Hard Sell: The Evolution of a Viagra Salesman (22 page)

Under normal circumstances, most doctors cautiously
refused to try a new drug for at least a few months following FDA approval. There were always a few “cowboys” who wanted to practice cutting-edge medicine, and those guys, God bless ’em, would jump at the chance to try something new. For the most part, however, physicians liked to wait to see what the
New England Journal of Medicine
stated or what a partner in their practice said. Although I hated that attitude from the perspective of a sales rep, I appreciated it from the patient’s perspective. “Better safe than sorry” was certainly not a bad credo for a doctor to follow; just ask the patients who got Fen-Phen.

Physicians wanted proof that a drug worked, and then they wanted proof to back up the proof. They would then question the validity of the efficacy data, or they would argue that the study parameters were not strict enough or that there were not enough patients enrolled in the study or that the data had been collected in Europe, not the United States. Doctors wanted safety data showing that their patients were not going to grow a third eye or, worse yet, call them in the middle of the night to complain about gas.

Physicians also wanted to know if the drug was “covered” by insurance yet. This was an important point in terms of cash flow; both the patient’s and the doctor’s. Take Mrs. Jones, for instance. She did not like finding out from the pharmacist that the new drug prescribed for her was not covered by her insurance, and, as the result, she would have to pay $90 instead of her normal $5 copay.
Mrs. Jones would probably call her physician in this case to express her displeasure, which made for a disgruntled medical professional.

Additionally, every HMO cut deals with drug companies to lower their acquisition costs for pharmaceuticals; these agreements normally involved the HMO guaranteeing the company a certain amount of volume in exchange for a price break on that drug or another commonly used one. In order to hit that guaranteed number, however, the HMOs had to make sure the doctors participating in their health plans used Drug X exclusively over Drug Y. To ensure that, the HMOs did one of two things: withheld money from physicians throughout the year to be paid out only if the doctors met the required usage targets or paid doctors higher year-end bonuses based on their having met said goals. Faced with such incentives, many physicians wouldn’t even listen to a new product detail, saying, “Come talk to me when it’s covered.”

The urologists of America did none of the normal things American doctors typically did post–FDA approval. They didn’t want to see studies showing Viagra’s efficacy. They didn’t want detailed safety data. They didn’t even care whether the HMOs were covering it or not. We were stunned. We were bursting with information, and nobody would let us talk. As one insightful urologist explained to me, “We’ve been waiting years for this fucking drug.” The pun was not intended.

They wanted to know, in this order:

1. How do I dose it?
   

2. Who
   can’t
   I give it to?
   

3. How high can I go? (What’s the maximum dose?)
   

4. What are the side effects?
   

5. Can I use it in women?
   

Despite these seemingly simple questions, debate raged within Pfizer as to the correct answers.

Big shots in the company couldn’t even agree on the recommended dose. Pfizer produced tablets of 25 milligrams, 50 milligrams, and 100 milligrams. According to the FDA approved labeling, Viagra’s recommended starting dose was 50 milligrams to be taken an hour before sex. Twenty-five milligrams was recommended for elderly patients or those with renal dysfunction, while the 100 milligram dose was intended for men who had moderate or no response to 50. Pretty simple, right?

Although it was common industry practice to charge more money for a larger dose of a drug, Pfizer chose to charge the same amount for both the 50-milligram and 100-milligram tablets. This decision had nothing to do with corporate philanthropy and everything to do with keeping the sales representatives from pushing the higher dose.

Each rep had a quota that she was expected to meet each year. Let’s say Sally’s Viagra sales target was $1 million. Let’s also say the 50-milligram tablet and the 100-milligram tablet cost $7 and $8.50, respectively. To make her
quota, Sally could have sold 14,285 50-milligram tablets or 11,764 of the 100-milligram tablets. Considering that the average Viagra prescription written was for six tablets, making quota by selling the 100-milligram tablet would have required four hundred
fewer
scripts. For a sales rep, the choice would have been a no-brainer: Push the higher dose.

While that decision would be profitable for the sales force, it could be costly to Pfizer. With practically every pharmaceutical product, there existed a directly proportional ratio between the amount of drug given and the frequency and severity of side effects. Viagra was no exception; clinical trials demonstrated a higher side-effect profile with the 100-milligram dose. From a corporate standpoint, Pfizer couldn’t risk the physician negativity and possible negative publicity that accompany a high number of adverse events. Hence, HQ made it clear that the 50-milligram dose was the right one.

As a headquarters decision, it was not well received in the field. From the start, savvy sales managers realized that patients would ask their doctors to write prescriptions for the 100-milligram tablet, which the men would then cut in half, thereby saving half the money while slicing our profits in half. Some physicians didn’t wait for the men to ask; they instructed the patients to cut the pills from the start. Nothing makes pharmaceutical sales people crazier than news of “tab cutting.”

The members of the Viagra sales and marketing team thought they had nipped this in the bud through the
revolutionary design of the pill. In addition to being aesthetically pleasing, Viagra’s unique diamond shape was intended to make it impossible to fit the tablet inside a pill cutter, and, at the very least, extremely difficult to cut it manually with a knife. Regardless, pill cutting commonly occurred throughout the country.

Faced with a potential sales crisis, several regional managers got together and directed their reps to push the 100-milligram tablet as the more efficacious dose. This was spun to physicians by focusing on the apprehensive patient. “Doctor, I can understand your concern about cost, but what about that patient who tries ‘fifty’ and it
doesn’t work?
How much courage did that guy summon to come in here the first time and admit he had problems
down there?
Do you really think he is going to come back a
second
time, and basically tell your female receptionist and female nurses that even with
help,
he still can’t perform? There’s no way. Doc, go with the ‘one hundred’ and be sure.” If the physicians prescribed the 100-milligram dose, the patients wouldn’t be allowed to cut it in half, and our sales would not suffer. Unfortunately, teamwork between divisions suffered, as people gave doctors conflicting messages.

We were all united, however, in our efforts to halt the evil tab cutting. Predictably, the reasons we provided physicians for doing so varied dramatically. At first I pretty much told the truth when asked what would happen if a patient took a split Viagra. “We really don’t
know, Doctor,” I’d answer, hoping to strike fear into his control freak heart. Physicians don’t like surprises any more than they enjoy phone calls from angry patients. An unsuccessful try with a split tab Viagra could cause both things to happen.

Later on, I picked up a better response—one based on “science”—from Dr. Glove, a nationally renowned urologist and Viagra speaker. After he earned yet another $1,500 for touting the wonders of vitamin V to a dinner crowd of community physicians, I drove him to the airport for the next stop on the Dr. Glove West Coast Speaking Tour. We were having a drink in the bar while he waited for his flight, and I asked him how he would handle the tab-splitting problem.

Swirling the ice in his glass of scotch, he pondered my question for a moment. “Tell them that Viagra is covered in a thin film coating”—which was true—“and that the thin film coating is key to the absorption,” meaning the rate at which the drug is absorbed into the bloodstream. “Tell them that we don’t know what can happen to the rate of absorption when the film coating has been
compromised.”
What a great word, I thought, as he finished his drink.

“If it would normally take sixty minutes for Viagra to start working in a particular patient, maybe it’ll only take fifteen after the tab has been split, or maybe two hours. That could really throw off our man’s timing, so to speak, and maybe it won’t work.” I asked him if that was really true.

“Hell if I know,” he laughed, and signaled the bartender for another round. “But it sure sounds good, don’t it?”

So that’s what I went with—the film-coating crisis. It had been working fairly well until I strolled into a urology office south of Fresno one afternoon. Right away, the nurse revealed that the doctor was now telling all of his patients
not
to split their tabs “because of what Jack said.” I raised my eyebrows at this. Jack was a dinosaur—close to twenty years with the company—as well as a Bible thumper, two things that made him a wild card in my eyes.

“That’s great. What exactly did Jack tell you?” I asked with a nervous smile. At this point, the urologist came out of an exam room.

“He said the Viagra is actually found on only
one side
of the tablet, and there’s no way to tell which side. So anybody who splits it may not get the actual drug, just blue filler powder.”
Blue filler powder!
Maybe I had overlooked a sense of humor in good ol’ Jack.

I started to laugh. “That’s a good one,” I admitted, winking at the doctor to show him I was in on the joke. Only, no one else was laughing.

“You mean that’s not true?” he asked, annoyed.

“Uh, you know, Doctor, Jack has been with Pfizer a lot longer than I have. He knows a million people at headquarters in New York City—scientists, researchers, and everything—so it would not surprise me
at all
to find out that Jack knows something I don’t. In fact, I am going
to call him to find out about that, because that’s the kind of thing I need to be telling the rest of my physicians!”

He nodded. “Makes sense to me,” he confirmed. Oh boy. Was it a lie? Yes. Did it accomplish the mission? Yes.
Hello, Machiavelli.

Having fumbled the recommended starting dose, the geniuses at HQ blundered again in answering the second of the urologists’ questions: To whom
can’t
I give Viagra? Looking back, it seemed like an easy question. History has shown us that the answer should have been: guys on nitrates, guys who have had heart attacks, and guys who
look
like they are going to have heart attacks. Adding “fat guys” to the list would not have been a bad idea, either.

Of course, there was no such answer. The only men who were specifically ruled out from getting Viagra were those “who have a history of complications with Viagra.” I always get a kick out of that line, which can be found in the package insert of every drug on the market. I mean, how can someone have a history of complications with a drug if he has never taken it before?

There was a warning in the package insert, however, that made it crystal clear that men taking nitrates (a class of drugs commonly taken to prevent second heart attacks; many people have cylinders of nitroglycerin on their key chains) ran a significant risk of cardiac side effects. In most patients, Viagra caused a drop in blood pressure. In patients taking nitrates, however, a syner-gistic effect between the two drugs caused sudden and
significant drops in BP, often resulting in major medical crises. The warning was very clear in its wording, but it largely went unheeded. Unfortunately, a package insert warning resembled a yellow traffic light at an intersection; they were both easy to ignore, and most people did just that.

And guys started dying. As the media gleefully reported more deaths, I incorrectly thought I was going to get crucified by my urologists. Which is not to say that the urologists were unconcerned. Rather, they understood why it was happening.

During an initial office visit, most specialty physicians thoroughly review a patient’s medical history. Urologists are no exception. These consults take a great deal of time, but they provide the doctor with an essential view of all the disease states and lifestyle issues facing them in the treatment of the patient. Consequently, specialists often know a patient better than his primary care physician. This close relationship allows many specialists, especially urologists, to avoid prescribing Viagra to men who do not meet the guidelines.

Family practitioners, also known as primary care physicians (PCPs), faced a difficult task. Given fifteen minutes to see each patient, they do not have enough time to complete a thorough medical history. This played right into the hands of desperate men who
lied
about their usage of nitroglycerin. Additionally, many patients went in to see the doctor for treatment of allergies or
arthritis, only to ask for Viagra at the end of the visit. Short on time and badgered by men eager to revive their dormant sex lives, PCPs occasionally chose poorly and wrote prescriptions for bad candidates. The recipe for disaster was not lost on urologists.

“
Of course
they’re having heart attacks and dying,” an exasperated urologist barked at me. Dr. Charming, as my colleague referred to him, had a great sense of humor and rarely got upset about anything. “If you wouldn’t let a guy carry a suitcase up a flight of stairs, then he shouldn’t be fucking!”

Common sense not withstanding, the suits against Pfizer piled up. Yet Pfizer never settled a case, and Pfizer never lost a case. Our stance was simple, yet correct. Viagra did not kill those men; sex did.

Nobody took Viagra and then, boom, had a heart attack. Rather, they took Viagra,
had sex,
and then had a heart attack. The activity killed them, not the drug. Echoing the aforementioned “suitcase” logic, a rule of thumb heard in cold-weather areas said, “If you wouldn’t allow a patient to shovel the driveway, then you shouldn’t allow him to have sex.” After all, hundreds of men suffer heart attacks while clearing snow each winter. Yet Ralph Nader and his merry band of consumer advocates have never campaigned to ban snow shovels, have they?