What's on the doctor's mind?

I was recently asked by a rep why I write so many prescriptions for drug X, which was sold by his competition. I told him it was safe, effective and had a good side-effect profile.

But then I realized that a lot of drugs fit that description. Many products were equal in efficacy to drug X, but it was always my first choice for an antidepressant.

To answer his question, I began to really consider why I wrote so much for drug X.

In the process, I had a terrible flashback.

When I was a second-year resident, I treated the type of patient commonly referred to as a psychiatrist's nightmare. She was always suicidal, or at least chronically attempting suicide. She never succeeded, obviously, but she did succeed in challenging the day-to-day sanity of all of the resident physicians in my group.

One day she actually showed up to her appointment with her own Physician's Desk Reference,® ready to challenge anything I thought to prescribe.

Another time, she had me paged so that she could tell me that she had just overdosed. She preferred letting me know this rather than calling 911.

Obviously, this patient was a treatment nightmare. I recall telling her that there was a new antidepressant out - drug X - and that she should try it. She did and, wow, what a difference! She finally stabilized and, for the first time since I began treating her, I finally got some sleep.

Not surprisingly, I was soon prescribing drug X to nearly everyone who needed an antidepressant.

Although this experience changed my prescribing habits profoundly, I had entirely forgotten about it until the representative asked me.

Prescribing medications is quite routine for me (I prescribe approximately 40 different drugs to hospitalized patients on an average day, and give 30 prescriptions to various outpatients in the afternoon), but I had never questioned how subconscious influences had affected my prescription habits over time.

Subconscious influences

What does all this mean to you, the pharmaceutical sales rep? There are specific pros and cons that arise from subconscious motivations, and there are ways a rep can enhance products sales through this knowledge.

Good experiences: Let's practice some psychiatry. When I say the word father to you, you have a complex mental image that arises. This image is hopefully positive, but is a complex mixture of experience, memory, and perception. If I say drug X, (fill in any drug you like) you'll also have a complex mental image. Now, as a pharmaceutical rep, you are part of a physician's mental image of a product. That's why it is so critical to build a positive relationship with your doctors. All things being equal, we will lean toward drugs sold by the reps we like best, and avoid those sold by reps who formed a negative impression.

We are often unaware of the experiences that shape our habits so it is up to you to ask us. One of the best sales reps I know gets me talking about her drug by inquiring about my cases and treatment results. This allows me to really reflect on the product as she verbally highlights the positive experiences. She uses her time making me reflect and listens to me drag previously forgotten experiences to my conscious mind.

Formularies: Last year, a particular antidepressant was dropped from the formulary of a large managed care company. I still believed it was a fine drug so I continued to prescribe it and vowed silently not to let third parties dictate my prescription habits.

But after about two months, despite what I had decided, I realized I almost never wrote for this drug.

Upon reflection, I recalled that I had written for the drug several times, but had been paged by the pharmacist who said the patient was standing there, the insurance company would not pay for the prescription I wrote and would I change it over the phone? When I wouldn't, I had to call a customer service number at the insurance company, wait on hold for 15 minutes while my patients lined up in the waiting room and, eventually, write a letter arguing that the patient required a medicine that I had already decided they needed.

What a terrible and costly inconvenience! Over time, my brain decided for me that the antidepressant was not worth the battle. Subconsciously, I dropped it to the bottom of the list.

If a drug has been cast out of formularies, we may still prescribe it, but only if you make it easy for us. Find out if the doctor must call and, if so, find out which numbers are the least busy. Know what the requirements for approval of the drug are and any other information that will make prescribing easier and more pleasant.

I never had time to explore any of these answers during my day. If there is an easy answer, such as having the patient call a certain number before they go to the pharmacy or providing certain information, then doctors will respond more favorably.

Other doctors: We learn to be doctors by watching and listening to other doctors. Just because we are done with school does not mean the process suddenly stops. When I hear about a respected colleague's positive experiences with a drug I rarely prescribe, I often find myself prescribing it more without realizing why. This information makes its way into the subconscious as well, and we use it. If you have such information, share it with doctors who rarely use your product. PR