Unique Invulnerability

Curriculum to counter the influence of pharmaceutical industry promotion on

health care providers

Project funded by a grant from State Attorneys General Division of Consumer & Prescriber Education

• Internal Medicine– Linda Pinsky– Rick Deyo

• Pharmacy– Tom Hazlet

• Nursing & Ethics– Sarah Shannon

• Business – Mary Anne Odegaard

• Dean’s Office– Marge Weinrich– Harry Kimball

• Filmmaker– Michelle Mansfield

The Goal of the Curriculum

• Convince healthcare providers that we may

be susceptible to pharmaceutical products

promotions

The challenge

How much does pharmaceutical promotion directly or indirectly influence prescribing patterns?

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none a little a lot

others

you

How much does pharmaceutical promotion directly or indirectly influence prescribing patterns?

The GrantSixteen billion dollars is the estimated amount that the pharmaceutical industry spends each year on marketing to influence the attitudes, knowledge and behaviors of physicians, nurse

practitioners, physician assistants, and pharmacists in their prescribing for patients.

•

• Woody Allen relates the story of a man who tells his psychiatrist that his brother thinks he is a chicken. “What does he say when you tell him he is not?” the doctor inquires. The man replies- “We don’t---we like the eggs.” This is not unlike the attitude of healthcare providers towards the pharmaceutical industry.

• Our greatest concern is not the marketing practices of the pharmaceutical industry nor the lobbying for them done by the pharmaceutical (drug) representatives doing their jobs.

• .• The question that we care most about is how to educate/convince the health care community (physicians, pharmacist, nurse practitioners, physician assistants) that

their prescribing practices are being influenced by pharmaceutical marketing.

•

How can we convince our colleagues that the cost of those free “eggs” is just too high?

• Signed:Dr. Pesky

•Reference[i] Angell M, Excess in the pharmaceutical industry. CMAJ. 2004 Dec 7;171(12):1451-3.

• POSTED BY DR.PESKY AT 9:27 AM 0 COMMENTS • Subscribe to: Posts (Atom) • BLOG ARCHIVE• ▼ 2008 (1)

– ▼ June (1) • "Drug Reps in the Attic"

• tp://proveneffective.blogspot.com/

The goal of providers is to prescribe the most appropriate

medication for patients.

The goal of industry is to make sure that the medication

prescribed is their product, whether or not , it’s the

optimal choice.

Most of us getting information from

pharmaceutical industry or its

representatives consider ourselves

immune to its influence.

But the CEOs of these businesses are

neither philanthropists nor stupid.

The pharmaceutical industry conducts

outcome studies on their advertising

campaigns as they do now on their

medications.

Woody Allen relates the story of a man telling his

psychiatrist that his brother thinks he is a chicken.

“What does he say when you tell him he is not?”.

“We don’t---we like the eggs.”

This is not unlike the attitude of healthcare

providers towards the pharmaceutical

industry.

Our greatest concern is not the marketing

practices of the pharmaceutical industry

nor the lobbying for them done by the

pharmaceutical (drug) representatives doing

their jobs.

.

The question that we care most about is:

how can we educate/convince the health care

community

that our prescribing practices are being

influenced by pharmaceutical marketing?

How can we convince our colleagues

that the cost of those free “eggs”

is just too high?

Approach

• Promote changes using stages of change model• Promote reflection using portfolios

• Avoid inducing resistance• Avoid self-righteous attitude

Techniques

• Show rather than tell– Experiential learning

• Studies of evidence of influence

• Case studies /Personal epiphany

• Use of stealth education

• Humor

Technique: Experiential Learning

concrete experience reflective

observation

abstract conceptualization

active experimentation

Kolb DA Experiential Learning Prentice hall, Englewood Cliffs NJ, 1984.Smith CS, Irby DM Acad-Med. 1997 721: 32-5.

Resistance to persuasion

• Need ability to realize illegitimate authority

• Need to acknowledge vulnerability to manipulation

• A sense of unfair manipulation provides motivation for resistance

Sagarin, B. J., Cialdini, R. B., Rice, W. E., & Serna, S. B. (2002). Dispelling the illusion of invulnerability: The motivations and mechanisms of resistance to persuasion. Journal

of Personality and Social Psychology, 83, 526-541.

Aversion to being unduly manipulated

Aversion may stem from:– Avoidance of the punishing material & social

consequences of misguided decisions. – Because failure to do so threatens such undesirable

self-labels as dupes and fool— • consistent with research linking resistance to persuasion

with threats to the self » (Cohen, Aronson, & Steele, 2000; Jacks & Cameron, 2001;

Katz, 1960; McGuire, 1964; Sherif & Cantril, 1947).

Understanding techniques of persuasion

Automatic responses preceding rational thought

• Reciprocity-– someone does something nice for you and you feel you should be nice to

them– Uninvited debt

– Concessions

• Commitment- – You follow through on these mental obligations

• Consistency- – You match the rest of your thoughts about a person or medication in order to be

consistent with that fixed-action response mental commitments to a medication

• Social Proof/Authority – Your colleagues’ ( and experts’) support for interactions with agents of

persuasion reinforces the legitimacy of your thinking

Examples from the curriculum

Myths

Myth:

Healthcare professionals are too

smart, too critical, too scientific

to be influenced by

pharmaceutical industry’s

marketing

Myth: Free samples save patients money and don’t influence

prescribing practices

Myth: CME isn’t

influenced by commercial

sponsors

Myth : Direct to Consumer Advertising is good patient

education and doesn’t influence practice.

See slide show “Equip for Requip”

Equip for Requip®

Making Direct to Consumer Advertising

work for you

How do you feel about direct to consumer advertising?

• My patients rarely mention DTC

• I think it is great

• I think it is okay

• I have mixed feelings

• I don’t like it

• I hate it Ask your doctor

Objectives1. Define Direct to Consumer

Advertising (DTCA) & its impact on clinical practice

2. Learn approaches that use DTCA as an opportunity for better clinical practice

3. Have patient education tools that help patients be more informed consumers of pharmaceutical marketing

Your next patient is waiting in room 4

Wrap up

What is Direct-to-Consumer Marketing?

• Promotional advertising of pharmaceutical products directly to consumers via

- Magazine & newspaper ads

- Television & radio ads

- Product placement

- Web sites & other internet sites

Goal: Educate and/or sell products

Intentional communication • Tasks when approaching patient

• Acknowledge pt. initiative

• Clarify symptoms

• Confirm diagnosis

• Educate patient on condition

• Determine best patient management

& best Rx., if needed

• Ongoing education of patient on advertising techniques

Tools and Techniques• Intentional communication

• Non-industry sponsored sources of information

• Advertising techniques: explanations for patients• Discussion of meaning of effectiveness, monitoring of

ads, advertising techniques via Bingo, talking points used by other physicians, etc.

Share the techniques you use to avoid being influenced by marketing to physicians

Teaching Approach

• In this slideshow, we attempt to engage the learner and incorporate their opinions in the discussion, early in the presentation. We then present information on the topic using a focus on direct to consumer advertising to make the same points of vulnerability that we are trying to address for direct to provider advertising as well, with the hope this approach leads to less resistance in the learner..

Presentations of material used to mislead

Misleading information

• Fluid information – Exaggeration

– Ambiguity

• Omission of information.

• Distraction– Appeal to our desire for power or simplicity or sex or self

respect or self esteem. • Most common way to appeal to our desires is with images

Power

39

Respect /Self

esteem

40

Simplicity

41

Sex

42

Celebrity

Cal Ripken, Jr. is not hypertensive and is not taking PRINIVIL

Creating Demand for Prescription DrugsCategory of content Weighted %

Factual Any factual information (eg, symptoms) 82.0

Biological nature or mechanism of disease 53.9

Risk factors or cause of condition 25.8

Prevalence of condition 24.7

Subpopulation at risk of the condition 7.9

Appeals

Rational 100.0

Positive emotional 94.4

Negative emotional 75.3

Humor 36.0

Fantasy 22.5

Sex 4.5

Nostalgia 3.4

Adapted from Frosch D et al, Ann Fam Med 2007:5:6-13

Adapted from Frosch D et al, Ann Fam Med 2007:5:6-13Category of content Weighte

d %

Lifestyle

Condition interferes with healthy or recreational activities

30.3

Product enables healthy or recreational activities 56.2

Lifestyle change is alternative to product use 0.0

Lifestyle change is insufficient 21.3

Lifestyle change is adjunct to product 19.4 22.5 0.0 22.5

Adapted from Frosch D et al, Ann Fam Med 2007:5:6-13.

Medication portrayals Weighted %Loss of control caused by condition 67.4

Regaining control as result of product use88.8

Social approval as a result of product use83.1

Distress caused by condition53,9

Breakthrough67.4

Endurance increased as a result of product use

12.4

Protection as a result of product use11.2

Information: Small Gifts

• The influence of small gifts– Found to be a more powerful motivator for

persuasion by reciprocity• Hypothesized due to being less defended against them

Information: Larger Gifts

• Beliefs reinforced by financial stake in them– Sinclair Lewis: “If is difficult to get a man to

understand something when his salary depends upon his not understanding it”

Misleading reasoning- • Ad Hominem

• Arguments addressing the person and not the topic, by using either praise or ridicule

• Ad Verecundium • Arguments referencing authority, status, degrees, position

• Diversion • Arguments as a red Herring

• Law of small numbers • Arguments that use non-random anecdotes, in direct contrast

to the statistically significant law of large numbers

Misleading reasoning

• Manner or style• Arguments using the represntative’s good looks, pleasant voice,

ability to remember your name & your kids’ names

• Group Think/Bandwagon • Arguments appealing to your desire to be part of a group

• Newness • Arguments justifying use of medication because it is new

• Either /or (False dilemma)• Arguments creating a false Dilemma

• Straw Man Argument• Arguments that create a position and then argue against it

http://www.provenEffective.org

• See the website for other slide shows and the documentaries for additional information to supplement your teaching