Dumbing down or shaping up?
Malcolm Allison, an industry specialist from a 'specialist pharmaceutical company' articulates his thoughts, observations and recommendations for better industry-community interactions.

I recently had the opportunity to attend the inaugural conference on KOL interactions in London. Much was discussed and much remains unsaid. In providing fellow PHIDDERS with my perspective I will try not to fall into the trap of suggesting things were better in 'the good old days,' as I believe such a maudlin approach would be too easy a way to avoid some home truths that we must take on the chin as pharmaceutical experts. Instead, I would like to assert three ways forward to improve our relationships with the medical community and the public perceptions thereof.

1. Holding out for a hero: time to stop hiding and start proclaiming
There are no heroes any more in the pharmaceutical industry. Infact, at a time when we should be proud of our achievements (particularly the UK- based Industry) it is impossible to identify an intelligent, charismatic leader; there is no-one the press can doorstep for a vox pop. We need to be reminded, simply and often, of the value of pharmaceuticals and we need our trade associations to represent us more forcefully rather than pandering to yet more administration in the form of 'guidelines'. Hiding behind legislation stops innovation and affects everyone working at the interface.

2. Back to the future: turning nostalgia into action
Whatever our current situation, most of us joined this business because we want to help people. We could have sold soft drinks or cars if we were just seeking a 'marketing fix' but that wasn't our primary motivation. We need to revisit our roots and reasons for working in industry — to listen to doctors and patients again, attend congresses, make field visits, conduct patient workshops. We need to resurrect those primary purposes.

3. No blame, no gain: taking responsibility for public perceptions
As part of this we need to look inward and try to stop blaming the media or other people. We have been fortunate to work in an industry that pays us well, and is benign to our fallibilities. It is time to become more professionally-confident about how we interact with the medical community and why. This could be done by implementing industry wide professional training for marketing that makes no apologies about the need to use tactics of product marketing.

Or perhaps we need to acknowledge that the media and knowledge explosion that is the internet and web 2.0 tools has 'dumbed down' our approach to marketing and communicating about pharmaceutical products. I proffer this as a positive move and urge us to consider the advantages of dumbing down, based on several personal examples and experiences from thirty years in the pharmaceutical industry.

It's in the box
About 25 years ago, I was newly in charge of a Non Steroidal Anti-Inflammatory Drug and was particularly interested in the concept of 'new switch and repeat'. Digging deeper I realised we were losing patients for lack of effect. With an odd dosing schedule, patients were not complying, so they were not getting the value of the drug, and were discontinuing or switching to drugs with easier regimens. So I developed special packaging, one of the first calendar packs outside of the female contraceptive, in fact. we changed the perception of efficacy slightly, increased our average daily consumption by 20% along the way, which was an elegant demonstration for me, of the importance of both compliance and packaging.

About 10 years after this completed an MBA thesis on packaging. Working in the Middle East, in countries where adult literacy levels were below 50%. I found that our products were not known by their names, but by the colours of the packaging and the images on them. I built a theory, that packaging was the secret weapon in pharmaceuticals. Stating that pharmaceutical packaging could learn a lot from the consumer world, as product recognition would definitely improve patient compliance and recall, I actually said that when there are several alternative products with similar claims, it is a bit like chocolate. The headlines read 'pharmaceutical marketing is like selling chocolates' which saw me having to issue many apologies for pulling the industry into disrepute. Today the interpretation would be completely different because better-informed 'consumers' feel more comfortable about simple sound bites that save them time and for these generation-y-ers there is much less of a need to feel grateful in the shadow of supposed-authority; they carry a greater self-esteem that happily ingests 'dumbed down messages'. What holds true is that we need to see the whole deal, and the communication with the patient begins with the box.

Direct to the Consumer
There has been a seismic shift in our awareness of the end-user of our medicines. Several of the top ten pharmaceutical companies have made a virtue of hiring senior managers who are not constrained by the straight-jacket of Pharmaceutical marketing. Customer Insight is not a new phenomenon, it is just new to pharmaceutical marketing. We have seen it, and experienced it in clothing, in food, in car design, even in toothbrushes.

It is now hot, to hear the voice of the customer in pharmaceutical marketing. The ability to bring the skills and techniques of consumer marketing to bear on the pharmaceutical industry, will enable us to learn how to establish our brands for our customers. We are bringing the voice of the customer into the business.

'Customer Insight' is the new battle cry. Customer Insight is the new Market Research. Perhaps your company has made the transition? Market Research companies do not work with patients anymore, they work with the customer. It fits so much better into Porters Five Forces. Learning to think of patients as customers is a breakthrough step in extracting the insight, and helping us to understand and appreciate what differentiates us from our competitors. In the hands of professional researchers, it can be a revelation, to discover what our customers think of our products. I have no doubt at all, that our thinking is richer for the data that has come from in-depth discussion, focus groups, and particularly from following people around with cameras, as they live with their disease, to learn the constraints it places on their lives.

The Wisdom of Crowds
The end of wonder, the decline of organised religion and the breakdown of trust in authority, that has come with the anarchy of the world wide web has accelerated self reliance, freedom of choice and scepticism. No self respecting patient would dream of going to her doctor without a print out from the Internet to help him with his diagnosis. The information is gloriously un-regulated. Colour therapy, St. John's Wort and biological pharmaceuticals are separated by less than 0.00023 seconds in a Google search of therapies for depression. In fact, with the right rinky-dink piece of stickiness programming, colour therapy will crowd the biological onto the second page. But a bit of perseverance and you can get some serious stuff. in fact, it was proven last year that if doctors relied a bit less on experience and bookish stuff, and a bit more on Wikipedia, the rate of successful diagnosis would go up.

The essence of the Internet, that it is free from regulation, and is a blend of all the wonderful eccentricities in life, gives it a sort of 'wisdom of crowds' if you know where to search. No progressive pharmaceutical company can afford not to be part of it. In fact, the smaller you are, the more important it becomes that you get in there. A visitor from another planet would not know that Pfizer is 100 times larger than Basilea, if all they saw was the internet sites.

The internet has changed the push versus pull paradigm for ever. The patient/consumer is motivated to assemble his own diagnosis, in the same way as he assembles a bookcase from IKEA. Just putting stuff out there, for patients to access from the comfort and security of their own home, reinforces the transition from patient to consumer. Check out what is on there from your competitors, even from your own site, and try this experiment. Over the past couple of years I have heard some really clever stuff, encouraging the industry to face up to its responsibility, and give the patients what they really want, which is more accurate information about the efficacy and safety of the products they are likely to take. They want less nanny, more brutal truth about efficacy and safety. Drop in on patient blogs and listen closely. Perhaps one face of the internet, is that it has become the new father-confessor, because it is anonymous, and does not pass judgement. In '100 years of solitude', Aureliano Buendia remarks that everything is known. If all knowledge is known, then dipping your toe in the waters of the Channel at Dover makes you at one with the beachcomber in Cancun. Only try to resist participating, because you will stand out like the undercover policeman at a Rave.

Is it serious, Doctor?
A colleague joined us a year ago, from a much larger company that is more 'primary care' oriented. A bit like the relationship that used to exist between GP representatives and their hospital colleagues, he had been a little in awe, that our product makes a difference in a serious disease. He told me, that he had been surprised to discover that our specialized disease area is relatively easy to understand, and that the mystique was somewhat over hyped.

The challenge, I told him, is that once you know something, it seems easy. What he had not realized, was that in a global function we concentrate things, and reduce them to the absolute core. We consolidate data. As long as we can get an agency to telephone interview 100 physicians for market research, and as long as this can be represented as bar graphs in full colour plus special blue, we might easily forget that prevalence is 25 in 1,000,000, and that there are only 5000 prescribers in the universe. The challenge of rare disease, is that it is rare. It is special, because it is the diagnosis that makes it different. Rare disease does not smack the average physician in the eye. Instead, it hides in among the obvious suspects, and only snaps into focus when seen for its differences. There may even be subliminal avoidance, if the prognosis is wretched. Interestingly, once you have seen it, you tend to be more alert the next time. It is a bit like spotting animals in the bush, from a moving vehicle. Once you have seen the first, your eyes adjust and you become more confident that you can see a second.

Somehow, we have to find the balance between that rarity, the severity of the disease, and the simplicity of therapy. We have to preserve the sanctity of the diagnosis, the seriousness of the disease, and present it in such a way that the physician can confidently address the patients, and can respond with a steady gaze. The diagnosis and the treatment are both serious. The diagnosis brings hope, but it does not bring a cure. The treatment might not work, but it represents the best option.

Digital Medicine
I wonder if you are aware what 60mgs/dL, <40% of predicted, >7%, 140 over 80 mean? I think I have seen a number of other examples that point in the same direction. I call this digital medicine, which is the business of reducing facts and data to a string of numbers. A former colleague dealing with Chronic Obstructive Pulmonary Disease, once referred to 'knowing your numbers'. In her case she meant Forced Expiratory Volume, which is the <40%. For diabetes, the number would be Haemoglobin A1c, which is >7%, for cholesterol it would be High Density Lipids above 60 mgs per dL, and for blood pressure it would be 140 over 80 mmHg.

This shorthand is easy to use, it is seductive, and it saves the time of saying the thing out in full. Unfortunately, things we can say easily and conveniently are not always well communicated or even well understood. The number itself is just a number, it is the connotation, a surrogate for the disease. Hypertension, for example, is itself a surrogate for serious consequences such as renal failure and ischemia. When we reduce Hypertension to a number, we make it something easy to read, but we do not always retain the link to the disease behind the number. Our goal becomes just reducing that number. And if we start with 150 over 90, we have a goal of reducing by 10. A quick check of labels, will show us that over 40 drugs can do this. In the same way that we can reduce a Rolling Stones song to a stream of data, and rip it from a CD to an MP3 player in seconds, we have devalued what we are actually doing. It is a deviation, but take a look at where the money is for musicians now. The big discussions are about the professional management, including co-branding and product placement that comes not in recorded music, but in live performance. Differentiating between these 40 drugs, now we have dumbed renal damage down to hypertension and dumbed hypertension down to 140 over 80, is incredibly difficult. Trying to persuade a physician to prescribe a drug that costs 5 dollars a day instead of one that costs 3.5 dollars a day, when we have taught that doctor that reducing blood pressure by 10mmHg is the goal, there can be no-one to blame but ourselves. Our ingenuity, in establishing the link between these numbers and the consequences, is the seed of our downfall.

Does it matter? Can we reverse the trend? I have no idea, but we should give it some thought.

In conclusion, none of these things might be related but take a look at the pharmaceutical industry today. Perhaps you have done some image research? Scan the papers, and see where we come out on the continuum from bad to good. We are slightly above Estate Agents, in the same melee as lawyers. The Harris Poll placed us number 16 out of 21 industries, in their survey this summer. Perhaps we have reduced our 'Unique Selling Proposition' to a set of numbers, and perhaps along the way we have dumbed ourselves down to the point where our audience cannot value our efforts, because our products have been simplified to the level of consumer goods?

Just a thought. Just my perspective. Are we dumbing down or shaping up. Do we need to do one before we can attempt the other? I know that I would like to be considered a hero of medical science again. I suspect that you would too.