Communication Currents

Part of physicians’ profession is to alleviate suffering. Physicians pursue this objective by examining patients and often prescribing drugs to improve their health. Because patients’ well-being is at stake, physicians need to make informed decisions about the drugs they recommend. In modern medicine, however, physicians rely heavily on meetings with pharmaceutical representatives to choose among competitors’ drugs. There are, in fact, an astounding 2.5 pharmaceutical sales representatives for every prescribing physician in the United States. Imagine, then, what happens if physicians are not properly informed about the health risks of a drug. Or worse, what if sales agents are trained by their own company to deceive physicians or hinder their ability to make informed decisions? This is exactly what happened at Merck, a multi-billion dollar pharmaceutical company that designed and promoted the pain drug, Vioxx.

Between 2000 and 2004, approximately 60,000 patients died of heart attacks while taking Vioxx. The company has been investigated by Congress and sued by thousands of individuals. Today, the company is still involved in class action lawsuits. These lawsuits require the public release of internal documents. Some of the documents include the manuals and the PowerPoint slides that were used to train sales representatives to communicate with physicians. When we looked at the documents closely, we found that Merck was training sales representatives to communicate unethically with physicians. This was surprising in part because Merck describes its business as “preserving and improving human life” and commits “to the highest standards of ethics and integrity.” In particular, we found four main problems with the sales techniques that sales representatives were taught to use.

First, Merck taught its employees to focus on the economic bottom line rather than to be informative and ethical. Trainers told new sales employees to ask themselves, “Who are my customers? Which customers offer the most potential? . . . Who are my competitors? How is their business?” Merck leaders also taught their employees to “control” the meeting and to “change the physician’s prescribing behavior.” Trainers told sales reps, “Tell the doctor that you’ll follow up on the action he or she has agreed to . . . [This] enables you to hold their feet to the fire.” Throughout all Merck’s training materials, sales employees were taught to see their interactions with physicians in purely “business” terms. In contrast, the training materials did not encourage the sales representatives to give details about the relative quality of Merck’s medication to help physicians make informed choices.

Second, Merck leaders drew on the language of war to teach employees to see the meeting as a competitive, dangerous environment. They used combative rather than medical words to frame the context. Physicians were framed as a “territory,” sales goals as “targets,” and certain messages as “quick hit” responses. Although the language of war is not new, it is concerning to see it used in the context of medicine, where patients’ health is at stake. Sales representatives, in fact, were coached to see themselves entering “an on-going battle” and to go on the “offensive.” We believe that the language of war should be replaced with a language of medicine and ethical responsibility that positions physicians as serious healthcare professionals.

Third, Merck trained employees to see physicians’ questions as “unsolicited” obstacles to overcome.  In fact, sales representatives were told to “dodge” direct questions about Vioxx’s cardiovascular risks. For example, if a physician asked, “I heard that Vioxx has a higher rate of [heart attacks] than naproxen, why is that?”, trainees learned to respond in this way: “Doctor...because the study is not on the label, I cannot discuss the details with you.” To put it simply, Merck trained its employees that physicians’ medical concerns were not as important as selling more of their drug. In contrast, should have viewed physicians’ questions as an opportunity to clarify Vioxx’s potential risks as well as its potential benefits. 

Fourth, Merck encouraged the sales agents to use subtle verbal and nonverbal skills to pressure physicians to prescribe Vioxx. Employees were told to use “driving” words to be persuasive by lacing their talk with phrases such as “Quality of lifeplummets,” “The shocking truth is,” or “The staggering statistic is.” These phrases were meant to cause an undue sense of urgency to prescribe Vioxx. In addition, they were coached to mimic physicians’ nonverbal cues with a technique called “flexing” or “mirroring.” This conversational tactic is used to “match” the physician’s body posture, gestures, tone, eye or head movements. According to the materials, this nonverbal mirroring “subconsciously raises [the physician’s] level of trust by building a bridge of similarity.” The employees, thus, were taught to appear supportive in order to lower physicians’ guard. In truth, however, Merck taught employees to control, steer, and manipulate the discussion for Merck’s benefit alone. Instead, sales reps should be trained to speak to physicians with genuine transparency and allow an authentic conversation develop.

Merck’s communication training is unethical because it teaches employees to hinder physicians’ ability to gather needed information about Vioxx, a drug with potentially deadly risks. Trainers encouraged employees to think of medicine mainly as a business, to treat physicians’ medical concerns as “obstacles,” and to use manipulative techniques to subtly pressure physicians. Merck effectively short-circuited the process of decision-making that physicians need to follow to serve their patients’ health interests effectively. Unfortunately, this communication training regiment is not unique to Merck. News articles and other court cases show that many Pharmaceutical companies now use manipulative sales techniques. Because patients’ lives are at stake, we suggest that meetings between pharmaceutical representatives and physicians must be guided by the principles of justice and ethics. As such, pharmaceutical organizations like Merck have an obligation to teach their representatives to communicate ethically. Sales reps should be trained to support physicians’ need to make informed choices, treat physicians as serious medical professionals, answer their questions with the best information available about the drug’s true risks and benefits, and allow transparent conversations with physicians that develop authentically.