The transformation of a
Jacksonville psychiatrist from a skeptic on
Seroquel into a super-prescriber was marked by
months of gentle pestering, generous $1,500
speaking engagements and giveaways of everything
from a plastic brain to gourmet chocolates.
A neurologist in Tampa
joked with Seroquel sales reps that she doled
out so much of the powerful antipsychotic drug
for migraines that they probably thought she was
psychiatrist. She was rewarded with free trips
to Scotland and Spain. "I want to go too !
=)" her Seroquel rep wrote.
A busy Panama City
physician had no problem leaving patients to
stew in the waiting room while he listened to a
pitch about Seroquel from a persistent
"Dr had 3 pat
(patients) waiting and did sit down w (with)
me," the rep wrote after a series of snubs
at the front desk. "You never know what you
will get w/Dr B."
Every day, legions of drug
reps troop into doctors' offices, then scoot
back to their cars and enter notes about their
encounters onto laptops or handheld devices.
They include reminders about everything from
medical questions to the doctor's new Nissan
350Z or his kid's Eagle Scout badge.
The notes are uploaded to
a secure database at company headquarters and
used by the drug rep, her partners and managers
as the company refines its sales spiel.
Thanks to thousands of
lawsuits pending against Seroquel, AstraZeneca's
best-selling antipsychotic, hundreds of pages of
call notes concerning several Florida doctors
recently were made public. Though specific to
Seroquel, the salespeople's notes reflect
industry-wide practices. They give insights into
what happens behind closed doors while patients
cool their heels.
It's not a pretty picture,
with sales reps laying on the swag and doctors
complaining about late honoraria and angling to
get on the AstraZeneca's "advisory
Company spokesman Tony
Jewell said the drug maker's philosophy is that
"any interaction with health care providers
should be about providing information that helps
them decide on the right medicines, for the
right patients, at the right time."
But notes from pharma's
emissaries reflect two different goals: Get the
doctor to prescribe the drug. Then push him to
boost the dosage.
A sales rep in
Jacksonville was ecstatic when a nurse
practitioner prescribed Seroquel at twice the
dosage used by the psychiatrist in the same
goodies," the rep wrote. "Biggest user
of Seroquel in the office!"
• • •
AstraZeneca's sales reps
have worked wonders. Though approved only for
schizophrenia and bipolar disorder, relatively
rare mental illnesses, Seroquel has been one of
the world's best sellers. Last year sales
reached $4.5 billion.
But Seroquel's widespread
use for everything from insomnia to anxiety has
also triggered lawsuits alleging the drug caused
weight gain, diabetes and other health problems.
AstraZeneca, a U.K.-based company, denies the
charges, noting that the FDA has repeatedly
upheld the safety of Seroquel.
It also has denied that
its salespeople illegally promoted unapproved,
or off-label, uses of the drugs to doctors. Reps
"are trained to ensure that every product
promotion discussion with (a) health care
provider conforms to the FDA-approved
prescribing information," Jewell said.
Company lawyers vigorously
opposed unsealing sales reps' notes, saying they
contained confidential, proprietary information.
But at a recent hearing in Orlando's federal
court, AstraZeneca agreed to release call notes
from before January 2004, when Seroquel received
FDA approval for bipolar mania.
Heavily redacted, the
notes comprise what the company's commercial
brand leader, Alfred Paulson, described as sales
reps' "continuous conversation" with a
half-dozen Florida health care providers who
prescribed Seroquel to plaintiffs in pending
Depicting sales pitches,
on which millions of dollars of revenue hinge,
as simple "conversations" is an apt
description for what, in the end, comes down to
the chemistry between two people. Shahram Ahari,
a drug rep for competitor Eli Lilly & Co. in
1999 and 2000, now lectures physicians on how to
avoid being manipulated by well-trained
"As much as doctors
want to think the relationship with a sales
person is about the transfer of knowledge, it's
the affinity between two people that's the big
money-maker for the drug company," said
Ahari, who is part of Pharmedout.org, a
physician-education group in Washington, D.C.
"That's why drug companies hire former
cheerleaders and athletes as drug reps instead
of scientists. It's a question of how gregarious
and engaging you can be."
While AstraZeneca declined
to comment on its employees' compensation,
industry data shows drug reps earn an average of
nearly $100,000 a year, including bonuses based
They learn sales
techniques more often associated with
door-to-door soliciting than medical offices.
Doc too busy to see you? Send in several sales
people, daily if necessary, until you get a
sit-down. Show up on rainy days when patients
cancel. And even highly paid physicians find it
hard to resist a free lunch.
In 1999, Seroquel reps
tried to waylay Dr. Maria Carmen Wilson, the
Tampa neurologist, four times before hitting
"We were able to
speak to her at lunch that we brought for the
office," a rep wrote.
Wilson moved from free
food to free trips to medical meetings in Spain
and Scotland. By early 2002, a drug rep noted
that Wilson was using a "ton of Seroquel"
for patients with migraines.
Wilson, who says she was
surprised to learn that drug reps recorded their
interactions with her, denies that she was ever
a big Seroquel prescriber. Despite her initial
hopes, she says the drug did not turn out to be
effective against chronic headaches.
"I still use it in
low doses for people with intractable
insomnia," said Wilson, an associate
professor at the University of South Florida.
"But I make sure patients are acutely aware
of the potential for weight gain, especially if
they have a predisposition to diabetes."
Wilson says the
industry-funded jaunts to Europe did not unduly
"I went because I
want to be up-to-date and learn," she said
of the seminars, which she did not report, as
required, to USF officials. "But frankly,
I'd prefer they were in Orlando."
• • •
The call notes show that
massaging doctors' egos consumed an inordinate
amount of a drug rep's time.
Saleswomen in Miami
quickly honed in on psychiatrist Dr. Heriberto
Cabada's need for extra schmoozing. "Would
not pay attention, all about him," wrote
one frustrated sales rep in 2001. So the line
worker pulled in a "customer
solutions" specialist who offered to redo
the doc's patient history forms with a
She agreed to Cabada's
demands for multiple revisions, "one side
only and ... marbled type paper." More
attention was funneled his way through a "preceptorship,"
in which a sales rep shadows the doctor for the
day and pays for the honor.
In a few months, Cabada
went from prescribing what he called
"chicken dosages" of Seroquel to
higher doses. Soon after his conversion,
however, Cabada closed his practice and moved to
Spain, where he now lives. He did not respond to
an e-mail seeking comment.
Drug reps are taught to
use free samples as a strategic weapon: Parcel
them out sparingly, even if there are box loads
in the trunk.
"It makes the doctor
even more grateful," said former Lilly rep
Ahari. "And when he gives a freebie to the
patient, the doctor feels like a hero."
Dribbling samples out in
small caches, and requiring the doctor's
signature each time, also gives the rep another
chance at valuable face time.
"Samples are key to
access," wrote a sales rep who was
routinely brushed off by Dr. John Roy
Billingsley in Panama City.
AstraZeneca said it has
voluntarily banned many of its
"reminder" giveaways to docs — free
pens, pads and hand wash emblazoned with drug
names. But the company declined to say how such
changes have affected its spending on
Ahari said he doubts drug
companies have pared back their marketing
budgets. "The money going to influence
physicians is exactly the same,'' he said.
no enforcement of these voluntary guidelines.
All the incentives are still in place to wine
and dine doctors at Hooters if he needs
The reason: it works.
Case in point: Dr. Mohamed
O. Saleh, a Jacksonville psychiatrist who was
involved in early clinical studies of Seroquel.
In 1998, he was telling AstraZeneca reps that
their product wasn't effective and two years
later he was still dodging salesmen.
By 2003, however, the rep
was crowing that Saleh "really loves
seroquel for elderly... said that he would —
dose of 800 (mg) and even higher if
Saleh and his nurse
practitioner, Richard Daniel Malcolm, were wooed
with everything from holiday treats ("Left
pumpkin candy baskets ... put seroquel labels on
them") to a video of Saleh for his use
during a visit to Africa in 2002.
AstraZeneca also furnished
Saleh with freebies for the trip. The payoff:
the doctor told the drug rep he would put a
picture on his Web site showing "African
healthcare workers holding the Seroquel bags
filled with (a text book) and pens/etc.
Appreciated our support."
Saleh, who said in July
that he is still receiving $10,000 to $15,000 a
year as a speaker for Seroquel, seemed aware of
the persuasive power of drug company payola. In
October 2003, he told AstraZeneca reps that he
was concerned about his nurse practitioner, who
had taken a fishing trip with the Seroquel rep
and was pushing for his own speaking gigs.
payments to Dan (Malcolm) and can be inducement
for scripts b/c paying so much," wrote one
of the two reps assigned to Saleh's office.
Malcolm joined Saleh's
office in June 2001, four months after he was
disciplined by the Florida Board of Medicine for
pleading guilty to charges of domestic battery,
driving with a suspended license and fraud in
obtaining a medicinal drug.
Neither Saleh nor Malcolm
returned calls or e-mails seeking comment.
• • •
When doctors complained
that patients were ballooning up on Seroquel,
sales reps often handed them a study by Chicago
psychiatrist Dr. Michael J. Reinstein. Its
startling message: "Use of S (Seroquel) to reduce
weight and reduce risk," according to a
salesman who visited Panama City's Billingsley.
Back at headquarters,
however, company executives had serious
questions about the validity of Reinstein's
findings. "Our clinical colleagues have
significant and numerous issues in the past with
the quality of research that this group has
produced," a note from Seroquel's brand
manager said in 2001.
While sales reps were not
allowed to explicitly promote Seroquel for
anything other than schizophrenia prior to 2004,
the notes reflect a not-so-subtle, broad-based
In early 2000,
Billingsley's sales rep wrote, "S best in
new Schizo's, kids, adolescents, bi-pols, blacks
Dr. Guido Nodal, Jr., a
psychiatrist in Hialeah, at first was cautious
about Seroquel, fearing potential links to
cataracts. In late 2001, he told a male sales
rep he would keep the drug in mind only for
"smoking sciz pts."
Two months later, however,
a female rep wrote that Nodal "LOVES SER.
FOR ELDERLY." By year's end he had 15
nursing home patients on the drug. (Later the
FDA made all antipsychotics warn that use in
elderly with dementia could cause death.)
"Claims that he is
switching patients from Risperdal to Seroquel at
the nursing homes," a sales rep wrote in
2003. "Writing as much as he can to all
Notes show that in the
interim, Nodal received a textbook, mug,
penlights ("Using lots"), payment for
a preceptorship and dinner at Ruth's Chris Steak
House. He denies the giveaways influenced his
"If drug companies
stopped marketing, I think prescribing
(patterns) would be more or less the same as
they are now,'' said Nodal, who said he tried to
become a Seroquel speaker but was not accepted.
"It didn't affect me at all."
Nodal closed his private
practice last year and now works for the state's
Department of Corrections in Florida City. The
agency does not allow drug reps to lobby its
Carolyn Edds contributed to this report. Kris
Hundley can be reached at firstname.lastname@example.org or