MICHAEL J. OLDANI
Department of Anthropology
Princeton University
Thick Prescriptions: Toward an Interpretation
of Pharmaceutical Sales Practices
Doctors aren’t that corruptible.
The (drug) reps provide good information, and they are functioning
in a system where that is how you sell medicine.
The most comical thing is doctors’ attitudes. You will never hear a
physician say, “This is influencing me.” They are just so arrogant and
naive.1
Anthropologists of medicine and science are increasingly studying all
aspects of pharmaceutical industry practices—from research and devel-
opment to the marketing of prescription drugs. This article ethnograph-
ically explores one particular stage in the life cycle of pharmaceuti-
cals: sales and marketing. Drawing on a range of sources—investigative
journalism, medical ethics, and autoethnography—the author examines
the day-to-day activities of pharmaceutical salespersons, or drug reps,
during the 1990s. He describes in detail the pharmaceutical gift cycle,
a three-way exchange network between doctors, salespersons, and pa-
tients and how this process of exchange is currently in a state of involu-
tion. This gift economy exists to generate prescriptions (scripts) and can
mask and/or perpetuate risks and side effects for patients. With impli-
cations of pharmaceutical industry practices impacting everything from
the personal-psychological to the global political economy, medical an-
thropologists can play a lead role in the emerging scholarly discourse
concerned with critical pharmaceutical studies. [pharmaceuticals, gift
exchange, prescriptions, salespersons, North America]
Part I: Introduction
Critically engaged medical anthropologists have thus far told us very littleabout the everyday world of pharmaceutical salespersons in the UnitedStates and their interactions with health care providers. It is even more
striking that the first “detail man” appeared in America in 1850 (Smith 1968) and
Medical Anthropology Quarterly, Vol. 18, Issue 3, pp. 325–356, ISSN 0745-5194, online ISSN 1548-
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326 MEDICAL ANTHROPOLOGY QUARTERLY
that today there are an estimated 68,000 salespersons (Kirkpatrick 2000) promoting
products for pharmaceutical corporations in the United States. The historical depth
of this relationship requires a detailed ethnographic assessment of how the daily
interaction between “reps” and doctors not only translates into billions of dollars
of prescriptions annually but also how this constant commingling affects patient
care and modern health care in general.2
The central reason for the lack of anthropological literature on the drug rep
and the rep–doctor interaction is straightforward: anthropology has yet to ob-
tain regular access to the everyday world of drug reps.3 An examination of the
ethnographic literature on pharmaceutical sales practices in general reveals this
lack of access: there is a conspicuous gap concerning the day-to-day activity of
pharmaceutical salespersons. Nevertheless, other disciplines, such as investigative
journalism and the medical-ethics community, have provided early ethnographic
glimpses of pharmaceutical sales practices. Ethnographers of science and medicine
can build on these initial studies through long-term, critically based fieldwork and
present a more nuanced picture of sales representative activities. This article will
follow along these lines and provide an initial entrance into the everyday world of
pharmaceutical sales practices in the United States.
My access to the pharmaceutical sales environment is somewhat unique and
requires a brief explanation. I spent nine years working for a multinational drug
company (referred to as Company X in this article) as a pharmaceutical sales
representative, or what is more commonly used in the medical marketplace a
drug rep, or simply a rep, and occasionally what some still refer to as a “detail
man.”4 Near the end of my selling career in pharmaceuticals, I returned to grad-
uate school, completed my Master’s degree in anthropology, and have continued
on toward a doctoral degree in the anthropology of medicine and science. My
past circumstances have created an opportunity for me to autobiographically, or
autoethnographically (Moffatt 1992),5 explore pharmaceutical sales practices as
well as to develop and maintain contacts/informants throughout the drug industry
and medical community. Though much of what I present here can be characterized
as “memory ethnography,” I did begin to take field notes late in my sales career
for just this type of ethnographic investigation.6 Perhaps one advantage I have
today is that I can speak from the perspective as a former “native,” in the sense
that I understood and practiced the rules of the game (Bourdieu 1977), which
has been helpful for an anthropological understanding of the pharmaceutical rep–
doctor interaction as well as for ongoing work concerned with the health care
marketplace.
The major focus of this article describes what I call “the pharmaceutical gift
cycle” and how it operated throughout the 1990s at Company X and continues
to operate in a more general sense throughout U.S. health care, albeit in an al-
tered form. Much has been said about pharmaceutical gifts in both the media and
the medical literature. However, there has been little “thick description” (Geertz
1973) of these prescription-generating activities in the anthropological literature.
A modest goal of the descriptions below is to give readers a better idea of how
the social tools (and capital) of the pharmaceutical industry have impacted how
(and how often) prescriptions are generated for patients. Drawing from a variety of
sources, I focus specifically on the day-to-day activities of sales reps, who are the
key players (or brokers) within this exchange network. In particular, I concentrate