the pharmaceutical sales rep/physician relationship in turkey

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The Pharmaceutical SalesRep/Physician Relationship inTurkeyDilaver Tengilimoglu PhD a , Adnan Kisa PhD b &Aykut Ekiyor MSci ca Gazi University, School of Business , Ankara, Turkeyb Baskent University, School of Health Sciences,Department of Healthcare Administration , Ankara,Turkeyc Ministry of Finance, Ankara ProvincialAdministration , Ankara, TurkeyPublished online: 04 Oct 2008.

To cite this article: Dilaver Tengilimoglu PhD , Adnan Kisa PhD & Aykut EkiyorMSci (2005) The Pharmaceutical Sales Rep/Physician Relationship in Turkey, HealthMarketing Quarterly, 22:1, 21-39, DOI: 10.1300/J026v22n01_03

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The Pharmaceutical Sales Rep/Physician Relationship in Turkey:

Ethical Issues in an International Context

Dilaver Tengilimoglu, PhDAdnan Kisa, PhD

Aykut Ekiyor, MSci

ABSTRACT. In many developed countries, the physician/pharmaceu-tical sales representative relationship has increasingly become the focusof ethical questions. Given this context, the purpose of the present studywas to determine the ethical dilemmas faced by pharmaceutical salesrepresentatives in Turkey in their relations with physicians, and to iden-tify possible solutions. Through an investigator-designed questionnaire,the ethical problems perceived by 215 pharmaceutical sales representa-tives were quantitatively analyzed. Nearly all of the participants (96.7%)reported that they had faced ethical dilemmas in marketing drugs to phy-sicians. The most commonly reported problems included paramedicalrequests (for free lab test kits, etc.) and the necessity of bargaining withphysicians over the use of their firm’s drugs by offering gifts and spon-sorships. The participants in the study felt that physicians were the pri-mary source of ethical problems in the marketing of drugs, and the

Dilaver Tengilimoglu is Associate Professor, Gazi University, School of Business,Ankara, Turkey.

Adnan Kisa is Associate Professor, Baskent University, School of Health Sciences,Department of Healthcare Administration, Ankara, Turkey.

Aykut Ekiyor is affiliated with the Ministry of Finance, Ankara Provincial Admin-istration, Ankara, Turkey.

Address correspondence to: Adnan Kisa, Associate Professor, Baskent University,School of Health Sciences, Department of Healthcare Administration, Eskisehir Yolu20. Km., 06530 Ankara, Turkey (E-mail: [email protected]).

Health Marketing Quarterly, Vol. 22(1) 2004http://www.haworthpress.com/web/HMQ

© 2004 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J026v22n01_03 21

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participants’ most highly ranked potential solution to these ethical prob-lems was a better understanding, on the part of physicians, of the role ofpharmaceutical sales representatives. At the end of this study, sugges-tions are given with a view to helping health policy makers understandand address the current controversies involving drug company represen-tatives and physicians. [Article copies available for a fee from The HaworthDocument Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2004 by TheHaworth Press, Inc. All rights reserved.]

KEYWORDS. Pharmaceutical sales representatives and physician rela-tions, Turkish healthcare system

INTRODUCTION

With the population of the world rapidly increasing, the equally rapidevolution of the landscape of human disease has mobilized the drug in-dustry anew. Drug firms are simultaneously obligated to meet increasesin current demand, to outperform rival firms, and to increase scientificresearch to discover new drugs. In such an intensely competitive envi-ronment, the survival of a firm depends on its marketing of products.Firms have to maintain a strong presence in the market while lookingfor ways to increase their market share, and this requires clinical feed-back for the improvement of products. These converging factors, alongwith legal restrictions on drug advertising, have led to the creation of anew profession, that of the pharmaceutical sales representative (PSR).

The primary function of pharmaceutical sales representatives is to con-nect their drug firms to the physicians and pharmacists who actually getthe firms’ products to patients, who are the final consumers. Pharmaceu-tical sales representatives are given considerable responsibility in amethod of drug marketing where personal contact is important (Gaedeke,Tootelian, and Sanders, 1999). Drug firms that understand this providemore opportunities for their pharmaceutical sales representatives, andtrain them so as to continually increase their efficacy in the market.

The entrance of multiple versions of the same type of drug in the mar-ket increases competition in the drug industry. Through their pharma-ceutical sales representatives, drug firms not only try to explain theunique and superior aspects of their drugs to physicians and pharma-cists, but also to reward the physicians and pharmacists who play the

22 HEALTH MARKETING QUARTERLY

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role of mediator in delivering products to consumers and maintaining orincreasing market share. Competition in this form can lead to excessivepromotional efforts, which in turn can create ethical problems in rela-tions between pharmaceutical sales representatives and physicians, inaddition to increasing the costs of drugs (Wall and Brown, 2002).

One of the most interesting aspects of the recent increase in the mar-keting efforts of pharmaceutical companies is that the approaches usedin the United States, Europe and Japan are spreading rapidly to develop-ing countries. This particular example of globalization offers some uniqueinsights into the process of economic transition toward market econo-mies that many developing countries are struggling to accomplish. Thisis important not only in terms of the potential markets that those coun-tries represent, but also in terms of the potential range of marketing phe-nomena which could be studied in developing countries by treating eachcountry as a different combination of the same basic parameters. Thepresent study was conducted in Turkey, and it examined the ethical con-cerns of pharmaceutical sales representatives in relation to their interac-tions with physicians. In the research literature, very little information isavailable on this interaction from the perspective of pharmaceuticalsales representatives, so this study is intended to contribute toward amore complete baseline for further study of this question in Turkey andin other developing countries.

THE PHARMACEUTICAL SECTOR IN TURKEY

From the founding of the republic in Turkey in 1923 up to the end ofWorld War II, drug production here was limited in scope and was drivenby foreign markets. In the 1950s, however, the domestic drug sector re-ally started to develop. Particularly with the legislation introduced in1954 to encourage foreign investment, inflow of foreign capital ensuredrapid improvement in the drug sector (Semin, 1998). Today, Turkeymeets 95% of its drug demand through domestic production. However,almost 75% of the raw materials used in this production are importedfrom other countries (Atay, 2001).

Of the 34 foreign capital firms active in the drug sector, only eight ofthem possess a production facility in Turkey. As a result of tax incen-tives implemented in 1994, investments in the drug sector have in-creased and consequently production technology has been renewed.The drug sector in Turkey has also initiated EU harmonization efforts

Tengilimoglu, Kisa, and Ekiyor 23

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by making the necessary amendments, in parallel with the legal amend-ments realized in 1995 in EU countries (Kisa, 2001a; Kisa et al., 2002).

As of 1998, 134 establishments were active in the drug sector in Tur-key. Among these are the Social Insurance Organization Drug Factoryand the Army Drug Factory of the Ministry of National Security, butthese belong to the public sector; their products remain within the gov-ernment system and do not enter the market. The rest belong to the pri-vate sector. In 1998, domestic capital firms accounted for 49% of totalsales in the drug sector, and the share of foreign capital firms was 51%(Syndicate of Drug and Chemical Industry Employers, 2000).

According to the international research firm IMS Health, as of Janu-ary 2000 there were 2,658 drugs on the market in Turkey. This numberincreases to 4,635 if delivery types are taken into account (tablet, cap-sule, ampule, syrup, etc.). The number of personnel working in the sec-tor was approximately 18,500 (Eczacibasi, 2001).

In Turkey, the national government regulates the pharmaceutical in-dustry. The Ministry of Health sets drug prices by adding labor, man-agement expenses, profit, indirect profit, wholesale agent profit, andpharmacy profit to the costs of raw materials and packaging. This pro-vides an incentive for the use of expensive raw materials and packaging,especially for those over which a monopoly exists.

For the patenting of drugs, Turkey’s efforts toward joining the Euro-pean Union have produced a new law which closely resembles that inthe EU. The law in Turkey has been in effect since 1999 and will likelyraise drug prices (Savas et al., 2002). There have been efforts to pro-mote greater use of generic drugs, but physicians still largely prescribebrand name products. This suggests that physicians are influenced bythe marketing efforts of pharmaceutical companies.

Drug companies in Turkey sell their products through wholesalepharmacy depots, retail pharmacies, contracts with hospitals, and con-tracts with some state institutions. In Turkey, some drugs that are avail-able in other countries only by prescription can be bought over the counter.Pharmacies may therefore sometimes serve as alternatives to prescrib-ing physicians.

Health insurance coverage for drugs is provided by four main sources inTurkey, all of which are run by the national government. The Social Insur-ance Organization (Sosyal Sigortalar Kurumu, SSK) covers private sectorand blue-collar public sector employees and their dependents, and requiresa 20% co-pay for drugs from those who are still working and a 10% co-payfor retirees and their dependents. SSK hospital pharmacies must be used, incontrast to the other three systems which all have contract agreements with


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retail pharmacies. SSK gets drugs at a discount from manufacturers by vir-tue of its monopoly power; also, SSK usually requires the use of genericdrugs (Kisa et al., 2000). The health insurance plan for the self-employed iscalled Bag-Kur, and it likewise requires 10% and 20% co-pays from retir-ees and actively working members, respectively. For retired governmentemployees there is Emekli Sandigi, which requires a 10% co-pay from itsmembers (Kisa, 2001b; Savas et al., 2002). Currently working white-collargovernment employees and their dependents are covered by their particulardepartments, and must make a 20% co-payment. For the poor with no otherhealth insurance, the Green Card program covers all medical expenses ofthose who qualify (Kisa, 2002). The rest of the uninsured population, foundmainly in rural areas, pay for drugs out-of-pocket, and this creates an incen-tive for their physicians to prescribe generic drugs they can afford.

PHARMACEUTICAL SALES REPRESENTATIVE/PHYSICIAN RELATIONS

Pharmaceutical sales representatives are a type of salesperson em-ployed in situations where the goal is to provide information concerningproducts and to assure good relations with current and potential clients.This is the reason that pharmaceutical sales representatives are some-times called missionary salespersons. In this respect, firms’ expectationsof their pharmaceutical sales representatives are high. A successful phar-maceutical sales representative is expected to have regional dominance,high sales and prescription rates, and a superior ability to keep current cli-ents and find new ones (Kisa, 2001a; Korkmaz and Tengilimoglu, 2000).As their employment depends directly on their sales capacity, their firms’willingness to continue to employ them at all can involve rather high ex-pectations of sales.

Another role of the pharmaceutical sales representative is that of in-formation provider. A major part of the pharmaceutical sales represen-tative’s job involves informing physicians about newly released drugs.Physicians who receive information on how a drug can be used to treatpatients will tend to prescribe that drug. Advertisement-related infor-mation about drugs, training conferences sponsored by firms, and clini-cal studies sponsored by firms have all been shown to alter the prescribinghabits of physicians (Lexchin, 1993).

As in the more developed countries, policies concerning the relationsbetween drug representatives and physicians, as well as ethical stan-dards for drug studies and the preparation of guidelines regarding these


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issues, are also desired in Turkey (Korkmaz and Tengilimoglu, 2000).Guidelines for pharmaceutical sales representatives have been pro-posed by the Chamber of Physicians and the Syndicate of Drug andChemical Industry Employers, and include the following. Pharmaceuti-cal representatives should receive medical and technical training suffi-cient to enable them to provide medical and technical information in anaccurate, responsible and ethical way; pharmaceutical representativesshould be respectful of ethical criteria and deontology in each phase oftheir duties; pharmaceutical representatives should transfer accurate,evidence-based information when presenting advertisements either ver-bally or in writing; pharmaceutical representatives should not make un-just or misleading claims, nor suggest a therapeutic superiority which isnot yet proved; advertisement of drugs by pharmaceutical representa-tives should be limited to authorized indications; pharmaceutical repre-sentatives are bound to comply with the preservation conditions ofmedical items under their responsibility, and to take the necessary pre-cautions to assure these conditions are met; pharmaceutical representa-tives should not offer physicians, dentists, pharmacists or other relevantpersonnel material inducements; the employer is responsible for all ad-vertisement activities and bids of its pharmaceutical representatives, in-cluding verbal statements about its drugs; the employer is responsiblefor the basic and ongoing training of its representatives (Guven, 1990).The medical advertisement principles published by the Syndicate ofDrug and Chemical Industry Employers are considered as the basis fortraining pharmaceutical sales representatives (Syndicate of Drug andChemical Industry Employers, 2000).

METHOD OF THE STUDY

It is well known that representatives of drug firms frequently visitphysicians who write prescriptions for patients. These visits have in-creased in number as part of the rapidly expanding competition betweendrug firms. Various methods are exercised to persuade physicians. Theaim of this study is to identify ethical problems encountered in relationsbetween pharmaceutical sales representatives and physicians, and tosuggest possible solutions.

The universe of the survey was comprised by the pharmaceutical salesrepresentatives working for drug firms within the city borders of Ankara.As of June 18, 2001, these representatives numbered 1,346. This numberwas acquired through telephone interviews with 86 firms having regional


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offices in Ankara. With a population of approximately four million, An-kara is the second largest of the three major metropolitan areas in Turkey,and for this reason it was considered to be a reasonable choice in terms ofgeneralizability of results toward the other two metropolitan areas. Phar-maceutical representatives based in Ankara visit smaller cities in the sur-rounding province as well, and this is the case in Istanbul and Izmir, theother two major metropolitan areas in Turkey.

A preliminary version of the questionnaire was administered to 20pharmaceutical sales representatives, and questions that were consideredunclear were edited. By systematic random sampling, 215 representatives(15.97% of the study universe) were selected to complete the revisedquestionnaire, and all agreed to participate. The questionnaire was ad-ministered by mail, and a telephone follow-up was made two weeks laterto find out whether the participants had received it. All questionnaireswere completed and returned. An investigator-designed questionnairewas used for the survey. The questionnaire consisted of 40 questions andwas divided into four sections. The first part addressed demographiccharacteristics of the participants, the second addressed their educationaland training needs, the third addressed their professional techniques, andthe fourth addressed the ethical problems they encounter in their interac-tions with physicians. Questions in the survey were chosen in the contextof the relevant research literature (Tengilimoglu and Korkmaz, 2000). Acover letter attached to the survey assured the participants of confidential-ity and instructed participants to answer questions to the best of theirknowledge.

Limitations of this study include the possibility that pharmaceuticalrepresentatives in Ankara are not precisely representative of those inother parts of Turkey. In the sampling process, gender and age were notcontrolled for.

RESULTS

As shown in Table 1, of the pharmaceutical sales representatives whoparticipated in the survey, 34.0% were women and 66.0% were men. Interms of age, 57.7% of participants were 20-29 years old, 36.7% were30-39 years old, 5.1% were 40-49 years old, and 0.5% were 50 andover. This suggests that drug firms employ mostly young sales staff.The age 20-35 interval contained 94.4% of the participants in this study.

In Turkey, pharmaceutical sales representation is being chosen as a pro-fession by an increasing number of people. Institutions that provide educa-


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tion at a bachelor’s degree or pre-bachelor’s degree level in this field arerelatively few in number, and people with various educational backgroundsmay enter this field. However, drug firms tend to hire baccalaureate-levelgraduates in management, economics, chemistry and other fields relevantto the pharmaceutical industry (Korkmaz and Tengilimoglu, 2000). Re-garding the highest level of education completed by the participants in oursurvey, 29.8% had graduated from high schools or equivalents, 3.3% weregraduates of health professions high schools, 16.3% were pre-bachelor(two-year college) graduates, 47.0% were university (four-year college)


TABLE 1. Social-Demographic Characteristics of Pharmaceutical Sales Repre-sentatives

n %

GENDERFemale 73 34.0

Male 142 66.0

AGE

20-29 124 57.7

30-39 79 36.7

40-49 11 5.1

50 and Above 1 0.5

EDUCATIONALLEVEL

High School and Equivalents 64 29.8

High School of Health Profession 7 3.3

Two-Year College (Pre-Bachelor) 35 16.3

University (4 Years and Above) 101 47.0

Postgraduate Degree 8 3.7

TITLE

Pharmaceutical Sales Representatives 71 33.0

Sales Manager 19 8.8

Drug Sales Agent 29 13.5

Drug Representative 55 25.6

Other 41 19.1

EMPLOYMENTDURATION

1-5 Year(s) 128 59.5

6-10 Years 61 28.4

11-16 Years 20 9.3

17-21 Years 6 2.8

AVERAGEMONTHLYEARNINGS

150-250 Million Turkish Liras* 10 4.7



500 Million Turkish Liras* and Over 117 54.4

TOTAL*(1 USD = 1,350,000 TL)

215 100.0

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graduates and 3.7% had postgraduate degrees. According to these percent-ages, 67% of the pharmaceutical sales representatives in this study hadtwo-year college degrees or higher.

Of the participants in this study, 33.0% referred to themselves as apharmaceutical sales representative, 8.8% as a sales manager, 13.5% asa drug sales agent, 25.6% as a drug representative, and 19.1% definedtheir title with other terms. In years of professional experience, a highconcentration is observed in the one year to five years range, and therepresentatives having 10 or more years of experience are mostly salesmanagers or regional directors. As shown in Table 1, 59.5% of pharma-ceutical sales representatives had worked for 1-5 year(s) in this sector,28.4% for 6-10 years, 9.3% for 11-16 years and 2.8% for 17-21 years.More than half of the participants (54.4%) reported their averagemonthly earnings to be 500 million TL and over, whereas 26.5% re-ported monthly earnings between 350-450 million TL, 14.4% between250-350 million TL, and 4.7% between 150-250 million TL.

Regarding the participants’ sales visits, 7.9% (17) reported that theyvisited physicians once a day and 10.2% (22) said they visited physi-cians three or more times a week, while about half (53.0% or 114) madevisits once or twice a week. On the less frequent side of the distribution,28.4% (61 participants) said they visited physicians once a fortnight,and 1 participant reported visiting physicians once a month. In terms ofinterview duration, the largest group of participants reported that theirinterviews with physicians usually lasted 6-10 minutes (40.5% or 87participants). This was followed in frequency by usual interview timesof 11-15 minutes (32.6% or 70 participants), 1-5 minutes (15.8% or 34participants), 16-30 minutes (9.8% or 21 participants) and more than 30minutes (1.4% or 3 participants). According to the data in this study, thegreat majority of interviews lasted 1-15 minute(s) (88.9%).

Regarding the types of physician visited, the type most often reportedas presenting “excessively many” problems was that of practitioners,with this being reported by 29.4% of participants. The fact that ethicalproblems are mostly experienced with practitioner physicians may de-rive from the relatively frequent communication of pharmaceuticalsales representatives with this type of physician group (see Table 2).When the mean scores of female and male PSRs were compared in thecategories of ethical problems experienced according to physician type,no statistically significant differences were found (p > 0.05).

When participants’ educational levels were grouped into two catego-ries–less than four years of college versus four years of college ormore–participants with less than four years of college were found to ex-


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perience more ethical problems with specialists, practitioners, and re-search assistants (mean = 2.56, Std. Dev. = 1.07) compared to partic-ipants with four years of college or more (mean = 2.92, Std. Dev. = 1.08)(t = 2.08, p < 0.05).

This study also examined the relation between years spent working asa pharmaceutical sales representative and ethical problems encountered.Overall, 96.7% of participants said they “experienced ethical problemswith physicians,” whereas 3.3% stated that they “did not experience ethi-cal problems with physicians.” Of the participants with 1-5 year(s) of ex-perience, 96.9% (124 PSRs) encountered ethical problems, and 3.1% (4PSRs) did not; of those with 6-10 years of experience, 95.1% (58 PSRs)encountered ethical problems and 4.9% (3 PSRs) did not; and 100.0% ofthose with 11-21 years of experience (26 PSRs) reported encounters withethical problems. In summary, slightly more seniors and beginners werefound to have experienced ethical problems with physicians, but thesedifferences were not statistically significant.

Pharmaceutical sales representatives’ frequency of providing infor-mation when suggesting a drug to physicians was addressed in the sur-vey. Of the participants in this study, 78.6% (169 PSRs) stated that they“always” inform physicians about drugs when suggesting them, and21.4% (46 PSRs) reported that they “sometimes” do so.

In terms of how often they clarified the deficiencies of their ownfirms’ drugs relative to rival products, the pharmaceutical sales repre-


TABLE 2. Distribution of Ethical Problems Experienced by Pharmaceutical SalesRepresentatives According to Physician Type

Title ExcessivelyMany

Many Some Few Very Few Mean Std.Dev.

n ( %) n ( %) n ( %) n ( %) n ( %)

Academician 30 (17.0) 44 (24.8) 51 (28.8) 32 (18.1) 20 (11.3) 2.82 1.24

Specialist 29 (16.1) 53 (29.5) 65 (36.1) 25 (13.9) 8 (4.4) 2.61 1.05

Research Assistant 26 (15.2) 51 (29.8) 57 (33.3) 24 (14.1) 13 (7.6) 2.69 1.12

Practitioner 53 (29.4) 43 (23.9) 47 (26.1) 21 (11.7) 16 (8.9) 2.47 1.27

Specialist, Practitioner 29 (18.2) 43 (27.1) 61 (38.4) 17 (10.7) 9 (5.6) 2.58 1.08

Specialist, ResearchAssistant

10 (6.9) 34 (23.5) 71 (48.9) 22 (15.2) 8 (5.5) 2.91 0.97

Practitioner, ResearchAssistant

23 (15.3) 31 (20.7) 66 (44.0) 22 (14.7) 8 (5.3) 2.74 1.06

Specialist, Practitioner,Research Assistant

24 (15.8) 33 (21.7) 60 (39.5) 27 (17.7) 8 (5.3) 2.75 1.09

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sentatives in this study tended to be somewhat selective. When asked todescribe their frequency of this kind of clarification by using the wordsalways, sometimes, rarely or never, 10.7% (23 PSRs) said “always,”32.1% (69 PSRs) said “sometimes,” 21.4% (46 PSRs) said “rarely” and35.8% (77 PSRs), the largest subgroup, said “never.” These proportionsapplied regardless of participants’ gender, years of work experience, oreducational level, with no statistically significant differences beingfound in terms of these criteria (p > 0.05).

Tables 3-7 show how participants responded to three separate rankingtasks, the results of which are all presented here with the same analyticmethod. In the task summarized in Table 3, participants were asked to rankthe factors determining physician responsiveness to the suggested use of a


TABLE 3. Factors Determining Physician Responsiveness to Suggested Use ofa Drug, as Perceived by Pharmaceutical Sales Representatives

DEGREE OF IMPORTANCE WEIGHT*

FACTOR 1stDeg.

2ndDeg.

3rdDeg.

4thDeg.

5thDeg.

Total % Rank ByImportance

(1 = Highest)

Representative’s gender 60 12 24 12 7 115 3.6 11

Representative’s personalappearance

85 52 39 38 18 232 7.2 5

Representative’s persuasiveness 200 132 87 66 19 504 15.5 2

Representative’s educational level 65 104 36 30 18 253 7.7 4

Image of the drug firm 305 152 102 32 24 615 19.6 1

Providing detailed information about drugs 190 152 72 48 21 483 15.0 3

Leaving drugs as samples 10 32 48 26 24 140 4.2 9

Panels and conferences to advertise drugs tophysicians

30 60 57 40 19 206 6.3 6

Advertisement brochures 5 8 30 14 7 64 1.9 13

Promotions and gifts 50 64 33 36 11 194 6.0 7

The fact that a drug you presented is lessexpensive than its rivals

10 4 21 18 12 65 2.0 12

The fact that a drug you presented has less sideeffects than its rivals

15 28 39 34 13 129 3.9 10

The fact that a drug you presented is indicated formore disorders than its rivals

0 4 27 14 5 50 1.5 14

The fact that your drug is well known and used 50 56 30 22 15 173 5.3 8

The fact that a comparable drug is not known bythe physician

0 0 0 0 2 2 0.4 15

TOTAL 3,225 100

*Weighted Total = (1. degree frequency � 5) + (2. degree frequency � 4) + (3. degree frequency � 3) + (4. degree frequency � 2) +(5. degree frequency � 1).

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drug, in descending order of importance. Responses to a given factor werethen expressed as a weighted sum of the frequencies at which that factorwas ranked in the top five by the participants. In Table 3, for example, gen-der was ranked first in importance by 12 people, second by 3 people, thirdby 8 people, fourth by 6 people, and fifth by 7 people. These numbers werethen each multiplied by 5, 4, 3, 2 and 1 respectively, to get the figuresshown in the table. These multiples were then added to give the weightedsum for the factor of gender, which in this case was 115.


TABLE 4. Problems Encountered by Pharmaceutical Sales Representatives


Problems 1stDeg.

2ndDeg.

3rdDeg.

4thDeg.

5thDeg.

Total % Rank byImportance(1= Highest)

Bargaining on which drugs should be prescribed 285 220 87 32 9 633 19.6 2

Paramedical requests (free lab test kits, etc.) 400 224 51 34 8 717 22.3 1

Unscientific considerations by physicians inprescribing drugs

85 52 180 20 13 350 10.9 4

Difficulties in making appointments for salesvisits

30 28 36 42 8 144 4.5 6

Physicians’ requests for gifts other than medicalproducts

40 96 117 98 27 378 11.7 3

Physicians’ personal interests influencing drugselection

70 36 63 90 42 301 9.3 5

Lack of respect by physicians 25 32 27 14 15 113 3.5 7

Physicians’ lack of knowledge about thepharmaceutical sales representative profession

20 24 21 26 13 104 3.2 9

Physician requests for drug companysponsorship

5 56 6 20 26 113 3.5 8

Physicians’ career changes 5 0 9 2 4 20 0.6 16

Physicians writing prescriptions exclusively forone firm’s drugs

20 12 0 14 11 57 1.8 13

Personal relations between physicians andpharmaceutical sales representatives

15 16 0 8 6 45 1.4 14

Unmet demands for sponsorships forconferences, journals, etc.

20 16 21 6 3 66 2.0 12

Physicians’ lack of willingness to communicate 0 4 3 2 0 9 0.3 17

Physicians listening seriously, but ignoring thedrug when writing prescriptions

30 16 9 12 6 73 2.3 10

Physicians’ requests for additional promotions toconduct studies

15 16 15 8 18 72 2.2 11

Physicians’ requests for funding to includephysicians’ spouses at conferences

10 12 0 2 6 30 0.9 8

TOTAL 3,225 100


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TABLE 5. Relative Importance of Perceived Sources of Ethical Problems Encoun-tered by Pharmaceutical Sales Representatives


Perceived Sources ofEthical Problems

1stDeg.

2ndDeg.

3rdDeg.

Total % Rank by Importance(1 = Highest)

Due to the structure of the profession 84 38 23 145 11.2 4

Due to communication abilities ofpharmaceutical sales representatives

30 38 24 92 7.1 7

Due to educational status ofpharmaceutical sales representatives

30 42 37 109 8.4 6

Due to physicians 183 92 44 319 24.9 1

Due to lack of ethical rules regardingemployees in their profession

180 78 30 288 22.3 2

Due to the ways hospitals or healthfacilities function

72 90 37 199 15.4 3

Due to management structure ofdrug firms

66 52 20 138 10.7 5

TOTAL 1,290 100

*Weighted Total = (1. degree frequency � 3) + (2. degree frequency � 2) + (3. degree frequency � 1).

TABLE 6. Weighted Ranking of Potential Solutions of Ethical Problems Encoun-tered by Pharmaceutical Sales Representatives


Potential Solutions toEthical Problems

1stDeg.

2ndDeg.

3rdDeg.

4thDeg.

5thDeg.

Total % Rank byImportance

(1 = Highest)

Training of PSRs 170 156 105 50 31 512 15.9 3

Understanding by physicians regardingPSR visits

335 240 90 60 12 737 23.0 1

More promotions to physicians 55 64 87 42 40 288 8.9 5

More incentives from firm managers toPSRs

70 120 129 78 19 416 12.9 4

No more promotions and gifts fromfirms

385 140 72 56 35 688 21.3 2

Involvement of PSRs in firm manage-ment

0 24 12 38 41 115 3.6 8

Getting rid of physicians’ misconceptionsof the profession

30 56 63 28 17 194 6.0 7

Raising PSRs’ social status 0 32 24 4 7 67 2.0 9

Facilitated entrance to hospitals andhealth facilities

30 28 63 74 13 208 6.4 6

TOTAL 3,225 100


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Regarding the factors that influence physicians to prescribe a particu-lar firm’s drugs, the one ranked highest by the most pharmaceuticalsales representatives (19.6%) in this study was the image of the drugfirm. Participants stated that a pharmaceutical sales representative’spersuasiveness influences sales (15.5%) and that pharmaceutical salesrepresentatives with good persuasion skills sell more. Participants saidthat having detailed drug information influences physicians (15.0%).The educational level of the pharmaceutical sales representative (7.2%)and personal appearance (7.2%) were also reported to play a consider-able role in terms of attracting the physician’s attention.

As seen in Table 4, among the various physician-related problems en-countered by pharmaceutical sales representatives, the one they rankedhighest was paramedical requests (for free lab test kits, small medical de-vices, and other non-drug items). They affirmed that they had to bargainon which drugs (in terms of brand names vs. generic) should be pre-scribed, and ranked this problem second. Requests for gifts other thanmedical products came in third place, unscientific considerations came infourth, and ranked fifth was the perception that personal interests wereimportant in a physician’s selection of drugs.

Table 5 shows the relative importance of the participants’ perceivedsources of ethical problems in encounters with physicians. The most im-portant perceived source, with a 24.9% share of the total, was physiciansthemselves. This was followed by the lack of ethical rules regarding em-


TABLE 7. Physicians’ Preferences for Promotions, as Perceived by Pharma-ceutical Sales Representatives

DEGREE OFIMPORTANCE

WEIGHT*

OpinionsConcerningPromotions

1stDeg.

2ndDeg.

3rdDeg.

Total % Rank by Importance(1 = Highest)

Giving drug samples with no charge 99 50 21 170 13.2 4

Sponsorship for international anddomestic scientific conferences

135 80 44 259 20.1 3

Assurance of participation inscientific conferences

84 158 55 297 23.0 1

Distribution of brochures, magazines andbooks concerning the drugs

84 36 41 161 12.5 5

Invitation to dinners and cocktails 18 66 39 123 9.5 6

Distribution of large and smallparamedical gifts

225 40 15 280 21.7 2

*Weighted Total = (1.degree frequency � 3) + (2. degree frequency � 2) + (3. degree frequency � 1).

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ployees in their profession (22.3%), and the ways in which hospitals orhealth facilities function (15.4%).

Regarding the overall resolvability of ethical problems, participantswere asked to give their opinions in terms of a five-level Likert Scale(overall mean = 2.70, Std. Dev. = 0.94). Nearly half (48.4% or 104 par-ticipants) agreed that ethical problems “can be resolved,” followed by27.9% (60 PSRs) who chose “will be resolved,” 10.2% (22 PSRs) whochose “will definitely be resolved” and 8.8% (19 PSRs) who chose“cannot be resolved.” Only 4.7% of participants (10 PSRs) said that eth-ical problems “can definitely not be resolved.”

When the means of female PSRs and male PSRs were compared regard-ing the resolvability of ethical problems, no statistically significant differ-ences were found (female mean = 2.58, Std. Dev. = 0.80; male mean =2.76, Std. Dev. = 1.0) (t = -1.38, p > 0.05). No difference was found be-tween PSRs with less than 10 years of work experience (mean = 2.69, Std.Dev. = 0.92) and those with 10 years or more (mean = 2.73, Std. Dev. =1.04) (t = 0.74, p > 0.05), nor between PSRs with less than four years ofcollege (mean = 2.75, Std. Dev. = 0.97) and those with four years or more(mean = 2.65, Std. Dev. = 0.91) (t = - 0.19, p > 0.05).

When asked for possible solutions to the ethical problems they hadencountered in drug marketing, 23% of participants in the study gavefirst rank to an increased understanding on the part of physicians con-cerning visits of PSRs. Ranked second (by 21.3% of participants) wasthe idea of discontinuing all promotions and gifts by all firms. Trainingof PSRs, the need for firm managers to present more incentives to PSRs,and the provision of more promotions to physicians ranked third, fourthand fifth, respectively, as potential solutions. Interestingly, while phar-maceutical sales representatives ranked a lack of education as sixthamong sources of ethical problems with physicians, they ranked educa-tion third among potential solutions to those problems (see Table 6).

When asked to rank the various forms of drug promotions in terms oftheir importance to physicians, pharmaceutical sales representativesgave first place to the assurance of participation in scientific confer-ences (23.0%). Large and small gifts came second (21.7%), and spon-sorship for international and domestic scientific conferences was rankedthird (20.1%). The distribution of educational materials (brochures,magazines and books) was ranked fifth in terms of perceived impor-tance to physicians, which is somewhat lower than might be expectedwhen considered in context with the priority given to participation inscientific conferences (see Table 7).


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DISCUSSION AND SUGGESTIONS

The implications of this study for future studies include the possibil-ity of taking a nationwide sample, and of taking into account the age andsex of participants as well as the size of the pharmaceutical companythey work for. These would contribute to a greater generalizability ofresults, with the overall goal being that of identifying phenomena thatcan be compared across countries. In particular, the physician/pharma-ceutical representative situations in developing countries might be ex-amined in terms of their similarity to those in the more developed,market-driven countries such as the United States, as a reflection of eco-nomic similarity to developed countries in general.

Firms that produce drugs market them vigorously. The most impor-tant targets for marketing by drug firms are physicians who can pre-scribe the drugs and thereby get them to the actual consumers who drivethe whole process. Drug firms have to keep their relations with physi-cians good so as to increase their market share. This is the fundamentalreason for employing pharmaceutical sales representatives in the mar-keting of drugs. Recently it has been observed that drug firms prefer tohire representatives who have sophisticated marketing insight in addi-tion to experience with pharmaceutical products, and who can combinethese to compete successfully.

While the marketing of a drug is important for drug firms, the thera-peutic value of a drug is significant for physicians in terms of professionalsuccess. Pharmaceutical sales representatives bring these two aspects to-gether. It is their job to present their firms’ drugs to the best advantage,but they also play a key role in providing physicians with information onnewly released drugs. An environment of fierce competition has grownup among pharmaceutical sales representatives marketing their firms’drugs, and physicians’ expectations have evolved along with this envi-ronment. Together these have given rise to ethical quandaries in the rela-tions between pharmaceutical sales representatives and physicians.

In the present study, most pharmaceutical sales representatives (53.0%)said they visited physicians once or twice a week, and the most commonlength of visit was 6-10 minutes in duration (40.5%). This suggests thatrelatively short visit-times achieve the greatest overall quantity of visitsto physicians. Also, it would be more efficient for both physicians andpharmaceutical sales representatives to adjust the time of visits in accor-dance with the least hectic days and hours. The management of firmsand hospitals can coordinate their efforts in this regard by specifyingvisiting days and hours for pharmaceutical sales representatives.


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Approximately 78% of pharmaceutical sales representatives statedthat they always give information to physicians about drugs, and 21.4%of them said that they sometimes give information about drugs. While35.8% of pharmaceutical sales representatives stated that they never in-formed physicians about the deficiencies of their drugs in comparison tothose of rival firms, 32.1% said that they do. Nearly all pharmaceuticalsales representatives in the study (96.7%) affirmed that they encoun-tered ethical problems in their relations with physicians.

The obligation of bargaining with physicians in order to have theirdrugs prescribed is one of the most important ethical dilemmas for phar-maceutical sales representatives. Participants reported that physiciansinclude non-medical considerations in their dealings with pharmaceuti-cal sales representatives that they request gifts other than medical prod-ucts, that their interests are not always guided scientifically, and thattheir choices of which drugs to prescribe can be influenced by personalinterests. Conflicts of interest arise in both parties, and ethical problemsare the result. However, patient satisfaction is the goal of both sides andthis presents a basis for resolving these conflicts.

According to pharmaceutical sales representatives, physicians arethe primary source of ethical problems encountered in the pharmaceuti-cal sales representative-physician relation. Other sources indicated byparticipants were a lack of ethical rules for their profession and the oper-ational procedures of hospitals and health facilities. Participants saidthat the most important way to solve ethical problems in their relationswith physicians is to help physicians better understand visits by phar-maceutical sales representatives. Other highly ranked suggestions in-cluded doing away with promotions and gifts by all firms, trainingpharmaceutical sales representatives, offering more incentives to phar-maceutical sales representatives and increasing promotional efforts to-ward physicians.

When ranking their promotional efforts, pharmaceutical sales repre-sentatives gave first priority to ensuring physicians’ participation in sci-entific conferences. This was followed by large and small paramedicalgifts (lab test kits, etc.), and sponsorship for physicians to participate ininternational and domestic scientific conferences. Promotional methodsshould remain within moral boundaries, with a view to the scientificvalue of drugs and the increase of drug prices in step with promotions. Itshould be kept in mind that while promotional campaigns influencephysicians, the ultimate measure of a drug’s success is the benefit that itprovides to patients.


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Societal patterns of behavior must be consciously chosen in order toprevent ethical problems from arising between pharmaceutical salesrepresentatives and physicians. From the standpoint of physicians, sug-gestions could include the following. Physicians should consider drugsscientifically; physicians should give priority to the interests of patients;physicians’ salaries could be augmented with incentives provided frompublic funds; scientific studies could be funded publicly rather than pri-vately; activities for the training of physicians such as congresses andsymposia could be organized by professional societies; participation inmedical training programs as a speaker could be determined by theTurkish Union of Physicians instead of drug enterprises; frequency andduration of pharmaceutical sales representative visits could be regu-lated through cooperative efforts by health facilities and drug firms.

From the standpoint of pharmaceutical sales representatives, sugges-tions include the following. Professional organizations to hold pharma-ceutical sales representatives accountable are needed, and universalstandards for the profession should be determined. Pharmaceutical salesrepresentatives should be receive thorough education and job training,and in the interest of the public and their own future business landscape,drug firms could provide financial support for the education of pharma-ceutical sales representatives. However, as this could lead to an increasein drug prices, just as public support of physicians and drug researchmight shift the financial burden of drug production without increasingits efficiency, it appears that these issues will ultimately be decided bythe societal array of priorities that collectively make up the health careeconomy.

REFERENCES

Atay, O. (2001). Place and Problems of Drugs in Health. Yeni Türkiye Newspaper,Health Special Edition II, Year: 7, Issue: 40, Ankara.

Eczacibasi, B. (2001). Political Interventions Should End so as to Be Protected fromNew Crises, Yeni Türkiye Newspaper, Health Special Edition II, Year: 7, Issue: 40,Ankara.

Gaedeke, R. M., Tootelian, D. H., Sanders, E. E. (1999). Value of services provided bypharmaceutical companies: Perceptions of physicians and pharmaceutical salesrepresentatives. Health Marketing Quarterly, 17(1):23-31.

Guven, C. K. (1990). Code of Laws Concerning Drug, Istanbul.Kisa, A. (2001a). The performance and problems of the Turkish pharmaceutical indus-

try: Is there a need to develop a national drug policy? Journal of Medical Systems,October; 25(5):309-18.


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Kisa, A. (2001b). The Turkish Commercial Health Insurance Industry, Journal ofMedical Systems, August; 25(4):233-9.

Kisa, A. (2002). Financing Healthcare for the Poor: An Examination of the TurkishGreen Card Case, Proceedings Book, Editor: David Paul, American Business andHealth Administration Association, Chicago, IL, February 27-March 1.

Kisa, A., Kavuncubasi, S., & Ersoy, K. (2000). Is the Turkish Social Insurance Organi-zation Ready for the 21st Century, in Proceedings of Local Healthcare, GlobalMarkets: An International Conference on Healthcare Systems for the New Millen-nium, Ashish Chandra, Editor, 29-32.

Kisa, A., Kavuncubasi, S., & Ersoy, K. (2002). Is the Turkish health care system readyto be a part of the European Union? Journal of Medical Systems, April; 26(2):89-95.

Lexchin, J. (1993). Interactions Between Physicians and the Pharmaceutical Industry.What Does the Literature Say? Canadian Medical Association Journal, 15 Novem-ber, (149), Toronto.

Savas, B. S. et al. In Thomson, S. & Mossialos, E., eds. (2002). Health care systems intransition: Turkey. WHO, Copenhagen, European Observatory on Health CareSystems, 4(4).

Semin S. (1998). Drug in Its Social and Economic Dimension, Turkish Union of Physi-cians, Ankara.

Syndicate of Drug and Chemical Industry Employers. (2000). Activity Report 1999,Mem Ltd.

Tengilimoglu, D. & Korkmaz, S. (2000). Sales Management in Drug Marketing: Prob-lems Originated from Relation of Medical Sales Representative and Physician, 5thNational Marketing Congress Poster Statement, November 16-18, Antalya.

Wall, L. L. & Brown, D. (2002). Pharmaceutical sales representatives and the doctor/patient relationship. Obstetrics and Gynecology. September; 100(3):594-9.


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the pharmaceutical sales rep/physician relationship in turkey

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