Tuesday, January 23, 2007
Drug Rep Rant
I'm not a big fan of pharmaceutical reps. I make no secret of that. I know that they have their place in the huge (failing) US health care system. If for anything else, they bring sample meds for those of my patients who cannot afford them and who do not qualify for indigent medication programs.
I think my real issue is that I have never liked sales people whether it's selling me a car, or selling me a pair of shoes, or selling me a drug. For the most part, sales people don't really care about you and they don't care about my patient. All they care about is one thing - Dr. A prescribing their product.
Our office has drug reps bring in lunch 2-3 days a week. For me, I'd rather go home for lunch, and not have any drug rep lunches - EVER. But, out of courtesy for bringing lunch for the office, I go into our lunch room with a smile on my face.
The rep then starts with her dog and pony show. The product today is insulin. I get to see all the funky charts and graphs of why their product is better than the others. I'm also shown the recommendation THE some ivory tower commission recommending starting insulin earlier in the treatment course for diabetes.
Then, as I'm quickly eating my lunch, I feel my muscles tense up a little bit as they reach "the ask" where they try to get a committment from you to at least give their product a try. I always hate this part of the lunch.
I inform them how difficult it is to at least talk about insulin with some of my patients. There's a lot of myths that I have to deal with when it comes to insulin therapy.
"But Doctor A, my product is so easy for patients to use. You can proudly tell them that they hardly ever feel the needle. And, isn't my product so much easier to take than the many pills that you have your patient on?"
As I always do, I give a fake laugh and tell them that they have made good points. I also tell them that I will keep their product in mind. Then I scurry out of the room....
I get back to my office and close the door. I'm fuming at this point. How dare this rep come in my office and push a product on me! Of course, I know that insulin is better to start earlier rather than later. I've seen the data on this.
One of the things I've always wanted to do is to bring in a rep with me and say, "Ok, Mr. V is in room 3 and I think he needs to be on insulin. I don't want you to come out of that room until he's agreeable to start insulin." See what I go through everyday, not just once a day, but several times a day.
"But, Mr. V, you won't even feel the needle. And, it's so much easier than all the pills that you're taking." That thought makes me chuckle.
Good primary care docs have a rapport with patients. The age of paternalistic medicine is over. Gone are the days where the doc says take this medicine and the patient did it. Patients are more knowledgable about medicine and the meds that they take. They hear about side effects from friends, from drug store printouts, from television, and other sources. Don't get me wrong, more knowledge is good.
There's also a lot of misinformation and myths out there, especially about insulin. Many of my patients think insulin therapy is equal to hospice care - means that nothing else can be done and they will die soon. Many cringe at the thought of giving themselves an injectable medicine.
Sometimes, it can take months and months of communication. I have to understand where the patient is at and hopefully they understand my point of view when it comes to insulin. Drug reps have this TV show mentality that everything is solved during the 10 minute office visit with a prescription for their product in hand. Sorry, it doesn't work that way.
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The one plus side is that this has given you a push out of your writer's block. :)
By the way, we need more doctors like you.
What to do when your GP breaks that rapport trust, and lets you down. And have nowhere to turn, medically speaking.
Film at '11!
He didn't fail in his skill, technique, or expertise; he failed ME, as his PATIENT, in something that . . . . well, anyway, I'm on my own.
NOT looking for advice that way here, of course, but I thought it might make an interesting blog topic for you (not me specifically, but the problem in general). I've been with him since he finished residency, 16-17 years ago. I'm not about to leave him. It's one of those things where, after mulling it over, I still think he failed me, but I also think it's possibly not something he's aware of, although if I get the courage to mention it I think he'll see what I mean.
ANYWAY! The smarminess of the whole drug rep thing, would drive me nuts.
while it’s quite easy, and popular, to bemoan those evil pharmaceutical companies for their marketing practices, this is ignorant of the reality of business. for every herceptin, gleevac and prozac, there are a hundred failed chemical compounds that eat up resouces, lab time, and most importanly, and forgotten by the public, cash. in order to recoup that incredible lost money, they are required to charge seemingly exorbinant prices and outlandish advertising. the end result of limiting the companies income, would be a sharp, drop in the outuput of life saving drugs.
a patient point of view...not related to insulin or drug reps. I have always been very fortunate to have great health benefits with excellent insurance companies. However...good Primary Care Docs are few and far between. Even if you are able to find one that is still taking new patients the chances of building a repertoire with them are rather low. They just don't have the time. The thought of "months and months of communication" is unheard of. It seems like you are a great doctor for your patients... I'm just saying.
I can see how salespeople piss you off but not all salespeople are just looking to make a buck.
I currently work in a gift shop and I dont just try to push crap on customers.I strive to assist the individual to pick out a proper gift for them.I try to help them and sometimes some of my customers have become my friends too.
I really enjoyed this post. Thanks for sharing a little of the day-to-day Dr. A. I look forward to more of the same.
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Find out the answer at Jonny Rage (http://jonathanrage.blogspot.com).
I liked this post. And for the record, I'm commenting at nearly 5am because I cannot sleep. Maybe this is partially due to the fact that somebody at work has been reading my blog while at work (stressful, and I blogged about it) and also because I worked until 11pm tonight and got home after midnight and can never unwind that easily. I fell asleep for like 30 minutes and then woke up and have been awake ever since, so I decided to catch up on some blog-hopping.
I can see also what wealthandtaste is saying about pharmaceutical research, and I think there are some drug company commercials that try to show this to the public - about how the researcher is inspired by their grandparent with alzheimers and the like. I do agree that probably a lot of the chemists and researchers are inspired in the same ways that we are inspired to go into medicine and nursing because of various stories and reasons. But still - the drug pushing that goes on still borders on criminal sometimes!!
I used to work in research at the headache center where I also go as a patient - although I was volunteer. Not gonna get into that aspect right now. So anyway - I was there through countless drug lunches. At one point, I remember sitting and eating my lunch and just overhearing this drug rep offering my former neuro tickets to Phillies games for box office seats and all this stuff. Now - I like to think he declined because this is his integrity and not because I, his patient, was also at the table. I really think that he's not the type to accept things like that. But it was just hard to listen to. Even though you can accept those things and then still choose not to listen to the drug reps and prescribe their drugs, doesn't one feel guilty if they go and enjoy the box office seats and then pick the other drug? I dunno... I'm glad I don't have to make that moral choice. I might write with a neoprofin pen I got from a drug rep, but I'm not picking whether to give that or indomethacin to my baby - the docs are!
Some of us who go to the headache center used to have this running joke that the center's psychiatrist's kids must have their college education funded by Eli Lily based on prescriptions of Concerta. (I think that's who makes concerta....no?) He seemed to have almost all his patients on it!! I went on it for a genuine reason because my brain had been obliterated (or so it seemed) by the topiramate. And then that one - a ton of research studies have come out of the center regarding the efficacy of topiramate for migraine and other headache types. I would wager a guess that a lot of those were funded by the drug company that makes topamax! Now - I won't say that for sure because I'm not currently taking the time to look it up.
I remember going to this one conference for the American Headache Society and walking around looking at the poster presentations. I was standing in front of a few in a row on topamax and this one rep from the drug company started to talk to me. So I got into it - because I hate topamax - and started saying how I feel the effects on memory and concentration can be quite prohibitive for some patients. (Wayyyy back when I first started on topamax, the effects on cognition were listed as "rare".) The drug rep says to me, "Well the data now is showing that it only effects 1 in 5! Isn't that great?!" Oh yea....1 in 5 people on your drug gets so stupid that they might lose their job or fail their classes - I think that's wonderful.
Now I know the drug does wonderful things for temporal lobe epilepsy and some with migraine have found true bliss with it. I just have been one with a bad experience.
So here's another drug-related question. If you, as a physician, were to personally have a bad experience with a medication and its side effects - do you think it would in any way alter your prescribing of the drug, even unintentionally? I had to give topamax to an infant recently, and I had to cringe the entire time I was doing it, even though I knew the baby needed it! I don't know what I would think if I were a doc and prescribing for headaches. But it is an interesting ethical dilemma, you must admit!
Anyhow - gonna try to get some sleep. I haven't had a sleepless night in awhile, and I'm so tired that you'd think I could sleep like a rock! Wish me luck! lol
Who's in charge of your office? Why do you have to go listen to a rep if you don't want to? Is your staff pressuring you for the free food? I agree with your observations, but I've gone a step further and acted on them. Life is too short to spend time fuming about encounters you don't really have to have.
I won't even get into the pharma canard about "all the failed compounds" accounting for exhorbitant drug prices. Most of that research is done at public expense through federal funding of academics, which is then patented and financially exploited by pharma. The biggest single line item on the pharma budget -- after "profit" -- is Marketing. R&D is way down the list.
Damn; you got me started. Now I shall stop.
Dr. A. totally off topic but I wondered if you are having problems getting in to Bobby's site? I try and nothing. It's like it is completely gone! I was wondering if maybe he is having PC problems?
i used to sell different sorts of products before, so i can have allowance for school. money that i will never have if i don't sell anything.
it might piss other people off if i tell them about the products i sell, but i will never sell anything if i never tell anyone.
dr. A, i know where you're coming from, and i agree with why you are fuming mad at how insistent some reps are. to save you the trouble of feeling negative things about the rep, here's my unsolicited advise: you can try looking at the whole situation this way: they are just doing their jobs, because if they don't, they would be lousy employees, and will not make money that they need.
i know it takes a lot not to be rude to sales people, because really, why would we listen to someone tell us about something we don't like or need? but it wouldn't really hurt to just politely say no either. so you may be fuming mad, but at least you have the decency to be polite. that still makes you a good person. so, i think what i'm saying is: keep up the fake smile, with a real good intention. you are making one rep's life less miserable. you make a difference!
I probably spend way too much time with the reps in our office, especially if they bring lunch, but I have a canned response as soon as a rep pressures me to "try just one patient" on his/her product: "I am unable to predict the type of patient I'm going to see over the next several days, nor can I determine in advance if your product would be appropriate for my patient. So, no, I will not promise you that I will write for your product within the next several days -- or if at all. Thanks for lunch and your time." Smile graciously. The change from the discourse we had prior to the question is so obvious, even the most determined rep realizes he's crossed the line. That "hard sell" turns me off EVERY time.
Keep up the good work -- and don't be tense regarding those lunches 'cause you'll end up with indigestion!
I enjoyed this post also. I can't really comment on the intricacies of the exact situation as I an not a doctor but I suppose this may be a place for you to practice your diplomacy skills?
I would think of the pharm. reps as tools. Use them for what you need and don't allow them to irritate you if you can.
I don't know, I would sit through just about anything for a free lunch but I work in a non-profit and am broke. I should have gone to med school when I had the chance.
It must be highly annoying sitting through all that thrice a week, I agree that pitching it to the patient is not quite so simple as pitching it to the doc.. Even when the reps are right.(most drugs-you gotta wonder about, they're probably not even as effective as older/proven ones) It's also kind of sad(to me,anyway) said patients' viewpoint regarding insulin injections(though common) maybe they need to see examples of people living a long + healthy life on it. I'm sure you have a few model diabetic patients you could use as examples.. Either that, or I can come over and knock some sense into their heads.
Actually my sense is that federal funding for research has been declining and the privately funded studies by the drug companies are picking up this slack.
The free marketeers might see this as a good thing, but it's a little like allowing the fox to guard the henhouse, no?
You would be surprised at how the pharms pitch their products to the news media, even out here in Podunksville. They know my name; they have my phone number; they know my e-mail address. At various times they've sent me trinkets such as a pen shaped like a hypodermic needle, a snow globe containing faux drug capsules, etc. etc. The mind boggles at the waste of money.
I agree with the doctor,drug company's are greedy,and so are the reps.As far as insulin goes,I wouldn't rush people that fear the needle. I would tell them to read diabetic magazine,so they can read,and learn about people that use the product,so they will feel more comfortable about insulin shots.Ive been on Insulin for almost 7-years now,for my type 2.
and that helped me into insulin shots. Robert
As a person with type 2 diabetes, I currently have an AC1 of 5.1 ....WITH oral medications (not insulin). My doctor(a family practice doctor that I have seen for the past 20 yrs) knows my preference is to stay away from shots for as long as possible, but that I am also committed to staying healthy without complications even more. One day, as the disease progresses, I may have to consider other meds or shots to control my diabetes..but for now I dont...and for that I am thankful. In fact, he suggested that as I continue to loose weight, that we might consider just diet and exercise alone (without meds). Not everyone that has diabetes needs insulin right off the bat. Different things work for different people differently. There is a saying that "your mileage may vary" where treating diabetes is concerned. This certainly is true as what works for me might send someone else's blood glucose through the roof and vice versa. No one could convince me that a shot would be less painful and more convenient than the two pills I take twice a day. The only thing that would convince me insulin might be a better choice for me would be seeing my AC1 and daily numbers rise to an unacceptable level where my diabetes could not be controlled with just oral meds, diet and exercise. I would be offended if I was treated like a piece of meat when I went into the Dr's office...where it might be assumed that one size fits all in treating patients. Thankfully my Dr was sensitive to this and listened to me as he offered his expertise in treating me.
I'm not the first to notice: The funk is ovah!
But I'd balk at sticking myself too.
Cool blog. I hate sales reps, too.
Fortunately, I have a terrific MD (Internist) but because I've lost my job and my husband's insurance stinks we're going to have to switch to an HMO. Gasp!!! I guess I'll be going to Mexico along with my friend to obtain our meds because the price is sooooo high here.
I concur with the previous writer about Topamax ("Dope-a-max").
Thanks for your blog and giving us an opportunity to see things from the other side of the stethoscope!
Wow! I had no idea that drug reps are that intrusive. It sure seems to pay well-- I teach criminal law at a law school, and a few of my students became drug reps instead of defense attorneys or prosecutors. I thought that was sad at the time, but now it seems even sadder.
If the drug rep causes this must internal angst, tell the jerk that NO, you're not gonna have the free lunch today. Sorry, but to come online and sulk about it just doesn't make sense to me.
I hope you're not dissing the funky charts and graphs, as my life's work is to churn out the data to support them. I probably made the ones for the competing products, too. Amazing what you can do with data. ;)
the way the reps do it is by providing lunch for the entire office, i.e. the nurses and secretaries too.
then if you tell the rep to f off, you're the bad guy and everyone hates you. fiendishly clever, really.
As a pharmacy technician, and also as a friend of a drug rep, I have conflicting opinions on this subject. I have sat through many a drug rep spiel. Most of the time it was just in one ear and out the other, while I wondered to myself if this rep had ANY idea what, exactly, their so-called "miracle" drug actually did. Do the drug reps really know what other treatment options are out there? Do they understand the differences between their product and the "competition"? I had a rep come in pushing Synthroid, of all things!!! I mean, come on. So when I mentioned something about levothyroxine (generic drug name of exact same above-mentioned drug) she gave me this blank look and asked me what that was!!!!
I do agree however, that drug reps do have their place if they are well-trained, well-informed and NOT ex-lawyers, ex-Arts grads, etc. It's sad that one of the only stipulations Pharmaceutical companies have for hiring drug reps is that they have graduated with a degree. They don't care WHAT degree. You could get a degree in "dog walking" and they would consider hiring you. I think the pharmaceutical companies need to re-think who they hire and get some knowledgable people instead of just the "hotties".
I think that doctors are much more at fault for the cost of rising health care. They cap the number of doctors in med school and residency to keep the cost high.
Uncap those med schools....let more doctors graduate and compete.
As for sales people....sounds like you are a terrible sales person when it comes to selling the patient on taking his drug. Let's face it...we are ALL SALES PEOPLE.
A teacher sells education...study hard to children/parents.
A lawyer sells their service.
A taxi sells rides.
Everyone in America is envious of those that make money and doctor...your head is on the block now that you thrown away your human shield...the drug rep...
I will see your head rolling soon.
I must be in the minority. I have never been upset by having a drug rep. visit. I think they try to be nonintrusive. Although most of the time they have not been great resources for knowledge I appreciate having samples to provide patients who are short of funds or coverage and especially like to try a medication and prove its value for that patient before I ask them to spend their hard earned cash on it.
The patient education matierials have also been a value. Recently, the patient information provided on the new vaccine gardasil has allowed me to give information that my patients can take home to review with their daughters and make an informed decision about either requesting the vaccine or waiting till they are older.
I don't feel obligated to use their products because of any promotional lunch and I believe they all understand that a pizza is not going to change how any physician directs care for their patients.
It's not about the food, or the push to prescribe, it's about sharing information in an interactive environment. If you want a rep to shut up, tell them to shut up. Then share your concerns with them so they leave your meeting more informed. They will take your experience and insight to the next lunch. At the end of the day, or week, you can take or leave what a rep has to share. Hopefully, the information you get is worth a few minutes of attention. If not, at least you won't go away hungry. Just a thought from a rep who actually cares about you and your patients.
You are not doing anyone any favours by going to the luncheon as a 'courtesy' to the drug rep for providing the meal. I happen to be a drug rep but more importantly I'am a consumer. I hate to be sold and especially asked for a committment. How do I avoid this? I tell the rep. You would find less reps coming around providing lunch if you were honest with them about their products / therapeuic area. I have had doc's tell me they will not use my drug because it is just too difficult to dose and they don't have enough time in a day to explain the strategy to their patients. I get that. Im not there to make your lives anymore hectic than they already are. Im there to provide a service and if my service is not of value then I wont waste your time - but pls dont waste my time either. Some docs - especially GP's - have a 'know it all' attitude and shut down when a rep (who is clearly inferior in the eyes of MDs) is explaining the fundamentals of their product. Who else is going to provide you with up to date info? Journals? Colleagues? Doubtful - Take your head out of your ass and man up when you don't have any interest in the topic of the day. You will be doing yourself, the rep and your patients a huge favour.
It's interesting because I spent 14 years in the pharmaceutical industry with many of those as a rep. I'm retired from the industry so I can comment as an outsider now. Yes, there are some pushy reps out there but there are also many (usually very experienced) reps who are not pushy. I was one of them. I always used my time with doctors to share published clinical studies with them. Many doctors just don't have the time to keep up with all the journals so I approached my job as to help them keep up to date with some studies they may have missed. This was usually much appreciated. So it just depends on the rep. Most of the doctors I dealt with welcomed me whether they used my company's products or not.
Clint, that is the biggest crock of hooha out there. The "busy doctor" argument is a worn-out chestnut. All I have to say is, I wouldn't be a very good doctor if my best source of information was a drug rep. That would be just pathetic.
Dr. Anonymous, I think you posted a reasonable narrative of a drug rep visit, and I have been there many times, my brother. Amen to you.
You Have Now Been Sampled (Drug Reps, Part 2)
While the pharmaceutical industry’s image and reputation has suffered, and has been complicated with their declining profits due to a few reasons, these companies still apparently insist on keeping most of their gift- givers on board. Known presently as simply drug reps today, this job has become a vocation void of a sense of accomplishment, which will be described below.
So they may be named at times in different ways, these promoters will be referred to as drug reps, which number close to 100,000 in the U.S. presently, it is believed. The cost to the pharmaceutical industry of these employees is around 5 billion dollars a year. Income for each rep grosses close to or above 100,000 grand a year on average, along with great benefits and a company car, as well as stock options as they gladly work from their homes.
The main function these days of drug reps, I believe, is primarily to offer doctors various types of inducements of a certain value. The drug sampling of doctors may be considered an inducement, and a rather valuable one for the drug rep, as many believe that these samples are what ultimately influence the doctor’s prescribing habits over anything else, including statements from drug reps. This may be why the drug industry spends around 20 billion every year on samples.
While historically drug reps have used their persuasive abilities to influence the prescribing habits of doctors in an honest and ethical manner. However presently, most health care providers now simply refuse to speak with them, or have banned all drug reps permanently from their practices for a number of reasons, including the recommendations from their colleagues. It is possible that this may be due to the following reasons:
1. The doctors lose money. Doctors are normally busy, so their time is valuable. As a drug rep, you are a waste of their time. Yet they will accept your samples still. The credibility you possibly have as a rep is not considered anymore to be present in your vocation due to various controversies associated with the pharmaceutical industry, it is speculated.
2. Most drug reps in the U.S. are hired for their looks and their personality. As a result, many are somewhat ignorant in regards to anything that is clinically relevant to a medical practice, so doctors seem to know this and have responded in such ways. Most drug reps have college degrees that do not correlate with their profession as a drug rep, which is to say that the clinical training of drug reps is limited. In fact, many consider this of such a serious nature that an Act is presently being considered called the SafeRx Act that would certify pharmaceutical reps, and this would be mandatory. One main reason would be to ensure personal accountability for their tactics and statements, I believe, which may improve the quality and safety of their function in the medical community.
3. Many drug reps, it is believed, are void of any ethical considerations due to ignorance of what they are coerced to do or say to prescribers by their employer, and this allows them to embellish the benefits of their promoted products at times in addition to offering inducements to doctors. This is usually due to the rep being unaware of the consequences of their actions at times, yet at other times what reps say is with premeditated intent for potential financial gain for such a drug rep. Worse yet, due to pressure to keep their high-paying jobs, they always are anxious to please their superiors, who require them to offer various types of inducements to physicians that are designated targets of a particular drug company. Such tactics are especially true with the larger drug companies. These reps are in fact coerced to spend these individual promotional budgets assigned to them by their employer. While legally risky, the drug companies continue to dispense to their reps these large budgets reps have been forced to be responsible for dispensing, and are required to spend these budgets. In fact, so much emphasis is placed on this promotional spending, there seems to be an association between the money a rep spends and the progression that occurs with their career working for their pharmaceutical employer. Disclosure laws are being considered presently to mandate the release of all funds dispensed from pharmaceutical companies, which is to say to allow others to see where their money goes and who it goes to, as it is presently very secretive, overall. It is not unusual for a big drug rep to spend 50 thousand dollars a year for clinic lunches alone. In addition, drug reps hire doctors as speakers for certain disease states, and they find many other ways to spend this money they are required to spend.
4. Another issue is what is referred to as data mining. The American Medical Association sells this prescribing data on individual doctors to pharmaceutical companies, which allows them to track the scripts a doctor writes, and the data is free of the patient names. Yet the names the products prescribed are well illustrated and available to the drug reps. This allows reps to tailor their tactical approach with any given doctor, if they see the doctor at all during an office visit. Worse yet, doctors who greatly support the promoted products determined by this data allow reps to reward those doctors who favor the rep’s products that they promote, and this could be considered a form of quid pro quo. Laws are being considered presently to prevent this practice of allowing reps to have this data. Doctors are opposed to the data the reps have as well about them for privacy and deceptive reasons, so they say.
5. Overall, reps can be best described as far as their function goes with their profession is to, whenever possible, manipulate doctors with remuneration or other forms of inducements, as they also continue to sample such doctors along with others their promoted meds. Also, frequent lunches are in fact bought often for doctors’ offices and their staff as a method of access, primarily, as stated earlier with the money reps spend earlier for this type of function. Essentially, because of the income and benefits the drug reps receive that they would likely not be able to obtain with any other job, they are compelled to do such unethical if not illegal tactics mentioned earlier that they perhaps normally would not do in another setting. Usually these drug reps rarely refuse to implement such tactics encouraged to them by their employers.
6. Samples keep the prescriber from selecting what may be their preferred choice of med due to cost savings from samples left with a medical office by a drug rep. In addition, doctors are now being paid by prescription providers, which are called pharmacy benefit managers (PBMs) that are typically owned by a managed care company to have a doctor switch their patients to generic substitutes, if they exist, and this is often not disclosed to such patients. Apparently, these PBM companies are doing this in response to the activities of the branded drug companies, as they continue pay doctors often for various reasons, which are questionable in themselves.
It is likely that most drug reps are good and intelligent people who unfortunately are coerced to do things that may be considered corruptive to others in order to maintain their employment, ultimately. It seems that external regulation is necessary to prevent the drug companies from allowing the autonomy of drug reps that exists, with their encouragement, which forces the reps to do the wrong thing for the medical community, possibly. Clearly, greed has replaced ethics with this element of the health care system, which is the pharmaceutical industry, as illustrated with what occurs within these companies. However, reversing this misguided focus of drug companies is not impossible if the right action is taken for the benefit of public health. Likely, if there are no drug reps, there is no one to employ such tactics mentioned earlier. Because authentically educating doctors does not appear to be the reason for their vocation. This is far from being the responsibility of a pharmaceutical sales representative.
“What you don’t do can be a destructive force.” --- Eleanor Roosevelt
Complaining about it here while being unable to have an honest, decent exchange with the rep about the items that won't make you prescribe his product is avoidant and passive to me. If you are bothered by the lunches, why cant you just say no to these lunches. And if you want your staff not to be deprived of those lunches, well then welcome the lunches and the conversation with the rep but to appear very accomodating, smiling, while seething inside shows your disorder in interpersonal dealings. Something to think about. Be real, that's all. Heck, I've had a lot of reps through but they know that their lunches are not our handshakes. They are merely business and social necessities of each other's trade. That's fine with me. But I make sure I am the doctor and be forthcoming and honest without being rude to the guy/gal who are just doing his/her job.
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