of the physician to use the pharmaceutical company's drugs, Effect of managed care formularies on the ability of the physician to prescribe a drug, The adoption sequence of the physician (that is, how readily the physician adopts new drugs in place of older treatments), and The tendency of the physician to use a wide palette of drugs Influence that physicians have on their colleagues. Physicians are perhaps the most important component in sales. They write the prescriptions that determine which drugs will be used by people. Influencing the physician is the key to pharmaceutical sales. Historically, by a large pharmaceutical sales force. A medium-sized pharmaceutical company might have a sales force of 1000 representatives. The largest companies have tens of thousands of representatives around the world. Sales representatives called upon physicians regularly, providing clinical information, approved journal articles, and free drug samples. This is still the approach today; however, economic pressures on the industry are causing pharmaceutical companies to rethink the traditional sales process to physicians. The industry has seen a large scale adoption of Pharma CRM systems that works on laptops and more recently tablets. The new age pharmaceutical representative is armed with key data at his fingertips and tools to maximize the time spent with physicians. Pharmaceutical Company Payments Pharmaceutical and medical device companies have also paid physicians to use their drugs, which could affect how often a drug is prescribed. For example, one study that looked at physician payments and pimavanserin found that "extensive physician payments have been associated with increased pimavanserin prescription volume and Medicare expenditures." More specifically, drug reps help to create a culture of gifting, or the "pharmaceutical gift exchange," where actual monetary transactions are rare. In reality, gifts, both large and small, ranging from cups of coffee to travel to medical conferences are exchanged on a routine basis with high prescribers in an effort to shift their obligations from patients to prescriptions and have proven effective. Peer influence Key opinion leaders Key opinion leaders (KOL), or "thought leaders", are respected individuals, such as prominent medical school faculty, who influence physicians through their professional status. Pharmaceutical companies generally engage key opinion leaders early in the drug development process to provide advocacy and key marketing feedback. Some pharmaceutical companies identify key opinion leaders through direct inquiry of physicians (primary research). Recently, pharmaceutical companies have begun to use social network analysis to uncover thought leaders; because