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Cooperstock (Ed.) Social Aspects of the Medical Use of Psychotropic Drugs.

Toronto: Addiction Research Foundation of Ontario. Physicians' Desk Reference, 1918–32nd edition Oradell, N.J.: Medical Eco

nomics Company. Prather, J. and Fidell, L., 1978—Drug use and abuse among women,” International Journal of the Addictions forthcoming.

1975—"Sex differences in the content and style of medical advertisements." Social Science and Medicine 9:23–26. Seidenberg, R., 1974—"Images of health, illness and women in drug advertising.” Journal of Drug Issues (summer): 264–67.

1971—“Advertising and abuse of drugs." The New England Journal of Medicine 284 (14) 789–80. Shader, Binstock and Scott, 1968"Subjective determinants of drug prescrip

tion: a study of therapists' attitudes.” Hospital and Community Psychiatry

19:384-87. Shapiro, S. and Baron, S., 1961—"Prescriptions for psychotropic drugs in a nonin

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ADDENDUM

Cartwright, A., 1974–-“Prescribing and the relationship between patients and able to see us. I had to take into account vacation schedules which I was supposed to have written down on my territory record card as well as the names of the girls in the offices including the nurses and receptionists. On this record card I was supposed to write the competitive drugs he used as well as Roche's and had to include the dosage forms and numbers of tablets or capsules he would write for in order to determine his writing habits.

and doctors” in R. Cooperstock (ed.) Social Aspects of the Medical Use of Psychotropic Drugs. Toronto: Addiction Research Foundation of Ontario.

PREPARED STATEMENTS

PREPARED STATEMENT OF CHARLES BRANNAN, FORMER DETAILMAN WITH

HOFFMANN-LA ROCHE INC.

There has been much written about pharmaceutical companies, pharmacists and physicians but little is known about the pharmaceutical salesman also called detailman or drug pusher and the pressure he is under to sell drugs. I am here today to give one salesman's opinion based on facts of what it was like to be a detailman working for Roche Laboratories. In the next few minutes I would like to give you a brief history of my background training, what I did as a detailman, how I was evaluated by Roche Laboratories for salary increases and bonuses and expound on the tremendous pressures that were exerted on me by the company's high pressure artists called divisional sales managers and regional managers. These pressures were exerted purely for profit and can eventually destroy the salesman and his family.

I was born March 21, 1945, in Cleveland, Ohio, and grew up in Shaker Heights the son of a successful radiologist. I went through high school actively participating in sports as well as being class officers. I then went to Denison University in Granville, Ohio and graduated in 1967 with a B.A. in Biology and a minor in Chemistry. With the Vietnam War in progress, I applied to Officer Candidate School in Newport, Rhode Island and was accepted. I went to O.C.S. in November, 1967, and graduated in March of 1968, as an Ensign in the United States Navy. I was sent to San Diego, California, and served on board the USS Ogden from March, 1968 to October 1969. While in the service I did an eight month tour in Vietnam and was later honorably discharged. I was married on July 12, 1969. While growing up I was very influenced by the Medical environment and also worked in hospitals.

On November 18, 1969, I was hired by Lou Grosso of Hoffman-La Roche to work a territory in San Diego and Yuma, Arizona. From the very beginning I was driven to produce by a very manipulative division sales manager. The object of the game I later realized, was to keep me off balance and not secure of keeping my job. My division manager would call at eight o'clock in the morning and tell me to pick him up at the airport to work with him. He would expect a perfect day which included calling on physicians at the appropriate time that they would be

For the first few months after I was hired I was put through extensive training both in a motel for two weeks at a time with two other salesmen and in Nutley, New Jersey for two weeks. The training was very complete and thorough. I would become qualified to promote the product by first being evaluated by a career associate, pass written and oral tests and finally become field qualified by my divisional manager. I was expected to see a minimum of six doctors a day and spend as much time as possible with the doctor discussing at least three products. I was also to call on two hospitals and three pharmacies a day and sell Roche goodwill. When I worked with my division manager (D.M.) I would often spend thirty minutes with a doctor and become nervous because they had patients jamming their offices. When I was by myself I would give the physician the information I was supposed to based on company policy in a very concise and organized manner because I had to get the message across rapidly and include three products. My sole purpose was to get him to prescribe Roche products instead of the competitors by any means I could. We were taught that after mentioning the first drug the next two drugs discussed would not be recalled, so Valium was presented first. The reason I knew this was that Roche would do telephone surveys through professional companies which would call physicians and ask when the last time they saw a detailman and what drugs they talked about. In my territory there were “reporting physicians” who would fill out a form which included what company they saw, what products were discussed and in what order. We were also graded by excellent, good and poor presentations and the doctor wrote down what samples were left. During the six years I was in the territory, through talking with other salesmen, and from the doctors themselves, I gradually learned who the reporting physicians were. Often my friendly doctors would have me fill out the form and grade myself and I would make sure I put down the products I was supposed to be promoting and in the correct order. The reason a doctor would do this was that the company would send his medical school ten dollars each report he did. At one sales meeting I saw the completed xeroxed copies of the reports done by doctors but one could not tell other than area, from which it originated.

I mentioned that salesmen would cooperate with one another giving out information on reporting doctors as well as which doctors were heavy prescribers and also which doctors not to leave samples with because they would sell them or work out financial deals with the pharmacies, especially if he was part owner in a pharmacy. We had to stick together because the pharmaceutical salesman has a pushing divisional manager in direct control of him and the pharmacist and doctor on the other side of the fence. I want to point out that only a few doctors dispense for profit and only a few pharmacists work deals out with samples because the rest are very dedicated to being professionals in the eyes of the patients and to themselves. In San Diego County there is

group of professional pharmaceutical salesmen who have drafted their own rules of conduct and ethics which is controlled by the by-laws of the Medical Service Society. The Society consists of approximately 80 members that are invited to join with two references from other companies. I have been the secretary and vice-president of this organization. Once a month we would get together to discuss the latest changes within the industry as to political effects such as the repeal of the antisubstitution act which in California changed the whole marketing concept of drug detailing. No longer was the doctor the ultimate decision maker but now the pharmacist has the power of success or failure of a salesman in a given territory. The members of the Medical Service Society would also do public services such as donating $4,000 to a Burn Center at University Hospital in San Diego. The money was raised by selling advertising to pharmacies. The advertising which was sold included the name of the pharmacy and telephone number by area which was printed on a poster and distributed to all the doctors offices in San Diego which made it easier for doctors to call in prescriptions. Only two companies discouraged their salesmen from joining the organization,

From talking with other salesmen in town as well as out of town in Yuma, I learned a great deal about other company policies and how each individual salesman was treated. At this point I was under pressure to produce, even though Roche was having outstanding years in 1972 and 1973 with a growth rate of approximately 15%. Valium was growing at such an unbelievable rate that Roche could afford to start new building projects but had to prepare for the future of Librium and Valium going off patent. Roche started acquiring new products to sell in the educational field under the division of ROCOM. I sold educational systems to teach coronary care nurses, Health History questionnaires, medical records based on the concept of problem oriented medicine, appointment systems and telephone message systems that were developed by Patient Care Systems, and finally the Health Employee Learning Program developed by Comprenetics which consisted of learning programs on inservice education in hospitals concerned with housekeeping, food handling and safety. programs. When selling these tangible products, it took time away from selling pharmaceuticals but it increased our credibility with doctors and other members of the health care team. On these products we were given sales goals, not quotas, because Roche does not use that word for legal reasons. In 1973, the San Diego division changed management. Lou Grosso had different territories to manage and Jack Gilden an employee of 18 years took over management of San Diego. Jack could not take the pressure of our division, not meeting sales goals on ROCOM products so he flew back to Nutley, New Jersey and asked to be fired. At the same time Bob Rose, one of the salesmen I was trained with, cracked in a doctors office while trying to sell ROCOM. He broke down and started crying because the pressure was too great. Bob had been on two Librax, four times a day for ulcers. He left Roche soon after.

To take Jack Gilden's place, Mr. Phillip Shapiro was promoted to Division Manager in May of 1973. Roche was experiencing the inflationary effects of the economy and revised the sales budgets because the cost of doing business had increased to the point that operating profit was decreasing beyond Roche's control. Due to political pressures going on in Britain concerning the price of Valium and Librium and Senator Edward Kennedy having hearings on promotional practices reform, Adolf W. Jann, the chairman and president of the Swiss based Hoffmann-La Roche, disclosed the company's financial earnings that were previously unknown. In 1974 Roche did world wide sales of $1.6 billion with $188 million profit after taxes ; in 1975 $2 billion with $220 million profit. Roche also gave $30 million in dividends which was 15% of the profits and spent $300 million on research. The reason I mention these figures is that at this point I was beginning to realize what it meant when my divisional manager said I would be evaluated by the ultimate bottom line. The reason I had my job was to sell drugs purely for profit. Roche labs in 1975, according to Robert B. Clark, had a good but not a dramatic year with sales of $600 million with a gain under 5% which was “not an acceptable rate of growth”. In 1975 Librium sales were $152 million which had grown from $79 million in 1971 and in 1975 Valium sales were $285 million as compared to $61 million in 1971. The total of Librium and Valium sales for 1975 of $437 million as compared to the company's total sales of $600 million quite clearly demonstrates the importance of these two products even though Dalmane, Bactrim, Nipride, Ancobon, and Larotid, a penicillin derivative which was cross licensed with Beecham Laboratories, were introduced. In 1975, ROOOM was disbanned by Roche because it was not a profit center and took too much time away from promoting pharmaceuticals in the doctors offices. Roche built a plant in Puerto Rico for tax purposes, at a cost of $50 million to make Librium, Librax and Dalmane; also a plant in Texas was proposed at a cost of $150 million to produce Vitamin A and E intermediates which was later suspended at the beginning of 1976. Roche does not borrow money to build plants. The money comes from profits. In September, 1976, the budgets were revised in Nutley to show $15 million total reduction in sales goals. This according to Robert B. Clark, was due to $20 million being spent on additional expenses such as salaries, benefits, wages and plant equipment, and Valium sales were off from the original sales forecast. This was attributable to unfavorable lay publicity, the drug control act placing Valium, Librium and Dalmane under schedule IV and raising inflationary costs.

Three months later a mailgram was sent to my division manager, see Attachment I. The pressure to sell Valium originated at the top and went down from

national level to regional level then to the divisional level and finally to the territory level. The object was to have Valium prescribed by physicians to be filled by the pharmacist who had to order Valium from the wholesaler or distribution center, thus producing sales on the bottom line. My territory alone did approximately $1 million and our bonuses depended on increased sales.

The system of promoting pharmaceuticals for Roche evolved from using samples of Valium and Librium in 1969, to the mailing of "free goods, starter supplies, clinical trial supplies" which were synonyms for samples. We launched Bactrim, a drug for urinary tract infections, but due to the investigations of Senator Kennedy, without samples. Burroughs Welcome, our competitor, launched an identical drug Septra with heavy sampling to the point that the salesmen did not know what to do with them all. At the same time, we were sampling Bactrim by mail but could not compete for the market share against Septra. All this time Roche watched as Septra's new prescriptions soared. At this point, I was still able to handle the pressure. I had made it through the ROCOM days even though in my division, Bill Petrik a salesman of 18 years went on a medical disability because he could not take the pressure from Phil Shapiro to produce sales even if it meant knocking Roche products off the shelves to have them break and be reordered. Bill is still on medical disability because he cannot do the job he did so well for so long ; under the current pressure to produce any way possible, I do not want to sound like a disgruntled employee, but what bothers me is the effects of pressure that takes its toll on salesmen not only working for Roche, but on the other salesmen working under identical pressures day to day to keep their jobs because of sales quotas. I would like to digress a moment and talk about other people who are no longer with Roche because of pressure.

In my division alone, Bill Petrik went on a medical disability, John Henderson went on a medical disability, Clint Johnson was fired by Mr. Shapiro, Jerry Moon was fired, Jan Pollard was fired and Stephen Gordon was fired. We were all told to get the business any way we could. Finally, the most tragic loss is that of my best friend Bill Wagner, who had had several heart attacks over the last few years while working for Roche and died April 18, 1978, from a coronary at 48 years young. On February 13–17, Bill attended a very high pressure sales meeting in Nashville, Tennessee, where Roche played a “golf" game. Salesmen were given "strokes" by graders who evaluated their sales presentations. There was a prize for the people who did best or closest to “par". Bill had to be at certain places at certain times which involved going up stairs and running to the next presentation. Bill experienced chest pain and went to the hospital where he met another Roche salesman who had suffered a heart attack at the meeting. Mr. Shapiro went to see Bill Wagner after he had had his second heart attack and only out of ICU two days earlier and started talking about Roche business, on how to cover Bill's wholesaler concerning a Larotid deal. Why would Mr. Shapiro do this? The answer is Pressure To Produce Sales at All Costs. This is why I am here giving this testimony. Mr. Shapiro was fired September 1, 1977, and Roche did not give him a reason for his termination of employment, but Roche knew as well as his regional manager, Alan Wasserstein, he was involved in a Larotid false invoice kickback scheme which cost money but made Mr. Shapiro's division look good on Larotid sales and paper. Before Mr. Shapiro was fired he also suffered from the tremendous pressure of managing a $6 million division. Mr. Shapiro had three-fourths of his stomach cut out from ulcers all by the age of 35 years young.

When I digressed I was talking about launching Bactrim without samples and the growth of Septra due to samples. A few months later Roche launched Larotid and again without samples. Roche's sales were low because Beecham Massengill was sampling heavy. The obvious recourse was to start sampling Bactrim and Larotid in order to get the business for Roche. The first thing Roche did was to have the pharmaceutical salesmen sign the “Roche Laboratories Statement of Policy on Distribution of Patient Starters of Prescription Drugs” in June, 1975, purely for legal reasons in case a salesman was using the samples to get the business for Roche and got caught, see Attachment II. When I signed the form for Mr. Shapiro, I was told to do exactly the opposite, which was to get the business any way I could even if it meant working deals by using samples because after all, at evaluation time I would only get average salary increases and average bonuses unless I did. When a salesman is evaluated the division manager and salesman get together and determine whether a salesman is Above Standards, Meets Standards, or is Below Standards according to the "Field Force Salary Administration Process and Guidelines". The salesman signs the form as well as the divisional manager and it is submitted for approval to the regional manager. If the salesman wants to contest the final rating, he can bring it up to the regional manager for review. The problem is that it would do no good to dispute his decision because the regional manager is very close to the divisional manager. In 1973, I received a bonus of $5,800, in 1974 $4,800 and when I did not play Mr. Shapiro's game, I received $1,600 in 1975, the best year I ever had with Roche because of Valium being on Medi-Cal and I had a large welfare territory. Incidentally, Bill Wagner received a $6,000 bonus that year and won Roche's President Achievement Award (PAA) which was well deserved.

It is interesting to note that on May 29, 1975, just before we signed the statement of policy on samples, Roche sent out to the sales force a seventeen page document and a tape on "The Effective Use of Starter Supplies”. This program outlined the use and techniques of using Bactrim samples in the doctors offices. The purpose was to make sure the doctor asked for the drug so that we would protect ourselves by saying these samples were unsolicited. At the next division meeting we were told to bring the tape and the paper and turn it into our division manager and we signed a form when we turned it in. I turned mine in but kept Bill Wagner's. I was working his territory after he had had his second heart attack and saved it for him. At the same time, I was sampling Bactrim and Larotid and having doctors sign a free goods form if they wanted Valium, Librium, Dalmane, Librax or any other product we were promoting. I could mail from our distribution plant in San Leandro, California, up to three hundred capsules or tabets at one time. Later, our free goods amount was changed to mailing only 100 tablets or capsules of a given product per dosage form. I would mail 100 Valium 2mg. 100 Valium 5mg. and 100 Valium 10mg. I was told by Mr. Shapiro that if the truth were known, Roche mailed out more in quantity than we ever carried as samples but this was quite secretive after all we were not sampling, but what was Roche to do to keep the competition from hurting Valium, Librium and Dalmane sales.

On March 1, 1975, I was promoted to Medical Center Representative and Carroll Hooks took my old territory. Roche and fifty other companies pay for the Distribution Data System (DDD) Printout Attachment III (in committee files]. On the DDD form my sales are those of a few pharmacies in Yuma, Arizona, because I kept that as part of my new territory which included calling on the VA Hospital, University Hospital, Kaiser Hospitals, Balboa Hospital and Scripps Hospital. I was now in a position of influencing residents, interns and medical students on the merits of Roche's products. I was never told to exaggerate claims on Valium, but if a confrontation came up about lay publicity I was to be able to handle it by showing reprints by physicians to dispute the other opinion or have Roche's professional services department send a folder of information on the area in dispute. I was to go by company policy at all times which included the "versatility of Valium" which was one promotional force and later turned to "appropriate use of Valium". If one looks at the DDD printout for 11/30/76 and my name, you can see that in my territory for the month of November 1976, $6.194 of Valium was sold. Below that number is the current year to date of Valium sold in my territory which was $55,931. Every time a bottle of Valium leaves our distribution center it is marked down as to which pharmacy it is shipped to by name and zip code. Likewise, everytime a wholesaler ships a bottle of Valium to a local pharmacy it is tabulated by name and by zip code. Consequently, the dollar volume of the drugs sold per product in my territory is compiled as well as the competitor's drugs and it shows what percentage of the market I have which in this case is 62.9% year to date. One can also compare yourself against the other salesmen as well as the division to the regional percent and national figures. I called this system the “velvet hammer" because the amount of pressure that can be exerted when bonus or salary evaluation time comes around. Remember the bottom line is the only thing that counts with Roche. This is also a great leverage tool for the other companies because they know what percentage of the market the competitive salesman has. An example of this is my competitor with Sandoz marketing Mellaril who has 5.6% of the market which is half of what the other salesmen in other territory zip codes have. However, one has to take into account the factors influencing the individual zip codes. Is Mellaril on the hospital formulary as in the case of my competitor ? In the case of Carroll Hooks, is Mellaril on the Medical formulatory and is this zip code a high welfare area which happens to be the case here at 13.9% as compared to 10.9% for the region. The salesman has

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