Transcript Healthy Skepticism about drug promotion

Education and
information for
prescribers and users
Porto Alegre
14 October 2005
Dr Peter Mansfield
Founder, Healthy Skepticism
www.healthyskepticism.org
[email protected]
GP, Dept of GP, University of
Adelaide
1
Tools for
rational
use of
medicines
2
A jigsaw with many dilemmas
3
Topics
Where I come from
A. Get the message right
B. Communicate the message the right way
C. With adequate resources
just a superficial coverage of what I think are
the most important points.
4
Muito Obrigado !
•
•
•
•
•
•
•
•
The traditional owners
The organisers and support staff
The sponsors
The tax payers
My family
My team
The translators
The audience
5
Where I come from
Brazil area 8.5M km2 popn 175M
19M
Australia area 7.7M km2 popn
6
Willunga
7
Healthy Skepticism
Countering misleading
drug promotion
www.healthyskepticism.org
8
Healthy Skepticism
• Philosophy:
Accepting claims that are justified,
rejecting those that are not,
whether it suits us, or others, or not.
• Methods:
Research, education and advocacy.
9
1. Get the message right
“The naïve believe everything but the astute
consider every step.”
- Proverbs 14:15
10
Steps to getting the message right
A1) Minimise bias.
A2) Set priorities.
A3) Ask the right question.
A4) Don’t misplace the onus of proof.
A5) Focus on the best evidence
A6) Tell the truth, without ambiguity or overconfidence.
A7) Tell all the relevant information without
oversimplification.
A8) Tell only information that is relevant without
distractions or unnecessary detail.
A9) Get feedback and evaluation and act on it.
11
2 types of right message
• The right content
eg “For indication A drug X is better than drug Y.”
- easy but learning limited
• The right process
eg “A medium quality systematic review suggests
that…”
-
dilutes content but enables learning that is
useful for other situations
12
A1) Minimise bias.
• This is the foundation!!!
• Bias  Wrong message  Harm
13
Types of bias
• Commercial Corruption
• Unintended commercial bias
• Lack of evidence
(funding bias, publication bias etc)
• Poor quality evidence
• Overconfidence bias
• Consistency bias
14
15
“One main problem with our thinking and
decision making is is that much of it suffers
from a lack of active open-mindedness: We
ignore possibilities, evidence and goals that we
ought to consider, and make inferences in ways
that protect our favoured ideas.”
Baron J. Thinking and Deciding. 3rd Edn Cambridge University Press 2000
16
Types of experts
Content experts
• May be biased
Process experts
• Older ones may not be able to explain their
processes
Hypothesis
• Best, least biased work is done by young people
with process skills
given time to learn the content and
feedback, not control, from old experts.
17
A2) Set priorities
•
•
•
•
Severe
Common
Community concern
Easy to improve
Morley D. Paediatric priorities in the third world.
18
A3) Ask the right question.
Otherwise you will get the wrong answer.
Example:
Celebrex vs old anti-inflammatory drugs
Or
Celebrex vs less selective anti-inflammatory
drugs (not diclofenac (Voltaren))
19
A4) Don’t misplace the onus of
proof.
• Don’t assume that current beliefs are correct
until proven otherwise.
• Don’t assume that new products are better until
proven otherwise.
• Put the onus of proof on those who make claims
that they benefit from.
20
A5) Focus on the best evidence
• Often there is no high quality evidence.
• Use the best evidence available and disclose
that there is uncertainty.
• Use your disclosure as an opportunity to teach
about critical appraisal processes.
21
A6) Tell the truth, without
ambiguity or overconfidence.
22
23
A7) Tell all the relevant information
without oversimplification.
24
Omission
• 16 “drug rep” visits to Melbourne GPs
64 drugs Roughead (1995)
– Warnings
– Precautions
5%
15%
– Special groups (pregnancy)
– Adverse effects
3%
27%
25
A8) Tell only information that is
relevant without distractions or
unnecessary detail.
26
27
A9) Get feedback and evaluation
and act on it.
• “So as much as we might not like to receive
negative feedback, customers who complain are
giving us a gift.”
• Customer complaints are one of the most
available and yet underutilized sources of
information but can be the foundation for
quality improvement. “This is no small gift!”
Barlow J, Møller C. A complaint is a gift. Using customer feedback as a strategic
tool. Berrett-Koehler Publishers. San Francisco 1996
28
Groupthink
29
Examples
• International Society of Drug Bulletins
– la revue Prescrire www.prescrire.org
– Butlletí Groc www.icf.uab.es/informacion/boletines/bg/asp/bg_e.asp
• Books
– British National Formulary
– Australian Medicines Handbook
• Others
– Therapeutic Initiative www.ti.ubc.ca
– Healthy Skepticism www.healthyskepticism.org
30
Example
Healthy Skepticism www.healthyskepticism.org
• Message   
• Communication ?
• Resources 
31
2. Communicate the message the
right way
“Go to the people
Live among them
Learn from them
Plan with them
Work with them
Start with what they know
Build on what they have…”
- Dr YC James Yen, Credo of Rural Reconstruction
32
Steps for good communication
B1) Understand the audience’s starting point.
B2) Learn from drug companies.
B3) Get and act on feedback and evaluation.
33
B1) Understand the audience’s
starting point.
34
35
If your audience feels content
Focus their minds on a problem
then
Show that what you want them to do is a good
solution.
36
B2. Learn from drug companies
“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.
37
Do not copy drug companies
• You won’t have the resources
“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 World Pharmaceutical News 2005; 3025: 57
• Drug companies are effective but not efficient
• Drug companies do not have much credibility
38
Controlled trials since the 1920s
• An advertiser "may try twenty-five letters, each
with a thousand prospects. He learns what
results will cost. Perhaps the plan is abandoned
because it appears unprofitable. If not the letter
which pays best is the letter that he uses. Just as
men are doing now in all scientific advertising."
Hopkins CC. My life in advertising (1927) & Scientific advertising (1923). Chicago. NTC
Business Books 1996
39
Promotion is a mirror to our souls
“Now can you think what the Mirror of Erised
shows us all?’ …
Harry thought. Then he said slowly, ‘It shows
us what we want … whatever we want …’
‘Yes and no,’ said Dumbledore quietly. It shows
us nothing more or less than the deepest, most
desperate desire of our hearts.”
40
Respect /
Self
esteem
41
Power
42
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
43
44
Motivations
Burnt out Dodo
Caring Bunny
Conservative Sheep
Entrepreneurial Wolf
Branthwaite A, Downing T.
Marketing to doctors – the
human factor. Scrip
Magazine 1995 March;32-5
45
Shortcut reasoning
46
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.
47
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
48
Appeal to Authority
• Informal logical fallacy
• Argumentum ad verecundiam
(Appeal to modesty) Locke (1690)
• When there is a range of expert
views who does industry fund?
49
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.
50
When we use
shortcut reasoning with
little or no
conscious awareness
then we are
vulnerable.
51
New is better
Usually correct when choosing computers
and fresh fruit
52
Ratings of new drugs by Prescrire
1981-2003.
Bravo
0.24%
? Helpful
15.85%
Not
acceptable
2.79%
A real
advance
2.68%
An
advantage
7.56%
Not new
66.63%
Judgement
reserved
4.25%
53
Industrial interests versus public health: the gap is growing. Prescrire International April 2004;13:70:71-76
Use multiple media
•
•
•
•
•
Publicity
Advertising
One to one visits
Meetings
Reminders
54
Example
DATIS (Drug and Therapeutics Information
Service) no website
• Message 
• Communication  
• Resources 
55
3. With adequate resources
“Where your treasure is, there your heart and
thoughts will be also.”
- Luke 12:34
“It is easier for a camel to go through the eye of
a needle, than for a rich man to enter into the
kingdom of God.”
- Luke 18:25
56
Steps for getting adequate resources
C1) Win political support.
C2) Focus resources where they will do most
good.
57
C1) Win political support.
• Collaborate with a wide range of groups who
stand to benefit from your success.
• Enroll others, especially people who are better
at enrolling others than you are.
58
59
Example
National Prescribing Service www.nps.org.au
• Message ?
• Communication ?
• Resources   
• Funding 2003/04 AUD $ 33 M = BRL 56 M
60
C2) Focus resources where they
will do most good.
61
62
Opinion leaders
63
Topics
A. Get the message right
B. Communicate the message the right way
C. With adequate resources
64
Healthy Skepticism
Countering misleading
drug promotion
www.healthyskepticism.org
65