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Changes are taking place across the healthcare landscape that will ultimately reduce physicians’ latitude in making treatment and prescribing decisions. An increasing number of the factors that drive physicians’ prescribing decisions are or will be beyond the control of pharmaceutical sales reps. As a result, tomorrow’s sales reps will have less ability to influence physician prescribing behavior than they did only a few years ago. For reps to be effective in this changing environment, they require new knowledge and new skills. Sales representatives need to be able to understand the physician not just as a clinical decision maker, but as a business person. Reps also need to understand the economics of practicing medicine in this environment and understand how those economics influence the physician’s priorities and behaviors. This article details the environmental shifts underway in the marketplace that are impacting or will impact sales representatives and the competencies that they will need to succeed in this changing landscape. 