|
Scott Pegler, MRPharmS, is principal pharmacist
and medicines information manager, and Roger Williams,
MRPharmS,
is pharmacy manager, at Morriston Hospital, Swansea NHS Trust.
Stuart J. Evans, MRPharmS, is interface/formulary pharmacist for
Swansea NHS Trust and Swansea Local Health Board.
Correspondence to:
Mr Pegler at Pharmacy
Department
Morriston Hospital, Swansea NHS Trust
Swansea SA6
6NL
e-mail scott.pegler@swansea-tr.wales.nhs.uk
Declaration of interest
Scott Pegler works as a consultant
for John Wiley & Sons, UK, regarding InfoPOEMs |
Angelo Gilardelli/Dreamstime.com
|
“Too often we… enjoy the comfort
of opinion without the discomfort of thought.”
— John F. Kennedy (1917–63)
“During training, I was told, when you’re out to dinner
with a doctor, ‘The physician is eating with a friend. You are
eating with a client’.”
— Shahram Ahari, former pharmaceutical
sales representative for Eli Lilly (US)
Lunchtime meetings sponsored by the pharmaceutical industry — drug
lunches — are an established mechanism for pharmaceutical company
representatives to present new information or reinforce current messages
to hospital pharmacists regarding the drugs they are promoting within
secondary and primary care.
A previous article has highlighted how the principles of information
mastery can be used to evaluate promotional information from the pharmaceutical
industry, ie, what they say.1 This article will illustrate a few of the
techniques used in the sales process (how they say it) and suggest how
pharmacists, by taking a proactive approach, can set the agenda for meetings
with representatives and quickly critically appraise the information
presented.
We make no judgement on the ethics of industry-sponsored lunchtime meetings:
the decision whether or not to attend must be a personal one. However,
we think that such meetings, if organised appropriately, can form an
important part of pharmacists’ continuing professional development
through use of pragmatic and practical critical appraisal skills.
Food, flattery, friendship …
The local “drug rep” entering the hospital pharmacy department
at lunchtime loaded with carrier bags is a common sight. The audience
subsequently listens politely, interrupted occasionally by the sound
of rustling crisp packets, to the well rehearsed message — essentially “prescribe/recommend
my drug” — supported by a colourful PowerPoint presentation
referencing “evidence” to support the verbal message.
This friendly, informal atmosphere is probably familiar to readers. However,
from a social science perspective, the influence these meetings can have
on subsequent behaviour may be more subtle than most pharmacists realise.
The influence of gifts in medicine has been reviewed extensively elsewhere
and is beyond the scope of this article. However, the act of bringing
food to a meeting also constitutes a “gift”.2 Recipients
of gifts are culturally programmed to feel indebted to the gift-giver,
as demonstrated by the commonly used response to a gift: “much
obliged” as a synonym for “thank you”.3 A special relationship
is developed between people who share food.4 However, in the context
of a drug lunch, the audience reciprocates the gift of food by politely
listening to the representative’s presentation.
It has been known for many years that individuals tend to be more receptive
to information when eating enjoyable food. This is why food is “the
most commonly used technique to detail the judgement aspect of decision
making”.3
Furthermore, the positive atmosphere created with good food and a friendly
representative helps to break down professional barriers, with evidence
showing that in this setting, individuals are more likely to accept the
delivered message even if they fundamentally disagree with it.5
Notably, so socially entrenched is the act of reciprocation that any
individual who fails to adhere to this social stereotype (in this case,
listening politely) is often considered to have bad manners by the rest
of the group.3 For example, an individual may be viewed as creating a
bad atmosphere simply by asking a probing question based on the data
presented by the representative, with the group viewing this action as
giving the representative (gift-giver) “a hard time” inappropriately.
“How they say and do it”
A pharmaceutical representative’s primary aim is to sell his or
her product and not to supply independent, unbiased information. Furthermore,
the “evidence” used to support the marketing message may
be of dubious relevance and validity, and is often accompanied by various
emotional appeals and logical fallacies.6 Indeed, one study analysing
the accuracy of information from representatives found that one in 10
statements — all of which favoured their product — were at
odds with the company’s own literature.7
Using the STEPS acronym (safety, tolerability, efficacy, price and simplicity)
described previously1 can help focus the pharmacist on those aspects
of a medicine that are essential when assessing its potential value to
patients. However, communication techniques used by the representative
when delivering information are probably equally important in determining
how the new medicine under scrutiny is perceived.
The appeal to authority A common technique used by representatives is
the “appeal to authority”.8 The representative will name
an eminent doctor or professor based at a nearby teaching hospital or
centre of excellence and say that he or she is a major advocate and user
of the medicine being detailed. This appeal is intended to make pharmacists
feel vulnerable that they, too, should be recommending this medicine.
Occasionally, a representative may use the name of an eminent doctor
who is unknown to the audience. The intention is again to make pharmacists
feel vulnerable, but this time not only because they should possibly
be using more of the medicine, but also because they have not even heard
of the eminent person purporting to advocate its use.
The flaw with the appeal to authority is that the reason the authority
is using the drug is not made clear. The eminent doctor, for example,
may only treat the most problematic clinical cases or patients who have
failed to respond to standard therapy, and that doctor, in fact, might
also agree that widespread use of the medicine being promoted would be
inappropriate. An example might be a consultant psychiatrist who uses
significant amounts of venlafaxine for resistant depression, where widespread
use of venlafaxine as a first-line therapy for depression would be inadvisable.
Many companies use the services of key “opinion leaders” who
are paid to speak or write on behalf of the company. With some individuals
the “independence” of this information can often be called
into question, although others may naively become involved in a game
being played out by a pharmaceutical company to promote its product.
Many, however, are simply happy to take the financial reward and remain
unaware of how they are actively influencing prescribing patterns either
locally or nationally.
The bandwagon effect Related to the appeal to authority is the “bandwagon
effect”.8 A representative might state that his drug is the most
widely prescribed drug in a particular hospital and use this fact as
a suggested reason for increasing prescribing of that drug at another
hospital. Again, the flaw with this appeal is that the pharmacist does
not know the reason why the medicine is the most used. Despite this,
the uncertainty creates a conflict that often results in enhanced use
of the medicine through individuals “following the herd” and
subsequently recommending the drug.
Representatives seek to be trusted so that the information they provide
is considered credible. They may deliberately use subtle words such as “we” or “our” during
their detailing, eg, “when we see our patients …” or “we
treat our patients using …”. The suggestion here is that they
(the representative and his company) are working directly alongside us
in patient care — a suggestion that is clearly not the case.
The appeal to pity The representative may make an “appeal to pity”8 for the target patients or sometimes for themselves, eg, “what
else can we offer these poor old patients with dementia …” or “I’m
having a terrible week, I’m soaking wet, I couldn’t park
the car and I’m now going down with flu, please can you give this
new drug for angina a try …”. In both cases, the aim is to
appeal to the audience’s emotions rather than their critical and
rational minds, again with the intention of increasing usage of the medicine.
The red herring
appeal The “red herring”8 occurs when pharmacists
are told an apparently interesting but often irrelevant fact about the
medicine, with the suggestion that this confers a theoretical benefit
to the patient. This might be a structural uniqueness of the drug molecule
or drug selectivity for a specific receptor sub-type or increased potency.
Although these characteristics might be of academic interest, they should
not distract the pharmacist from a critical evaluation of whether the
drug actually produces the claimed effects in the real world, ie, evidence
from clinical trial data showing patient-oriented outcomes that produce
tangible and clinically meaningful benefits to the patient being treated.
The appeal to curiosity The “appeal to curiosity”8 is similar
to the red herring and again involves highlighting a non-clinical unique
feature of the medicine. The presentation may use complicated graphics
or incorporate a practical demonstration using various gadgets. Once
more, the aim is to distract the audience from the primary question of
importance when assessing the value of a medicine, that is, does the
medicine have proven benefits in the real world that actually make patients
have a better quality of life or live longer?
The testimonial A
powerful technique commonly used by representatives is the testimonial.8 The
representative presents the results of one or more clinical trials, possibly
incorporating data on many hundreds of
patients, and showing clinical benefit of the drug. The representative
will then add a comment like: “I didn’t believe it myself
until my father took it. He was crippled with his arthritis and could
barely walk, but now he can do the shopping and take the dog for a walk.”
Once
more, the representative is appealing to pharmacists’ emotions
in order for them to make their decisions. The acknowledgement that they
are right to be cynical about trial data shows an understanding of their
way of thinking but, cleverly, this is supplemented by information that
creates an emotional response, the subliminal message being “if
he would recommend it for his nearest and dearest, then it must be OK
for our patients, too”.
It is interesting to note that pharmacists can usefully employ the testimonial
themselves when counselling patients. For example, a patient taking multiple
medicines for various chronic conditions may ask the value of using a
herbal remedy. In reply, the pharmacist might outline the available evidence
but supplement the message by saying, “well, if it were my mother,
I wouldn’t be recommending she take it”. In this situation,
the patient may be cynical about the pharmacist’s appraisal of
the evidence on the herbal product (“he would say that, wouldn’t
he?”) but may be more receptive to the emotional appeal regarding
the recommendation for his own mother not to use it. Why do they do it?
In 2002-03, the NHS spent £7.5bn on drugs in England of which 80
per cent was spent on branded medicines.9 Promoting these medicines in
the UK are approximately 8,000 drug company representatives. Many doctors
state that they rely on representatives for information, especially in
relation to new drugs,10 and this is one of the reasons why the industry
places such importance on their role in providing information, as this
privileged position can mean they are hugely influential in subsequent
prescribing decisions.
Furthermore, there is a generally held but naive view that advertisements
and marketing immediately make you rush out and buy something and one
demonstrates immunity simply by not acting immediately. However, the
absence of a knee-jerk response does not prove immunity from advertising’s
influence. Selling is subtle: all the representative might expect is
that, all things being equal, any subsequent decision may hopefully benefit
his product.11 So what can be done?
Using the STEPS acronynm can help pharmacists focus on the important
clinical issues when assessing the value of a medicine to a patient,1 and this philosophy should be combined with an awareness of commonly
used verbal communication selling techniques, as together they can
assist with spotting logical flaws or invalid claims made in promotional
talks from the pharmaceutical industry.6 Ultimately, however, any
encounter with a pharmaceutical representative requires a degree of healthy
scepticism.6
In their defence, pharmaceutical companies might suggest that their
representatives alert pharmacists to new information faster than other
sources. In addition
to often having questionable relevance and validity, the argument about
alerting clinicians faster to new information is also largely irrelevant
nowadays because there are numerous clinical awareness systems available
to deliver high quality appraised and unbiased information via e-mail
on a daily basis for those wishing to remain up to date (see Panel).
The pharmacy department at Morriston Hospital, for example, has taken
a proactive approach to lunchtime meetings with pharmaceutical representatives
and directs them to present data in a specific format to meet our own
requirements.
Representatives making an appointment for a “pharmaceutical industry
meeting” — not, note, a drug lunch — are provided with
a standard letter in which they are requested to present information
regarding their medicine using the STEPS format. (The term “drug
lunch” was dropped because it was thought to convey the wrong message,
with the emphasis on food rather than the medicine being discussed.)
Presentations are no longer than 30 minutes after which the representative
is asked to leave the meeting. A senior pharmacist then leads a group
discussion using a crib sheet (available on request from the authors)
on the perceived value of the medicine, using the STEPS criteria to guide
group debate, while any verbal communication techniques used in the presentation
are also highlighted and
discussed.
This format serves to emphasise to pharmacists the various factors that
influence formulary selection and drug choice by doctors, while also
ensuring all pharmacists leave the meeting with a clear and consistent
bottom line assessment of the real value of the medicine to patients
and its true place in therapy.
In practice, we have found this format to be enjoyable and an excellent
forum for continuing education. Supplemented by an introductory PowerPoint
presentation outlining the basic principles described above, the meetings
allow pharmacists to apply practical critical appraisal skills in the
real world, while also increasing awareness and understanding of some
of the more subtle techniques commonly used in the selling process.
A Drug and Therapeutics Bulletin article, “New drugs from old”,10 recently commented that most new drugs are “me-too” drugs
or minor variations of established products sufficient to secure a new
patent. Furthermore, many industry-sponsored clinical trials are designed
to find small advantages that can be highlighted in promotional material12
when the clinical significance of such benefit may be questionable.1
We believe that the most doctors and pharmacists have neither the time
nor the necessary skills routinely to undertake detailed critical appraisal
of promotional material from the industry, and few will ever have received
training on the associated marketing techniques used by representatives.
So a working knowledge of quick and easily applicable critical appraisal
skills that permit rapid and objective assessment of promotional information
is essential to ensure evidence-based and cost-effective use of finite
NHS resources.
Locally, there is an increased awareness of this format for appraising
industry-sponsored information through inclusion in the junior doctor
teaching programme and the non-medical prescribers’ course. It
is also being presented at consultant ward rounds and at meetings with
local GPs and practice nurses.
Working with the pharmaceutical industry can undoubtedly be beneficial.
However, an objective method of appraising “what they say” and “how
they say it” will provide health care professionals with more independence
in their objective assessment of promotional information.
References
1. Pegler S, Underhill J. Evaluating
promotional material from industry: an evidence-based approach. Pharmaceutical Journal 2005;274:271–4.
2. Chren MM, Landefeld S, Murray TH. Doctors, drug companies and gifts.
JAMA 1989;262:3448–51.
3. Katz D, Caplan AL, Merz JF. All gifts large and small. American Journal
of Bioethics 2003;3:39–46.
4. Murray TH. Gifts of the body and the needs of strangers. Hastings
Cent Rep 1987;17:30-38
5. Janis I, Kaye D, Kirshner P. Facilitating effects of “eating-while-reading” on
responsiveness to persuasive communications. Journal of Personality and
Social Psychology 1965;1:181–6
6. Shaughnessy AF, Slawson DC. Pharmaceutical representatives (editorial).
BMJ 1996;312:1494.
7. Ziegler MG, Lew P, Singer BC. The accuracy of drug information from
pharmaceutical sales representatives. JAMA
1995;273:1296–9.
8. Shaughnessy AF, Slawson DC, Bennett JH. Separating the wheat from
the chaff: identifying fallacies in pharmaceutical promotion. Journal
of General Internal Medicine 1994;9:563–8.
9. House of Commons Health Select Committee. The Influence of the pharmaceutical
industry. Fourth Report of Session 2004–05. Volume 1. London: Stationery
Office; 2005.
10. New drugs from old. Drug and Therapeutics Bulletin 2006;44:73–7.
11. Waud DR. Pharmaceutical promotions — a free lunch. New England
Journal of Medicine 1992;327:351–3.
12. Angell M. The pharmaceutical industry — to whom is it accountable?
New England Journal of Medicine 2000;342:1902–4.
Resources
• National Prescribing Centre: Information
mastery: feeling good about knowing everything
• Using evidence to guide practice. MeReC Briefing 2005;30(Sep):1–8
(PDF 450K)
• Using evidence to guide practice — supplement. MeReC Briefing
2005;30(Sep)(Suppl):1–7
(PDF 450K)
• No Free Lunch. Available at: www.nofreelunch.org and at www.nofreelunch-uk.org
• Pharmed
Out. Available at www.pharmedout.org |
The
Pharmaceutical Journal