Posted At TheStar.com

BY : Rita Daly

No gifts. No golf. No galas. No sports tickets, no special promotions and — to punish for one of the worst sins — no spouses at drug company-sponsored events.

As the Canadian pharmaceutical industry clamps down on its own lavish spending and aggressive marketing tactics aimed at the nation's 60,000 doctors, the focus has turned to the well-honed skills and performance of the drug sales rep.

It's no longer about gifts, but gift of the gab. The pitch is not about hard sell, but hard information. It's about looking good, talking straight, getting in and getting out.

Critics have long argued the entangled relationship between drug companies and doctors is the reason for spiralling drug costs, that the ubiquitous drug rep or "detailer" entices doctors to prescribe to their patients more drugs — often new, costlier brands — than are necessary. The cost of prescription drugs in Canada is now $18 billion, up from $13.2 billion in 2001.

But Vincent Woo doesn't see it that way. At 48, he has been a drug rep for more than 20 years and says a big part of the job has always been to educate doctors on prescribing. The quantity and complexity of drugs on the market make their relationship all the more crucial, he says.

"When I joined, it was more of a middle-aged white boys' club with mixed education," he said recently while driving to appointments he had at six doctors' offices in Scarborough. "It's changed now. It's very professional. The applicants have multiple degrees. There are nurses and doctors doing this job. There are more women in the business than men. And there are all ages and races."

Last month, the New York Times reported the U.S. drug industry was turning to young, energetic cheerleaders to beef up drug sales in doctors' offices, suggesting a variation on the "seductive inducements" that are being curtailed. But Woo, who has a B.Sc. in pharmacy, an MBA from Rutgers in New Jersey and is fluent in Mandarin and Cantonese, says a good drug rep needs more than good looks to get a foot in the door.

"I have to update doctors on clinical data, give them proper prescribing information and a lot of my time involves demonstrating the proper use of a device," he said. "There's a lot of personal relationship-building going on and that's where the value is for the rep."

It's estimated the Canadian drug industry spends about $2 billion a year on promotion, including free samples, with upwards of 10,000 drug reps regularly descending on doctors' offices. Studies from several countries, including Canada, show 80 to 95 per cent of doctors regularly see drug company reps, in their offices or over lunch. Many physicians deny drug reps influence their prescribing behaviour, although evidence suggests otherwise.

Dr. Ashley Wazana, a Quebec child psychiatrist whose own research led some medical schools to restrict drug industry contact with residents, said doctors are still open to influence despite the crackdown.

"Whether it's a gift, a meal, an interaction with a pharmaceutical representative, attending a conference where a speaker has been sponsored ... reading an article written by a researcher straight out of a pharmaceutical lab, these are different ways we can come in contact," he said. "The industry would not be investing the amount of money it does in the (doctor-detailer) contact if they didn't think it had an outcome."

The Canadian Medical Association has developed ethical guidelines for doctors, but maintains there is a legitimate exchange of information between detailers like Woo and, say, Dr. Henry Wong. Wong, a family practitioner, is one of Woo's regular customers. They exchange handshakes and a few jokes, then Woo demos a new inhaler and explains the company-designed "asthma action plan" for the doctor's patients.

Wong requests four sample packs for patients to try. He admits the samples may lead him to prescribe that inhaler, causing "a bit of influencing, but you try to minimize that. If a patient says they prefer to use the other product, you give whatever works for that person."

Woo says doctors are so inundated with information — there are some 5,300 prescription drugs on the market — that reps are now trained to simplify scientific terms and interpret data.

In the second-floor office of Dr. Gloria Meneses, at the corner of Eglinton and Brimley, Woo talks about a clinical trial that showed his company's drug lowered patients' bad cholesterol and raised their good cholesterol. "We are the only company out there advocating you should really look at the (good and bad cholesterol) ratio," he explains, reaching into a briefcase containing colour brochures and company-sponsored studies.

Critics argue information from drug reps is heavily slanted in favour of the product and misleading.

Last year, GlaxoSmithKline was accused of telling its sales force in 2003 not to mention to American doctors the results of a study linking its antidepressant Paxil to serious side effects in children and adolescents. Company officials said there was no deliberate attempt to hide adverse effects.

Merck came under fire this year for telling its detailers to sidestep questions about the heart risks of its arthritis painkiller Vioxx, according to company documents released at a U.S. congressional hearing. It said detailers were simply conveying the drug's known risks on the Vioxx label.

"The very education that the doctors are getting is being financed by the industry. You have to ask how unbiased is that," said Alan Cassels, a drug policy researcher at the University of Victoria whose recent book Selling Sickness accuses the drug industry of pushing pills on everyone.

RX&D, a national lobby organization for the Canadian pharmaceutical industry, said its ethical code of conduct clamps down on gift-giving. But it is also strict about detailers taking "an ethical approach to the transfer of information," said president Russell Williams.

Last year, RX&D beefed up its code of conduct and, starting January, will hold refresher courses for drug reps.

Some companies have taken their own tough stance. AstraZeneca introduced a zero-tolerance policy this year after it was threatened with suspension from RX&D. It had racked up an unprecedented number of violations, from handing out a magnet inscribed with a product's name to paying doctors' costs to a Jamaican conference.

The policy means "if you do something that results in an infraction under the code, your employment will be terminated," said Bill Charnetski, Astra's vice-president of corporate affairs. All employees also had to pass a compliance exam or risk being let go.

Woo said there is nothing wrong with telling doctors about the benefits and risks of products. "I have nothing to hide," he says, adding gift-giving was never part of his routine.