The ever-narrower limitations on field-force access to practicing physicians are well documented and well understood, with any number of factors labeled the chief culprit. Whichever is most important, all contribute to a shrinking opportunity for face-to-face interaction and a growing gap in the personal relationship between the practicing clinician and the pharmaceutical field rep. To regain trusted access, we must understand the modern physicians’ challenges, and support them in addressing and overcoming these challenges.
The gap between the field force and the physician in many ways parallels the growing gap between physicians and their patients. It is the parallel need for relationship-building —between rep and doctor, and doctor and patient—that offers us an opportunity to reestablish our value to the practicing clinician.
THE PROBLEM OF ALIENATION: FROM A RELATIONAL CONNECTION TOA TRANSACTIONAL ONE, AND BACK AGAIN
The field force is still listed by many physicians as a high-ranking source of useful medical information, and many physicians complain of alienation and a day filled with stress and isolation. The field force is one possible solution to this alienation; and yet, where once we had a beautiful relationship, where the field force could be both ally and confidant of the physician, we are now having trouble connecting. As a result, we are growing apart. Just as with any professional relationship, the key to rebuilding and maintaining a strong connection lies in focusing on areas of mutual interest, and working together to solve the problems we share.
The principal, and historical, area of common interest is (to state the obvious) a mutual stake in improving the health and lives of patients and consumers. Medications, and data about medications, are the pharmaceutical industry’s traditional strong suit when providing value to clinicians, and we still provide them. However, we cannot hope to offer new products or new data at every visit in a call cycle, and restrictions on the materials we can give the physician make it difficult to deliver value beyond the medications we create. It makes little sense to maintain that branded materials like pens and clocks somehow improve patient care, but there are still many areas of need in daily medical practice that healthcare marketers are well positioned to solve, and are well motivated to solve for our own, the physician’s, and ultimately the patient’s best interests.
Physician-patient communication is one area where physicians and other healthcare providers need the most support. Communication is as essential to the practice of medicine as are medications themselves; even Hippocrates, exhorting physicians to speak clearly and avoid “unfamiliar words,” realized its importance. In today’s medical environment, physicians have lost not only the time to talk to pharmaceutical field reps, but also the time to talk with patients. Without this conversation, the physician-patient relationship has evolved (or devolved) into a largely transactional arrangement, lacking in engagement and fundamental understanding. It is this lack of true conversation that many physicians find most alienating. And it leads, demonstrably, to poorer outcomes in the forms of misdiagnosis and non-adherence, as well as the softer measures of patient dissatisfaction and poor practice retention rates.
These physicians do not lack communication skills. Most physicians know how to have a good, effective clinical conversation with their patients, but many feel they lack the time in which to have these conversations. The tools they were trained to use, such as the standard medical interview and the process of differential diagnosis, require more time to execute than physicians have today. This is a compromise many physicians understand, and feel they have to make. And while they welcome insight that could help clinical practice, most communication tools add time to the visit, which makes them unusable in modern practice.
For example, the general Functional Assessment of Cancer Therapy (FACT) scale is a highly validated, respected, and well thought out tool designed to uncover the true impact of cancer treatment on a patient’s quality of life. It contains 33 items, and takes considerable time to apply correctly. As a communication tool, it works beautifully; it just won’t work in the 11 minutes that the average medical visits take.
What clinicians want, and need, are proven resources that can help them communicate with the patient—more clearly, efficiently, and effectively—and materials that improve conversation measurably without adding time to their consultation. We will discuss two instances where the field force was able to deliver validated communication materials that improved physician patient communication, without increasing visit time. At least one of these interventions also measurably improved patient (and physician) satisfaction with the visit, an important measure in modern medicine.
TREATING MIGRAINE: ONE SIMPLE QUESTION
There is a well-documented gap between migraine sufferers’ perceptions of the illness’ impact on their lives and their physicians’ understanding of that impact. In 2006, an observational in-office linguistic study showed that physicians’ communication patterns were directly responsible for at least some of that gap. Essentially, the physician’s use of closed (yes or no) questions during the differential diagnosis was preventing the migraneur from telling her “story.” This, in turn led to the physician missing key elements of that story, namely, the profound impact migraine was having on many of these patients. This impact would have made many of these women eligible for daily, preventive migraine therapy—had the doctor known about it. The study found, however, that many such women were prescribed OTC or abortive migraine therapies, based on physician misperception of impact.
This state of affairs was in part perpetuated by physician fears of migraine patients taking control of the conversation and using more time than the doctor could afford; at the core, most clinicians worried that, if given the chance to talk about migraine impact, patients would start and never stop. What physicians needed was a solution that was both efficient in terms of information exchange, and effective in terms of office time-management.
The American Migraine Communication Study (AMCS), phases I and II, provided just such a solution, which was proven to be both more efficient and effective. A simple communication training that prompted physicians to ask “one simple question: how do migraines affect your life?” was implemented. Follow-up study showed that it increased the level of agreement between patient and physician about the impact of the patient’s migraine. Importantly, this intervention was “time neutral,” and indeed appeared to shorten, not lengthen, migraine visits. The outcomes were greater patient and physician understanding and greater visit satisfaction.
This tool had two important effects. The first, and most immediate, was that trained physicians were able to identify the needs of their migraine patients, and to treat them better; through training, they became, in a real sense, better doctors for these patients. The patients, by being prescribed more preventive medication, were more likely to have a lower burden of migraine in their lives. And for the sponsor, more patients who were eligible for their therapy were prescribed that therapy, which meant that doctors, patients, and the pharmaceutical company all benefited.
The second important effect was that the company now had a validated, proven tool that it could use to open doors at practices across the country. This led to the creation of materials that could be delivered by the field force, which reinforced and supported the training provided. This, in turn, led to multiple opportunities to talk about the treatment of migraine and create a meaningful, ongoing relationship between the field force and the clinicians.
TALKING ABOUT RISK AND WELLNESS: RED, YELLOW, GREEN
The AMCS study provided a roadmap for creating useful, meaningful dialogue tools that could be validated and then leveraged across multiple contexts and platforms (e.g., symposia training that is supported by Internet training, specialized field calls, and rep-delivered materials.) Since then, the process has been replicated in several fields, both symptomatic and asymptomatic. The tools are not always the same, as the problems and their solutions can vary.
For example, it is known that patients, and human beings in general, have a difficult time assimilating the concept of “risk” into daily practice; we either believe something will happen imminently, or we don’t. This is true of medical conditions that center on risk—dyslipidemia is not a disease per se, it merely indicates that we are at elevated risk for a future coronary event. This remote risk is difficult to understand, and this difficulty can be seen in conversations in which physicians struggle to convey urgency around increasing risk for their patients who are at risk. For preventive therapies of asymptomatic conditions, then, the key is to create tools that translate remote concepts of “risk” into immediate concepts of health and wellness—tools that show “you may or may not have a stroke some day, but you are definitely unhealthy now.”
For this category, we helped the client create a series of tools that translated levels of risk into color coded categories—today, right now, you are red, and this is bad.
As with the migraine example above, this approach led to better discussions and diagnoses, more appropriate treatments, and greater likelihood of patient adherence; it also led to greater contact with practicing clinicians and their staff, as materials were disseminated.
Pharma is uniquely suited to help practitioners hone the ways they communicate, with patients and with one another, by using real-world linguistic data to develop communication-based training. Regardless of the category, the idea that simple, validated tools can improve interactions, outcomes, and access, has held true. Through programs such as these, the field force can maintain relevance and access, even in the face of mounting competing demands on the HCPs’ time.