Greg Ciola Interviews Kathleen Slattery-Moschkau

September 15, 2006

Prescription Drugs Under Fire Again

Former Pharmaceutical Sales Rep Reveals The Inside Secrets And Deceptive Tactics Used To Sell Dangerous Drugs

CRUSADOR Editor, Greg Ciola, Interviews Former Drug Sales Rep, Kathleen Slattery-Moschkau.

Kathleen Slattery-Moschkau spent ten years of her life selling drugs…legally, that is. She worked for one of America’s corporate darlings – the pharmaceutical industry.  Kathleen had it all – a big salary, a company car, a closet full of business suits, company perks, and a growing pit in her stomach.

Throughout the course of her ten year career, she documented both amusing and frightening incidents that occurred in her daily life as a sales representative for big drug companies. In this eye-opening interview with CRUSADOR editor Greg Ciola, Kathleen shares with the public the pill-pushing tactics of the pharmaceutical industry’s leading companies and the reasons why we all need to be concerned about the drugs doctors are prescribing to patients. 

Crusador:  Kathleen, it’s great to have the privilege to interview you.  You expose the pharmaceutical industry from a different perspective, one that I haven’t covered yet in CRUSADOR, and that is as a former pharmaceutical sales rep.  Last year we ran a very revealing interview in our publication with Dr. David Graham, the FDA employee that blew the whistle on Vioxx and tried to get it pulled from the market before thousands of people died. As a former pharmaceutical sales rep I am really interested in knowing some of the ins and outs of what goes on in the industry.  Let me begin by asking you how you actually got involved as a pharmaceutical sales rep?
              
Well, it’s interesting.  When I first came to work for them I was 23 and a year out of college.  I majored in political science.  That was my “science background.”  I really avoided science like the plague as an undergrad; it was just not my strength.  I went to work for the cellular phone industry right out of college selling phones for about a year.  Then one day I got a call from a recruiter who had asked me if I had ever considered pharmaceutical sales. I said “No, I don’t have a science background.”  He basically said that they can teach you all that you need to know.  They’re just looking for someone with sales experience.  Then he mentioned, “Oh, you get a company car, and here’s this big, fat paycheck, and we’re going to fly you all over the country.”  It all sounded great. They assured me that they could teach me exactly what I needed to know in order to do this job.  So away I went, and spent the next decade of my life in the industry.
              
I’d say for the first three to five years, they basically told me what to say, and I said it.  They taught me how to say the big medical words. I really didn’t ask a lot of questions at that point. I think I was just young and relatively naïve.  Throughout the course of my 20s I started to grow up, mature and began taking a closer look at the world around me and what was going on.  I started to feel increasingly uncomfortable with what I was doing for a living.  Every day things were happening in the course of my career that in some cases were very humorous, and in some cases very shocking.  In the end, all of it was very scary when you think about the fact that people’s lives were on the line based on information that I was giving these doctors.
              
The part that’s really hard for me to admit, but I think was an important part of the process, is that every time I was just sick enough to walk away, I’d get a big raise or a new company car. I found myself rationalizing or spinning that PR that they were giving to me such as, “What would we do without the pharmaceutical industry,” and, “Oh, your role is so important in educating physicians.”  I found myself using that spin to rationalize why I was staying.  Then after ten years, I couldn’t even look at myself in the mirror anymore.  I was so uncomfortable that the information I was being given and then giving to physicians could potentially cause harm, I just had to walk away.  I didn’t care if I had to flip burgers for a living.
              
Crusador:  Are you at liberty to mention which company or companies you worked for?
               
Over the course of ten years I worked for three different companies.  I started with a small company called Muro Pharmaceutical, and was recruited away from Muro by Bristol-Myers Squibb. In the end I was recruited away from Bristol-Myers Squibb by Johnson & Johnson. What I was realizing with the companies I worked for, and in talking to my colleagues, is that these are problems that pervade the industry as a whole. It’s not about any one company. 

Crusador:  Were there specific drugs as a sales rep that you were supposed to promote or did you promote all their drugs when you went in to see physicians?  Can you also tell me what your typical day was like and what you did when you’d go into an office?
               
Typically, at any one time I’d have between two and three drugs in my bag.  Over the course of the ten years I covered multiple specialties.  I had an antihistamine decongestant line, a liquid steroid line, and I worked on a lot of the CNS’s like antidepressants and anti-anxiety medications. I also had antibiotics. That’s what was kind of ridiculous about the whole thing. It just depended on what the flavor of the day was for that particular pharmaceutical company, and which drug they were trying to promote the most.  Then, they would shift the sales force around and give you a new drug to start promoting.  The bottom line is that I didn’t have any business telling anybody about these drugs, or telling doctors about these drugs.  I only knew exactly what the company wanted me to know.
              
When I look back, I think it is part of the reason that they recruit people like me – political science majors, history majors, business majors – because I didn’t have the ability to question anything they told me. I can’t tell you how quickly I could get in over my head if I was talking with a physician about these things. Although I might have known a specific amount about my specific pill or a specific disease stage, once the doctor started asking questions outside of that, I would start to glaze over.
             
The typical course of my day would be going out, driving around to different physician’s offices, making appointments, and schlepping in a lot of food.  We used to joke that you don’t even need a political science degree for this job; you need a professional caterer’s license. It was a lot of wining and dining, and trying to get a moment with the physicians to give them the spin that the company gave you to give on that particular drug.

I was completely evaluated. My whole job surrounded how many pills I could push, and how many prescriptions I could get the doctors in my territory to write for those particular drugs. Patient safety, what was in the best interest of the patient, always took a back seat.  When I say that, it’s because it all came down to market share.  How I was evaluated as a rep, how I was paid as a rep and my ability to keep my job as a rep solely came down to my ability to push that particular drug with the physicians in my territory. Whatever tactics worked to drive that market share is what they wanted you to do. 

By that, I mean we would get lists of every doctor within our territory, and we’d have the prescribing information on every doctor in that area.  I’ll use this as an example:  If I was selling an antidepressant, I would get a list of all the doctors who wrote prescriptions for antidepressants, and I would get updated on a weekly basis.  If I was looking at Dr. Smith, I would see exactly what percentage of my drug that doctor was writing versus Prozac, versus Paxil, versus any of these others.  Before I would go in and talk to that doctor, I’d have to look to see what he was writing. I’d tweak my pitch just enough to make sure to go after that number one competitor, not what is in the best interest for Dr. Smith’s patients.
              
Crusador:  There have been many accusations over the years that pharmaceutical companies would offer doctors vacations, perks, cars, cell phones, and other free things to get them to prescribe a particular drug.  A lot of that has been denied and in many cases swept under the rug.  Are any of these accusations true and what tactics did you use to get these doctors to write more prescriptions for your drug?  
               
Well, there’s a lot of different tactics that were used.  One of the things that would often happen is we were given a lot of training in personality profiling.  We would go into the home office and have days worth of training on personality profiling. Then, we would sit down with our manager and strategize how we could sell more of our drug.  Let’s say for example that I was selling an antidepressant. I knew that if I could move the market share with my top 20 or 25 doctors within my territory who wrote antidepressants, that it would significantly increase my overall market share.  So we’d sit down and we’d look at each one of those physicians within that top 25 and we’d do some personality profiling.  What works with this doctor?  Is this doctor more of an analytical doctor?  Is this doctor more of a social person who likes the wining and the dining?  Is this person a golfer?

What we did was so calculated. We would sit down and go through each one, and then because we were getting updates on a weekly basis, we could see exactly what worked.  So if we took the doctors to the nicest restaurant in town and brought in a certain speaker, I could look the next week to see if that worked, if the market-share of the doctors that attended went up. If I took them golfing, or if they responded to a certain kind of study versus another kind of study, I could tell if that worked. 
              
When you’re talking about trips and that sort of thing, it’s interesting. The industry did put in, over time, some self-imposed regulations. There were certain things you were not allowed to do, but in the end, it really didn’t matter. Maybe the really overt tactics of flying a doctor and his whole family out to the Bahamas for a weekend might have pulled back a little bit, but it was made up in other ways.  Instead of just calling them trips it was called continuing education, or continuing medical education. That’s how they got around it from a PR perspective.  Now we’re going on the trip, but we’re tying it to a lecture so we can call it continuing education.  It takes on a lot of different forms. 

Now, maybe what they’ll do is look at the top prescribers within the country. They’ll categorize those doctors as opinion leaders, go after those people and stroke their egos. They’ll say things like: “Because you’re such an opinion leader in the area of antidepressants and you’re leading the country in your use or your philosophy on this, we’d like you to come on board and be a consultant for our firm.”
              
So basically, we would hire them to be a consultant, which meant as a consultant, they’re now being paid and have a financial relationship to that company.  With being a consultant, there were oftentimes trips because they’d have these think tank or brainstorming meetings.  All that changed was how it was handled. 
              
There were other things that went on like free samples, which was a very interesting way that the company would manipulate doctors.  Doctors, unfortunately, would often see samples as the one act of benevolence that the industry provides. Really, the samples were a huge marketing tool.  I was evaluated as a rep by how many samples I could push through my territory. There was a direct correlation between the number of samples you moved, and the number of prescriptions written for that drug.  If you could get a doctor comfortable enough to hand out free samples, that doctor is now comfortable enough to pull up a prescription pad and write.  It just makes really darn good business sense.  Yeah, give out a week’s worth or a month’s worth of this antidepressant or this cholesterol-lowering medicine, because you know what, that patient oftentimes is now going to be on these drugs for a year, two years and in some cases a lifetime.  We would even go to some doctors who had free clinics to give out these samples. We knew that if they became comfortable handing them out to the indigent patient population, that they’d come back to their private practice and then write prescriptions for those drugs.
              
Again, this is something I think people need to be aware of. Those samples often are for the most expensive and least tried and true drugs on the market.  There’s a reason they’re giving them out for free.  They want you to get hooked on them.  They want you to take them.
              
I can honestly say in the course of my ten years that there was never any direct bribery. We were never asked to directly pay doctors to do certain things.  But again, there were other ways both were handled.  For instance, if a company really had a drug that they wanted to push hard, and it wasn’t being picked up fast enough by the market, they might develop a post marketing study where they go to key opinion leaders within each territory and ask that doctor to participate.  For that, the doctor would maybe get paid for the enrollment of each patient that participated in the study.  That study often involved a patient using the samples of that drug, and then ultimately getting a prescription.  Then, that patient and doctor turned in a form that was like a survey that would be used for the results of the study.  In the end, the whole reason they’re doing that is to get the drugs into the hands of these high-prescribing doctors, and creating a financially beholden relationship.  I think some doctors really did not see it as they were being manipulated, but I can honestly say, from an inside point of view, that was the whole purpose of those studies. 
               
Crusador:  What about the accusations that pharmaceutical companies like to mainly pick young pretty women as sales reps and have them dressed up in a provocative way to entice a lot of the male doctors?  Is that true?  Have you seen any of that?  
               
That’s a huge inside joke within both the pharmaceutical industry and the medical industry, and it’s very true.  I remember about a year and a half in to the job, I’m working with my manager one day and everywhere we went there were other reps.  I’m looking around, and I turned to him and said, “Is it just me, or do you specifically hire like that? Everywhere I go it seems like so many of the reps are these young, beautiful things.” 

He shared with me that it’s absolutely a key part of the hiring strategy.  Their philosophy was doctors see sick patients all day long, a lot of times elderly patients.  What better way to give them cause for pause in their day and listen to the pitch than to put some hot young person in front of them.  There are approximately 90 to 100,000 reps out there right now. When you look across this sea of reps, you see all of these beautiful people, this sea of Ken and Barbie’s.
              
Again, there was a method to that.  There was a specific reason.  Every single thing that the pharmaceutical industry does, they do because it works.  The definition of “works” meaning, it drives the writing of prescriptions and the sale of drugs.  So anytime you see them doing anything, even if it looks like it’s just an act of goodwill, there’s a very, very large amount of calculation behind that.  They have found that if they do that one particular thing, it helps them drive market share of their particular drug.
              
With these reps, it definitely worked.  I don’t know if you saw the article by the New York Times that was out five or six months ago, but it said pharmaceutical companies were heavily recruiting cheerleaders on campuses across the country because obviously that was working for them.  It isn’t just women though. They also use young, charming, good-looking men too, because there are two philosophies here.  Although I don’t know the exact demographics of physicians right now, it is still probably a little heavier on the male dominated side.  Sometimes female reps would have more luck getting in front of a doctor like that.  But, the demographics of a front office staff are still primarily female.  The young, charming, good-looking men could often woo their way past these front office staff and get back to the physician to have some face time.  It can work both ways. They will use both very effectively, and to their benefit.
              
Crusador:  Critics of the FDA and the pharmaceutical industry are very upset and concerned about drugs being prescribed for off-label use, meaning a drug was approved by the FDA for one thing but the off-label use is for another thing.  Were there drugs that you were pushing for off-label use?
              
Well, legally we were never supposed to be able to push them for off-label use.  But again, there are certain tactics around that, because certainly with some of these drugs, the vast majority of the things that they’re prescribed for are not for the specific thing that they’re indicated. Physicians also have that liberty to be able to use drugs for purposes that they see fit. 

We were often told in training sessions exactly what all the off-label uses were.  It was always prefaced by, “We’re never supposed to talk about these things” – half wink wink – “But here are all the other ways that doctors are finding success with our drug.”  We’d also get updates in terms of the studies or articles that were done on off-label use.  Again, wink wink.  You’re not supposed to use any of these in the field when you’re talking to physicians, or if you are talking to them you have to heavily preface it by, “Dr. Smith, this Drug A is not indicated for X, Y or Z, but I just thought you might find this article interesting.” You knew darn well that Dr. Smith is now going to read that article, because maybe it’s a patient type he’s struggling with, or whatever the case is, and that’s going to plant that seed in Dr. Smith’s mind.
              
So although you always had to be careful how you worded it, it was certainly known, I think, industry-wide that there were ways of planting those seeds.  This is how the industry became so amazing at marketing their drugs.  I mean that in a scary sort of way, because they use physicians to help them promote their drugs.
              
One of the key ways in terms of off-label use would be to find a doctor in a certain territory who was actually having a lot of success using a drug in an off-label sort of way. Then it was a matter of stroking that doctor, grooming him as an opinion leader, giving him the ego boost, asking him to come on board and be a consultant and then having that doctor hold round-table discussions with other doctors within the territory to talk about that specific drug, and the things that it’s indicated for.  Since it’s peer to peer, that doctor        is then going to bring up all the other ways he or she is using that drug and having success.  And now, because they’re hearing it from another doctor, those ideas spread, and the other doctors are much more likely to take action. 
              
Maybe you hold a dinner program where a doctor is giving a presentation on a drug or a disease state.  You invite the doctor who’s using it for off-label use to come to that talk, and then maybe raise that use during a Q and A where he shares how he’s using it for all these other things.  There were specific legalities, or specific guidelines that were in place, of things companies could or could not do. They were very, very effective at legally skirting those issues in many ways, because they were getting other people to talk about it.
               
Crusador:  I think it’s very hypocritical that the pharmaceutical industry uses people with little to no medical background or knowledge on nutrition to give medical advice to doctors on which drugs to prescribe.  I think it should be illegal. If someone in a health food store gave out medical advice that wasn’t licensed or connected to the pharmaceutical industry they could be brought up on charges of practicing medicine without a license. 
               
I don’t have a strong amount of knowledge of everything that’s going on with the FDA and the natural food market. It is ironic though considering that the medical community and the FDA say we should only be able to disseminate evidence-based medicine. Show me evidence-based medicine, because right now the studies that are being done on any of these drugs that are FDA approved are funded by the drug companies. They only put forth the studies that show what they want them to show. Everybody is financially beholden to the pharmaceutical industry, and that evidence is just not there.  The evidence is so skewed.  So to say that that is evidence-based medicine, but yet what the natural community is doing is not, it seems like such hypocrisy.
               
Crusador:  What kind of starting salaries do they offer to a lot of the sales reps and what did you make in your peak?
               
There often is a very comfortable starting base salary that ranges from company to company.  It kind of ebbs and flows in terms of what percentage is salary, versus what percentage is bonus. The salaries start anywhere in the 50, 60 to $70,000 range.  That’s the base salary.  Then there are the bonuses that are on top of that.  In the end I was making over six figures.

There was another article that was published a few months back saying how some of the bonuses were capped to some extent so you could only make a certain percentage in bonus.  Now they’re talking about uncapping the bonuses, which again shows that the only way I was able to keep my job and make bonus money, was by shoving prescriptions through my territory, and getting my doctors to prescribe more, more, more of my drug.  That was the entire way I was evaluated.

I think that alone shows how the industry is all about profit.  It’s all about sales and very little about what’s in the best interest of the patient.  I often hear people say, “Well, you know what, that’s kind of just how it is in corporate America.  The same holds true for the auto industry or for any other industry.  They do have to show a profitable bottom line.”

People will bring that up, and as far as I’m concerned, the pharmaceutical industry should be held to a higher level of accountability.  These are drugs that people are taking into their body, and in some cases can be -- as we found out with Vioxx -- the difference between life and death.  How all the information is disseminated, information that doctors need in terms of making the best objective prescribing decision, that information is not available.  It’s so skewed by everything being driven towards profits.

Crusador: What about side effects?  Were there specific drugs you knew were causing problems that you were instructed to sweep under the rug and still promote to the physicians?
              
There are certain roads I’m not at liberty to go down, but in general it is all about presenting the drug in the very best light possible.  Not only were we told exactly what to say about the drug in terms of the benefits, the pearls and that sort of thing, but we were trained very well in objection handling.
              
If a doctor had a patient who was experiencing certain side effects or they heard that this drug had certain side effects, they’d bring up that issue or that objection.  We were very well versed in how to handle that objection in such a way that brought it back to the benefits of the drug, and sometimes used those objections to our benefit. It’s all about the spin.  If they raise X, Y or Z, this is exactly how we handle it. This has been proven to either do damage control, or in some cases, even increase the number of prescriptions that the doctor is going to write.
              
That’s what played out with the Vioxx case.  Even when there started to be these whispers about what’s going on with the cardiovascular problems with Vioxx, what is killing Merck right now is that they’re showing that they had these little objection handling cards that they were having the reps bring out to be able to effectively skirt that issue when it was brought up. Bringing up the bad parts about the drug were really not something that the industry was very interested in doing for obvious reasons. 
                
Crusador:  You said you couldn’t even look at yourself in the mirror after a while because you got so disgusted with what you were doing.  Obviously when you’re dealing with people’s lives and their health, there’s a lot more at stake.  Were the side effects what ultimately made you get out of the industry or is it everything we have been discussing?
               
There were these moments throughout my career that led to this, so it was a compilation of things.  In the end, the bottom line was I was uncomfortable with how the industry as a whole, over the course of ten years, operated.  Some companies do a much better job than others in terms of great PR in pretending that they’re the company that’s different; they’re the company that gives more objective information.  In the end it’s all a bunch of lies.  You could have plopped me into any one of the companies I worked for and they all felt the same, tasted the same, and sounded the same.  As I talked to my colleagues, the same was happening in every other company that was out there.  The thing I could not live with was not sharing the whole picture. What we were told to say about the drug wasn’t always the whole picture that doctors needed in order to make the best choices for their patients. 
                
Crusador:  And so one day you decided this is it, I can’t take it anymore and you quit.  When was that?
               
I walked away in 2002.

Crusador: What would you like to see happen with the pharmaceutical industry?
               
In terms of the pharmaceutical industry,  I’ve seen it happen before where they pay lip service or they suddenly get a good PR team onboard, and they try to show that they’re being more objective and that they truly are protecting and prolonging human life. I don’t buy it.  I’ve been around long enough.  I’ve been on the inside. 
              
What I would like to do is raise awareness so we are smarter consumers about these drugs.  We’re being bombarded with beautiful drug ads 24/7.  They’re effective.  They cost the pharmaceutical industry millions to make and to run on prime time spots.  But they’re willing to do it because they generate billions of dollars in sales.  We are not only walking into our doctors’ offices and asking for these drugs, we’re walking in now, demanding them and saying if you don’t give me this, because I saw it on TV and this is what it does, I’m going to go somewhere else.
              
If we can raise awareness and show people how calculated and manipulative the industry operates behind the scenes, we can be smarter consumers. They won’t be able to manipulate us the way that they have.  If we’re not buying what they’re selling, they’re going to have to change the way that they do business.  One great way to lessen our reliance, or lessen our need for the pharmaceutical industry, is to take better care of ourselves, to be thinking more about prevention, eating better and taking a natural approach.
              
If we’re doing that, then we’re not going to need these drugs. I can’t ask for more than that, because I believe that individuals can make the best choices, but they need good information.  They need solid, objective information on both sides of the issue so they can make the best choices for themselves.  I’m hoping that the medical community can see that as well.
               
Crusador: There are a lot of people that are disgusted with the system.  In almost every sector of the medical/pharmaceutical industry, somebody has woken up to the truth and has kind of flipped on them. I believe the system is going to end up changing from the inside.  Look at Dr. David Graham.  He was an FDA employee and he came out and blew the whistle and said, “Hey, the FDA knew people were dying on Vioxx.”  You were a sales rep.  You were on the inside.  You saw it from a different perspective but a very powerful perspective.  I think that we’re going to see more and more attention on this issue.  People are getting fed up with taking all these drugs that are doing very little for their health problems, and in a lot of cases, are actually harming or killing them.  
               
I think the most important thing is to not be discouraged and to keep talking about it.  I hope through my efforts that I can show people the influence the pharmaceutical industry has at all levels. You’ve obviously got the direct-to-physician advertising with the rep, but then you have the direct-to-consumer advertising, the financial relationship between the FDA and the pharmaceutical industry, how the studies are funded, how these huge medical journals are financially beholden to the industry (because the industry does so much advertising with them) and how they’re the largest lobbying group on Capitol Hill.  They have really got every layer locked up and that’s what I want to expose.  They have done their homework, and they are so effective at all these different things. 

Like you said, there are now great books that have been written, and some great journalists doing really good work exposing the industry.  There are people like you that are out there talking about this, and I think it’s a compilation of all these things that we have to be confident and have faith that we are making an impact.
               
Crusador:  Well Kathleen, I’d like to wrap up the interview with that.  I’m sure we could talk about a lot of other things, but you certainly shed a lot of interesting light on these issues. I wish you the best and best appreciate your bold stance against the injustices being committed by the pharmaceutical industry.

Thank you for giving me the time and the audience to get this message out. 

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Kathleen has written, directed, and produced a fictional movie with actress Katherine Heigl titled “Side Effects” based on many of the events that occurred during her ten year career as a pharmaceutical sales rep. She has also produced a separate documentary titled “Money Talks: Profits Before Patient Safety” that provides some amazing, explosive and compelling information from leading experts on the subject.  People can visit her website at: www.sideeffectsthemovie.com to get a copy of the film or documentary.

CRUSADOR CAUTION: The movie “Side Effects” is rated R because it contains momentary language and brief sexuality. As a Biblical based Christian organization, we cannot give our seal of approval to the movie because certain scenes would be offensive to other Christians. We fully endorse the documentary because it does not contain any offensive material and has great educational value.