Hey, guys. Welcome to the podcast. My guest today is Rob Rasti. He is a senior medical science liaison with Tercera Pharmaceuticals, and he discusses effective relationship strategies for MSL success with commercial counterparts. Awesome conversation. Hope you guys enjoy it. Don't forget to follow us on, LinkedIn and our YouTube channel, and check us out on MSL Talk LIVE, which is the first Tuesday of every month at 1:30 pm Eastern time. Thanks for joining us.
Welcome to MSL Talk with Tom Caravella, a podcast specifically designed for MSLs and all things field medical. Hey, Rob. Welcome back to the podcast, my friend. How you doing? Tom, always great to be here. Thanks for having me back again. I really appreciate it. Yeah, man. So this is round 2. I'm I'm excited. I'm looking forward to this. And little background, so, folks, this is a topic that comes up a lot. People have asked me about this.
I've gotten a lot of requests to talk about this relationship between MSLs and their commercial counterparts, their sales colleagues. And then Rob mentioned it to me and was like, hey. Maybe we could do something like this. So, I'm excited because I know he's gonna do a great job. So, Rob, why don't you do an introduction? Tell everybody who you are, where you're from, and a little about your background. Alright. So hello, everyone. I'm doctor Robert Rosti.
I am currently a senior medical science liaison for Tercera Therapeutics in their pain division, covering the East Coast. I've been in field medical affairs for 16 years, and before that I did spend some time in the commercial organization when I first started in pharma many years ago. So I have some broad range of experience on both the commercial side and how they view things, and then how the medical affairs side and field medical and how they view things.
That's why I approached Tom with with this topic because I know Tom works with a lot of newer MSLs, and this can be a very daunting and challenging task is, you know, how do I stay compliant, do what I need to do to get my job done, to keep my supervisors happy, but, you know, but also play nicely in the sandbox, so to speak, with my commercial colleagues.
And these are interactions that you you pretty much have to have when you're in the field and you're working, you know, both with sales reps and sales managers. Yeah. Cool. I can't wait to get into it. Before we do that, I wanna give a quick shout out. We have, actually a new audience, a new group that we are now ranking in Kuwait really high. Our numbers are really high in Kuwait. Wanna welcome all of our new listeners in in that area.
Thank you guys for sharing this podcast, one of the fastest growing, podcasts in in history right now. I mean, we're we're really our numbers are just it's like we're doubling every time I turn around. So, thank you guys. I appreciate you all for listening. And, so, Rob, let's go back to kind of the basics. And one of the questions that people ask me is when you look at, an organization, what's kind of the ratio between the number of sales reps versus the number of MSLs?
And how many sales folks does one MSL typically support? So that's a great question. Unfortunately, it's a question without a definitive answer. So it will depend on many things. A, it's the size of the company and their commercial footprint. So currently, like, I'll use my current situation. I work for Tercera Therapeutics in their pain division. There are 8 sales representatives for the entire country. I cover off on 4 of them.
So there's 8 sales representatives and one sort of national sales manager. And it's a very ultra rare disease product. So there's not a lot of KOLs, so hence I have a large geography and the reps have a large geography. We'll say where I came to before this, where I was at Biogen for the unsuccessful launch of aducanumab, there were 50 MSLs just on the Biogen side and there were close to 1200 sales representatives. And it's a very, it's a broader disease. It's not as rare.
So it really depends on the company, their size and therapeutic area and their footprint. For me, from my experience, you know, going all the way back to 2,006, I would overlap anywhere between 4 to 10 sales reps and anywhere from 1 to 3 sales managers, depending on how the geographies and territories were drawn out. Awesome. That's exactly what I was kinda looking for as far as an answer, and I know that it does vary.
But I think that puts a lot of things into perspective, as far as what people might be able to expect. If you're new to the role, or if you're looking to get into the role, I think that that's probably as consistent of an answer as as I could, you know, expect. Now what about the expectations in this relationship between sales rep and MSL? But from the MSL side, what are the expectations on the MSL? So there this is a great question. Again, a lot of branches on this tree.
First and foremost, what I recommend to whether it's a newer MSL or someone that's new with a company, when you're going through your onboarding, there almost always will be an SOP on commercial medical interactions. You're usually it's either you read it and take a quiz on, or you read it and just check off as part of your onboarding. I highly recommend that any MSL at any company of any level of experience get to know that document very well. For me, I always save a hard copy to my hard drive.
I know it inside and out because that's going to be your bare minimum ground rules of what's acceptable, and that will range from company to company. So some companies will have very loose firewalls, not very restrictive, very open. It'll run the gamut to somewhere in the middle. And I've also worked for companies where they're extremely restrictive. So really your minimum operating standard is your SOP for commercial medical interactions.
With that said, you want to couple that with your own personal experiences and your personal comfort. So again, we use myself as an example. I've been doing this a very long time. I have a lot of situations that I've been in, some positive, some not so positive. So it's sculpted on how I interact and how I set things up, and we can talk about that later when this comes up in a little more detail.
But it's getting to know your own comfort level and what you are allowed to do and what you're comfortable with doing in terms of how you're managing these relationships. Because these are relationships that you have to have at most companies because one thing you don't want to do, especially if you're a newer MSL, as I can implore to them, you don't wanna be silent and you don't wanna be invisible.
Because unfortunately, and I've been down this road many a time, people will assume if they're not hearing from you, that you're not working. And then the ground swell, the the back chatter starts to starts to go up. So I'm not saying you need to be front and center 247, but there needs to be at least some level of interaction. And again, that's also gonna be guided by your company's SOPs for commercial and medical interaction. Got you. Okay. A lot to unpack there.
Obviously, MSOs are responsible for their KOL relationships. Exactly. So and that's what you mean by, you know, being active and, and engaging and and whatever else. But you mentioned the comfort level in in what they're, you know, willing to say and and how they're about, you know, how they go about that relationship. And I think what you're talking about is from a compliance standpoint. Correct?
Yes. Compliance is one of it, and a lot of it, too, will be based on the experiences that both sales managers and the sales reps bring to the table because they also come from usually a variety of different companies that have had a variety of different policies for commercial medical interaction. So one of the best examples I always give is when I'm new, as I mentioned, I always understand the SOP. Once I finish my onboarding, I usually will have a conversation with my immediate supervisor.
I'm going to reach out to my commercial manager. I usually start from the top and work my way down. Go to the managers first, have a conversation. And really, it's just a simple conversation of, Hi. I'm Robert. I'm a new MSL. Just want to sit and have a conversation. You know, what's your experience in working with MSLs? What are your comfort level? What are your expectations? What's been your past experience? It's just very open ended, broad ranging questions.
What that does is it gets the manager talking. And I often take notes when I listen to these conversations because it helps you identify one areas of commonality. So areas where you can work together and can partner partner in a compliant fashion. But also, more importantly, it brings out potential pain points.
Because, again, there are not to pass judgment or disparaging your paint with a broad brush, but there are managers that do believe that an MSL is their MSL and they report to them and they're part of their team. And that simply is not true. So you need to flesh that out as as quickly as humanly possible. So after I get the information from the sales manager about their experiences, then I overlay that with, okay, you know, as you know, this is what our compliance rules say.
This is what I'm comfortable with. So you always want to start off with an area of agreement. This is great. I think we can agree on these areas. There may be some pain areas. You have further discussion. So once you reach some agreement and you're not going to reach agreement on everything, you want to at least close that conversation. Okay, this is how we're going to operate going forward.
I always follow-up with an email to the sales manager, copying in my manager, thanking him for the time, rehashing exactly what we talked about, what we agreed upon, areas of potential, you know, difficulty. This way you have sort of a living, breathing document if problems do arise. Unfortunately, sometimes problems do arise. Yeah. After that conversation's done, then I asked the manager, I'd like to hop on a call with your team. And then I do the exact same thing with their team. Got you.
So this way everybody's in the know, everybody's on the same level, everybody understands where we're all coming from. Mhmm. But it's important to get that manager at least as much buy in as possible first. Yeah. So, Rob, can you tell us what are the rules of the road as it relates to what the MSL is responsible for versus what the sales reps are responsible for? Excellent question. So especially when you think about a commercial organization, Sway, your sales reps are just that.
They are there to promote the product on label to drive growth, drive prescriptions, get the doctor to write a prescription for that drug, to use that drug. The MSLs on the other hand, we're more of the fair balanced, sort of impartial person from the company. We provide the deeper knowledge, the deeper medical scientific clinical information that allows the doctor to make the best decision whether to use a drug or not.
So oftentimes, we will have access to off label data, deeper knowledge with studies, studies that are really beyond the scope of what a sales rep would get in training. So we're that deeper, more knowledgeable touch point. We're we're essentially doing the same thing. We're getting the information to the physician, but it's a deeper, broader, more balanced information which allows them to make the best decision possible. And sometimes the decision is, yes, I think this agent is a perfect choice.
Other times, no, based on the data, this agent is not a good choice. So the physicians look to the MSLs as being that broad sweeping, all encompassing, we're gonna give you the fair balance, you know, we'll give you the good, the bad, the ugly, and really sort of everything in between. Yep. And obviously, sales folks are promotional, driving sales, promoting the use of the product, whereas MSOs are fair, balanced, educational Non promotional.
Disseminating, you know, information, and it's non promotional. Correct? Yep. So that's kind of that's a great that's a great way to really look at it. Yeah. So we've got we sort of have a non vested interest in the outcome. We're there to be sure that the way we interpret as a company and medical affairs interprets our data and the breadth of data that's out there.
This is how we interpret it, and this is the information that's out there that allows a doctor to make sort of the the best decision on the fullest picture possible. Right. So, Rob, let's talk about the communication aspect. How are you engaged to go in on a visit? How does that work? How do you communicate, or how how are the reps communicating to you when you're needed? How are you communicating with them? Usually, there's a there's a a couple of ways.
And so, again, there's a there's a multilayers to this question. So usually, when I have those as aforementioned conversations with a manager, with a sales rep, one of the common things that I hear is just let me know when you're in my accounts. Just let me know when you're talking to my to my KOLs. Unfortunately, that becomes too burdensome, at least for me, is because you're constantly sending updates.
You know, what I like to do sort of the halfway point is, you know, that that's a lot of that's a large ask of me, whomever. What I will tell you, though, is if something comes up in the conversation that's relevant to you as a rep, a manager, or the commercial organization, you will immediately hear from me. So that's sort of the way I kind of artfully dodge when someone wants to say, I want to know where you are 247.
Usually, if a rep gets a question that they're not allowed to answer, they will have what's called an MIR or an MIRF form, medical information request or medical information request form. They will fill that out. Sometimes it's electronic. Sometimes it's paper. It goes into usually your medical information department. Sometimes that's in house. Sometimes it's the 3rd party. That gets routed to the MSL. It's the physician, the question, the topic. You follow-up.
That's sort of your reactive part of the job. The more proactive is you're reaching out unsolicited to the doctor. I'd like to I'd like to meet with you just to kind of get to know your your your practice, your research, if they work, they do research, work in a lab, kind of get to know them a little better, get to see what they expect from your field medical, counterparts. So some some KOLs that I work with, they like regular contact, you know, keep me up to date on the newest data.
Let me know what's coming available. Others are more, you know, just kind of reach out to me if you've got areas of interest for studies that I could be a part of. Others are, you know, more, quiescent. Okay. I'll reach out to you when I need you. So there's a nice balance out there, so it really fills your day. So a rep might average 5 to 7 calls a day. A good MSL, depending on the company, the disease state, the territory, you might average anywhere from 2 to 4 calls a week.
Terms of daily or weekly contact, but these conversations are often greater than 90 minutes. Most of my conversations are usually an hour, hour and a half, sometimes 2 hours. Yep. They're very scientifically intense. They're very rigorous. They're very in-depth. Okay. Good stuff. I like how granular we're getting too because I think there's a lot of people out there that don't know about this stuff. So this is really helpful. Now you mentioned before you used the word issues.
I think it I think it were problems. So what I'm like Let's talk about that. What Okay. Issues or pitfalls or things can what can happen in these relationships with your sales counterparts? So as I mentioned earlier, when you're talking to the managers, you're talking to the sales reps, they all come from a variety of different backgrounds with different companies that had different relationships.
What I often term as a potential issue is what I've phrased as what I call a false sense of accountability. So an example, a manager will say, I want you to tell me when you're in the accounts in my area, or I want access to your calendar to know where you are. My own manager doesn't ask that, so I'm not gonna give somebody else that I really don't have any accountability to. I'm there as a resource.
I usually will artfully dodge that and say, you know, that that's something that I'm just simply not comfortable with. There's really no need for that. That can spurn some conversation. Again, that gets into some of these managers that are a little more possessive, a little more controlling. It's my area. They're my people, my accounts. You really want to try to artfully steer away from that and try to say, look, I unfortunately can't do that for you, but this is what I can give you.
And as I said earlier, if something comes up that's relevant to you, you will be the first to know. Your rep will get a phone call. You will get a phone call. And I often recommend any contact that you have usually be via phone because everything via text and email is considered discoverable if you are audited. And, unfortunately, sometimes the most innocent texts or innocent emails, when looked at in a singularity context, these things have sunk companies.
It could be the most innocent, harmless text or email, But when you look at it just in a singular lens, when a lawyer gets a hold of it in audit, what did and you get deposed. What did you mean by this? What is this about? They don't have the full picture. So I often tell people in LJUs, no footprints in the snow. If you need to talk to me about something about you, send me a text. Can we talk? Phone conversations are the best way to go.
But back to the the issues are really when some when these sometimes the managers and the sales reps want to be a little more controlling and they want to be knowing of everything. And really when you phrase it back to them, you know, I don't ask you to tell me when you're going into these accounts. So why would I need to tell you? Like, this what are you looking to gain from this? A lot of times it's just a simple they just want to know that you're there.
So what I've done over the years is usually when I'm in an area, I'll usually contact a rep ahead of time. Hey, I'm coming into your town. I don't give specifics as to what. Let's have coffee. Let's have lunch. And we'll just sit and have a conversation. Great example. I was in Cleveland last week. Hey, I just stopped the Cleveland Clinic. I never mentioned who or where. Stopped the Cleveland Clinic, had some really good conversations with some of your top people.
Again, keeping it very broad based. Things are going well. Nothing came up that was irrelevant to you or, yes, this came up that you might need to be interested in. And usually those type of conversations, very 10,000 foot, very vague, very obtuse, that's enough to keep most people happy. They just wanna know that you're there, you're in your area, and you're talking to their people. Well and that was gonna be one of my next questions. Obviously, it's very important to have good relationships.
Yes. Successful relationships with your commercial counterparts. That's great advice. What other things do you do to ensure that successful relationship with your sales folks? I usually try to do probably once a quarter. I'll just put something on the sales manager's calendar, usually 30 minutes. And again, very brief, very open, very high level. Just say, hey, I'm just checking in, let you know I've been to these places. I don't see any issues. I don't see any problems. These are common.
I just want to let you know anything you want to bounce off of me. Again, sometimes it's like anything else. People just want to be heard and they want to feel valued. And again, I do that with the managers. Like I said before, I could do it with the reps. I don't do it every time I'm in in the reps area, but usually once a quarter if I'm in a certain area for a certain representative, I'll just go have a cup of coffee with them. And again, a lot of times it's just nothing specific.
It's just vague generalities. It goes a long way. It goes a long way. So, that's sort of what I do to kind of manage those type of relationships. Now to the other side of that, when you have reps or managers that are a little more difficult, that becomes a little more sensitive. And sometimes the best approach is to pull back. You need to be less involved, less engaged.
And again, this is going to come with experience As you get more experience in the field, as you work for different companies, work for different managers, you'll begin to build what you're comfortable with. And this gets back to something that I always do when I talk to the managers and representatives. There are 4 things I tell them that when I first talk to them. This is what I can do, can't do based on compliance and the rules of the road.
This is what I will do, won't do based on my experiences. Let's talk about that if you have any issues. If not, we're just gonna keep moving forward. Yeah. Well, it's good advice. That's really good advice. But it sounds to me like communication's really important.
Staying in good graces, staying in touch with your commercial counterparts with the right people, but also having that self awareness and emotional intelligence to realize that if you do need to pull back because it might be a difficult manager, someone whose expectations don't necessarily meet your expectations or your manager's expectations, then maybe you pull back. But is there ever a point in time where you need to go to your manager, your supervisor to say, hey. Listen. I don't know, man.
They're asking me stuff they're asking me for things that I can't do or, has that ever happened? I've had a very few situations where I've had to go and, again, as you gain experience, you begin to sense these things. And I'm gonna step back real quick. The great word you use is expectations. When you do some of the things that I mentioned earlier, you begin to manage expectations, and you can see problems before they potentially happen.
So I've had 2 scenarios, one where I could sense a potential issue. I went to my manager, talked to them about it, and I said, this is probably best as a manager to manager discussion. So it takes you a little bit. It takes some of the personal you know, when we're involved in things, we become deeply personal. We sometimes our judgment gets clouded.
So that's why it's always good to bounce a potential difficult situation off your manager and have a manager to manager discussion because that resonates differently. I did have one situation in a past career where it was a very controlling manager who implored that on his team. And when I would he when I would check-in every now and then some of the questions I was getting, some of the requests from him, I had to rope in compliance. So we got on a call with his team, the manager in compliance.
And compliance didn't say anything. They just sat there and listened. And I artfully handled some of the questions. And then when the compliance officer sensed there were some issues, she stepped in and said, okay. We need to have sort of a retraining on what's acceptable and what isn't. And unfortunately, the outcome was there was we were barred from communication.
The rep and the the reps and managers were not allowed to communicate with me for 6 months and I was not allowed to communicate with them. That is the worst case scenario that changed. But again, my hand was forced because of what I was experiencing over a pattern, and I had done these other things. I had tried to speak with the manager. I had conversations with my manager who then spoke to this manager. Nothing changed. That is sort of the Armageddon scenario. Again, that's very, very rare.
But again, it's a potential that it could happen. But again, if you some of these strategies that I talked about before and you'll learn them over time, you really can sense these things ahead of time and learn to artfully dodge them.
Well, and I'm glad you mentioned it because it there's people need to be aware that there is that is a certain possibility, if you have a situation where either it's again, expectations or a difficult manager or a really controlling manager or if you're not holding up your end of the bargain. I mean, I'm I'm talking as if it's always the sales folks fault. You know, we can you know, everybody makes mistakes. That's a great point. You have to have self awareness and self reflection.
Great, great point. I when I first started out, I was kind of a little more rigid, rules of the road, you know, wasn't as savvy as, you know, as agent experience give you. The joke that my sales team used to tell me is they would call me doctor no because all I told them was no. I gained a reputation for being difficult to work with. Yeah. So once that kind of filter back to me and I had some time to reflect about it, I said, okay, I need to change how I'm handling this.
And what I do now is somebody will express something to me. Okay. Unfortunately, that's something that I can't do. How about this? Would this be amenable? And more often than not, it usually is. So it's you provide them a solution. I would just say no and stop there and just say, okay, that's it. But when you're a little more proactive, a little more cerebral, okay, I can't do A. How about B? This is what I'm comfortable with or this is what we're allowed to do.
How does that does that meet your needs? 9 times out of 10, that's perfectly fine. Yeah. Let's talk about why it's so important to do that. Why it's so important to be compliant, and what happens if you get caught or there's an issue and the OIG comes in with the CIA? Like, let's talk about all that stuff. Try to define what these what these acronyms mean and why it's so important to stay compliant.
So the Office of Inspector General, as you said, they sort of are the policing hand of pharma, and we often hear about large scale fines. And it's not just for reps promoting off label or homemade sales piece of reference. There's a lot and history is littered with them for noncompliant MSL interactions. And that's usually why most, if not all, compliance documents are the MSL and the sales rep are not allowed to be in the same call at the same time.
And most companies now that I've worked for and I've heard for and speak to my colleagues, you're not even allowed to be talking to the same KOL in the same day. So if I have an appointment with a KOL at 10 AM, the rep can't come in until the next day. Wow. They just really wanna keep it separated, so there's no sense of and what would happen in the past was the MSL would come in, say, at 10 AM. You'd have a nice off label conversation.
The rep would bring lunch in at 12 and say, so what did you guys talk about? What did you guys talk about with my MSL? Oh, yeah. And then they would launch into some off label conversations or things. And it was a very thin veil for some of the more lascivious companies to operate.
Or if you had a rep and an MSL in the same call at the same time, you've got someone that's promotional and supposed to stay on label in the room at the same time having the same discussion with someone that can talk off label. That just looks bad. So and the government frowns upon that. So now they're really separating these rules to really keep it very, very hard lines, hardly defined in terms of who can be when and where and talking about what.
Because, like, we'll use my company, for example, our product is for ultra rare diseases, about $35,000,000 in sales. If we get hit with any kind of fines, especially some of these bigger fines that happen, the company is just gonna shut its doors. Yeah. I mean, the fines are these corporate integrity agreements, these CIA fines are substantial. J and j was hit with 2,000,000,000 for off label promotion for Risperdal. 2,000,000,000 even for a big behemoth like j and j. That is still a large hit.
That's a big, big number. So you really need to be compliant. And that's why, you know, what I when I get some of these questions sometimes and a lot of them, if not all of them, they're sincere. It's it's not like there's some shady backdoor guy hanging out in an alley smoking a cigarette says, Hey, MSL, I need you to do this for me. This is more, Rob, can you help me out here? Yeah. Okay. Unfortunately, I can't. That's non compliant. Let's talk about other ways.
Maybe we can partner, do things. You provide other opportunities. Because and a lot of times it's innocent. It's it's innocent. And again, especially when you get something over email, the best thing to do, what I say to people, is immediately close the loop. Reply back, tell them why you can't do something, and then follow-up with a phone call and say, hey, look.
Again, just a reminder, nothing over email because that singular email, if audited and taken in just a single snapshot in time, an astute lawyer can make a very strong case out of that. Yeah. Yeah. And that's how it had it's that innocent. It's that simple. It's 99% of the time, Tom, these requests that I get from commercial people, they're innocent. They they don't know any better. They don't mean they don't mean anything by it.
There's that rare person that is really trying to buck the system, and that's where you really have to dig your feet in and say, no. Like, I'm not gonna do this. And if you continue to ask me, we're gonna have to get compliance involved. I've only had to do that once where I've had to make a threat. I don't like making threats, but I've had to do that for very and thankfully, the rep eventually his behavior warranted removal from the company. So it was he made it easier on me.
But there are there are those again, they're very, very rare. They're more the exception than the rule. But, again, it's just really having smart conversations, again, usually over phone preferably. Yeah. Awesome. Rob, this was an amazing amount of information. I learned a lot. Any final thoughts? Anything else you wanna share with folks? Sure. Just especially for for the newer people, let your internal clock, your internal gut, so to speak, be your guide.
If it feels uncomfortable, if it sounds uncomfortable, usually it's not copacetic. And, if you're not comfortable because you're new or maybe it's just not your type of personality, always feel free to rope in your manager. Sometimes the best solution is a manager to manager discussion. And as you get experienced and older and more tenured, you'll feel more confident in saying, unfortunately, that's not acceptable or that's something I'm not willing to do. Let's talk about other ways.
And sometimes the only answer is no. And be comfortable with that. Be comfortable saying no. And that's difficult, especially when you're new. I know you have a lot of newer MSLs, people looking to get into the industry. Nobody wants to say no. Nobody wants to be the person that says no. I wanna be the team player. Unfortunately, that's what gets a lot of people into trouble. Alright, doctor. No. We're gonna have to leave it at that. Thanks a lot.
Thanks, Rob. You're awesome, Rob. Thank you for coming on again. Thanks anything, Tom. Appreciate your time. Alright, man. We'll see you soon. Bye bye. Thank you so much for listening to the show. And if you enjoyed it, please subscribe so that you don't miss an episode in the future and feel free to leave a rating or a review or a comment. Thanks again, and we look forward to seeing you soon.