Transcript Pharmaceutical promotion

Influence Techniques
11 May 2006
Dr Peter R Mansfield
GP
Dept GP, Adelaide Uni
Director, Healthy Skepticism Inc
[email protected]
Influence techniques
•
•
•
•
•
Warnings
Thank you
Decision Making Shortcuts
Are you influenced?
Sales techniques
2
Warnings
• Decision making is not rocket science
• It is much more complicated and difficult
3
• Simplification
4
• Human limitations
5
6
Adult
content
7
Bias
8
Pro - Health Professionals
9
Pro – Drug companies and consumers
10
Muito Obrigado! (Much obliged)
• Traditional owners
• DATIS: Debra Rowett, Joy Gailer, Sue
Edwards and Josephine Crockett
• Pharmacy Guild of Australia
• WHO, PHARMAC, ANVISA, RACP
• Healthy Skepticism
• Participants
11
Context:
Information
Overload
Pressure for quick
decisions
12
How do you choose your
favorite drugs?
13
Decision Shortcuts
14
Decision Shortcuts
15
Mother Turkey’s shortcut
reasoning
Appeal: “Cheep Cheep”

Reasoning:
If A says “Cheep Cheep”
then A is my chick
 I should protect A.

Conclusion: I should protect A.
16
Respectful Health Professional’s
shortcut reasoning
Appeal: “Expert X recommends Therapy A1”

Reasoning:
If an expert recommends A then A is superior
 I should use A.

Conclusion: I should use A1
17
Shortcuts can be:
• A quick easy path
to the right
conclusion
• A quick easy path
to the wrong
conclusion
• Difficult to avoid
because of lack of
time
18
Other common shortcuts
• Newer is better
• Popular is better
• Trusting people we like
19
Continuous spectrum
20
Influence techniques
• Influence techniques trigger shortcuts.
• Shortcuts are quick
• Preparing influence techniques can take a
long time.
21
Use of influence techniques can be:
• Deliberate deception (Promoter does not
believe in the shortcut or the conclusion.)
• Good intentions (Promoter believes in
both.)
• Pragmatism (Promoter believes in the
conclusion but not the shortcut.)
22
Just as a practiced driver can change gears with
little or no conscious awareness an expert decision
maker can make decisions with little or no
conscious awareness.
23
When we use
shortcut reasoning with
little or no
conscious awareness
then we are
vulnerable.
24
Are you influenced?
25
How much influence do sales representatives
have on your prescribing?
A lot
1%
A little
38%
None
61%
Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of
medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001
26
May;110(7):551-7.
How much influence do sales representatives have on
other physicians' prescribing?
None
16%
A lot
51%
A little
33%
27
Denial justified by “intelligence”
“Doctors have the intelligence to evaluate
information from a clearly biased source.”
- Dr Rob Walters, ADGP chair
Richards D. Guess who’s coming to dinner. Aust Dr. 2004;23 Jan:19-21
28
Denial justified by “education”
“Mr Brindell [corporate affairs manager,
Pfizer Australasia] said doctors, who were
obviously highly educated, could sort the
chaff from the wheat.”
Riggert E. Doctors seduced by drug giants: Drug companies’ tactics spark
rethink by doctors. The Courier Mail. Brisbane 1999;July 26:1-2
29
Promotion is effective
“As an advertising man, I can assure you that
advertising which does not work does not
continue to run.
If experience did not show beyond doubt that
the great majority of doctors are splendidly
responsive to current [prescription drug]
advertising, new techniques would be
devised in short order.”
Garai PR. Advertising and Promotion of Drugs. in: Talalay P. Editor. Drugs in
Our Society. Baltimore: John Hopkins Press; 1964.
30
“The industry spends
perhaps around 10%
of its revenues on
conducting clinical
trials, and then
another 30%
promoting its
products.”
Mehta V. Batten down the hatches in
2005. Scrip News Update 2005 May
11
www.pjbpubs.com/cms.asp?pageid=277&
an=S00881592&bb=false&newsproductid
=8&ln=y
31
32
33
Your ability to cope with potentially
misleading promotion depends on your
understanding of:
• Medicine
– Pharmacology, Epidemiology, Public Health, Evidence Based
Medicine, Drug Evaluation, Pharmacovigilance
• Social sciences
– Psychology, Semiotics, Economics, Sociology, Anthropology,
Management, History, Politics, Communication Studies,
• Humanities
– Logic, Rhetoric, Epistemology, Linguistics, Literature, Art
• Marketing
– Product Management, Advertising Account Planning, Public
Relations
• Statistics
34
Radar of
critical
appraisal
35
Under the radar
36
Promotional meetings
Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician
prescribing patterns: there’s no such thing as a free lunch. Chest 1992;102:270-3.
37
52 Observational studies:
Exposure to promotion
does more harm than good.
Becker MH, Stolley PD, Lasagna L, McEvilla JD, Sloane LM. Differential education concerning
therapeutics and resultant physician prescribing patterns. J Med Educ 1972;47:118-27.
Mapes R. Aspects of British general practitioners’ prescribing. Med Care 1977;15:371-81
Haayer F. Rational prescribing and sources of information. Soc Sci Med 1982;16:2017-23.
Bower AD, Burkett GL. Family physicians and generic drugs: a study of recognition, information
sources, prescribing attitudes, and practices. J Fam Pract 1987;24:612-6.
Cormack MA, Howells E. Factors linked to the prescribing of benzodiazepines by general practice
principals and trainees. Family Practice 1992;9:466-71.
Berings D, Blondeel L, Habraken H. The effect of industry-independent drug information on the
prescribing of benzodiazepines in general practice. Eur J Clin Pharmacol 1994;46:501-505.
Caudill TS, Johnson MS, Rich EC, McKinney WP. Physicians, pharmaceutical sales representatives, and
the cost of prescribing. Arch Fam Med 1996;5:201-6.
Caamano F, Figueiras A, Gestal-Otero JJ. Influence of commercial information on prescription quantity in
primary care. Eur J Public Health. 2002 Sep; 12(3):187-91.
Watkins C, Harvey I, Carthy P, Moore L, Robinson E, Brawn R. Attitudes and behaviour of general
practitioners and their prescribing costs: a national cross sectional survey. Qual Saf Health Care. 2003
38
Feb; 12(1)29-34.
Bad news
•
•
•
•
•
•
•
•
Doctors are human
Drug companies aim for profits
Research is biased
Journals are biased
The news media is biased
Governments are political
We have a system problem
People are being harmed
39
GPs are human
We have less evidence about:
• Specialists
• Pharmacists
• Other health professionals
• The general public
40
People are mindless,
irrational, easily
manipulated dolts…
It's how our brains are
wired.
You make up your mind
first then you rationalise
it second.
But because of the odd
mapping of your
perceptions you're
convinced beyond a
doubt that your decisions
are based on reason.
Doctors are human
“Medical men are subject to the same kinds
of stress, the same emotional influences as
effect laymen.
Physicians have, as part of their self image,
a determined feeling that they are rational
and logical, particularly in their choice of
pharmaceuticals.
The advertiser must appeal to this rational
image, and at the same time make a deeper
appeal to the emotional factors which really42
influence sales.”
Doctors main motivations
Burnt out Dodo
Caring Bunny
Conservative
Sheep
Entrepreneurial
43
Wolf
Branthwaite A, Downing T.
Companies aim for profits
“if, indeed, candor (honesty), accuracy,
scientific completeness, [etc] came to be
essential for the successful promotion of
[prescription] drugs, advertising would have
no choice but to comply.”
Garai PR. Advertising and Promotion of Drugs. in: Talalay P. Editor. Drugs in
Our Society. Baltimore: John Hopkins Press; 1964.
44
In their shoes
• You are responsible for promotion of a new
drug that is no better than the old ones but
will be sold at a higher price.
• If you do not succeed you will lose your
job. Because you will not be able to get
such a well paid job elsewhere you and your
family will loose your house.
• What promotional methods will you use? 45
Did you plan to tell:
• the truth?
• the whole truth?
• and nothing but the truth?
46
A system problem
“Put a good person in a bad system, and the
system wins, no contest.”
- W. Edward Demings
A ocasião faz o ladrão
[The situation makes the thief]
- Brazilian saying
47
Blame
• Normal to blame individuals/
groups/companies.
• But the main determinate of behavior is the
situation (the system of inputs).
• If we improve the information and
incentives that actors receive then their
behavior is likely to improve.
48
People
are
being
harmed
49
Direct harm
“Needless injury or even death may occur
because physicians have been persuaded to
prescribe products for uses for which they
had not been adequately tested or to
substitute therapies that may be less safe or
less effective than the alternatives.”
-US FDA Commissioner Kessler
Kessler DA. Addressing the problem of misleading advertising. Ann Intern
Med. 1992; 116:912-9.
50
Estimated toll from Vioxx
“…the increased risk of 16 events per
1000 patients treated for up to 3 years…
…a potential excess of several thousand
cardiovascular events caused by
rofecoxib. This may represent an
underestimate of the number of events
caused by rofecoxib, because patients with
inflammatory arthritis are likely to be at
higher baseline risk of cardiovascular events
than the “low risk” population included in 51
VIGOR (2000)
Vioxx
Total
serious
adverse
events
9.3 %
Naproxen RR
(95% CI)
7.8 %
1.21
(1.041.40)
52
Nov 2000
53
May 2001
54
Sep 2001
55
“Doctor, once daily
Vioxx has no effect
on platelet
aggregation.
Once daily Vioxx is
therefore not a
substitute for aspirin
for cardiovascular
prophylaxis.
However once daily
Vioxx 50mg had no
affect on the anti- 56
platelet activity of
CLASS (2000)
Celebrex
Total
serious
adverse
events
6.8 %
ibuprofen RR
and
(95% CI)
diclofenac
5.8 %
1.17
(0.991.39)
57
Harm for patients
• Some corruption
• A lot of unintended bias
leading to
• A little direct harm from sub-optimal drug
use
• A lot of indirect harm from opportunity
58
59
Damages
patient’s
trust in
health
professionals
BMJ cover
60
Sales techniques
• Appeal to experts
• Social validation
(peer pressure)
• Liking
• Commitment consistency
• Reciprocation (gifts)
• Scarcity
Cialdini RB. Influence Science and practice. 4th ed.
Boston Allyn & Bacon; 2001.
Roughead EE, Harvey KJ, Gilbert AL. Commercial
detailing techniques used by pharmaceutical
representatives to influence prescribing. Aust N Z J
Med. 1998 Jun; 28(3)306-10.
61
The appeal to modesty
“When men are established in
any kind of dignity, it is thought
a breach of modesty for others
to derogate any way from it, and
question the authority of men
who are in possession of it.”
Locke, J. An essay concerning human understanding.
1690.
62
63
The improver of natural
knowledge absolutely
refuses to acknowledge
authority, as such. For
him, skepticism is the
highest of duties; blind
faith the one
unpardonable sin.
- Thomas Henry
Huxley, biologist and
educator,
Huxley TH. Aphorisms and Reflections.
1907
64
Social validation (Peer pressure)
Rep: …and that's why, I think, everyone agrees,...
Rep: This is the most commonly prescribed antibiotic in
American hospitals (ciprofloxacin)
Rep: "Brand G“ (nifedipine), which you know, of course,
is the second top prescription drug in the world
65
Popularity
Which US President won office
with the largest majority?
What is the world’s
top selling food?
66
Social validation
67
Liking (Friendship/Attractiveness)
Drug reps keep and
share detailed records
of personal
information to assist
them to appear
friendly.
68
Cristin Duren, Drug Rep
Saul S. Gimme an Rx! Cheerleaders Pep Up Drug Sales. New York Times.
November 28, 2005
69
70
Commitment consistency
People prefer to act in ways that are consistent
with past commitments so as to maintain their
sense of self and to avoid the discomfort of
admitting an error or of acknowledging
complexity.
71
72
73
74
Eating increases acceptance of
persuasion
“more opinion change
tends to be elicited under
conditions where subjects
are eating”
Janis IL et al. Facilitating effects of “eatingwhile-reading” on responsiveness to persuasive
communications. J Pers Soc Psych
1965;1:2:181-6
75
He who pays the piper calls the tune
76
77
Scarcity
• Increases perceived value.
• Examples:
– Diamonds
– Available “For a limited time only at
MacDonald’s”
• Not common in drug promotion
when health professionals do not
pay for drugs.
• Is used to increase perceived value
of prizes.
78
Desires/
Fears
79
Evaluate
this ad
Exaggeration
Desires for
sex, safety,
simplicity.
Scarcity.
Science
babble.
80
Strategies in response
to pharmaceutical
promotion
11 May 2006
Dr Peter R Mansfield
GP
Dept GP, Adelaide Uni
Director, Healthy Skepticism Inc
[email protected]
Strategies in response to
pharmaceutical promotion
•
•
Change
Treatments
–
–
–
–
•
Improve regulation of drug promotion
Redesign the incentives for health professionals
Redesign the incentives for drug companies
Improve health care decision making
Healthy Skepticism
82
Change: Bad news
• No option has been adequately tested.
• It is likely that a combination of options will be
required for success.
83
Change: Good news
•
•
•
•
The Zeitgeist (the current set of shared beliefs in
society) is changing.
There are some ideas for system reform that
might work.
If so, all will benefit including drug companies
who could have good returns with lower risk.
There are some simple things that you can do to
be part of the solution.
84
85
Treat the causes
Companies are rewarded for doing what
works for increasing sales and prices.
Promotion (including disease mongering)
works because people have human
vulnerabilities.
High prices and sales fund more promotion.
86
Treatments
•
•
•
•
Improve regulation of drug promotion
Redesign the incentives for health
professionals
Redesign the incentives for drug
companies
Improve health care decision making
87
Redesign the incentives for
health professionals
88
Banning large gifts won’t work.
89
Disclosure of conflict of interest is
not enough
“We would not permit a judge…to have equity in
a for-profit prison, even if the judge disclosed it”
Krimsky, Sheldon. From an interview in the Chronicle of Higher Education, as quoted in
the The Bulletin of the Canadian Association of University Teachers. February 2003. A9.
90
Disclosure can make bias worse
Random
assignment
Advisor paid to
recommend
higher estimate
Estimator paid
for accurate
estimate count
of coins in jar
No disclosure
by Advisor
Disclosure of
competing
interest
Higher
Higher estimate
recommendation
Cain DM, Loewenstein G, Moore DA. The Dirt on Coming Clean: Perverse
Effects of Disclosing Conflicts of Interest. J Legal Stud 2005;34:1–25
91
The only solution that could work:
ban all gifts
Just say no
to drug reps’
gifts
92
93
Redesign the incentives for drug
companies
Pay separately by open competitive tender for
separate functions:
– Manufacturing
– Promotion
– Research
– Education
94
Improve health care decision making
• Promotion would improve to match
• But there is a limit to how much humans with
limited resources can be expected to improve.
95
If the decision is important take
more time
96
Use
more
reliable
info
sources
97
Recommendations re shortcuts
• If you decide without checking all the evidence
yourself recognise you have used a shortcut
• So don’t be too confident in the conclusion
• Treat the conclusion as a hypothesis to be tested as
soon as possible
• Use countermeasures against shortcuts
eg. Be skeptical of paid experts
98
Options for responding to promotion
1. Abstinence
or
2. Harm minimisation
Warning: There are no proven methods to
ensure more benefit than harm from
exposure to drug promotion.
99
100
101
102
103
104
Reducing vulnerability to
misleading promotion
Increasing skills
- a little improvement
Increasing perceived personal vulnerability
- a big improvement
Sagarin, B. J.; Cialdini, R. B.; Rice, W. E., and Serna, S. B. Dispelling the illusion of
invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc
Psychol. 2002 Sep; 83(3):526-41.
105
Illuminating the techniques used in drug advertisements
www.healthyskepticism.org/adwatch.php
106
Main conclusion
• There is no known training for health
professionals that would ensure that more
good than harm comes from exposure to
drug promotion.
107
Until we
can fix the
system the
best we
can do is
avoid all
contact
with drug
companies
108
Healthy Skepticism
Countering misleading
drug promotion
www.healthyskepticism.org
109
Healthy Skepticism
• Improving health by reducing harm from
misleading drug promotion
• International non profit organisation based in
Australia
• Everyone who is interested in improving health
care is welcome.
• Members, Paid Subscribers, Free Subscribers
• Mostly doctors and pharmacists.
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