Pharmaceutical promotion by jolinmilioncherie

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									               Influence Techniques




              Dr Peter R Mansfield
11 May 2006   GP
              Dept GP, Adelaide Uni
              Director, Healthy Skepticism Inc
              peter@healthyskepticism.org
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
                        Wolf        43

                           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     Naproxen RR
                             (95% CI)

Total       9.3 %    7.8 %      1.21
serious                        (1.04-
adverse                         1.40)
events

                                        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   ibuprofen RR
                     and        (95% CI)
                     diclofenac
Total       6.8 %      5.8 %       1.17
serious                           (0.99-
adverse                            1.39)
events

                                           57
Harm for patients
• Some corruption

• A lot of unintended bias

leading to

• A little direct harm from sub-optimal drug
  use
                                               58
• A lot of indirect harm from opportunity
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 “eating-
               while-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

              Dr Peter R Mansfield
11 May 2006   GP
              Dept GP, Adelaide Uni
              Director, Healthy Skepticism Inc
              peter@healthyskepticism.org
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                       Advisor paid to             Estimator paid
    assignment                   recommend                   for accurate
                                 higher estimate             estimate count
                                                             of coins in jar
    No disclosure
    by Advisor

    Disclosure of                Higher         Higher estimate
    competing                    recommendation
    interest
Cain DM, Loewenstein G, Moore DA. The Dirt on Coming Clean: Perverse
                                                                               91
Effects of Disclosing Conflicts of Interest. J Legal Stud 2005;34:1–25
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.

                                                   110
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