Has the current approach to pharmaceutical sales passed its expiry date?

The registrar has struck up a good conversation with her and she thinks that she is onto a winner with this bright eyed and enthusiastic young doctor (little does she know that he is looking for material for the next Vocational Training Scheme session to pick over and analyse to look at the techniques used by drug reps to sell drugs). Time is ticking by and the partner from the other site who often runs half an hour late has not made it – the reps 30 minute slot is rapidly becoming a 10 minute slot – what chance has she got to cover anything in useful detail in such a short period.

Oh well maybe she can get rid of the box full of gifts that she has been carrying around for the last six months. There are some really nice bookmarks and other useful items here after all. But wait a minute what is that in the waste bin – a pile of plastic book marks and bits and pieces from the last rep. Clearly this surgery has all the bookmarks that it needs. One of the doctors mutters I wish that these reps would bring us something useful or don’t bother to bring anything at all. Those anatomical models and charts used to be really great for talking to the patients with – we never seem to see these anymore. And I could always do with good well put together education CDs – this rep has not even brought stuff that my kids can use to improve their street cred at school! Well at least we can stock up on pens – no matter how many pens are left at the surgery we are always short.

Now for the presentation. This rep is going to struggle to do anything useful with 10 minutes! Wait a minute - what is she selling – oh another statin. This one seems to offer about 1% improvement in efficacy using some artificially contrived end point that my patients don’t give a damn about. Oh yes here comes the standard presentation tricks – she is dressing up the efficacy by talking about relative improvements rather than absolute improvement – and oh yes here is the next one – she is comparing competitors performance from their own published trials – but of course there is no head to head data– so it is all a bit meaningless anyhow. Is she going to talk about safety and tolerability- yes here it comes – oh I blinked and missed it. Is she going to give a hand out – yep here it comes, yet another piece of glossy cardboard to dump in the bin. Is she going to stop at the allotted 10 minutes or is someone going to have to be politely rude to her and ask her to leave?

The natives are getting restless. David who runs this meeting and is really keen to get on to important clinical matters is fidgeting and starting to look at his watch. The registrar who has asked all his questions before the meeting is getting out some material for his next Vocational Training Scheme session that he is desperate to finish. Our part time sessional doctor is asking a few polite questions to avoid embarrassment. The senior partner who is mostly planning his retirement isn’t even bothering to show any interest at all. Ah it looks like she is finally getting to the close of her presentation. In a meek voice she asks if the material she has presented has been useful and will it make any difference to our practice? David makes a polite reply that there may be special cases that her drug could be useful for – but we find that the generic drugs are perfectly acceptable and do a more than adequate job for us. She thanks us and slinks out.

Over the last few years the way in which primary care doctors are compensated has been changing. The government has been executing a public health agenda and also indicating what services and quality of services they want to see in primary care with new types of contract and the Quality Outcomes Framework. The organizational and administrative burden of reaching these targets which are an important source of income is ever increasing and time consuming. Most GPs are finding their time more and more precious and are asking serious questions around the value of seeing representatives from pharmaceutical companies. This means asking some searching questions about what you can bring to the table that they will value. The customer that you are presenting too is now less and less a doctor and increasingly running a business. He will mostly care about what you bring that will add to his business.

All doctors are being educated on interpreting data and evidence based medicine has taken a firm hold on how doctors decide on the value of a given treatment approach. What this means is that they will be focused on questions concerning the real impact on disease that a given new drug is likely to have or an improvement in safety. We have all seen break-through drugs come and go. Experienced GPs are always conscious of the potential to do harm every time they prescribe. Who would ever have predicted that one of the outcomes of the marketing of the COX2 drugs would be an increased awareness of the long term risks of prescribing all NSAIDs and increasing caution in the use of this class of drugs. If you want to sell your drug as being better then it really does have to be better in absolute terms – not a few percentage points of absolute efficacy magnified by presenting relative improvements.

Most doctors at the start of their practicing years will have a solid knowledge base built up from standard text books and learning aids as well as absorbing the general approach used by their mentors. In primary care, with the introduction of formal appraisal, a practitioner is now required to have a plan and approach for continuous ongoing professional development that can be documented. This is time consuming so learning resources have to be selected carefully. A presentation by a pharmaceutical company representative is not going to count! Increasingly learning and updating is being done on line. The BMJ leaning site, doctors.net, GPnotebook and Onmedica are now well established sources of e-learning material being used by large numbers of doctors from both primary and secondary care. These resources enable the doctor to choose when and what they want to learn and offer discussion groups and selected news items as well. A huge advantage of using these sites is that enable a record of learning activities to be kept that can be presented as part of appraisal.

Most, but not all consultations end with the writing of a prescription. Over the last few decades the pharmaceutical industry has done a magnificent job of developing a series of new and effective drugs. However, the bulk of prescriptions are still for older drugs – after all we are still using aspirin and digoxin – just about the oldest known drugs! While there has been a steady trickle of new treatments where none existed before, most diseases have a reasonable generic alternative medication that is almost, if not as effective, as the branded products available. In fact these days the product requirements that new pharmaceuticals are developed to are so tight that it is unlikely that there will be an ‘achillies heel’ that competitors can exploit effectively. This means that when the first pharmaceutical launched in a new class goes generic there will be a very limited market for the remaining branded products.

Not only is the government executing a public health agenda through primary care, but also the quality of care is being standardized. In the UK this is particularly driven by the activities of NICE and the steady stream of NICE guidelines that have been published. The most recent of these being the guideline on hypertension, which has a big impact if you are dependant on beta-blockers for your sales! These are not the only guidelines – there is a British Society for most therapy areas who also publish practice guidelines and other national organizations such as SIGN. These various guidelines, while constraining, give a framework where different classes of drug can fit in and are very influential on current practice. You need to be aware of where your drug fits into whichever relevant guideline if you are to present your product successfully.

I know from my experience on the research and development side of the pharmaceutical industry that several hundred million dollars are spent on developing the products that are eventually approved. Once approved many more hundreds of millions of dollars are spent on obtaining further data, product development and product placement. So far the presentations that I have seen from pharmaceutical representatives have been a poor reflection of the immense amount of work and investment that a huge team of people working for sometimes over a decade have achieved. I am sure that most of them would be horrified to see their work and dedication reduced to a few glossy detail aids presented to a disinterested audience that ultimately does not prescribe your drug. You should be aware of and feel the responsibility to that team every time you present your product.

We live in a changing world. In past decades the current model of pharmaceutical sales did its job, and in fact the direct interaction between pharmaceutical representatives and doctors probably does still influence some prescribing. However, the army of sales representatives has grown while their influence has diminished. It is time for a rethink of the whole process. This needs to start with Research and Development. While developing me-too products has been an immensely profitable approach in past decades, particularly when the first product to market often had weaknesses, the world has moved on and (apart from the unpredictable idiosyncratic safety problem) generally any drug now approved be it the first or the last will have been developed to stringent product quality guidelines, making the me-too approach much more challenging. In fact while the me-too approach may contain development risk, it simply shifts the risk to the commercial side of the organization. Both regulators and prescribers want to see products that address current therapeutic problems. I would give my right arm for an effective and safe medication that is either an analgesic, anti-inflammatory or a disease modifier in osteo-arthritis. As recent safety concerns have emerged regarding the NSAIDs, paracetamol has become the first choice treatment for those afflicted. A new therapy that truly adds to the current range of therapies and fills a medical need will almost sell itself. Assuming that you have such a wonder drug then is the right approach to use a scattergun approach and sell to all? Probably not – while I have had my doubts regarding the way that we pander to key opinion leaders – the reality is that prescribing can be strongly influenced by the treatment approaches of these influential doctors both at a local level and a national level – they after all will be more informed than any primary care doctor could ever be in their given area. Finally the internet has transformed the way in which information is transmitted. Doctors are spending increasing amounts of time using this technology – it has even made it into the consulting room – with the use of GPnotebook in the context of a consultation becoming more common. This often enables a primary care physician to decide a treatment approach without resorting to referring to a specialist. The pharmaceutical industry needs to recognize and embrace this change in it’s sales techniques.