Network connectedness of pharmaceutical sales rep (FLE)-physician dyad and physician prescription behaviour: A conceptual model Received (in revised form): 20th May, 2008

Ramendra Singh is a doctoral student in marketing at Indian Institute of Management at Ahmedabad in India. He is currently pursuing his thesis on salespersons’ customer orientation and sales effectiveness. Ramendra has presented several research papers at international conferences such as the Academy of Marketing Science Conference and the Academy of Marketing Conference, among others. He has also published articles in several international journals such as Asia-Pacific Journal of Marketing and Logistics, and Global Business Review. Previously Ramendra worked in sales and marketing functions in several organisations such as Indian Oil Corporation, ExxonMobil Corporation and ICICI Bank. He is a member of INFORMS, AMA and AMS.

Keywords network connectedness, physician prescription behaviour, business networks, pharmaceutical sales rep, DTC advertising Abstract Influencing physician prescription behaviour has always proven elusive for pharma companies. This is especially so in these changing times when physicians are tightly pressed for time to spare on attending to sales calls from pharma sales reps. Previous studies have examined physician prescription behaviour (PPB) as an impact of detailing activities of pharma salespersons (FLEs) and marketing mix variables deployed, with little emphasis on the network connectedness aspects of the physician–salesperson dyad, and its impact on the PPB. This paper aims to fill this gap. From a business networks perspective, a new conceptual model is proposed that incorporates three aspects of network connectedness — resource transferability, activity complementarity and actor relationship generalisability — as antecedents of PPB. The moderating effect of FLEs’ role ambiguity, which is a key intervening variable affecting sales performance, is also examined. The suggested propositions highlight the importance for pharma companies to leverage resources, bring complementarity in promotional activities and capitalise on the positive word-of-mouth references of physicians to increase the effectiveness of their salesforce in influencing physicians. Journal of Medical Marketing (2008) 8, 257–268. doi:10.1057/jmm.2008.14

INTRODUCTION Ramendra Singh Marketing Indian Institute of Management Ahmedabad FPM House No-1; IIM Ahmedabad Vastrapur, Ahmedabad Gujarat 380015, India Tel: + 919998493034 Fax: 917966306896 e-mail: ramendras@iimahd. ernet.in

detailing efforts of the salesforce, given the diminishing returns on their efforts. According to the extant literature on pharma salesforce, the sales reps have been considered as primary disseminators of product information to physicians in an increasingly cluttered marketplace, especially when the physicians also rely on

Most studies carried out in the pharmaceutical industry context have viewed the prescription behaviour of physicians as a consequence of the detailing activities of pharma salespersons (FLEs) and marketing mix variables,1–6 and have suggested ways of optimising

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other sources of information such as trade journals and continuing medical education (CME) programmes.7–10 The major reasons behind the increasing influence of pharma FLEs on physicians’ prescription behaviour is primarily the latter’s time constraint, and the reduced cost of procuring reliable information in the age of ‘information explosion’.11 Another important influence that medical reps have over physicians is the fact that they are a single point source for obtaining free drug samples and also for staying in touch with developments happening in medical practice.2 This becomes extremely important in the backdrop of their suspicious attitude towards direct-to-customer advertising. Research shows that almost 52 per cent of physicians actually disapproved of the DTC advertising practice.12 There are, however, no published studies, to the best of my knowledge, that have looked at the network connectedness aspects of the physician–salesperson dyad, and how it impacts the physician’s prescription behaviour (PPB), once detailing has been accounted for. To fill this void in research, the study in this paper investigates the network connectedness of the physician–salesperson dyad and how it impacts the drug prescription behaviours of the physician, taking a networks perspective. In this study, the detailing efforts of the FLE are controlled for, as the number of visits made by the FLE each month to a particular physician is almost fixed, and the level of detailing and the quality of sales pitch is almost standardised by the company. In most markets, especially emerging markets like India, physicians only meet medical reps for a few minutes. In such a situational context, it is up to the medical reps to decide which of the several molecules that their company is marketing to actually pitch to the physician, given the limited attention span of the physician. However, if time is given

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and the product line is fixed, the nature of the sales pitch is fairly standardised and uniform. I spoke to several pharma sales managers and most of them agreed that the medical reps are neither trained nor incentivised to customise their sales pitches. On the contrary, by dint of their sales training, they can actually repeat the sales pitch almost verbatim any number of times. To help the sales reps in their sales pitches, they are equipped with sales tools such as regular flip charts, product brochures and free drug samples. Sometimes, senior sales managers may also make IT presentations using laptops. This study adopts a networks perspective of the dyad, unlike the atomistic perspective taken in previous studies, and looks at the specific effects of the antecedents of network identity of the firm in a business network, namely, resource transferability, activity complementarity and actor relationship generalisability (RT, AC and ARG respectively, henceforth), which capture the connectedness of this focal relationship, as perceived by each partner. These three aspects of connectedness would positively impact the cooperation and commitment of the dyad partners,13 thus leading to favourable economic outcomes (ie an increase in PPB). In contrast to the business networks context, the understanding of the antecedents of relational cooperation and commitment is at best only partial in the dyadic framework.13 This research looks specifically at each of the following three aspects of relational embeddedness, and how each of these impact PPB: (a) The extent of resource (product knowledge) transfer by pharma FLEs from their relationships with other physicians, to the focal physician. (b) The extent of the complementarity of promotional activities undertaken by Pharma FLEs with physicians (including the focal physician).

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(c) The extent to which maintaining strong relationships with other physicians helps in building strong relationships with the focal physician.

propositions provided. The paper ends with managerial implications and directions for future research.

LITERATURE REVIEW The study gives a call that the suggested model be empirically tested, using these three facets (RT, AC and ARG) of the network connectedness of the FLE– physician dyad as antecedents of the drug prescription behaviour of the focal physician. The moderating effect of role ambiguity on the relationship between the three facets of network connectedness and PPB is also suggested. Role ambiguity has been recognised as an important intervening variable between various job conditions and job outcomes14 and defined as, ‘a direct function of the discrepancy between the information available to the person and that which is required for adequate performance of his role’(p. 73). Thus, this study is important from several perspectives. First, it proposes a conceptual model of dyadic relational exchange in embedded nature, unlike most of the previous studies on FLEs that view dyadic exchanges from an atomistic perspective. Secondly, the study includes three facets of network connectedness, each of which has been hypothesised in our model to independently impact the physician drug prescription behaviour. Finally, the moderating effect of FLE’s role ambiguity on the relationship between network connectedness and the physician drug prescription behaviours is suggested for further investigation, as it has a critical impact in the job performance of boundary personnel. The remainder of the paper is organised as follows. The first section is the review of the extant literature on the role of pharma FLE vis-à-vis DTC advertising on impacting drug prescription behaviours of physicians. After this, a conceptual model is proposed and a set of

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In the context of an organisation’s interaction with its environment, the role of the boundary spanners (eg frontline employees) becomes extremely important. Aldrich and Herker15 mention two main classes of functions performed by boundary spanners on behalf of their organisations: information processing and external representation. Tie-strength literature suggests that information sharing among social actors depends on the degree of network connectedness in the social network.16 In the pharmaceutical industry context, an FLEs’ primary role of product information dissemination to physicians is a major determinant of the latter’s drug acceptance and prescription behaviour.7–10 Pharma FLEs’ influence on physician’s prescription behaviour is primarily based on the latter’s time constraint, cost reduction and the ‘information explosion’.11 Hence, their reliance on medical representatives is high and second only to that of pharmacists.8 Although information gathering about specific drugs is the key reason behind physicians meeting the pharma FLE, other reasons include obtaining free samples and staying in touch with developments in medical practice.2 The pressure on physicians to catch up with changing product launches and medical progress is compounded by the continual developments in drug approvals by regulatory agencies like the Food and Drug Administration.10 Thus, physicians’ own authority and their increased dependence on Pharma FLEs for product information has motivated pharmaceutical companies to increase their marketing expenditure by increased use of pharma FLEs17 vis-à-vis advertising, as the

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physicians themselves have different perspectives on the value of DTC advertising. Some studies in the US context have found that only 15 per cent of physicians had a positive attitude towards DTC ads, 33 per cent were neutral and 52 per cent actually disapproved of the practice.12 A relatively recent study by Andaleeb and Tallman,7 however, points out that pharma FLEs, despite being considered an important source of information, are increasingly being considered only an alternative source of information. Wright et al.18 suggest that the pharma FLE’s role of information dissemination is also fraught with potentially harmful outcomes, and depends on the representative’s personal characteristics such as values, credibility and honesty. Thus, pharma FLEs from certain (well-known) pharmaceutical companies have a more favourable perception in the eyes of physicians.19 Moreover, repeated exchange transactions are likely to lead to habit formation and institutionalisation of behaviour20 and this provides a sound basis for impacting physicians’ drug prescription behaviours.

THE CONCEPTUAL MODEL: THEORY AND PROPOSITIONS From a networks perspective, the physicianpharmaceutical FLE dyad is connected in the network of collective actors. Being connected implies that exchange in the focal dyad is contingent upon the presence or absence of exchange in other relations.16 The pictorial representation of the network connectedness of physician–representative dyad is depicted in Figure 1 and the theoretical model in Figure 2.

RESOURCE TRANSFERABILITY RT is defined as the extent to which resources such as knowledge systems and solutions developed from maintaining other relationships of focal firms can be transported for developing and maintaining the focal relationship. In the context of this study, it means the extent to which knowledge, both tacit and explicit, gained by the pharma FLEs in the course of developing relationships with several physicians, can be used for improving the relationship with other physicians (eg the focal physician) to increase the efficiency

Other Physicians

Patients Regulatory Authority (FDA)

Other Pharma ceutical FLEs

Pharmacists

Focal Dyad

Pharma ceutical FLE

Association (e.g.IMA)

Physician

Hospitals Suppliers

Medical Association

Primary Functions Secondary or Network Functions Figure 1: Network connectedness of physician-pharma FLE dyad

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Network connectedness Network Connectedness of Physician-FLE Dyad RT

FLE experience

Physician Experience

P2

P3 P1 P8 FLE Role Ambiguity

Promotional Activities AC New Drug Launch Related AC

P9A P4 Physician Prescription Behavior

P10A P5

P9B P10B P6

Cooperative Efforts ARG

P7 Relationship Strength ARG

Control Variables: Detailing, Gift Giving

Figure 2: Model of impact of network connectedness of pharma sales rep and physician on physician prescription behaviour

of their sales call. This view is supported by Granovetter’s16 suggestions that at least some basic principles can be taken from other relationships to be employed in the focal relationships. In the financial sector context, Uzzi21 found that firms with embedded relationships with their lending institutions were able to achieve lower financing costs because higher embeddedness increases use of information in creating innovative low cost loans. Further, the jointly shared resources developed in the focal relationship are likely to enhance the network identity,13 which is defined as the perceived attractiveness or repulsiveness of a firm as an exchange partner due to its unique set of connected relations with other firms, links to their activities and ties with their resources.

RESOURCE TRANSFERABILITY AND PHYSICIAN PRESCRIPTION BEHAVIOUR In the physician–representative focal dyad, the network identity of a pharmaceutical

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firm is positively associated with high resource transferability in the focal dyad. A firm with stronger network identity or higher perceived attractiveness with respect to its partners is likely to possess a higher perceived equity among its relationship partners,13 and thus the latter perceive lower relational risk in initiating, sustaining and developing the relationship. The fraternity of physicians forms a community in which they are connected not only in business relationships but also share common social and family ties; this is especially true in the case of certain social classes. Such connectedness of physicians often leads to informal recommendations by colleagues, which is a very important influential factor impacting PPB.22–24 Pharmaceutical companies serve the network of these physicians in each of the several therapeutic categories, so that a certain set of activities with physicians in a particular product category may be shared with other physicians of the same category. Pharma sales reps, whose primary job responsibility is information dissemination

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on drugs, including physicians’ education, are likely to utilise knowledge gained from relationships with other physicians (outside the focal dyad) and transfer (or leverage) the same knowledge, as and when applicable to the focal relationship. Weitz et al.25 have also emphasised the role of salesperson knowledge, pertaining to specific selling situations and the salesperson’s skill in collecting customer information, as moderators of their sales performance. Several other studies have emphasised that domain knowledge (eg product knowledge) has a substantial impact on performance in that domain.26–28 This resource leveraging is likely to impact physicians’ prescription behaviour in two ways: by enhancing the perception about the pharma FLE’s credibility, and secondly, by increasing the perceived brand equity of the pharmaceutical company. Hence it is posited that Proposition 1: Higher resource (product knowledge) transferability in the pharma FLE’s relationship with other physicians is associated with higher drug prescription behaviour of the focal physician. An experienced FLE is likely to have handled multiple and difficult relationships with physicians and gained more knowledge about drugs, competitors and the marketplace to better convince the physician to prescribe a particular drug to the patient. Similarly, an experienced physician is also more likely to be influenced (than his/her younger counterpart) by the information provided by the pharma FLE.8 However, it is contradictory to the findings of some of the earlier studies.29–32 In the salesforce

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literature it has been found that the influence of others on the gaining of information is positively associated with age,33 and that elderly people use salespeople as an information source to a greater extent, than younger people. 34 Elderly people are less competitive and more obliging.35 Finally, physicians also know that a more experienced pharma FLE is likely to have more knowledge about drugs, competitive activities and competitor drugs. Since the competing drugs are fast becoming cluttered and undifferentiated products, the dependence of physicians on pharma FLEs for information increases manifold. Thus, it is posited that Proposition 2:

The relationship between FLE’s resource (knowledge) transferability and physician drug prescription behaviour is stronger when pharma FLE’s experience is high.

Proposition 3:

The relationship between FLE’s resource (knowledge) transferability and Physician drug prescription behaviour is stronger when the focal physician’s experience (medical practice) is high.

ACTIVITIES COMPLEMENTARITY AND PHYSICIAN PRESCRIPTION BEHAVIOUR AC is defined as the positive scale effects of activities carried out by pharma FLEs with some physicians, on their

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relationships with other physicians. The scales arise from the volume of activities performed or it can be qualitative in nature. The concept is illustrated through two examples: several physicians react positively to new drugs when other known physicians have already accepted the drug; a successful new drug launch in one city is likely to increase the chances of its acceptance by physicians in other cities (after they receive the information). Another qualitative example is positive word-of mouth-from other physicians about the company and its products through informal discussions, even before the pharma FLE has actually spoken about it in the sales call this has an important impact on prescription behaviours.22–24 Thus, an increase in volume of any particular activity or set of activities in representative-other physician relationships may reduce the cost of undertaking any such activities in any particular relationship with the physician. This qualitative or volume-based impact of activities on the drug prescription behaviours of the physicians also improves the perceived brand equity of the pharma company. Another example of activities complementarity is a pharmaceutical company increasing the availability of their products at more retail pharmacies based on the recommendation of few physicians, which in turn increases the likelihood of drug prescription by other physicians. A qualitative effect may be the contingent effect of more free samples to other physicians, increasing the likelihood of a particular physician’s prescription behaviour. In the physician–pharma FLE dyadic relationship context, new drug launch activities and promotional activities such as the CME of physicians are the most common activities and happen on a continuing basis. CME, a form of medical communications, encompasses a number of different facets, including key opinion

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leader development to support product uptake, and strategic publications planning to provide credible product claims and to build relationships with medical experts (Rod et al., 2007). CME has been found to increase prescription behaviours in previous studies.36 According to the MM&M/CME LLC physician opinion survey,37 CME was rated as the most valuable source of information for physicians, followed by medical journals, peer interactions and sales reps. Thus, it is posited that Proposition 4:

Higher quantum of promotional activities such as CME by pharma FLEs with other physicians is associated with focal physician’s higher prescription behaviour.

Proposition 5:

Higher quantum of new drug launchrelated activities by pharma FLEs with other physicians is associated with focal physician’s higher prescription behaviour.

ACTOR RELATIONSHIP GENERALISABILITY AND PHYSICIAN PRESCRIPTION BEHAVIOUR ARG is understood as the implications of cooperative efforts made by pharma FLEs with other physicians and is viewed by the focal physician positively and favourably. It is also a form of positive signalling to the other physicians in the network of the pharma FLE. This ‘positive side effect’ is likely to enhance the perception of a pharma company’s attractiveness and enhance its brand image. Thus, a signalling

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effort from the pharma FLE to the focal physician, that the pharmaceutical company values the feedback of physicians, is likely to increase the drug prescription behaviour of the focal physician. Relationship generalisability as a concept is also emphasised in relationship marketing in terms of managing collaborative business relationships between suppliers and customers,38 as well as making an attempt to integrate ‘other infrastructural partners into a firms’ developmental and marketing activities’.39 Similarly, if a pharma company sets up a panel of physicians for a new drug launch and other market activities prior to the product launches, then it would be positively perceived by the community of physicians as a signal that the pharma company values relationships with them. Moreover, since physicians perceive personal sources of information (eg colleague and salesperson) as a more credible source of information than nonpersonal sources such as advertising,30,40 and more specifically, their colleagues.41 Hence ARG is expected to be explicitly present in this context. Under these conditions, the pharma FLEs are likely to receive a positive response and increased PPBs. Thus, it is posited that

Proposition 6: Pharma FLE’s higher cooperative effort with other physicians is associated with focal physician’s higher drug prescription behaviour. Proposition 7: Pharma FLE’s strong relationship with other physicians is associated with focal physician’s higher drug prescription behaviour.

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PPB: THE MODERATING EFFECT OF FLE ROLE AMBIGUITY The study will now examine the moderating effect of role ambiguity on the relationship between network connectedness and the PPBs. Role ambiguity has been defined as the ‘degree to which a sales representative is uncertain about others’ expectations with respect to the job, the best way to fulfil known expectations and the consequences of role performance’.42 Salespeople experience role ambiguity in activities like planning, handling objections, how to perform these activities and how others expect them to perform their jobs. Ford et al.,43 however, identify four sources of role ambiguity: family expectations, customer expectation, sales manager’s expectations about job performance and company policies and procedures concerning performance. This study focuses only on the customer (physician) expectation dimension of the FLE’s role ambiguity, as it is the most salient dimension pertaining to the study. The reason for choosing the customer dimension of role ambiguity is that while company and supervisor dimensions are significant in predicting a salesperson’s job satisfaction, the uncertainty due to customer expectations is more critical in determining behavioural outcomes like their job performance.44,45 Since customers’ expectations related role ambiguity has been found to have a more deleterious impact on a salesperson’s job performance,46 it is expected that pharma FLEs with high role ambiguity will weaken the relationship between each of the three facets of relational embeddedness and PPB. Thus, it is posited Proposition 8:

The relationship between pharma FLE’s RT and PPB is stronger when pharma FLE’s role ambiguity is low.

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Proposition 9a:

The relationship between pharma FLE’s promotional activities complementarity and PPB is stronger when pharma FLE’s role ambiguity is low.

Proposition 9b:

The relationship between pharma FLE’s new drug launch related activities complementarity and PPB is stronger when pharma FLE’s role ambiguity is low.

Proposition 10a: The relationship between pharma FLE’s cooperative efforts with other physicians and PPB is stronger when pharma FLE’s role ambiguity is low. Proposition 10b: The relationship between pharma FLE’s strong relationships with other physicians and PPB is stronger when pharma FLE’s role ambiguity is low.

CONTROL VARIABLES: DETAILING AND GIFT GIVING (INCLUDING FREE SAMPLES) This study controls for the detailing and gift giving to physicians. Detailing has been shown in previous studies to have a strong impact on physicians’ understanding of drug characteristics and subsequent prescription behaviour.2,5,47,48 Detailing is controlled in two ways: through both the quantity of detailing (number of physician visits made per month and average

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duration of sales call), as well as quality of detailing (eg standard sales pitch). Further, prescription behaviour also gets influenced by the number of drug samples handed out to a physician. Since gift giving is a common practice (despite being regulated) with all pharmaceutical companies and physicians, and pertains more for new (rather than existing) products, its relevance to our study is at best neutralised, as this research includes both new and old products. Thus, disaggregating the impact of gifts and free samples for each type of drug (old and new) is likely to be speculative. It is also noted that in emerging markets like India, it is a common practise to sponsor the physicians in various ways, including paying for their trips to attend technical conferences, even when they are in foreign countries (which are in many ways, a disguised form of vacation for the physicians). This practise is very common among many pharma companies and since it serves the vested interests of both entities (companies as well as physicians), and is difficult to prove, the practise continues to date. Manchanda and Chintagunta5 however note that this practise is also prevalent in developed markets like the US.

MANAGERIAL IMPLICATIONS AND CONCLUSION Pharma sales reps are a valuable resource for their companies. Medical marketing companies, as well as pharmaceutical companies, however, are often not very sure of how to use them most effectively with physicians. Most often physicians are pressed for time and hence, pharma sales reps get only a few minutes of their time. Due to these time pressured situations, it is of ultimate importance to make sure that relationships are built with physicians and that pharma companies complement the efforts of their sales reps by leveraging common resources among all physicians.

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Several caveats may follow this study. Many researchers point out that in cluttered and time pressured sales situations such as those experienced in pharmaceutical selling, it is virtually impossible for companies to build or sustain healthy business relationships with physicians. Such scenarios however may not be entirely correct. Use of CRM can demonstrate that despite the reduced time availability of physicians to meet the medical reps, the latter’s sales effectiveness can be increased (through the use of IT presentations, simulated product dems and use of SFA tools). Other studies, such as that by Parsons and Vanden Abeele,47 focus on the notion that sales effectiveness in pharma companies is largely impacted by the use of free samples and product literature. This study boldly departs from such assumptions. Thus, not withstanding the viewpoints taken by several studies that pharma selling is different, it is contended that business relationships occurring in other industries such as b2c or b2b are also important in pharma industry. Pharma companies can successfully build relationships with physicians through effective training and utilisation of medical reps as key resources of their companies. In this context, the concept of resource leveraging will prove the hallmark in increasing both the effectiveness as well as the efficiency of pharma sales reps. Medical sales reps are a resource that needs to be leveraged for effective selling, but a network of physicians is also a valuable asset (a form of resource) that pharma companies in general, and sales reps in particular, should leverage to optimise output, measured in terms of relationships with physicians and drug sales. This study highlights how differential utilisation of sales reps as resources can bring marginal benefit to pharma companies. For example, the study highlights the importance of utilizing the experience of senior sales reps with more

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experienced physicians to increase the credibility of the product information message and the messenger. This study provides a conceptual model that the pharma companies can use to increase leverage on their network identity (equivalent to their corporate and product brand identities) with physicians. Similarly, taking care of the complementarities of the activities that pharma companies favour in the market with physicians can serve to reduce their costs. Also, making sure that word-of-mouth works successfully is also of ultimate importance because physicians often give more credence to information they receive from someone of their own community and fraternity, such as a fellow physician, especially who is either well-known and established or at least closely involved in the community. Finally, the relationship generalisability aspect can help companies by making them leverage the existing relationships they enjoy with other physicians. ‘Seeing is believing’ seems to work here as well, and if a physician– pharma company relationship is seen to be working for both, it would create a positive impression on other physicians as well. To sum up, this article calls for the adoption of a three-pronged strategy by pharma companies incorporating leveraging knowledge as a common resource among all the physicians who the pharma sales reps target with samples and product literatures; making the most important activities like CME complementary among as many physicians as possible; and finally by capitalizing on generating and utilizing positive word-ofmouth from those physicians to sell to other physicians. Last but not least, a clarion call is also sounded for pharma companies to train and provide feedback to sales reps on a regular basis to reduce their role ambiguity, as the latter is a major role stressor and is likely to reduce

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sales effectiveness in the short and medium run and may even lead to attrition in the long run. Medical sales reps are almost always in the field and it is very likely that they lose close touch with corporate guidelines, job requirements and role functions. A timely intervention, but better still, a coaching and mentoring boss, would not only keep the reps on their toes but would also keep them strongly moored to their roles and responsibilities. This study also calls for future researchers to validate the proposed conceptual model and the posited propositions and to further strengthen the findings that have immense implications for pharma companies. References 1 Gonul, F., Carter, F., Petrova, E. & Srinivasan, K. (2001). Promotion of prescription drugs and its impact on physicians choice behaviour. J. Market. 65, 79–90. 2 Lexchin, J. (1989). Physicians and detailers: therapeutic education or pharmaceutical promotion. Int. J. Health Services. 19, 663–679. 3 Lilien, G. L., Rao, A. G. & Kalish, S. (1981). Bayesian estimation and control of detailing efforts in a repeat purchase environment. Man. Sci. 27, 493–507. 4 Lurie, N., Rich, E. C. & Simpson, D. E. et al. (1990). Pharmaceutical representatives in academic medical centers: interaction with faculty and housestaff. J. Gen. Intern. Med. 5, 240–243. 5 Manchanda, P. & Chintagunta, P. K. (2004). Responsiveness of physician prescription behaviour to salesforce effort: an individual level analysis. Market. Lett 15(2–3), 129–145. 6 Wittink, D. R. (2002). Analysis of ROI for pharmaceutical promotions. unpublished study conducted for the Association of Medical Publications. Available at http://www.rxpromoroi.org/arpp/index.html. 7 Andaleeb, S. S. & Tallman, R. F. (1996). Relationship of physicians with pharmaceutical sales representatives and pharmaceutical companies: an exploratory study. Health Market. Quarterly. 13, 79–89. 8 Evans, K. R. & Beltramini, R. F. (1986). Physicians acquisitions of prescriptions drug information. J. Health Care Market. 6, 15–25. 9 Haddad, C. & Barrett, A. (2002). A whistle blower rocks an industry. Business Week, 24th June, 126–130. 10 Lagace, R. R., Dahlstrom, R. & Gassenheimer, J. B. (1991). The relevance of ethical salesperson behaviour on relationship quality: the pharmaceutical industry. J. Personal Selling and Sales Manage. 11, 39–47. 11 Hunt, R. E. & Newman, R. G. (1997). Medical knowledge overload: a disturbing trend for physicians. Health Care Manage. R. 22, 70–75.

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