The Drug Rep: Historical Backround

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The most critical player at the interface between the medical profession and the pharmaceutical industry is the pharmaceutical sales representative, otherwise known as the detail person, or more simply the 'drug rep.' It is in the persona of the drug rep that the industry has the most frequent and extended personal contact with the physician. What practising physicians think of the drug rep will guide what they think of the industry and of their own interaction with it.
modern drug reps arrived on the scene at an auspicious time in the twentieth century. They bore, by implication, the stamp of approval of organized medicine; and they filled a vital role that no one else at the time was able to fill. How physicians perceive reps today has been heavily conditioned by this historical backdrop.


Around 1890-1900, the American Medical Association (AMA), which had consolidated its power as the political force speaking for mainstream medical practice, looked with particular dismay at one segment of the pharmaceutical industry. The AMA's ire was concentrated on the manufacturers of so-called “patent medicines.” There were two major reasons for dismay, one public-spirited and scientific, the other self-serving. The better reason had to do with the secrecy surrounding the formulas of these medicines. The AMA had argued in its original code of ethics in 1847 that physicians could not in good conscience prescribe or recommend a medicine whose contents were unknown and whose safety and effectiveness could not be subjected to the scrutiny of the scientific community. The self-serving reason for the AMA to oppose patent medicines was that they were marketed directly to the public and usually could be obtained without prescription. The advertisement for the medicine, or the salesman who promoted them offered both diagnosis and treatment, without the need to see a physician and pay a fee. At a time when most American physicians were barely managing to survive financially, these lost revenues were a sore subject with the AMA's members.
The AMA looked for allies in its battle against the patent medicine makers, and found some among the relatively small firms that manufactured the pure drugs that were needed to make up the physician's prescriptions. In that era, most prescriptions contained two or three drugs and had to be compounded individually by the pharmacist; it would be some years before the market was dominated by tablets and capsules made by the manufacturer and merely dispensed by the pharmacist. The manufacturers of pure drugs openly labelled their products and marketed them directly to physicians and pharmacist, not to the general public. They advertised based on the purity and quality of their chemicals, not on inflated claims of miracle cures. To distinguish these scientifically respectable firms from the patent medicine makers, the AMA took to calling the former the ”ethical” drug companies.
While the AMA sought assistance among the “ethical” drug makers, the real turning of the tide in the battle against patent medicines came during the muckraking era at the beginning of the twentieth century. Exposés by investigative reporters revealed the unreliable and unsafe ingredients in patent medicines and grossly fraudulent advertising. Slowly the public began to turn against the makers of Lydia Pinkham's pills and similar products. Probably even more important were the scientific advances in bacteriology and other branches of medicine during this era. The public's perception of the value of consulting a physician instead of picking something off the counter of the drug store finally swung in favor of the physician. As physicians gained public respect, the “ethical” drug companies rose in stature along with them. From the 1930s, when less than 10 percent of medicine sales in the United Sates were in the form of prescription drugs, to the 1950s, when the new wonder drugs of the postwar era were flooding the market, the drug firms grew in size and importance.
One example of early pharmaceutical marketing helps us grasp the image of the “ethical” drug company of that time. A volume called
Excerpta Therapeutica was distributed free to physicians by the U.S. Branch of the London-based drug firm, Burroughs Wellcome and Company. The 1916 edition of this work is about four by seven inches and half-an-inch thick, a convenient size to slip into a pocket, though it holds more that four hundred pages. Most of the volume consists of two alphabetical lists--the first of the drug preparations, the second of diseases. The drug list briefly states what each drug is used for and then lists the different forms in which it is available. The second list contains a summary of the recommended drugs for treatment under the name of each disease. It appears that Burroughs Wellcome manufactured virtually every drug in the U.S. Pharmacopeia, so a list of its own products was largely indistinguishable form any noncommercial list of drugs. The book does, however, point out in several places that the word “Tabloid” in the name of a drug preparation is trademark of Burroughs Wellcome, so that if the physician wishes to be sure that a drug is of the highest quality and purity all he has to do is begin his prescription with “Rx Tabloid...” followed by the usual name of the drug, such as “Rx tabloid Hyoscine.”
Excerpta Therapeutica then provides the physician with a number of tables of information on assessing pregnancy and gestation urine analysis, recommended diets for different diseases, and other medical topics. At the end is a price list of the company's drugs, and many pages of color photos of medicine cases sold by Burroughs Wellcom. The cases are quite handsome (some covered in fine leather or silver-plated) and presumably are designed specially to fit bottles sold by Burroughs Wellcome and not to accommodate the bottles of other manufacturers. The cases reflect the various forms of transport physicians might have used in 1916—-pocket cases, a saddle case, a case designed to be hung on a bicycle, and even a case designed to look like a life preserver and to me hung up on a boat.
Other items scattered through the volume describe the company's London manufacturing plant and New York offices, and a page of color photos shows fields of herbal products growing under the careful attention of Burroughs Wellcome experts.
We can imagine the impact a book like this would have had on the average physician of the day. According to the AMA nomenclature, Burroughs Wellcome was an “ethical” drug firm, and indeed at the time perhaps the largest and most important such firm. This little volume seems a solid statement of how the company proposed to work in partnership with the medical practitioner. Here was one stop shopping brought to its limit. From one firm the physician could obtain every drug he needed to use, plus a handy little book to tell him how and when to use each one, and to top it all off, a handsome medicine case to show off his professional stature to the admiring community, The Burroughs Wellcome salesman who showed up to provide the doctor with his free copy of this year's Excerpta Therapeutica could hardly have expected anything other than a warm welcome.


Drug wholesalers employed salesmen as long ago as the 1850s. William Osler, professor of medicine at John Hopkins and the most famous American physician of his era, wrote in 1902 that “the 'drummer' of the drug house” was a “dangerous enemy to the mental virility of the general practitioner.” When Rufus L. McQuillan was mustered out of the Army Ambulance Corps in May 1919 and took a job with a major drug house, the jobs of salesman and detail man were intermingled. Many physicians still dispensed drugs from their offices and could be expected to place an order with a salesman, but McQuillan was still expected to “detail” (provide all the details of medications to) physicians who did not order from him directly but who instead wrote prescriptions. As his territory was all of Illinois and Indiana, he would be lucky if he saw rural physicians annually. In 1920 there were only an estimated 2,000 detail men in the United States, compared to 15, 000 I the late 1950s.
By the early 1930s, prescription products were bringing in larger profits than over-the-counter drugs. It therefore began to make economic sense for companies to invest more heavily in sales staff who had the credentials and the techniques to win over physicians. In 1940, a book of instructions for detail men was published, with its author drawing upon many years of sales experience, and an article describing the job responsibilities of the detail person appeared for the first time in 1949 in an official government list of occupations.
The 1940 article in “Fortune" explained the tradeoffs for the “ethical drug house.” The company gave up lucrative patent-medicine sales and direct-to-consumer advertising as the price of developing a special relationship with the medical profession. The company trained its detail men to give physicians important, up-to-date information about its products and paid a select group of physicians research grants to perform scientific studies on new drugs. The physicians, in turn, warmly embraced the detail man, seeing him as a friend and colleague, and prescribed the drugs that he recommended. This company representative did not take any orders directly, and usually avoided any hint of having “made a deal” with the physician creating the comforting aura that he was of a completely different breed from the vulgar “salesman.”
What did the “detail-man” think of himself? Tom Jones, in his 1940 instructional book for his fellow reps, said forthrightly and up front, “Detailing is, in reality, sales promotion and every detail man should keep that fact constantly in mind. Arthur F. Peterson, in his manual on detailing published in 1949 and reissued in 1959, seemed at first to be aiming for a higher, explicitly professional standard. He referred to detail men as “Professional Service Pharmacists,” describing their work as follows:

The well-informed “detail man” is one of the most influential and highly respected individuals in the public-health professions. His niche is and extremely important one in the dissemination of scientific information to the medical,
pharmaceutical, and allied professions. Upon him frequently depends the saving of life or relieving from suffering by virtue of his his intelligent discussion of it with a physician. His opportunity to render service of extraordinary value to physicians for the benefit of their patients is in itself a source of real satisfaction. He serves humanity well.

But Peterson was unable to maintain this high tone for long. A few pages later, he wrote, “The Professional Service Pharmacist’s job is one of scientific selling in every sense of the word...he must be a salesman first, last, and always”; and,”It is apparent that the first qualification for a prospective Professional Service Pharmacist is sales ability, a love for selling, a 'selling heart.'” Later he added, “The representative who has an idea that he is not supposed to sell but only to impart scientific information in his contacts as a service offered by his firm is very much 'off the beam.' The ultimate objective of every phase of any business is to produce more sales at a better profit.”
Salesmen or otherwise, the pharmaceutical reps who appeared in physicians offices, saying, “I’m from Merck” or “I'm from Squibb,” had the distinct advantage of the AMA's “ethical” terminology. The AMA said, in effect, “This drug firm has been on our side during our long fight with the patent-medicine crowd, forgoing any profits that might have been made by catering to the general public, and advertising their products only to you. Now, this friendly and knowledgeable person has come to add a new dimension to our relationship with this company, in an era when new drugs are appearing so fast that it's tremendously hard to keep up, this person is here to tell you about the latest pharmaceutical miracles, you owe it both to this ethical manufacturer and to your patients to listen carefully to what he has to say.” Small wonder that in a 1959 survey American physicians indicated an overwhelming disapproval (by ratio of 17 to 1) of any of their brethren who might refuse to talk with reps.

pp. 139-143, of Hooked by Howard Brody (2007)

pharmacists, drugs, prescription, 1900,
the ama
Lydia Pinkham's Pills
William Osler