Physician-Patient Dialogue: Unscripted Scrutiny

The battle for the hearts, minds and prescription pads of physicians treating targeted patients has always been challenging, but competitive pressures have never been more intense. Impending patent expirations threaten to expose billions of dollars in branded products to generic erosion. Mounting regulatory pressures, a feverish political climate and lukewarm economic conditions place even greater restrictions on how products are promoted to physicians and patients. It is clear that to compete and flourish pharmas need ground-level data on how best to connect and build lasting relationships with target customers.

Enter the naturally occurring dialogue between physicians and patients. Imagine if Plavix—sold by Bristol-Myers Squibb and Sanofi-Aventis—could gain visibility into real-life conversations patients and physicians are having about the launch of Eli Lilly and Daiichi Sankyo's Effient, which threatens to be a more potent, albeit more narrowly indicated, alternative. Or imagine the advantage brand and agency teams would have if they understood what is truly being said, not recalled, about competitive products in pre- versus post-launch environments. Imagine how this privileged exchange of information could be leveraged to architect and align functional and emotional brand benefits to the situated wants and needs of patients and physicians at the point of care.

The Promise Before the Product
Vimpat, a new antiepileptic drug (AED) from Belgian biopharmaceutical company UCB, launched in the US in June 2009. By that time, however, neurologists had been spreading news about the product to patients with epilepsy and their caregivers for several months. The discussions contained no information about potential risks or benefits of Vimpat, and very little in the way of product attributes such as scheduling and cost. Rather than educating patients about forthcoming treatment options, neurologists were evangelizing the promise of a coming-to-market therapy as a means to give patients hope:

Doctor: The big thing is you might go for six or eight months and not have any seizures and all the sudden you'll have a big one that breaksthrough and then you'll get the headaches back and everything will just start steamrolling on top of you.
Patient: I'm so tired.
Doctor: Well, there's going to be a new group of medications, there's actually a new seizure medication coming out in about three months. But there's a whole new group of medicines coming out next year called the Generation 3, these are the cleanest medications. A lot of them are going to be once a day or twice a day. And you'll be on one if [Medicaid] allows us to prescribe a new medication.
Patient: Yeah, I know.
Doctor: And so convincing them when the new ones come out next year, that is the way for you to go.
Patient: I have to pay $45 just for Keppra.
Doctor: Oh really. Well, they have a generic now. (January 2009)

Doctor: There is a new medication coming out in a week called Vimpat, which is going to be probably the number one seizure medication on the market.
Caregiver: OK.
Doctor: And he's the perfect candidate for it. That's something we're going to have to talk about. If everything calms down just by doing that, that might be his regimen, and then eventually [we'll] talk about going to twice a day…And then, Vimpat is supposed to be out soon, and so we're just going to put him straight on it.
Caregiver: Vimpat. (February 2009)

The above interactions illustrate how neurologists leverage yet-to-be-launched products to attend to the emotional concerns of patients and caregivers. This is most evident in the evangelical manner in which neurologists couch pre-launch products in positive superlative descriptions (“the cleanest,” “the number one”) while refraining from providing any form of a fair balance statement.

Consider the following interaction between an oncologist and a patient, currently on Torisel, battling renal cell carcinoma.

Patient: How did that report come out yesterday?
Doctor: Well, the report itself doesn't look very encouraging. Let's see how much increase, some increase has been there. OK. The mass measured 8 cm. Um, it has grown slightly. It has not grown tremendously but has grown slightly. Well, it has gone up more than 25% so we can say that some of the things have gone up more than we would like them to. You know what I'm saying?
Patient: Yes, um.
Doctor: What we need to do is to see what other options we have. There are newer drugs coming up in the renal cell carcinoma and, I can just tell you about those things. Um, there is a new drug called Everolimus. It is a newer drug which has been, I think it has been approved. (March 2009)

Here, the physician delivers news that the patient's cancer has worsened in a cascade of statements, with each statement indicating greater severity and concern about the cancer than the preceding one. The physician then effectively asks if the patient is able to read between the lines and understand that hope for remission is fading. After the patient indicates that he understands what is being said, the physician calls the patient's attention to hope on the horizon, focusing on the impending availability of Everolimus (Afinitor). Similar to the Vimpat examples, the oncologist does not provide functional information or education about the product. The product is purely symbolic, a white horse on the horizon meant to encourage patients to persist and maintain hope.

The key takeaway from these examples is that pipeline products are in the unique position of helping physicians attend to the interpersonal and emotional needs of patients. For marketers, especially marketers involved in creating and defining brands, the pre-launch environment is where the art of creating aspirational value—beyond the touting of product features and benefits—matters most in achieving a strategic advantage over competitor brands. The question that remains is, once launched, what effects do new products have on physician prescribing patterns in particular disease categories?

The Post-Promise Product
When new products become available, it is not uncommon for physicians to set these products against inline competitive products when introducing them to patients. For example, physicians often introduce Effient as “a new form of Plavix,” Onglyza as “a new cousin of Januvia” and Pristiq as “a new variation of Effexor” or “Effexor-light.” This manner of new product introduction enables physicians to effectively reposition brands in the minds of patients, removing them from their pre-launch mythology and redefining them in more familiar terms. Here is where the promise of a new product is balanced with potential drawbacks, where physicians take more time to educate patients about product characteristics and the overall risks and benefits of adopting new treatments, as illustrated in the Effient example below:

Doctor: So, that new form of Plavix is now out and available.
Patient: OK.
Doctor: And there is absolutely no problem with taking it together with a proton pump inhibitor like Prilosec, Prevacid, Nexium. No problem at all.
Patient: That is good.
Doctor: Here's the one bad.
Patient: All right.
Doctor: In some groups of people, including very elderly, it has been shown, or only really in very elderly, but I will tell you that it's across the board. There's a warning to be very careful, uh, because it can increase bleeding risk. So, it's a more potent blood thinner or caused a little bit more bleeding than Plavix did, enough that I've got to tell you that.
Patient: Right.
Doctor: The benefit, however, is that there is absolutely no contraindication to use it with a proton pump inhibitor. So, when someone like you, you really need something to suppress stomach acid, then that's a good medicine to take, but you have to understand there is a slight risk of increased bleeding above and beyond Plavix. So you got to decide if the benefit outweighs the risk to you. That's sort of the bottom line.…And then as soon as you decide, I will be happy to prescribe it for you.
Patient: Yeah. That sounds, that sounds great.
Doctor: It's called Effient.
Patient: OK. (August 2009)

While it's clear that the physician (a cardiologist) here is recommending the newer Effient over Plavix appropriate to prescribing guidelines for a patient on a proton pump inhibitor (PPI), what is more important to note is the way in which the physician positions the two products to the patient. First, the physician touts Effient's advantage over Plavix in that it is not contraindicated for use with a PPI. Second, the physician greatly downplays Effient's black-box warning about bleeding risk by suggesting that he is sharing this risk information out of obligation, not out of overt concern for the patient. The physician then goes on to promote Effient over Plavix, persuading the patient that the benefits outweigh the risks.

A secondary challenge facing new-to-market products is raising awareness of the product among different types of physicians. In the interaction above, the cardiologist had a thorough understanding of Effient's indications and was able to persuasively sell the patient on the need for and appropriateness of the drug. Conversely, as illustrated in the primary care physician example below, when physicians are not suitably familiar with (new) products prescribed by other physicians, they are not able to meaningfully address patient concerns and drive patient persistence on assigned therapies.

Doctor: [Physician name other] gave you that pill that was expensive?
Patient: He gave me, all my pills I got from him is expensive. You know this Effient, whatever that, that thing is?
Doctor: Which one?
Patient: Effient.
Doctor: OK.
Patient: It's a, it's a new one.
Doctor: For?
Patient: For the, uh, circ, blood.
Doctor: Oh, yes, yes, yes, yes.
Patient: And through the clotting in my legs.
Doctor: Yeah. Yep.
Patient: Yeah.
Doctor: Do you want me to get you some samples of Exforge?
Patient: Whatever you got, I can use it. Because that cost $158 a bottle.
Doctor: Yeah. (January 2010)

Here, the primary care physician refers to Effient as “that pill,” signaling a general lack of familiarity with the drug. The patient responds by providing vague descriptions (“new one,” “for the blood”) of Effient, attempting to activate physician knowledge of the product. The physician ultimately recognizes Effient and acknowledges the cost burden, but quickly shifts the topic away from Effient and offers to provide samples of Exforge, one of three blood pressure medicines that patient is currently taking. Through this topic shift, the physician is able to address the patient's overall cost burden, but he does not directly and meaningfully situate the cost of Effient within the context of its functional health benefits and life value.

Putting Your Money Where The Mouth Is
Listening to the naturally-occurring in-office dialogue between physicians and patients provides marketers with a unique and advantageous view of what truly influences treatment decisions when new products come to market. Notably, pipeline and inline marketers can leverage authentic dialogue insights during pre-, peri- and post-launch environments. For those who are commercializing new products, authentic dialogue enables marketers to identify information that meaningfully influences treatment selection versus information that is viewed as inconsequential or shared only out of professional obligation by physicians. This linguistically-derived understanding provides marketers of pipeline products with a grounded platform from which to develop next generation messages and materials that effectively link the pre-launch promise (emotional attributes) with the post-promise product (functional attributes).

For marketers of existing inline brands, authentic dialogue identifies relevant core messages and serves as the bedrock on which to build a new entrant response strategy. Importantly, in-office dialogue reveals how physicians truly position new products to patients and provides an invaluable competitive awareness and messaging tool for non-personal promotion and sales training teams.

Jeff Kozloff is the president and CEO of Verilogue and David Franke is director of linguistic insights and analytics at Verilogue

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