going to promote our products. She started with
the familiar phrase "we are all adults here" and went on to basically tell her "team" to
make the right decision regarding how each one of us will promote our products.
What was clear is that she was not adhering to the zero tolerance policy of Company
X (i.e., telling us not to break the rules). Instead, she was playing an old managerial
card, which constantly placed the decision of how to promote products specifically
with the rep. After this meeting I was left with the realization that one is not an
"example" to spare others of a similar fate but a "scapegoat" who existed to satisfy the
needs of higher corporate power.28 In my district it was business as usual.
In the days that followed, I watched and listened while my colleagues'
confusion grew regarding how to promote Company X's products. A paradigm shift
was in effect. Some representatives continued to push the off-label style of promotion
while others, especially my replacement, embraced the "zero tolerance" policy
regarding product promotion. I had gone "clean" on the day of my demotion and over
several months realized (ironically) that I could still sell following corporate
guidelines. More importantly, my replacement had always been clean and was very
28 Recall that the original "cut-and-paste" material sent to the FDA was not of my creation and
that Company was losing ground in the race for FDA approval of new indications for their
SSRI to the competition. My belief is that Company X needed to give the FDA a name and the
proof of taking severe disciplinary action against a senior representative (who was ranked
number one) in order to appease FDA investigators and thereby eliminate any further setbacks
regarding future SSRI indications. However, without access to internal Company X
documents, it's impossible to prove.
successful selling Company X's products. He was promoted to my old position based
on his past performance. So why did I need to break these rules when others did not?
As an ethnographer, I realize that my effectiveness as a sales rep never
changed after my demotion. I was using only FDA and Company X approved
material, and I could still sell. My past activities were related to a hegemonic
apparatus that was entrenched at Company X, one where district and regional
managers helped maintain the risky ideology of off-label promotion even after the
onslaught of zero-tolerance corporate policies. Historically many reps felt it was the
only way to operate - it provided our sales edge. Corporate management at Company
X knew off-label information was important, sometimes vital, in expanding market
share over the competition. However, why should the company risk having a
representative rummage through the journals in medical libraries in hopes of finding
information on a Company X product, when they could set up official corporate
channels to disseminate this information in accordance with the FDA?
The corporation no longer needed reps to fill the off-label void - this was too
risky in the then current FDA climate. Company X overcame this risk by having reps,
when solicited for information by doctors for an unapproved indication, send a request
to the medical department. The doctor would then receive an official letter signed by
a Company X clinical researcher (e.g., a doctor or PharmD) telling the physician for
example that "although Company X's SSRI is not indicated for the treatment of panic
disorder, I have provided you with several articles discussing its use for this mental
disorder" - in essence off-label promotion done legally. The paradigm shift I was a
part of was aimed at negating specific risky rep behavior and not off-label promotion
in general, the latter being a core tactic for expanding market share and increasing
sales. Renegade sales activity, which previously had accomplished the same goals as
"medical department requests," was being eliminated and thereby improved the
corporate image of Company X in the eyes of the FDA. More importantly, Company
X was able to sustain off-label business through official (and legal) corporate
channels.29
As an ethnographer I began to turn this zero-tolerance policy upside down and
ask more critical questions. I discovered that zero-tolerance policies, which created a
morally polarized atmosphere (at district meetings im particular) of good reps and bad
reps, was in fact corporate camouflage - an ingenious Company X diversionary
tactic. By publicly punishing rule breakers and renegades within the corporation and
thereby demonstrating its commitment to being ethical, Company X could assure the
FDA, as well as physicians that the normal, daily activities of its salespersons were
both moral and ethical, and in the best interest of patients, not pharmaceutical
manufacturers. By shifting the emphasis to rogue representatives (like myself) and
29
Representatives sdll found a way to use medical department letters at the local level that
broke company policy.
managers who encouraged creative regional and district policies, the company had
shielded itself from more critical outside assessments while continuing to promote
pharmaceuticals aggressively, in this case, off-label, all the while generating large
profits in return.
"Tricksters" of the everyday
Looking back at my nine years as a pharmaceutical salesperson for Company
X, I have struggled to interpret and critically examine the everyday events that led to
my corporate demise and that continue to operate today.30 Situating the
pharmaceutical salesperson in the field of anthropological discourse remains a crucial
task for critical medical ethnographers if we are to further our understanding of
pharmaceutical sales practices. Anthropological literature concerning
"pharmaceuticals" in general continues to grow but what remain scarce in the
literature are specific interpretations of pharmaceutical sales practices.
Shorris's The Nation of Salesmen (1994) provides a useful point of entry for
interpreting the activities of the drug rep. Shorris is a non-anthropologist who uses an
ethnographic-like method in his analysis of American salespersons in general. He
borrows from structural anthropologists and their comparative studies concerning folk
stories and myths to understand "a quality of selling" that is "common across tine,
distance, and cultural difference" (35). Shorris fmds these early mythical salespersons
have particular qualities in common:
30 My interest in pharmaceutical sales practices is an on going project (see Oldani 2001), and I
continue to maintain relationships with infonmants that are both past and current employees of
Company X, as well as with representatives of other pharmaceutical corporations. What I have
found comes as little surprise: reps like to talk about their work, their activities, especially
anonymously. What has begun to standout during my conversations with informants is that
many representatives maintain a "love-hate" relationship with their job and with the image of
themselves regarding their actions and behaviors. The experienced representatives also realize
that to be "effective" requires a complete understanding of the social nature of sales. An
informant recently discussed a retirement party for a senior representative that she attended
along with many physicians that the new retiree had called on over the years. During the
event, a local psychiatrist (who was a product spokesperson for the company) made a toast in
which he told the audience that "Stan, was the best drug rep he had ever met because he never
mentioned a product by name" during their years of interaction. The doctor told the audience
that Stan realized "its all social." This comment opens a wide field for interpretation. The
simple fact that doctors were present at the retirement event demonstrates the family-like
relationships that can develop over long-term interaction and/or the creation of an atmosphere
where doctors and representatives work for the same company. The doctor's statement is also
ambiguous if he is a Company X speaker: he and Stan no doubt talked about products and
stipends often. Yet, he chose to tell a room full of other representatives and doctors how to be
good salespersons.
They speak. They influence others to act, but do not themselves

participate in the action. They have the advantage of superior
knowledge; that is they know more about others than others know
about them. They know a great deal about the world of things. They
are privy, either through observation, interrogation, or intuition, to the
deepest desires of others. And they are always outsiders, floaters,
wanderers, creatures without roots, more act than substance.
(1994:36)
Whether described as "trickster, devil, courtesan, culture bearer, merchant or
god," one of their goals is conversion from the world of myth to historical reality
(1994:36). Shorris centers the role of these mythical characters around knowledge-
"knowledge as the connection between God and man"-where the
trickster/salesperson is the possessor of superior information.
Shorris focuses on trickster myths, such as the Aztec trickster, the
Tezcatlipoca/Smoking mirror, and the Navaho's "Coyote," where the trickster
becomes the mediator between life and death (1994:39). Tricksters "can foresee
nothing beyond the desires of their customers (or subjects); they have no other
advantage in the world; they are merely the oracles of desire" (1994:40). The
intellectual burden on the trickster is twofold; they must know both desire (of their
customers) and the world and must be able to choose the one object that can best
satisfy desire. If the object is new or dangerous (prohibited by the gods) the other
quality of the trickster comes into play-language, the "sine qua non of selling"
(1994:41). The ambiguous character of the trickster allows it to be the "mediator"
between worlds (between paradise and civilization, between good and evil). The
trickster exists at the level of necessity and is often "punished" because he is operating
at the level of contradiction. Shorris's salesperson becomes the modem incarnation of
the trickster who succeeds by guile as an outside force causing actions he has no stake
in-neither the maker nor the consumer, but the pure communicator (1994:41-2). The
tales I have described above do portray a world where the pharmaceutical salesperson
simultaneously crosses and maintains boundaries between different and often
contradictory worlds-the marketplace and human healthcare. And like the tricksters
of myth, I and other representatives were punished when our activities were exposed,
when we were caught playing our games.
Hyde (1998) in Trickster Makes this World has also described a trickster as a
"boundary-crosser:"
Every group has its edge, its sense of in and out, and trickster is
always there, at the gates of the city and the gates of life, making sure
there is commerce. He also attends that internal boundaries by which
groups articulate their social life. We constantly distinguish - right
and wrong, sacred and profane, clean and dirty, male and female,
young and old, living and dead - and in every case trickster will cross
the line and confuse the distinction. Trickster is the creative idiot,
therefore, the wise fool, the gray-haired baby, the cross dresser, the
speaker of sacred profanities. Where someone's sense of honorable
behavior has left him unable to act, trickster will appear to suggest an
amoral action, something right/wrong that will get life going again.
Trickster is the mythic embodiment of ambiguity and ambivalence,
doubleness and duplicity, contradiction and paradox. [1998:7]
Hyde is more cautious than Shorris when discussing an earthly embodiment
of the trickster, however he does see a protagonist of a reborn trickster myth in the
American version of the "(con)fidence man" (1998:11). Through this line of
reasoning he goes on to speculate that perhaps America, with its land of rootless
wanderers and the free market, represents the "Apotheosis" of a trickster - he's
pandemic (a parallel to Shorris's "nation of salesmen"). Yet tricksters such as Coyote
are complex. Modern thieves and wanderers lack an important element of the
trickster's world; his sacred context-the ritual setting-is missing. 'Trickster
belongs to polytheism or, lacking that, he needs at least a relationsilip to other powers,
to people and institutions and traditions that can manage the odd double attitude of
both insisting that their boundaries be respected and recognizing that in the long run
their liveliness depends on having those boundaries regularly disturbed" (1998:13).
This is precisely where I see the metaphor of trickster applying to the pharmaceutical
salesperson. The doctor-sales rep interaction has become a sacred/ritualized space
(often occurring in the physician's office) where gifts are exchanged and the
boundaries between competing worldviews and powers between the drive for profits
in the marketplace and the patients health interests are blurred and confused.3' The
end result is often "the sell" or "the commitment" to write a prescription, where both
the rep and the physician have (re)established their own boundaries (i.e., improving
sales and helping to cure sick patients) thus allowing both to maintain their livelihood.
The pharmaceutical representative, like the trickster of myth and folklore, isn't a run-
of-the-mill liar and thief. "When he lies and steals, it isn't so much to get away with
something or get rich as to disturb the established categories of truth and property and,
by so doing, open the road to possible new worlds" (1998:13)-in the case of
pharmaceuticals, new markets.
Hyde reminds us that the trickster is not a crook but a "culture hero" who
belongs to the "periphery." In the world of pharmaceutical sales and marketing that I
participated in, the "best" reps ultimately became culture heroes both among
31 A large part of the doctor-rep interaction is based on gift exchanges (see Wazana 2000 and
Oldani 2001) and one could say the act of gift giving has become institutionalized within the
industry. Gifting occurs at various levels on an everyday basis from the plastic pen with a
product name on it (that ideally writes a "script") to the expensive dinner with tickets to the
opera.
colleagues (i.e., other reps) and within the higher structures of the corporation, such as
32
upper management. Moreover, my experiences at Company X parallel Hyde's
observation regarding the paradoxical nature of this type of hero: "If trickster were
ever to get into power, he would stop being trickster" (1998:13). The best
salespersons within Company X often became legendary and most reps wanted to
know their sales "bag of tricks"-how they remained consistently on top. Others,
however, used their status and accepted promotions to management positions (i.e.,
starting their movement into the "core" of the corporation).33 As a result, these reps
would lose their trickster "powers" (this would be the case with my third manager)
and, ironically, were forced to combat trickster behavior among the reps they
oversaw.-4
Much of what I have recounted during my time as a pharmaceutical rep is
simply the trickster-like communicative acts of everyday interaction, the performances
and language games that are embodied in the actions of pharmaceutical
representatives and other "players" within the biomedical-industrial complex. The
emphasis here has been on the pharmaceutical industry side of the equation, however,
I want to stress that pharmacists, nurses, and doctors are part of a complex and
dynamic interaction - all of which influences and leads to the generation of millions
of pharmaceutical prescriptions for patients.
It should come as no surprise that many physicians are quite adept at
mediating the boundaries between the market and healthcare. For example a central
part of my job as a drug rep was to "develop" psychiatrists I would ask to speak about
depression to other community physicians in order to help generate more prescriptions
for Company X's antidepressant. Doctor D., a "key-influential" doctor - one who
essentially changed prescription habits- was a typical case. What I discovered as a
representative is that physicians like Doctor D. were marvelous salespersons. Better
than the best reps. Doctor D was quite adept at giving a balanced presentation (i.e.
giving equal time to all antidepressant medication in terms of side effects and
32
"Best" in the eyes of the corporation, meant being consistently ranked high on the
company's "Goal Achievement Report" (GAR). Your 'ranldng" was directdy related to
exceeding quota on a regular basis. The representatives who finished consistently in the top
five to ten percent of the divisional field force were rewarded with prizes, trips, and status
recognition (i.e., internal company publications with quota numbers and photographs).
33 The President and CEO of Company X at the time of my departure had began as a
phamaceutical rep with the company and had moved his way up over some tfirty plus years to
thetop position.
34 The rep that becomes manager provides an instance to examine the second dimension of
trickster behavior within Company X. The first dimension discussed above is trickster as
extenal boundary crosser between the market and medicine. The second dimension is the
internal boundary crosser within the corporation itself. My second manager was never
comfortable with his position of power and ultimately moved back into the field.
efficacy) and would begin his talk by listing all his industry sponsors over the years.
This was a very clever maneuver because most attendees at these speaker programs
expect at some level a "commercial." Doctor D simply was able to "spin" a possible
objection (i.e., "you are working for Company X, so this talk is biased") into a benefit
and strengthen his credentials (i.e., "I have spoken for so many different companies
and done research on so many products that what I am going to tell you today is
therefore an unbiased medical presentation of all my experiences.").
Moreover, Doctor D showed his true talent during question and answer
sessions by weaving the benefits of Company X's SSRI together with powerful
anecdotal (individual patient) success stories. He and I would often discuss strategies
before such programs: Could I "plant" a question or two? What type of audience am I
dealing with? Are they skeptical of Ivory Tower medicine (should he "dumb it down
a bit")? Finally, Doctor D knew how to negotiate his "stipend." I specifically
remember him being upset that he was not on the "national speakers bureau" because
these "product experts" were getting up to $1,500 a lecture. At the time he was being
paid around $500 to $750 for approximately a one hour of speaking. Dr. D therefore
became a "manager's call" - wanting to talk with my boss or my boss's boss in order
to tap into larger budgets and speaker funds.35 The point I want to stress (and the
irony of the opening quote of this paper on medical "altruism" by Dr. Cantenkin
should be apparent) is that the social dynamic involved between the physician and the
pharmaceutical representative is complex. To begin by saying the pharmaceutical
industry can influence physician prescribing habits may be a valid statement in a
variety of contexts.36 However, the day-to-day relationship between doctors and reps
35 I have managed to keep tract of Doctor D since leaving Company X. Currently, he is on

Company X's "National Speaker's Bureau" and has continued to move up the academic ladder
as well and is the chairperson of a large geriatric psychiatry program. He also is the lead
investigator on several clinical trials involving Company X's psychotropic medications as well
as other pharmaceutical manufacturer's products.
36 The medical establishment is concerned with the increasing influence of the phannaceutical
industry towards their profession. Pharmaceutical company product has been examined in a
series of articles in the Journal of the American Medical Association (JAMA). Tenery (2000:
391-393) in his "Commentary"' raises several important issues regarding whether a patient's
best interest will come into conflict with industry's focus on the bottom line. He realizes that
funding for continuing medical education CME has become so financially intertwined with the
pharmaceutical industry that he calls for a special task force to focus on conflicts of interest
with the charge of developing industry-wide standards of conduct. He is basing his comments
largely on the results of Wazana's (2000) review article, "Physicians and the Pharmaceutical
Industry: Is a Gift Ever Just a Gift?" in the same issue. Her comprehensive review and
analysis provide several startling statistics which call for further investigation from both the
medical community and from medical anthropologists. For instance the mere fact that more
than $11 billion dollars is spent each year by pharmaceutical companies in promotion and
marketing is underscored by the $5 billion portion of that money that goes directly to the
activities of sales representatives and their externally oriented activities.
needs to be unraveled further-trickers are everywhere! Critical medical anthropology

can play a vital role by creating a deeper understanding and a richer ethnographic
picture of the doctor-representative interaction and its wider societal implications.
Controlling Processes
The "culture of cheating" that I have described thus far is complex and
multidimensional. It is far too simple to limit (and label) the activities of
representatives (and physicians) as merely cheating or not cheating, engaging in right
or wrong activities (as defined by the FDA). The term "culture" in this sense is
restrictive as well. As mentioned above, not all reps were engaged in the same
activities. Although we were expected both to follow the company's main goal-
increasing prescriptions-and adhering to all of the "rules," representatives were
motivated at times by different factors. I have argued that Company X created a
"black and white" system of right and wrong (that is subject to public/FDA scrutiny).
However, coinciding with this system is another more ambiguous system, a gray area
where much of the "selling" takes place. Many representatives (myself included)
thrived in this space where we could incorporate our own ideas into our day-to-day
practices. How we sold products was only questioned as Company X began to
increase in size and profits. What was natural to us began to change. We had
previously been empowered by an corporate system that not only provided us with
knowledge and information (through both official and unofficial channels), but also
was reinforced both through success stories (pharmaceutical folk tales) by veteran
representatives and managers and through rewards and incentives (such as bonus
payments). Theoretically, these influences on the activities and practices of certain
individuals can be further articulated by using the Comaroffs' discussion of
hegemony, ideology, and culture as a guide. (1991:19-27) Building on the work of
Williams (1977) and Bourdieu (1977) regarding Gramisci's (1971) prison notebooks,
Comaroff and Comaroff (1991:23) understand hegemony to be "the order of signs
and practices, relations and distinctions, images and epistemologies - drawn from a
historically situated cultural field - that come to be taken-for-granted as the natural
and received shape of the world and everything that inhabits it." Before I was
demoted, I existed in a particular kind of sales hegemony. As this old order began to
crumble, particularly in my district, I began to witness first hand the clash of
subordinate ideologies embodied in representatives who realized that there were
different ways to exist at Company X.
The sales "culture" of Company X can now be seen as a relationship (or an
interaction) between a particular hegemony (such as stressing the importance of off-
label promotions) and various forms of ideology where "power enters-or more
accurately is entailed" (Comaroffs 1991:22). Within a corporation like Company X,
much of the power is embodied in management, and as I have described above, this
managerial power was used to influence our promotional strategies throughout my

entire career. When I departed from Company X, new managerial ideologies were
beginning to emerge to combat this older hegemony regarding product promotion.
However, even though these managers may have differing opinions and belief systems
regarding the nuances involved in product promotion, they were united by Company
X's singular drive for profits through increasing product prescriptions and the overall
expansion of pharmaceutical product market share. This drive for profits led
Company X to develop the slogan "number 1 by 2001" in the mid-1990s as a way of
motivating representatives and impressing Wall Street investors. This, of course, was
not part of the public image of Company X, but a specific internal ideological
message passed on to representatives during POA meetings through managerial
speeches and company videos as well as to investors at shareholder meetings.
At the same time Company X's public image was being (re)structured both
around the phrase "we are part of the cure" and public proclamations (usually through
media outlets) regarding the amount of money spent annually on research and
development. These messages were a direct response to the negative publicity
surrounding President Clinton's first-term scrutiny of the pharmaceutical industry.
His administration had uncovered "price gauging" by the industry (annual increases in
drug prices above the rate of inflation) and had labeled pharmaceutical manufacturers
as part of the problem of rising health costs. These conflicting messages help to
explain some of the motivations behind my (and other representatives') daily practices
and the ideologies that are part of the central ethical paradox of the pharmaceutical
industry.
A sales atmosphere was created where a culture of winning (Oldani, n.d.)
helped to produce specific activities. For instance, I was extremely comfortable
walking into intensive care units (ICUs) in the early moring hours with several dozen
of donuts and bagels, plastic pens, and paper scratch pads ready to talk to doctors and
nurses about using company X's anti-fungal drug for extremely sick patients. The
best case scenario would be to get a doctor (or nurse) to discuss a patient in the ICU
who might be a "candidate" for product F. The "hard close" would entail asking the
doctor to "call down to pharmacy" and order product F for her or his patient that
morning. Occasionally, this would prove successful and a feeling of elation would
pour over me as I walked out of the ICU, past the waiting room full of family and
friends, and through the hospital-I was walking tall. This was a "good call;" it had
served the ultimate dual purpose-curing the sick and making the sale. However, the
patient was always kept in the background and more often than not, "rankings,"
"quotas" and company "profits" were the benchmarks of our success and not actual
patient "cures" by our products.37
37 During POA meetings and both through electronic mail and voice messages, we discussed
the "numbers" at length (Oldani 1997:11-14). This concerned personal rep rankings per
product within the district and at the regional as well as the national level. Percents of quota
Moreover, in the mid-1990s "generating scripts" became our main concern

and our direct way to winning, as representatives (and the pharmaceutical industry in
general) began to utilize information technology through "third parties."38 "Script
tracking" (or learning doctors' prescribing habits) empowered sales reps with "I know
exactly what prescriptions you are writing" information. This increasingly put
physicians at a serious disadvantage during the negotiations of a typical sales call. I
could now enter an office completely aware of a physicians habits; curtail my
presentation to this knowledge (i.e., highlight my product's advantages over the
specific competitive product that the doctor was writing); and, return on the next call
informed by new script tracking information (i.e., did she or he actually write any
scripts for my product). Around the time I left Company X (1998), "high
prescribers," doctors who daily write extremely high amounts of prescriptions for
pharmaceuticals, were being inundated with sales calls by pharmaceutical
representatives, gifts of every sort by the industry, and an abundance of free samples.
Script tracking completely changed my daily routine while at Company X and
is now reshaping the interactions of representatives and doctors as well as the nature
and scope of pharmaceutical industry power. According to my current informants,
prescription information is now downloaded weekly into "doctor profiles" that are
contained in the databases of every representative at Company X giving the average
representative an extreme advantage in the marketplace. The pharmaceutical industry
continues to perfect the culture of winning (i.e., generating millions of new "scripts"),
(eg.,. "Mike Oldani: 190% for Product P and ranked #1 in the midwest") were posted on the
walls of meetings, exalting the winning reps and humiliating the losers. The goals were
always clear: "vice presidents club" or "circle of excellence" for individual reps and "number
one" ranking for the district. The year I was demoted we finished number one as a district and
we all were given a four-day all-expenses-paid-trip to Vail, Colorado, with a guest as our
reward (I was allowed to vacation ahead of the rest of the district, avoiding confrontations and
awkward situations with my district manager and some of my district members.). On a daily
basis my last manager was adept at sending little "reminders" to her reps concerning our
collective efforts. Postcards quoting Vince Lombardi's perspectives on winning were her
favorite.
38 Before 1995 all sales were tracked through zip code sales. Company X could buy sales data
from wholesalers regarding what they had distributed to pharmacies and hospitals within a
specific zip code. In rural territories this was a good way to track business because most
prescriptions were filled in the same zip code or in a zip code in a nearby town that was still in
your territory. In bigger metropolitan areas this method proved problematic because several
territories were close together and reps were "losing scripts" to other reps (i.e., doctor X's
prescription was filled in a colleague's zip code). Script tracking theoretically would track all
prescriptions that a doctor wrote, even if the territory was part of Alabama and the patient
traveled to Texas on vacation and filled the script there - the rep received credit. All this
information was apparently bought through various third parties, such as pharmacy benefit
management (PBMs) companies. There seemed to be a lot of room for error (and a lot of
mathematical formulas), but reps for the most part believed managers when they said that the
"system works."
but at what cost? The anthropologist Hugh Gusterson (1997:727-8), in response to

Nader's (1997) discussion of "Controlling Processes," has asked "what other issues
might profit from a similar analysis" of controlling processes used by corporations
that draw upon (and profit) from "the authority of science" (and medicine). There is
perhaps no better candidate for examining controlling processes at work within the
corporation, as well as at work in "the field" through the practices of sales
representatives, than the multinational pharmaceutical industry, which uses the
authority of science and medicine to expand the market share of products and gain
incredible profits in return. The issue at stake remains furthering our understanding of
the activities, motivations, and ideological underpinnings of pharmaceutical
corporations as they continue to influence medical care. Gusterson directs our
attention to pharmaceutical executives who claim that one third of the world's
population may be taking psychiatric medication within two decades (Harper's Index
1997). What I have attempted to show above is that these executives can only make
such a claim with a full understanding of the complex machinery in place that can
generate millions of prescriptions of their respective pharmaceutical products. The
industry fully understands the extent of its power-which includes a population of
salespersons now numbering close to 70,000 in the United States, one for every eleven
doctors (Kirkpatrick 2000), and armed with a variety of resources including
sophisticated information technology. The task remains for a critical medical
ethnography to fully grasp and further articulate the dynamic nature of pharmaceutical
power.
Conclusion
The daily activities of representatives are just a small slice of the hegemonic
pie that is the multinational pharmaceutical industry. The industry, like other
institutions of power and control, continues to present a formidable task for
ethnographers interested in "representing the complexities of personal experience
without losing sight of connections" (Nader 1997:71 1). To date, the most
comprehensive anthropological review regarding pharmaceuticals in general remains
"The Anthropology of Pharmaceuticals: A Biographical Approach" (van der Geest, et
al. 1996). The authors take a novel and useful approach by creating a genealogy or a
"life cycle" of a drug including: production (research and developmen), marketing,
prescription, distribution, purchasing, consumption, and efficacy. As the authors note,
"each phase has its own particular context, actors, and transactions and is
characterized by different sets of values and ideas" (153). The authors specifically
focus on the fact that sales representatives have attracted very little attention from
anthropologists. Part of this reason could be the previous models used for studying
pharmaceutical-related questions. For example, Kleinman (1980) realized a trend in
medical anthropology was to focus on the "folk" and the "popular" sectors of
healthcare versus focusing "prinmarily on the transaction of pharmaceuticals within
professional settings" (van der Geest, et al. 1996:155). Ethnographies looking at
pharmaceutical "transactions" within the professional setting (i.e., health clinics,
Oldani Tales from the "'Script" 173
hospitals, and pharmacies) have predominantly taken place outside the United States
(e.g. Sachs 1989, Sachs and Tomson 1994, van der Geest 1982, Waddington and
Enyimayew 1989/1990). This "conspicuous gap" concerning American
pharmaceutical rep-doctor interactions in the literature comes with an ironic twist.
Although anthropologists have just begun to intensely study pharmaceutical
sales(persons), the industry itself has not failed to study us the consequences of which
are quite disturbing. By referring to anthropological studies that show how non-
Western peoples cherish vitamins, blood tonics, anti-diarrhea medicines, and
hormonal preparations, the industry has been able to claim an "openness" to local
variations in cultural concepts of health, illness, and medicine. In short, the
"anthropological perspective is congenial to market research" (van der Geest
1996:158). From a biomedical and critical anthropological perspective,
pharmaceuticals may seem "overused," and certain drugs may seem dubious, useless,
or even dangerous, yet thanks to the ethnographic work of anthropologists (and their
emphasis on pharmaceutical relativism), the industry can claim it is only providing for
all of humankind what people welcome as useful and effective medications for their
own culturally specific treatments and "cures." The pharmaceutical industry and sales
and marketing in particular, are quite adept at this type of "spin selling." Every
objection (by physicians, patients and the general public) can be turned around and
become a positive "thing," something to be valued and sold. In fact, this logic
permeates every level of the industry, right down into the depths of everyday verbal
exchanges between doctors and reps.
To even begin to understand the logic of the pharmaceutical industry, we must
begin to conceptualize the critical (and everyday) site for pharmaceutical
transactions-doctor-drug rep exchanges. 9 This paper has used my personal
experiences as a "detail man" at Company X for a touchstone of both auto-
ethnographic exploration and pharmaceutical power analysis. The sales practices of
drug reps can no longer be mentioned only in passing (see Ferguson 1981, Nichter
1983 and Wolffers 1991, in van der Geest et al. 1996:158 for mention of reps outside
of the United States). They must become central to both a critically engaged
ethnographic project concerned with pharmaceutical sales, marketing, and promotion,
and to anthropological questions concerned with fully understanding and
conceptualizing the pharmaceutical industry.
39 The logic of the phanraceutical industry is what Nader (1997:722) would describe as
"cultural hegemonies at home." This paper was in part motivated by the "shortage" of
ethnographic analyses of home-grown, U.S.-based, ethnography as described by Nader. It is
quite clear that anthropologists may never gain access into the pharmaceutical corporation;
however, as I have mentioned above, reps like to take risks (like revealing company secrets)
and they love to talk.
Acknowledgments
I would like to thank the following people for reviewing previous drafts of
this paper and offering valuable comments and corrections: Ann Fox, Deidre Prosen,
Ian Whitmarsh, Chris Garces, and Stefan Sperling. In particular, I would like to thank
Emily Martin who offered critical remarks to an earlier draft and, through our
discussions of the pharmaceutical industry in general, helped to shape the scope of
this current paper. I also owe a special thanks to both Meg Hiesinger and Eugene
Raikhel for their editorial skills as well as their theoretical insights. I take full
responsibility for the information and ideas presented in the final draft of this paper.
Works Cited
Bourdieu, Pierre
1977 Outline of a Theory of Practice. R. Nice, trans. Cambridge: Cambridge
University Press.
Comaroff, Jean and Comaroff John
1991 Of Revelation and Revolution: Christianity, Colonialism, and
Consciousness in South Africa. Chicago: University of Chicago Press.
Crossen, Cynthia
1996 Tainted: The Manipulation of Fact in America. Tokyo: Simon and
Schuster.
Ferguson, A. E.
1988 Commercial Pharmaceutical Medicine and Medicalization: A Case Study
From El Salvador. Culture, Medicine, and Psychiatry 5(2):105-34.
Gramsci, Antonio
1971 Selections from the Prison Notebooks. Q. Hoare and G. Nowell Smith,
eds. and trans. New York: International Publishers.
Gusterson, Hugh
1997 Reply to Controlling Process. Current Anthropology 38(5):711-737.
Harper's Index
1997 Harper's, July: 13.
Hyde, Lewis
1998 Trickster Makes This World: Mischief, Myth, and Art. New York: Farrar,
Straus and Giroux.
Kamat, V. R. and M. Nichter
1998 Pharmacies, Self-Medication and Pharmaceutical Marketing in India.
Social Science and Medicine 47(6): 779-794.
Kirkpatrick, David D.
2000 Inside the Happiness Business. New York Magazine, May: 37-43.
Kleinman, A.
1980 Patients and Healers in the Context of Culture. Berkeley: University of
California Press.
Levinson, Jay Conrad and Charles Ruben
1994 Guerrilla Advertising: Cost Effective Techniques for Small Business.
Boston: Houghton Mifflin.
Levinson, Jay Conrad, Seth Gordin, and Charles Rubin
1995 The Guerrilla Marketing Handbook. Boston: Houghton Mifflin.
Lexchin, J.
1989 Doctors and Detailers: Therapeutic Education or Pharmaceutical
Promotion? International Journal of Health Service 19(4):663-79.
Nader, Laura
1997 Controlling Processes: Tracing the Dynamic Components of Power.
Current Anthropology 38(5):711-737.
Nichter, Mark
1996 Paying for What Ails Your: Sociocultural Issues Influencing the Ways and
Means of Therapy Payment in South India. In Anthropology and
International Health. Mark Nichter and Mimi Nichter, eds. Pp. 239-264.
New York: Routledge.
Oldani, Michael
N.d. Uncovering Contradictions and Power Plays in the Pharmaceutical
Industry. Unpublished MS, Anthropology Department, Princeton
University.
N.d. Thick Prescriptions: Towards an Interpretation of Pharmaceutical Sales
Practices. Unpublished MS, Anthropology Department, Princeton
University.
Sachs L.
1989 Misunderstanding as Therapy: Doctors, Patients, and Medicines in a Rural
Clinic in Sri Lanka. Cult. Med. Psychiatry 13:335-49.
Sachs L. and G. Tomson
1994 Brokers, Medicines, and Rationality: Mirroring Health Centers in Sri
Lanka And Sweden. In Medicines: Meanings and Contexts, N. L. Etkin
and M. L. Tan, eds. Quezon City, Philippines: Health Action Information
Network.
Shorris, Earl
1996 A Nation of Salesmen: The Tyranny of the Market and the Subversion of
Culture. New York: W. W. Norton and Company.
Smith, Mickey C.
1968 Principles of Pharmaceutical Marketing. Philadelphia: Lea and Febiger.
Sutton, David
1960 A Plea for Detail Men to Tell the Truth. Medical Marketing 19:13.
van der Geest, Sjaak
1982 The Efficiency of Inefficiency: Medicine Distribution in South Cameroon.
Soc. Sci. Med. 16:2145-53.
van der Geest, Sjaak, Susan Reynolds Whyte and Anita Hardon
1996 The Anthropology of Pharmaceuticals: A Biographical Approach. Annual
Review of Anthropology 25:153-78.
Waddington, C. and K. A. Enyimayew
1989/90 A Price to Pay: The Impact of User Charges in Asanti-Akim District,
Ghana. Int. J. Health Management 4:17-47; 5:287-312.
Williams, Raymond
1977 Marxism and Literature. London: Oxford University Press.
Wolffers, I.
1991 Traditional Practitioners and Western Pharmaceuticals in Sri Lanka. In
The Context of Medicines in Developing Countries: Studies in
Pharmaceutical Anthropology, S. van der Geest and SR Whyte, eds.
Dordrecht: Kluwer.

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Tales From The "Script": An Insider/Outside View Of

Pharmaceutical Sales Practices

participation in gift exchanges, and promotion ("detailing") of pharmaceutical

My interest in how salespersons promoted pharmaceuticals stems from my

maneuverings, and psychological stress. My pharmaceutical sales career came to an

In addition to this divisional schism, widely differing sales philosophies

Managers, and representatives, myself included, were operating in denial on

17 As a Senior Institutional Healthcare Representative, I was seen as a leader and mentor to

They speak. They influence others to act, but do not themselves

35 I have managed to keep tract of Doctor D since leaving Company X. Currently, he is on

needs to be unraveled further-trickers are everywhere! Critical medical anthropology

managerial power was used to influence our promotional strategies throughout my

Moreover, in the mid-1990s "generating scripts" became our main concern

but at what cost? The anthropologist Hugh Gusterson (1997:727-8), in response to

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