The Patient Was…

The patient was a male on the younger side of middle age, and he had neither heart disease nor any significant medical problems. He was a regional sales director of a pharmaceutical company, and we met through my work in pharmaceutical advertising. He asked me, and I agreed, to be his physician.

Most people, I believe, would agree that humility  —   in the sense of a modest or even perhaps a low view of one’s importance or place in the world  —   is not a trait often associated with physicians. In fact, the opposite is more likely the usual.

Physicians are afforded rare privileges in our society, including unusual intimacy with others, access to private information, and the ability to do things that would be improper and illegal if done by most others. In general, physicians earn good incomes; and, although perhaps somewhat less so today than several decades ago, they tend to be held in high regard. They are usually among the most respected members of the community. Humility, therefore, may not come easily.

During my almost thirty years of actively practicing medicine, I also had a number of non-clinical roles, that is, positions that were not directly involved in caring for patients. One such was serving as Medical Director of a large pharmaceutical advertising agency, medical education company and medical public relations company. Not only were those roles great fun, and a complete change from the intimate, stressful encounters that practically define clinical cardiology practice, they provided an opportunity to make sure that messages directed at physicians from pharmaceutical and medical device companies were scientifically accurate and did not violate the rules and regulations of the FDA (Food and Drug Administration) and other governmental agencies.

Pharmaceutical and device companies had several ways of communicating with physicians and other professionals who had an impact on prescribing and using  their products.   And this before there was DTC (Direct to Consumer) advertising, such as the TV ads that seem to flood the airways today. There was advertising in medical journals, there were sales representatives who visited the offices of physicians and delivered sales pitches, there were newsletters and “throwaway” mailings, there were scientific presentations at major medical meetings, and there were commercial “expos” at most major medical meetings where hundreds of companies set up booths and exhibits to attract the doctors between and, admittedly, even during the scientific sessions.

Among the most productive activities in terms of access to physicians and effectiveness in generating favorable views and increased prescribing of products were dinner meetings. There were usually held in upscale restaurants where physicians and their spouses were invited to a fine company-sponsored meal, and a lecture was delivered by a physician prominent in the region. In those days, expensive meals, spousal invitations, even little gifts, were permitted by law and regulation; currently those benefits are no longer allowed, and invitations are restricted to physicians, meals must be modest, and no additional benefits can be offered. The overall content of the lectures was regulated by official agencies, but considerable leeway was allowed and taken in some instances; the presentations were therefore considered “promotional,” and did not qualify for educational credits that physicians were required to get each year.

One of the clients of our advertising agency was introducing a drug that had been newly approved by the FDA. It was the sixth entry of a drug in a specific category  that was very important in cardiology. Now, the first drug in a category is often the market leader in sales even when others are introduced, because when it is new and there is no competition physicians become familiar and comfortable with it. Not infrequently, though, the second drug in a category becomes a so-called “fast -follower” and takes over the sales lead because the market has been prepared by the first drug and the second may offer some slightly new benefits. But later entries into the market rarely take over the sales lead, and the later the entry the less likely for that to occur.

To support the marketing and sales of our client’s drug, which was the sixth in the category, we developed a lecture and slide presentation for dinner meetings that was not only scientifically accurate and within regulations, but engaging and, we believed, quite compelling. We were extremely successful, as the drug became the sales leader in its category after its first year in the market place.Having had a major role in developing the lecture and slides, I was among the physicians asked to deliver the presentation at dinner meetings. Our plan was to engage 100 prominent doctors around the country to each deliver 10 lectures. So, over the course of a year, one thousand presentations would occur.  The presenters were paid a reasonable fee for their time, which often involved some travel, most of which was fairly local or regional.

One of my assignments was to deliver a lecture to a group of cardiologists whose practices were located in a rural area quite a distance from my home, and required me to drive about two hours to reach the dinner destination. It started to snow as I drove north and I was a bit concerned about the drive back, at night on unfamiliar roads, if in fact the snow continued. When I finally arrived at the restaurant, which was more like a rural pub, the pharmaceutical company’s local sales director was there, but nobody else.

“What’s going on,” I asked.

“Don’t worry,” he said, “they’ll be here.”

We waited, me getting increasingly anxious about the trip home because the snow had not only not let up but was coming down more heavily.

“Why aren’t they here,” I asked.

“Don’t worry. I’m telling you they’ll be here,“ he replied.

Finally, with me growing more anxious by the minute, they started to arrive. Cardiologists, dressed in jeans and overalls, flannel shirts, fleece jackets, dirty boots. And me standing there, in a double-breasted suit, starched white shirt, Italian silk tie, highly polished wing-tip shoes.

I gave my presentation, and it went well. The farmer-doctors seemed genuinely interested and asked pertinent questions, apparently knowledgeable about the latest science. It seemed incongruous: a bunch of scruffy, roughly-dressed guys, in a pub, talking about cardiovascular physiology. When the formal part of the evening eventually ended, and I was leaving to drive home, I commented to the sales director who was still there about how odd I had found the whole thing. He explained that along with being excellent cardiologists, they were all farmers and loved that life. And in a snow storm, they had to assure that their pigs, their horses and their cows had adequate food and water, and would be safe if the weather got really bad.

“They appreciated you,” he said, “they really did. But in the greater scheme of things, you’re much less important than the animals.”

Well, it was sometime later that I was asked to do a series of dinner meeting presentations on the West Coast. There were lots of cardiologists in the major cities, like Los Angeles and San Francisco, and they were important targets of medical educational promotions.

A particularly important group of potential high-prescribing cardiologists was invited to a dinner meeting at a well-known, expensive, normally-hard-to-get-into restaurant, and thirty-two of the invitees accepted. The regional sales director and two of the sales representatives who usually called upon the invited doctors were also in attendance.

I arrived early, as I usually do, to get the lay of the land, so to speak, to see the table layout, the location of the screen for slide projection, and discuss the presentation plan with the sales people. There would be a brief cocktail period for people to meet and chat informally with one another, an introduction to the evening, the first dinner course, then the “meat” of the presentation, followed by the main dinner course —-  during which, hopefully, the doctors would discuss what they had heard. The evening would conclude with a fancy dessert during which Q & A would occur. I was looking forward to a successful evening, as this format had worked well in similar situations.  So, with anticipation, I awaited the arrival of our guests.

Nobody showed up.

The sales director and the two sales representatives were very upset. They had spent a lot of money to provide a fancy dinner for thirty-two people, and no one was there. The restaurant staff were puzzled. They had been part of the planning of the sequential events of the evening; they expected to serve several tables and knew when to be active in the dining room and when to stand back during the discussions.

Time passed  —  a lot of time.

Finally, two doctors appeared. They seemed somewhat uncomfortable, but not surprised to see that they were alone among the invitees. When it became clear that nobody else was coming, I joined the two at a table; and rather than a formal presentation we had an informal and engaging conversation about the material I had planned to discuss.

After dinner, when we were more comfortable with one another, I asked them if they had any idea why none of their local colleagues had shown up.

“Oh yeah,” one said. “Don’t you know what happened?”

“No,” I replied.  

“Well,” the other cardiologist said, “You know that the Rolling Stones are in town tonight. Sales reps from another pharmaceutical company came through today with tickets to the Stones concert. They visited cardiology offices all over town and gave away the tickets free.”

The first doctor said, “Hey, you can’t feel bad about losing out to the Stones. I mean they’re like the biggest people around. It’s no shame to be second fiddle to Mick Jagger.”

“No,” I said, nodding in agreement. “But then, how come you came? I’m really flattered.”

“Yeah, well, don’t be,” he offered, reluctantly. “You see, they ran out of tickets before they got to us.”

Thoroughly chastened and properly humbled, I didn’t tell him what I knew and he didn’t. I’m also less important than a bunch of farm animals.