The trick is to give doctors gifts without making them feel that they are being bought. “Bribes that aren’t considered bribes,” Oldani says. “This, my friend, is the essence of pharmaceutical gifting.” According to Oldani, the way to make a gift feel different from a bribe is to make it personal. “Ideally, a rep finds a way to get into a scriptwriter’s psyche,” he says. “You need to have talked enough with a scriptwriter—or done enough recon with gatekeepers—that you know what to give.” When Oldani found a pharmacist who liked to play the market, he gave him stock options. When he wanted to see a resistant oncologist, he talked to the doctor’s nurse and then gave the oncologist a $100 bottle of his favorite cognac. Reidy put the point nicely when he told me, “You are absolutely buying love.”

Such gifts do not come with an explicit quid pro quo, of course. Whatever obligation doctors feel to write scripts for a rep’s products usually comes from the general sense of reciprocity implied by the ritual of gift-giving. But it is impossible to avoid the hard reality informing these ritualized exchanges: reps would not give doctors free stuff if they did not expect more scripts.

My brother Hal, a psychiatrist currently on the faculty of Wake Forest University, told me about an encounter he had with a drug rep from Eli Lilly some years back, when he was in private practice. This rep was not one of his favorites; she was too aggressive. That day she had insisted on bringing lunch to his office staff, even though Hal asked her not to. As he tried to make polite conversation with her in the hall, she reached over his shoulder into his drug closet and picked up a couple of sample packages of Zoloft and Celexa. Waving them in the air, she asked, “Tell me, Doctor, do the Pfizer and Forest reps bring lunch to your office staff?” A stony silence followed. Hal quietly ordered the rep out of the office and told her to never come back. She left in tears.

It’s not hard to understand why Hal got so angry. The rep had broken the rules. Like an abrasive tourist who has not caught on to the code of manners in a foreign country, she had said outright the one thing that, by custom and common agreement, should never be said: that the lunches she brought were intended as a bribe. What’s more, they were a bribe that Hal had never agreed to accept. He likened the situation to having somebody drop off a bag of money in your garage without your consent and then ask, “So what about our little agreement?”

When an encounter between a doctor and a rep goes well, it is a delicate ritual of pretense and self-deception. Drug reps pretend that they are giving doctors impartial information. Doctors pretend that they take it seriously. Drug reps must try their best to influence doctors, while doctors must tell themselves that they are not being influenced. Drug reps must act as if they are not salespeople, while doctors must act as if they are not customers. And if, by accident, the real purpose of the exchange is revealed, the result is like an elaborate theatrical dance in which the masks and costumes suddenly drop off and the actors come face to face with one another as they really are. Nobody wants to see that happen.

t he n ew d rug r eps?

Last spring a small group of first-year medical students at the University of Minnesota spoke to me about a lecture on erectile dysfunction that had just been given by a member of the urology department. The doctor’s Power-Point slides had a large, watermarked logo in the corner. At one point during the lecture a student raised his hand and, somewhat disingenuously, asked the urologist to explain the logo. The urologist, caught off guard, stumbled for a moment and then said that it was the logo for Cialis, a drug for erectile dysfunction that is manufactured by Eli Lilly. Another student asked if he had a special relationship with Eli Lilly. The urologist replied that yes, he was on the advisory board for the company, which had supplied the slides. But he quickly added that nobody needed to worry about the objectivity of his lecture, because he was also on the advisory boards of the makers of the competing drugs Viagra and Levitra. The second student told me, “A lot of people agreed that it was a pharm lecture and that we should have gotten a free breakfast.”