Peddling Pills

But then it's on to business. With clinical precision, Salcedo-Guzman reaches into her bag for a blue box the size of a long ladies wallet. She flips it open to reveal what she calls "a very exciting educational tool" — a tiny illustration of a set of lungs with airways shaped like tree branches, colored cherry red to show inflammation. "This is what the lungs look like when you have asthma, even if you're symptom-free," she enthusiastically explains. She pulls a cardboard tab to reveal a second illustration, this time of airways colored a faint, healthy pink. "But if you take a daily maintenance medication, your lungs can look like this." The box includes a quiz that can gauge the severity of someone's asthma; a booklet on the disease; and most important, several $20-off vouchers for Symbicort, a new asthma medication made by Salcedo-Guzman's employer, AstraZeneca. She asks Neuman to give the packet "to just that one person" whose symptoms aren't yet under control. "You guys are so creative," he says, playfully arching his reddish eyebrows. "Can I hold it?" She hands the box across the table. "Tenderly, please," she says, chuckling, "like a baby."

Welcome to the pharmaceutical sales pitch, 21st-century edition. Salcedo-Guzman is, of course, a drug-sales rep, and though most patients have no way of knowing it, a small army of people just like her are tugging at the lab coats of their doctors. Not long ago reformers thought they'd curbed this coziness between doctors and the Willy Lomans of Big Pharma, as physicians and drug companies alike instituted a widely publicized ethics crackdown. But with the drug industry facing the loss of more than $60 billion a year in sales to competition from generics, companies in recent years have been quietly inflating the ranks of these well-dressed professionals, with their suitcases full of samples. There were 35,000 reps in 1995, but the number is close to 100,000 today, according to the consultancy the Hay Group. Put another way, there's one office-based physician for every 975 Americans — and roughly one drug rep for every three of those physicians.

Once they arrive at the doctor's office, these road warriors use different methods to wield their influence, and the trinket is as powerful as the junket. The new rules bar lavish, Gordon Gekko-era gifts like opera boxes and airline tickets, but pharmaceutical companies are gambling that a blizzard of constant attention and small freebies can be more effective than big gestures when it comes to promoting their products. Almost all "detailers," as reps are known, leave behind a trail of persuasive literature and giveaways. Everything from hand sanitizers to wall clocks to computer memory sticks have been emblazoned with drug logos and given to physicians, along with roughly $16 billion annually in free drug samples. Reps also provide enough free lunches and dinner lecture programs to doctors and their staffs that at least one national Web site has sprung up to help them order all the take-out food.