The Doctors Mighty Pen Market research Pharmaceutical Executive October 1986

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Market Research Pharmaceutical Executive, October 1986

The Doctor's Mighty Pen

by Murray Simon

Murray Simon, DDS, is president of D/R/S HealthCare Consultants

This report on a survey reveals physicians' attitudes toward prescription writing and the factors that influence them in a rapidly changing health care environment.

   Momentous changes are taking place in health care delivery in the United States. During the first half of the 20th century, medicine came under physician control; as the century nears its close, physicians are losing that control. They are "caught between a rock and a hard place" as government, corporations, unions, and public interest groups try to contain health care costs. Furthermore, an oversupply of physicians is rapidly developing.
     A marketing research study was recently undertaken to measure the effect of these changes on physicians' prescription writing habits; the study focused in particular on the effect on prescription writing attitudes. The survey clearly demonstrated that physicians believe medicine is in an evolutionary state, and they are troubled by the potential consequences. These concerns affect their pharmaceutical thinking and prescription writing patterns. This article details the results of the study and suggests ways to apply these results to pharmaceutical thinking and prescription writing patterns. This article details the results of the study and suggests ways to apply these results to pharmaceutical market planning.
     There are 450,000 physicians in the United States. Assuming each has a daily average of 15-20 patient contacts suggests the formidable influence that this body of professionals has on U.S. pharmaceutical buying patterns. The pharmaceutical industry is attuned this fact, as evidenced by the large number of ongoing sales and prescription audits conducted by companies such as Pharmaceutical Data Services of Phoenix, Arizona, and IMS America of Ambler, Pennsylvania.
     In an effort to qualitatively evaluate medical thinking about existing and anticipated changes in pharmaceuticals and prescription writing, researcher conducted 45-minute telephone interviews with 18 primary care physicians in various parts of the country. They then conducted a Connecticut focus group with eight primary care physicians. Although 26 respondents is too small a group to project the results to a larger population, the findings my be useful as an indicator of the pharmaceutical thinking of primary care practitioners.

How Physicians View Change
The physicians interviewed said that the pharmaceutical industry is suffering some of the same problems as medicine in general - rapid change with too little overall industry control. They were particularly concerned with what they saw as their exclusion from the process of developing and manufacturing drugs. They see their relationship to the pharmaceutical industry as one of us and them. They believe they are losing control over the practice of medicine. This attitude was perhaps best expressed by a family practitioner who said, "People say we're egomaniacs, but we'd like to be in control because we're liable ... so, ultimately, I'd like to have control over my prescribing habits. It's not happening; we're getting less and less control."
     Some of the factors that influence the respondents' sense of diminishing control of prescription writing included generic substitution, Rx-to-OTC conversions, local pharmacy inventory practices, fear of litigation, and advertising pharmaceutical products directly to the public. Staying current in the area of pharmaceuticals is a serious problem; there are just too many compounds to keep up with. The picture is further complicated by physicians' overwhelming concern about potential liability, a concern that has a strong effect on what these doctors will and will not prescribe.
     Most of the respondents said their prescription writing habits have changed; the longer the time since their basic training, the fewer prescriptions they write. Certain ambiguities surfaced in this area. Despite their claimed cutbacks, the respondents believe that the enormous increase in the number of pharmaceutical compounds being manufactured has led to an overall increase in the number of prescriptions that their colleagues write. They believe that older physicians tend to prescribe more than their younger counterparts, and they indicated that writing fewer prescriptions goes hand in hand with better treatment control of their patients. Although they hold strong views, the respondents could neither substantiate nor quantify them. The doctrine of "sometimes wrong, but never in doubt" seems to apply.
     The physicians interviewed said that prescription renewal is in need of reform and that pharmacists too often ignore the specific number of renewals called for and tend to renew indefinitely. They would like FDA to pay more attention and suggest greater surveillance in this area.
     These physicians saw both positive and negative results emanating from increased consumer awareness of generic drugs and greater use of generic substitution. Patient interest in generics has led to greater practitioner awareness of comparative pricing. In the past, price differentials were of much lesser concern than efficacy and safety. Today, patients demand greater control of their health care costs, which is forcing physicians to consider price, particularly as it relates to patient compliance. These physicians strongly voiced concern that increased demand for generics could undermine the traditional doctor-patient relationship. Patients who demand generics may be unable to equate the relationship between price and quality, so they may believe that if their physician writes a prescription for an ethical drug when a generic equivalent is available, it is a luxury they cannot afford. Directly or indirectly, many patients question the rationale behind the prescriptions written for them. These questions inevitably come back to price because lay people cannot fully understand pharmacokinetics or bioavailability. An educational public relations campaign by pharmaceutical manufacturers - one that explains, in the simplest of terms, such issues as bioavailability, pharmacokinetics, and bioequivalence - could have far-reaching results in the medical and lay communities.

Physicians see both positive and negative results of increased consumer awareness of generic drugs and greater use of generic substitution.

Physician-Pharmacist Relations
The physician-pharmacist relationship is amiable but somewhat uneasy. The physicians in this survey were greatly concerned that pharmacists may "come out from behind the counter." They expressed genuine concern that expanding the pharmacist's role in the prescription decision-making process may lead to the following:

The doctor-patient relationship may be eroded by potentially conflicting prescription advice.
Treatment decisions may too often be based on price because pharmacists have only limited knowledge of the patient's health history.
Gray areas may develop in overall and specific liability; physicians are uncomfortable with the potential for liability when a prescription substitution is made.
Cutbacks in the number of patient visits may occur. Practitioners are greatly concerned that many people will substitute the advice of a pharmacist for a visit to their doctor.

Physician-Manufacturer Relations
Physicians see themselves in an us and them relationship with drug companies. They see themselves as patient sensitive; they see pharmaceutical manufacturers as market sensitive. A family practitioner put it this way: "They all want to treat those diseases that they know are going to be big markets." These respondents perceive themselves as excluded from the new product development and product extension processes. They think they are heard only in cases of repeated negative feedback on a product from the "doctors in the trenches." This strongly prevailing attitude has great potential marketing advantages for manufacturers who can successfully deal with it. Some possible approaches include using computerized polling machines at conventions to measure physicians' pharmaceutical wants and needs, publicizing toll-free hot line numbers for pharmaceutical information, having detail persons ask physicians pertinent questions and write down the answers, and sending thank-you notes to doctors who make suggestions.
Many physicians consider the time that a drug is switched from prescription to OTC status as a time to reevaluate and search for alternate methods of treatment. The OTC conversion often represents a sense of loss of control; it gives patients an opportunity to self-prescribe or to double up OTC doses to duplicate prescription strength.
A few respondents believe that OTCs offer convenience for dealing with minor problems over the phone. It is easier to tell a patient to go to a pharmacy for Advil or Motrin than it is to call in a prescription. On the whole, however, when faced with the choice between an OTC and a prescription drug, physicians generally will prescribe - if only for the physchological reinforcement of the written prescription.

Getting Product Information
Physicians seek information about pharmaceutical products from several sources, which include detailing, sampling, advertising, colleagues, and hospital formularies.
     Detailing. Physicians seem to consider the detail person an important source for "keeping current." Brand loyalty, however, is highly dependent upon constant exposure to a company and its brand names through detailing, direct-mail pieces, and journal advertising. A family practitioner said, "Even if you just see the name, it can pique your curiosity enough to read a package insert, and then you follow it up with the detail person."
     Detail persons got mixed reviews. Some are seen as knowledgeable and effective, others are thought to be very much the opposite. The physicians chiefly complained about detail people who recite without listening - they too often are seen as "actors reciting their lines." Physicians want the answer to this question: "Why should I use your product over all the others that are available?" The difference does not have to be earthshaking to be effective.
     Sampling. Dispensing samples is considered an essential ingredient in making product judgments. Respondents in this survey believe that the best way to evaluate the effectiveness of a particular drug is to observe its effect through samples dispensed to their patients. They also see giving samples as an effective practice booster; patients appreciate something for nothing and like the idea of saving a trip to the drugstore.
     Advertising. The demands on physicians' time, coupled with the vast and constantly changing drug spectrum, cause them to seek information by, among other methods, scanning advertisements and abstracts. If a name or concept is repeated several times, it often piques their curiosity, and they seek further information. They consider audio cassettes an effective way to stay on top of developments and generally use them while driving. They seem to be unconcerned about potential sponsor bias on tapes, which may be attributable to their appreciation for the convenience tapes offer.
     Colleagues. Some drugs become popular in certain geographic areas. This is often a result of word of mouth or multispecialty patient management. Physicians who are called in by their colleague to treat a patient already on medication obviously take note of those drugs and their relative effectiveness.
     Hospital Formularies. These respondents rate formularies as the most important influence on the prescription writing habits of today's physicians. Although physicians believe the formularies are biased and inherently self-serving, they recognize the hospital formulary as the young physician's first exposure to an organized program of pharmaceutical treatment. Many prescription writing habits may change during the years following residency, but a definite mind-set remains.

The survey respondents rated formularies as the most important influence on the prescription writing habits of today's physicians.

Product Efficacy, Safety, Price
Efficacy is almost invariably physicians' primary consideration when choosing medication. They expressed a strongly held belief that the range of efficacy within particular pharmaceutical categories is rather narrow. These physicians also were convinced that a significantly higher price is seldom accompanied by significantly greater efficacy or safety. One area of medicine in which safety generally supplants efficacy as a primary consideration is in the treatment of acute cardiac conditions. Here, safety is often a stronger factor in determining the medication to be prescribed.
Most respondents were somewhat embarrassed to admit that they have little awareness of the price or price differentials of the drugs they prescribe. Increasing patient demand for generics, however, generates pressure on physicians to develop greater awareness of price differentials. Despite recent emphasis on cost containment, some patients associate higher price with higher efficacy. Several respondents said they sometimes take into account a patient's financial status when deciding which drugs to prescribe.

Patient Education
The physicians surveyed saw patients as having limited medical understanding. For example, one dermatologist said, "Less than one percent of what I tell them is absorbed." An internist claimed, "The only thing they want to know is can they get it delivered." And a family practitioner said, "There are some patients who ask the proper question, but, in general, they're the exceptions."
     These physicians said that one of the biggest problems they face in discussing medications with their patients is the issue of side effects. Patients often will not take a drug if they are greatly concerned about the side effects. This problem is so widespread that, in response to it, all to these respondents remove the package inserts from sample drugs before dispensing them. This practice is so common that they expressed little concern for potential liability.
     The surveyed doctors consider it the physician's job to alert patients to possible drug differences and interactions. They believe the pharmacist is responsible for informing patients of the substitution regulations in their states. Manufacturers, they say, should alert physicians to differences in efficacy, safety, and price and keep them informed of potential liability problems.
     These doctors are anxiously awaiting developments toward large-scale prescription drug advertising to consumers. They see a number of serious negatives and, basically, nothing positive in its potential. They believe such advertising would strike at the very foundation of the doctor-patient relationship - they realize that the primary goal of the manufacturer is to make money, but believe that this would be a case of overstepping ethical bounds to do so. A move in this direction has the potential to create a serious public relations problem between pharmaceutical manufacturers and the medical community.
     These physicians believe that a great deal of medical misinformation is disseminated by television and print media. Special medical reports often intrude on their practices. They do not hold the pharmaceutical manufacturers responsible; rather, they see the problem as a constant search by newscaster and reporters for something "hot and new."

Prescription Changes Ahead
As the elderly population continues to expand and more people live on fixed incomes, prescription writing will change in several ways.

Greater use of generics. Although the overall physician response to generics was rather negative, pricing as a factor in compliance is very much on their minds and will lead to more frequent use of less expensive drug alternatives.
Fewer symptom-related prescriptions. This is because of increased physician price awareness and the current high level of concern for potential litigation.
Fewer prescriptions and one-a-day dosages will be important factors for improved compliance. Many of these doctors stated that elderly patients on multiple drug therapy often fail to comply properly because of confusion and forgetfulness.
More combination drugs will be used as medicine evolves more sophisticated treatment modalities.
Stronger patient management will replace some drug therapy, particularly in the treatment of patients with depression, anxiety, or other psychological disorders. Respondents expressed concern for mentally ill people who are in continuous drug-related "holding patterns."
    In one particular area no change is expected. Physicians expect to adhere to the philosophy that they will not prescribe a drug until it has been on the market for at least a year. Many of them tell of having been "burned" too many times by new "wonder drugs."
     The surveyed physicians are worried about changes taking place in medicine. They see themselves as losing much of their control over the treatment of patients; at the same time they see themselves as forced to assume more responsibility for overall treatment outcomes. They realize that cost containment is necessary, but believe that the emphasis on price is too much at the cost of quality. They see the traditional doctor-patient relationship as being wedged apart by well-intentioned individuals and groups with no experience in caring for sick people. Many of them consider pharmaceutical manufacturers to be walking a fine line between being partners and being competitors.
     As medicine moves through the latter half of the 1980s and changes continue to accelerate, drug manufacturers will have to carefully evaluate their marketing strategies. Above all else, they must maintain strong lines of open communication with practicing physicians. �