April 16, 2019
5 min read

Pharma reps: aggravation or asset?

Set up some ground rules to have good interactions with industry in the office.

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What is up with all the chest-thumping bravado about refusing to spend any time with sales reps? Social media resounds with all manner of derring-do as doctors try to protect their “perfect record” of avoiding contact with the men and women who make their living talking to doctors. You know, stuff like: “I am proud to say that I have yet to give 1 MINUTE of face time to a rep in my entire career.” Next thing you know, we will be seeing those “No industrial accident signs” in doctors’ lounges. “XYZ Eye has now gone 3,054 doctor-days without seeing a pharma rep.”

If you ask me, the whole notion is just silly.

Whenever I bring this up, the first thing fired at me is research showing an increase in branded medications prescribed by physicians who have been visited by a rep. That medical companies have proof that sending sales reps out increases sales is ipso facto a nullifying black mark against the sales reps and requires shunning that would make an Amish elder blush. This is swiftly followed by the revelation that companies do not care about our patients and their health; they only care about company profit. Duh. Because I willingly interact with the ophthalmic sales force, I could not possibly know these two critical facts.

Nonsense. Every non-patient who shows up in my office or OR is automatically assumed to be selling something. The anti-rep crowd must encounter enough colleagues for whom this is news that it makes sense to say this in the hope that it will trigger a behavioral change. To be sure, selling is a different game than it was back in the day. There were some pretty spectacular abuses, some of which constituted outright bribery. Stories abound of all-expenses paid trips flying private iron to ski the Alps or tee it up at Pebble. I missed all of that, but I can attest to photographic evidence that it really did happen.

Why are my SkyVision colleagues and I available to the sales representatives in eye care? My personal approach has been pretty much the same since my time as chief resident at NYU in the late 1980s and predates my work as a speaker and consultant by almost 20 years. With or without their knowledge or consent, I am essentially recruiting the reps as part of my team to provide the best care possible for my patients. At NYU, I found it odd that a rep’s job involved nothing more than becoming my best friend. Because I was the gatekeeper to the residents that year, a younger woman or an older man was supposed to be my buddy.


That did not sound like such a great job.

I set about learning how reps work and how they are paid so that I could understand the reality of the relationship. There is not really too much difference between compensation strategies in 1989 and 2019. A rep receives a base salary that is space-dependent (eg, glaucoma vs. dry eye disease; phaco machine vs. femto laser). Almost every sales rep will then receive a bonus based on how much product they sell. Yes, the more juice you prescribe or lenses you implant, the more your lucky local rep takes home in their paycheck. That is not the whole story, though. Promotions (and a larger base salary) depend on that rep having “meaningful” face time with you, the doctor. Like points on that addictive game app you cannot put down at night, each time they see a “decision-maker,” their rating goes up.

But is this not exactly what the “no reppers” are saying? Am I not just allowing myself to be led along the garden path of sales rep (and company) prosperity by giving them even 60 seconds of my time? I do not think so, and an example from the days of cataract packs illustrates why. Do you remember cataract packs? In the bad old days of nudge-nudge, wink-wink marketing of topical antibiotics for cataract surgery, a company would supply your patients with a steroid and NSAID for each fluroquinolone prescription written. A straight-up quid pro quo that was relatively acceptable in the days of easy insurance coverage of almost all of our branded meds. Who got the contract? Simple. The company that provided the most service for our patients and our staff (samples for uninsured, coverage help, etc).

What about today? In my opinion, everything about our modern medical world is much harder than it used to be. Whereas once I knew everything about a medicine or lens I might use before the reps did, often as not teaching them about their product, now I only have time to know this in my core subspecialties of DED and advanced cataract surgery. This hardship allows me to make good on one of the requirements we have for visiting reps. We ask them not to repeat a pitch or detail. If they have something truly new to tell me, I ask them to request an appropriate amount of time to fill me in. One of these meetings inspired me to do a ton of reading on nitric oxide “contributors” in glaucoma.


We are all smart. Tell us once, and we have it forever. If you try to tell us the same thing again, you get one reminder about the rules. Do it again, and you lose face-to-face privileges with all of our doctors forever. It has happened.

Prescribing branded medicines has become a nightmare. We expect our local reps to keep our sample closets full. We expect that they will respond to requests from the staff. Frankly, I do not understand the self-righteous institutions that ban samples from their clinics as a way to reduce face time with reps. How do you help patients with high deductibles or who need to start their medicine right away? Empty gestures like this hurt patients.

In any treatment space where more than one effective option exists, we are fully transparent with the sales reps and their companies. We prescribe the medication that is better covered by an individual patient’s insurance company. Reps must know the local costs of their products and how to minimize their impact on our patients. Coupon programs, rebates, Costco cash pricing — all of this is something a rep is expected to know and assist in navigating on behalf of our patients.

In reality, I spend little time interacting with sales reps in our office. Our simple rules of engagement make it easy to appear more accessible than I really am. Once or twice a year I learn something new. When a rep does something particularly noteworthy, I try to tell their boss. Their success generally translates into better service and care for our patients. Heck, some of the young punk reps around when I was a young punk doc are now running companies.

If you refuse to spend time with a sales rep, you miss the opportunity to educate the future vice president that sales only matter when they help somebody’s patient get better.

Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.