Teaching Doctors to Fish

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As a provocative and interesting thought problem, consider that Big Pharma might characterize a doctor as a drug delivery system. Perhaps it does this already. In this metaphor, a well-trained detail person loads the doctor with sufficient “micrograms” of information in the course of a 60-second contact. This allows the doctor (the “device”) to aim the promoted product at an appropriate patient (the “target”) and dispense it. Thus, the delivery system “delivers” the goods for the company.

The US pharmaceutical business sales model is the implementation of this metaphor: a detail person greets the doctor across a counter in an often crowded waiting room or a private break room. The sales rep hands over a signature page for the doctor to endorse, thereby recognizing receipt of samples and memorializing the visit for FDA and company audits. The rep utters a few carefully crafted marketing slogans about a product whose name is emblazoned on the nametag of the said salesperson, the box of samples, pens, facial tissue and an 8x12 glossy advertisement quickly displayed, but not explored. And for 93 of every 100 sales calls, this will all occur in under two minutes.

The closing portion of the interaction tediously renames the product that generated the visit, and drops what passes for a unique selling proposition into the ear of the just-barely hearing listener. Samples, with product name in plain sight, are left conspicuously on the counter so the brand can be apprehended yet again before the drugs are carried unceremoniously to a drug room or cabinet where the cherished product takes its place strategically among strangers and competitors.

Alternatively, the rep may schedule a lunch with the doctor in order to buy more time with him/her in order to acquaint him in greater detail with the value of a product. Or, the rep invites the doctor to a dinner lecture, a sports event (in the guise of a lecture program) a symposium in another rather sunnier locale or to become a speaker or clinical investigator for the product. Rather more mundanely, the rep may schedule an interaction with an expert, possibly one-on-one, who will talk only about a product, via teleconference or in-person meeting.

Occasionally the sales person is obliged to travel with their district or even regional director and visit the doctor with executive in tow. This austere ritual in which the rep, in the presence of his/her “boss,” looks truly terrified, or at least uncomfortable, usually generates sympathy on the part of the doctor, often resulting in the doctor allowing for additional face time with the rep. This usually eases the strain on the rep who, for the moment, becomes a beleaguered friend.

Having described the most common and far-from-ideal sales scenarios, consider that within the last eight years, the pharma sales force has nearly doubled in size, while the physician universe has increased by only 15%. To justify the lopsided nature of these two increases, each top MD/DO would need to allow a rep visit every two hours.

Other than the sales rep's Macaw function of naming a product as often as possible, what is really going on here? What is the anthropology of the pharma-physician interactions? How can the existing rituals be improved and how can the details bulk-up the bottom line for a greater return on a large investment? What is it that companies know about contemporary physician behavior? And more to the point, what do they either not understand or care not to recognize about it, to their peril and to the detriment of doctors and patients?

There is one fundamental assumption about physicians that seems to govern all detail interactions. That assumption is that doctors, once given a product, will know how best to employ it in its intended FDA-sanctioned therapeutic role and niche. Somehow, this capacity of proper utilization is thought to flow from mere knowledge of the name, dose and indication for a given product. Adverse reaction potentials and interactions are assumed to have been internalized, mainly from the package insert (optometrically challenging font size permitting).

Discrimination and subsequent preferential selection of one product from a competitor's preparation represents the action of the “black box” brain of the doctor. This foreseeable perplexity is confronted by the aforementioned strategy of repetition. This method of reiteration counts as “persuasion” in today's detail strategies. Thus, reps are instructed to appear frequently in the office of the doctor, say the name of the drug as many times as possible in a limited time frame, leave samples behind, interact pleasantly with the doctor, and particularly, his staff, and depart with the promise to return soon for more of the same.

The rep will provide lunch or sponsor dinner speaker programs under the guise that vital education about a disease state will be imparted at food and ethanol-saturated gatherings. The rep will provide clinical studies that prove the unique worth of a given product, and will leave behind slick brochures featuring colorful photographs of satisfied customers in action poses who have evidently richly benefited from the use of the cherished product. Displayed within the promo piece will be vibrant charts and bulleted data proving that a certain product is superior to another product, or at least superior to the infamous and always surprisingly effective placebo. 

How is the doctor to absorb and use all this rapidly shoveled data? How is the physician to integrate the numberless, repetitive, virtually identical encounters with drug reps of competitive houses, into his/her (if the truth be told) unique, self-created clinical repertoire? How does the doctor know which drug to choose in the welter of his day? How does he fulfill his role of “dispenser” effectively, seamlessly and safely?

Does the industry understand this dilemma, or do they actually create and foster it? Does it understand that if it teaches the doctor to fish rather than simply handing him a fish, the product will sell better, be perceived as superior, will not be so readily abandoned as a choice, be used more effectively and will raise the bottom line more predictably?

The simply stated problem from a marketing perspective: the doctor does not know how to sell. The sales rep is carefully trained to sell to the doctor. He/she is selected and groomed for the medical market. Then, the industry which spends a fortune on market research (without ever studying the real behavior of its customer), simply assumes that the doctor, as a clever, well-educated professional, has somehow and somewhere absorbed the commercial/medical/data analysis/linguistic wherewithal to “run” with a product once he/she knows about it.

It is assumed that the doctor will ask the patient pointed questions that will unmask their disease. The diagnosis will reflexively evoke the need for the detailed product. In this imagined sequence, the problem and its remedy will be presented to the patient in a clear, intelligent manner so that the patient will know precisely what his/her problem is. The patient will be instructed how to correctly, and without risk, use the prescribed drug to remedy their problem…just like on TV.

It is assumed that the doctor has a clinical method, or repertoire, with just the right “patter” to securely place the drug in its proper therapeutic sequence to control the disease for which the product was intended. It is assumed that the doctor will know how to prescribe the drug, employing a finesse that is apparently genetically acquired. It is taken for granted that the physician will have the skill to take a drug failure history if the product needs “resuscitation” for a patient who wants to abandon it for a competitor's brand. What if this imagined ideal sequence is completely wrong?

What if, for the outpatient problems that drugs are designed to treat—diabetes, depression, arthritis, erectile dysfunction, etc.—doctors are without finely honed questions to put to patients, without reliable methods to manage disease, without patter or clear language with which to effectively embed a product into their treatment plan? What if doctors have had no mentors to show them how to sell in the context of their work? Then, when a drug is available and appropriate to use, the likelihood of their using it in an ideal manner is, to put it in Las Vegas terms, a “crap shoot.”

So pharma reps spend their days cheerfully and enthusiastically filling the already-pathetically overfilled drug dispensers called doctors with often misleading clinical data. This data is too often reported in relative frequencies rather than absolute numbers, and fails to provide clinically meaningful data such as the “number needed to treat.” Instead they provide simplistic clinical materials doctors rarely use.

For example, they supply tear-off diagnosis sheets to be left on waiting room tables so that patients may discover them (finding them more often by accident during their causal foraging of waiting room reading materials), read them and fill them out. In this haphazard manner, complex clinical entities like depression, bipolar disease, sleep apnea and attention deficit disorders are identified by patients, and not by doctors who should be taking the diagnostic efforts to identify these conditions.

A complete, legible, clinically relevant user's manual is absent from the detail. Remember, teach the doctor to fish.

The failure to comprehend physicians' selling deficiencies leads to missed opportunities for the drug company. That is, what doctors actually do and how they behave around patients, and not merely what they say they do reflects a critical industry problem and represents a startling opportunity for change. If pharma understood the actual approaches that physicians adopt in their outpatient clinical work, it would be in a position to dramatically modify its approach taken with doctors and, in turn, detail them differently; they would be in a position to produce more face time and significantly and securely bolster their bottom line.

And let it be noted that the current gambit of electronic interactions represents nothing more than old wine in new bottles. Though the delivery system may have been updated, the content remains well off the mark of filling the doctors' educational need, and only perpetuates this educational and practical thirst.

Pharma is asking the wrong questions in its market research of the medical community and so misses the mark in the design of its detail methodology. It does not really understand its customer, attributing to him strengths that the doctor may not have, and ignoring weaknesses that are all too apparent. If it did understand the doctor and his/her real behavior and rituals better than it does, the industry could be far more effective at its selling and as a vital byproduct, achieve greater therapeutic effects for patients.

Because the doctor cannot sell, the opportunity to reach him/her more effectively is squandered. Additionally squandered is the opportunity to, through the doctor, treat patients more effectively and safely.

Pharma's sales paradigm has not changed but doctors have. They face an increasing emphasis for meeting quality-of-care standards and evidence-based medical demands, which represent significant changes in their performance standards. This fact mandates a change in the pharmaceutical sales model. This approach of selling to physicians is urgently needed and is available…perhaps surprisingly available.  

Scott A. Kale, MD, JD, MS, is medical director at Donahoe Purohit Miller, Robert L. Barkin, MBA, PharmD, FCP, is an associate professor of the Rush University Medical College and Peggy Moyer is a marketing consultant for Moyer DCS, Inc.

Lost in the details

Clinically relevant issues are rarely (almost never) addressed in the detail. A partial list of these might include:
Changes in the package insert since the last visit
The metabolic pathway the product uses, induces or inhibits, and its effect on the use of co-morbid pharmacotherapies
Specific cautions for use with elderly patients
The specific doses for various stages of renal and hepatic function and impairment
Patient responsibilities with the use of the product
For whom should the product not be used, or used with caution

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