Influence Techniques Dr Peter R Mansfield GP Dept GP, Adelaide Uni Director, Healthy Skepticism Inc firstname.lastname@example.org 11 May 2006
Influence techniques • Warnings • Thank you • Decision Making Shortcuts • Are you influenced? • Sales techniques
Warnings • Decision making is not rocket science • It is much more complicated and difficult
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
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.
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
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
Other common shortcuts • Newer is better • Popular is better • Trusting people we like
Influence techniques • Influence techniques trigger shortcuts. • Shortcuts are quick • Preparing influence techniques can take a long time.
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.)
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.
When we use shortcut reasoning with little or no conscious awareness then we are vulnerable.
Steinman MA, Shlipak MG, McPhee SJ. Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions. Am J Med. 2001 May;110(7):551-7.
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
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
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.
“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 11www.pjbpubs.com/cms.asp?pageid=277&an=S00881592&bb=false&newsproductid=8&ln=y
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
Promotional meetingsOrlowski 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.
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 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
GPs are human We have less evidence about: • Specialists • Pharmacists • Other health professionals • The general public
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. They aren't.Adams S. The Dilbert principle. New York: HarperBusiness 1996
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 really influence sales.”Smith MC. Principles of pharmaceutical marketing. Philadelphia: Lea & Febiger 1968
Doctors main motivations Burnt out Dodo CaringBunny Conservative Sheep Entrepreneurial WolfBranthwaite A, Downing T. Marketing to doctors – the human factor. Scrip Magazine 1995 March;32-5
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.
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?
Did you plan to tell: • the truth? • the whole truth? • and nothing but the truth?
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
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.
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.