A Loss of Innocence: Ida Smith’s Story
At the beginning of my career, I was a field rep in Corpus Christi, Texas. I sold a variety of medications, including Haldol (haloperidol) for schizophrenia and senile dementia. My territory, with the exception of Corpus Christi, was primarily rural. It included several small towns in the outlying countryside. The demographics of the area were largely Hispanics and the elderly who came south for the winter months.
It was the end of the third quarter, and I was behind in my sales quota for Haldol. That meant forfeiting a significant amount of money from the bonus pool if I didn’t make quota. My territory was at somewhat of a disadvantage because I didn’t have the large number of psychiatrists the reps in other metropolitan areas such as Dallas, Houston, and Austin had. It occurred to me that the most common drawback/objection I received from the general practitioners I called on with this product was patient compliance. (Patients would frequently discontinue the medication because of its side effects.) So, I determined the best way to build my Haldol business would be to campaign for the institutionalized patient. These patients were not only encouraged to take the medication; they were actually given the drug. This completely eliminated the compliance issue.
I set about scheduling training in-services in the local nursing homes and mental health and mental retardation (MHMR) facilities. I increased my call frequency on physicians whom I knew to have nursing home relationships and directorship responsibilities. I littered these offices and institutions with every type of marketing tool known to man. You could not look anywhere in my territory that there wasn’t a clock, coffee mug, calendar, candy dish, scratch pad, or pen displaying the Haldol name.
During my so-called “Haldol Blitz,” I made weekly visits to my nursing homes. The nursing staff was very supportive and appreciated being the recipients of all the goodies and attention that was rarely placed on them. (Reps notoriously do not like to call on nursing homes or abortion clinics.) They began to eagerly recommend to doctors that patients be placed on Haldol and actually kept track of patients who were put on the drug to report to me on subsequent visits. I rewarded these facilities and staffs with catered-in lunches and gift certificatesto local restaurants.
In my routine visits to one particular nursing home, I met Mrs. Ida Smith. (I have changed her name to protect her privacy.) Mrs. Smith was a petite, fragilelooking woman in her late eighties. Her snow-white hair was always neatly coiffed. She also wore a bright red lipstick that contrasted starkly with her delicate, pale complexion. Ida was a whirlwind of activity in her motorized wheelchair. She was frequently seen motoring from room to room, checking on and visiting with other residents. It was apparent the nursing staff was put out with Mrs. Smith’s meddling. Ida often complained to staff about patients who were not properly being cared for. She was the self-appointed hall monitor and was not afraid to let people know she was watching. I got a kick out of observing the nurses’ reactions when Mrs. Smith would demand someone change a bedpan or IV bag that had been left unattended. She could definitely hold her own in a debate.
Mrs. Smith became a bright spot in my visits to an otherwise gloomy, depressing facility that reeked with the stench of urine and disinfectant. However, I called on the home one day, and Mrs. Smith was nowhere to be seen. Before departing, I questioned the head nurse about her. “Oh, Mrs. Smith, she’s had a bad patch lately,” she said. “Her friend in 17B died, and it really upset her. She hadn’t been sleeping well and seemed a little disoriented, so we recommended her doctor put her on Haldol. She’s doing a lot better now…sleeping through the night…not combative and quarrelsome like she used to be.” She concluded, smiling.(It was obvious she thought she was making brownie points with me.)
As I rounded the corner to the front door, I saw an attendant pushing Mrs. Smith in her wheelchair into her room. Her head was hung, and she was drooling on her pretty, pink gown. Mrs. Smith looked like a zombie. She was in complete disarray. Her hair was uncombed, and her signature red lipstick was missing. I felt a pang in the pit of my stomach. Had I been responsible for this turn of events? Surely, Mrs. Smith was not the patient-type for whom I had promoted Haldol. Or was she?
I exceeded my quota in all four of my products that sales quarter. Shortly thereafter, I was promoted to a hospital rep’s position in Houston for the Baylor College of Medicine. I would never see Mrs. Smith again. However, my last memory of her would stay fresh in my mind and on my conscience for many years to come.
Selling Out for Sales
For the majority of my career, I sold what I considered, at the time, to be fairly innocuous drugs, even though, as I said previously, I sold several NSAIDs, which are known to kill thousands of people annually and hospitalize tens of thousands more. Over the course of the years, my knowledge base would expand with each new category of drug I sold as I learned about the disease states and the body systems affected by each drug. The flip side of this was that, if I hadn’t sold a particular drug or competed with that category with one of my products, I was as ignorant as the next guy about what it did, how it worked, what risks were associated with its use, and so forth.
One of the advantages I enjoyed while working with a number of key manufacturers was having exceptional training programs. Had I stayed with one company, I would not have had the diversity of product knowledge and variety of sales training I ultimately received. Looking back, I would realize the buyouts, downsizings, layoffs, and ultimate challenges that had forced me to change employment several times had given me a phenomenal array of medical education. In the span of fifteen years, I had promoted NSAIDs, narcotic analgesics, antibiotics, asthma drugs, muscle relaxants, antihypertensive agents, lipid-lowering statins, antifungal preparations, birth control pills, diabetes drugs, hormone replacement therapy, stroke treatments, and, of course, neuroleptic drugs. I had worked my way up the corporate ladder, starting with my first promotion from a territory rep to a hospital rep after only eighteen months with McNeil. Then, with Syntex, I was promoted to an ob-gyn specialist. Before being severed, I worked as a cardiology and neurology specialist. I was hired as a cardiology and diabetes specialist with Bristol-Myers Squibb. In nine months, I received the Pinnacle Award, which was given to the top three percent of its sales force. At the end of my career, as an independent contractor, I became an overdressed sample delivery girl. Basically, I was paid per signature. Well, actually, I was paid per call, but I needed to get a doctor’s signature in order to prove I had been there.
Out of all of the drugs I had sold over the years in various specialties, the only drug that ever really challenged my moral ethics was Haldol, particularly Haldol decanoate. This was the “Big Daddy” of all neuroleptics. It made me cringe while learning about this newest form of Haldol during the launch meeting when I envisioned the possible torture in store for some patients. As I indicated earlier, patient non-compliance was a fairly common drawback with Haldol treatment. The side effects of neuroleptic drugs can be absolutely unbearable.
As a hospital rep, I would frequently see institutionalized patients pacing frantically back and forth in waiting rooms, hallways, and outside in foyers. Some would literally wear the soles off of their house shoes. Others would fall sound asleep prostrate on the ground, wherever they were when the drug’s sedative effects hit. Patients frequently drooled, sat staring into space, experienced facial grimacing, or continually made pill-rolling motions between their thumbs and forefingers. I soon realized many of the bizarre behaviors and movements I had previously identified with schizophrenia and other mental illness were entirely the fault of the medications the patients were taking. They were not a manifestation of these disorders.
Once, I encountered a twelve-year-old boy in the emergency room who had taken his grandmother’s medication. His eyes had rolled into the back of his head and locked there. This is known as an oculogyric crisis. However, where my heart really went out was to the poor, little elderly patients in the Veterans Administration (VA) hospital, the nursing homes, and the psychiatric wards. They seemed to suffer the most on Haldol. I heard constant reports about excessive dry mouth, blurry vision, painful constipation, and urinary retention. (Nurses even complained about fecal impacts associated with chronic neuroleptic use.) These side effects are known as anticholinergic effects, and my training had actually consisted of a little rhyme to assist me in learning them. It went, “Patients on Haldol can’t see, can’t spit, can’t pee, and can’t shit.”
Reps were instructed to minimize these side effects by encouraging the doctor to simply administer an anticholinergic drug simultaneously with Haldol. Still, the most dreaded side effect by patients and doctors alike remained akathisia. A patient with agitated akathisia could not only be self-injurious, but was also a danger to other patients and staff.
These observations led me to question the medical prudence and moral ethics behind giving a long-acting, irreversible neuroleptic like Haldol decanoate, especially because Haldol was documented to have a huge potential to cause negative side effects. Once this drug was on board and a patient reacted to it, there was absolutely nothing doctors could do except give additional drugs to manage the side effects while the patient rode out the three weeks the injection was intended to last. Of course, three weeks was only the half-life of the drug. There would be remaining drug residual for some time after that.
The company’s position was that the untreated schizophrenic patient is a threat to society and himself. Traditional oral medications could not ensure patient compliance in the absence of an institutional setting. With larger numbers of mental health patients being forced into outpatient settings such as MHMR facilities, there seemed to be a real, perceived need for this extended release form of Haldol. Hence, the product managers argued the benefits outweighed the risks, particularly when you considered one of the benefits was that Haldol decanoate would enjoy an exclusive patent whereas the old haloperidol was available generically and sold at a significant cost reduction. Not only did Haldol decanoate ensure patient compliance, it ensured corporate longevity as well.