Influence Techniques

Dr Peter R MansfieldGPDept GP, Adelaide Uni Director, Healthy Skepticism Incpeter@healthyskepticism.org

11 May 2006

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Influence techniques

• Warnings

• Thank you

• Decision Making Shortcuts

• Are you influenced?

• Sales techniques

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Warnings• Decision making is not rocket science• It is much more complicated and difficult

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• Simplification

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• Human limitations

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Adult content

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Bias

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Pro - Health Professionals

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Pro – Drug companies and consumers

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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

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Context: Information Overload Pressure for quick decisions

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How do you choose your favorite drugs?

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Decision Shortcuts

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Decision Shortcuts

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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.

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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

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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

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Other common shortcuts

• Newer is better

• Popular is better

• Trusting people we like

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Continuous spectrum

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Influence techniques

• Influence techniques trigger shortcuts.

• Shortcuts are quick

• Preparing influence techniques can take a long time.

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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.)

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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.

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When we use shortcut reasoning with little or no conscious awareness then we are vulnerable.

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Are you influenced?

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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.

A little38%

A lot 1%

None61%

How much influence do sales representatives have on your prescribing?

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A little33%

A lot 51%

None16%

How much influence do sales representatives have on other physicians' prescribing?

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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

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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

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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.

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“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

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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

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Radar of critical appraisal

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Under the radar

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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.

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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;15:371-81Haayer 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.

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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

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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

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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

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Doctors main motivations

Burnt out Dodo

Caring Bunny

Conservative Sheep

Entrepreneurial WolfBranthwaite A, Downing T. Marketing to doctors – the human factor. Scrip Magazine 1995 March;32-5

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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.

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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?

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Did you plan to tell:

• the truth?• the whole truth?• and nothing but the truth?

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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

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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.

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People are being harmed

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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 KesslerKessler DA. Addressing the problem of misleading advertising. Ann Intern Med. 1992; 116:912-9.

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Estimated toll from Vioxx

“…the increased risk of 16 events per 1000 patients treated for up to 3 years… …a potential excess of several thousand cardiovascular events caused by rofecoxib. This may represent an underestimate of the number of events caused by rofecoxib, because patients with inflammatory arthritis are likely to be at higher baseline risk of cardiovascular events than the “low risk” population included in APPROVe.”

Langton PE, Hankey GJ, Eikelboom JW. Cardiovascular safety of rofecoxib (Vioxx): lessons learned and unanswered questions. Med J Aust 2004; 181 (10): 524-525.

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VIGOR (2000)

Vioxx Naproxen RR (95% CI)

Total serious adverse events

9.3 % 7.8 % 1.21

(1.04-1.40)

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Nov 2000

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May 2001

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Sep 2001

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“Doctor, once daily Vioxx has no effect on platelet aggregation.

Once daily Vioxx is therefore not a substitute for aspirin for cardiovascular prophylaxis.

However once daily Vioxx 50mg had no affect on the anti-platelet activity of low dose (80mg daily) aspirin.”

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CLASS (2000)

Celebrex ibuprofen and diclofenac

RR (95% CI)

Total serious adverse events

6.8 % 5.8 % 1.17

(0.99-1.39)

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Harm for patients

• Some corruption

• A lot of unintended bias

leading to

• A little direct harm from sub-optimal drug use

• A lot of indirect harm from opportunity costs

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Damages patient’s trust in health professionals

BMJ cover

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Sales techniques

• Appeal to experts • Social validation

(peer pressure)• Liking • Commitment consistency• Reciprocation (gifts)• Scarcity

Cialdini RB. Influence Science and practice. 4th ed. Boston Allyn & Bacon; 2001.Roughead EE, Harvey KJ, Gilbert AL. Commercial detailing techniques used by pharmaceutical representatives to influence prescribing. Aust N Z J Med. 1998 Jun; 28(3)306-10.

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The appeal to modesty

“When men are established in any kind of dignity, it is thought a breach of modesty for others to derogate any way from it, and question the authority of men who are in possession of it.”

Locke, J. An essay concerning human understanding. 1690.

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The improver of natural knowledge absolutely refuses to acknowledge authority, as such. For him, skepticism is the highest of duties; blind faith the one unpardonable sin.- Thomas Henry Huxley, biologist and educator, Huxley TH. Aphorisms and Reflections. 1907

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Social validation (Peer pressure)

Rep: …and that's why, I think, everyone agrees,...

Rep: This is the most commonly prescribed antibiotic in American hospitals (ciprofloxacin)

Rep: "Brand G“ (nifedipine), which you know, of course, is the second top prescription drug in the world

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Popularity

Which US President won office with the largest majority?

What is the world’s

top selling food?

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Social validation

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Liking (Friendship/Attractiveness)

Drug reps keep and share detailed records of personal information to assist them to appear friendly.

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Cristin Duren, Drug Rep

Saul S. Gimme an Rx! Cheerleaders Pep Up Drug Sales. New York Times. November 28, 2005

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Commitment consistency

People prefer to act in ways that are consistent with past commitments so as to maintain their sense of self and to avoid the discomfort of admitting an error or of acknowledging complexity.

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Eating increases acceptance of persuasion

“more opinion change tends to be elicited under conditions where subjects are eating”

Janis IL et al. Facilitating effects of “eating-while-reading” on responsiveness to persuasive communications. J Pers Soc Psych 1965;1:2:181-6

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He who pays the piper calls the tune

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Scarcity

• Increases perceived value.• Examples:

– Diamonds– Available “For a limited time only at

MacDonald’s”

• Not common in drug promotion when health professionals do not pay for drugs.

• Is used to increase perceived value of prizes.

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Desires/Fears

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Evaluatethis adExaggeration

Desires for sex, safety, simplicity.

Scarcity.

Science babble.

Strategies in response to pharmaceutical promotion

Dr Peter R MansfieldGPDept GP, Adelaide Uni Director, Healthy Skepticism Incpeter@healthyskepticism.org

11 May 2006

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Strategies in response to pharmaceutical promotion• Change• Treatments

– Improve regulation of drug promotion

– Redesign the incentives for health professionals

– Redesign the incentives for drug companies

– Improve health care decision making

• Healthy Skepticism

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Change: Bad news

• No option has been adequately tested.• It is likely that a combination of options will be

required for success.

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Change: Good news

• The Zeitgeist (the current set of shared beliefs in society) is changing.

• There are some ideas for system reform that might work.

• If so, all will benefit including drug companies who could have good returns with lower risk.

• There are some simple things that you can do to be part of the solution.

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Treat the causes

Companies are rewarded for doing what works for increasing sales and prices.

Promotion (including disease mongering) works because people have human vulnerabilities.

High prices and sales fund more promotion.

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Treatments

• Improve regulation of drug promotion

• Redesign the incentives for health professionals

• Redesign the incentives for drug companies

• Improve health care decision making

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Redesign the incentives for health professionals

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Banning large gifts won’t work.

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Disclosure of conflict of interest is not enough

“We would not permit a judge…to have equity in a for-profit prison, even if the judge disclosed it”

Krimsky, Sheldon. From an interview in the Chronicle of Higher Education, as quoted in the The Bulletin of the Canadian Association of University Teachers. February 2003. A9.

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Disclosure can make bias worseRandom assignment

Advisor paid to recommend higher estimate

Estimator paid for accurate estimate count of coins in jar

No disclosure by Advisor

Disclosure of competing interest

Higher recommendation

Higher estimate

Cain DM, Loewenstein G, Moore DA. The Dirt on Coming Clean: Perverse

Effects of Disclosing Conflicts of Interest. J Legal Stud 2005;34:1–25

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The only solution that could work: ban all gifts

Just say no to drug reps’ gifts

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Redesign the incentives for drug companies

Pay separately by open competitive tender for separate functions: – Manufacturing– Promotion – Research– Education

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Improve health care decision making

• Promotion would improve to match• But there is a limit to how much humans with

limited resources can be expected to improve.

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If the decision is important take more time

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Use more reliable infosources

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Recommendations re shortcuts

• If you decide without checking all the evidence yourself recognise you have used a shortcut

• So don’t be too confident in the conclusion• Treat the conclusion as a hypothesis to be tested as

soon as possible• Use countermeasures against shortcuts

eg. Be skeptical of paid experts

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Options for responding to promotion

1. Abstinence

or

2. Harm minimisation

Warning: There are no proven methods to ensure more benefit than harm from exposure to drug promotion.

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Reducing vulnerability to misleading promotion

Increasing skills

- a little improvement

Increasing perceived personal vulnerability- a big improvement

Sagarin, B. J.; Cialdini, R. B.; Rice, W. E., and Serna, S. B. Dispelling the illusion of invulnerability: the motivations and mechanisms of resistance to persuasion. J Pers Soc Psychol. 2002 Sep; 83(3):526-41.

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Illuminating the techniques used in drug advertisements

www.healthyskepticism.org/adwatch.php

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Main conclusion

• There is no known training for health professionals that would ensure that more good than harm comes from exposure to drug promotion.

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Until we can fix the system the best we can do is avoid all contact with drug companies

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Healthy Skepticism

Countering misleading drug promotion

www.healthyskepticism.org

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Healthy Skepticism

• Improving health by reducing harm from misleading drug promotion

• International non profit organisation based in Australia

• Everyone who is interested in improving health care is welcome.

• Members, Paid Subscribers, Free Subscribers• Mostly doctors and pharmacists.

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