Changing practices

Editor's note: Richard Vanderveer is chief innovation officer at ThinkGen. He can be reached at richard.vanderveer@think-gen.com.

New marketing challenges often require the use of new approaches to marketing research. For example, using free-flowing conversations as the data collection technique and the psychology of habit as the analytical framework, it becomes possible to deal systematically with an emerging pharmaceutical marketing environment, even if “We don’t know what we don’t know.”

More specifically, recent years have seen a reduction in the willingness of physicians to spend their time being detailed by pharmaceutical sales representatives (PSRs). This trend was significantly accelerated by the COVID-19 pandemic, as its required multi-month cessation of personal visits by PSRs to doctors’ offices caused doctors to reconsider their long-standing habit of allowing – and often encouraging – such visits. To fill the void during these lockdown months, pharmaceutical companies turned to “virtual details,” with PSRs “visiting” with physicians via Zoom and other videoconferencing platforms. During that time, companies also placed a greater reliance on e-mails, phone calls, etc., to keep in contact with physicians. 

Throughout the pandemic and moving into the post-pandemic period, we have been having monthly conversations (see below) with office-based physicians, primarily high-prescribing specialists, studying the backstories of their various forms of engagement with pharmaceutical companies. Increasingly, articles in the trade press and reports by major consulting firms are recommending the use of artificial intelligence to customize and personalize companies’ engagements with physicians. But, to take meaningful steps in this direction, companies need to understand the psychology of engagement. What are physicians looking to accomplish through their engagements with pharmaceutical companies? How satisfied are they with current offerings? What additional forms of engagement would they like to be offered?

Understandably, discussions with our clients have revealed that many of them are uncertain about the changes they are seeing in the marketplace. Of particular concern to many of them is the risk of reinstituting personal forms of engagement with the possibility that new coronavirus variants will once again lead to lockdowns. Of even greater concern is the possibility that, as a result of the pandemic, physicians’ preferred forms of engagement may have changed permanently. Keeping pharmaceutical marketers abreast of these changes is the purpose of conducting the On Doctors’ Minds (ODM) conversations on a monthly basis throughout 2022.

Get out of the way

To meet these information needs, we have found that conversations with physicians is the best methodology to employ. These conversations, typically conducted by a psychologist, are significantly more open-ended than even individual depth interviews. The philosophy here is that when you understand very little about the dynamics of the situation under study, it is best to simply get out of the way and let those who are actually involved in the situation do the talking. While focus groups can also serve this freewheeling purpose, that methodology does not readily allow for the identification of significant customer segments which were hypothesized to exist here and are in fact emerging.  

Procedurally, physicians are recruited for individual one-hour Zoom sessions. Potential discussants are asked to authorize the viewing of the Zoom recordings by clients, thus allowing pharmaceutical marketers to hear directly from their customers in an “open mic” environment. Rather than following a traditional topical guide, the flow of these conversations begins by our simply and honestly telling the discussant what we are looking to accomplish during the call. In this case, doctors are told that we are looking to get a thorough understanding of the kinds of interactions in which they are currently engaged with pharmaceutical companies. 

To provide guidance as a place to start this process, we ask each doctor to begin by telling us what engagements she has had with pharmaceutical companies in the last week. As that information is forthcoming, the doctor responds to probes of clarification (What do you mean by that?) and extension (What else?) to develop an overall understanding of the physician’s current pattern of engagement, her satisfaction with its various elements, how this pattern has changed as the result of the pandemic and how she would like pharmaceutical company offerings of various forms of engagement to change in the future to better meet her needs.

By using this conversational technique in which the physician drives the flow, the analysis of the resulting video recordings lets us get in touch with new insights that otherwise would be hidden from us even in an individual depth interview, where the interviewer determines the flow of the conversation and imposes her own terminology through the asking of specific questions. This conversational approach permits more organic forms of analysis to develop insights that include:

Salience: In what order does the physician introduce topics for discussion and how extensive are her comments on each topic? Topics of greatest importance to the physician are typically talked about earliest and longest in a conversation.

Emotion: What is the physician’s body language as a particular topic is discussed? Where is there positive affect and where is there negativity?  

Terminology: What words does the physician use to describe the various forms of engagement and her reactions to them?

Dynamics: In what ways has the physician’s participation in, and attitudes toward, various forms of engagement with pharmaceutical companies changed as the result of the pandemic?

Segments: What segments exist in terms of physicians’ utilization of, and attitudes toward, various forms of engagement with pharmaceutical companies?

Readers wanting to listen to a short example of a conversation conducted for this project can access it here.

Numerous learnings

The ODM project is still ongoing monthly, so the final results are not yet in and won’t be for a year or more. However, numerous learnings are already available. Some of the most important include:

Longstanding physician habits pertaining to engagement with pharmaceutical companies were forced to be reconsidered as the result of the pandemic lockdown.

Without doubt, the most important finding of this project is that the decades-long habit of physicians willingly having regular, in-person visits by pharmaceutical sales representatives was put on hold by infection control requirements in doctors’ offices and by company policies that pulled PSRs out of the field. This hiatus, in turn, has resulted in physicians reconsidering this form of engagement and the amount of time that they are willing to dedicate to interacting with PSRs in particular and pharmaceutical companies more generally. In brief, the months-long absence of PSR office visits, as well as pandemic-induced pressures on physicians’ time, reelevated time allocation to the executive mind, where active consideration and scrutiny were given to what once was easily managed in the habitual mind.

Importantly, many doctors are quick to explain that the pandemic’s impact in this regard was simply to hasten a trend that had already been underway for several years. This trend, as doctors explain it, was toward their increasing resistance to subjecting themselves to repetitious promotion of products through presentations that bring no new information. While the pharmaceutical industry called such presentations “reminder details,” doctors called them annoying.

Over the course of the pandemic, and now into the post-pandemic period, physicians have developed new engagement habits.

In continuing to study the psychology of engagement, it has been fascinating to hear about how a particular physician’s habits in this area are logical and consistent with what that doctor is looking to accomplish through the engagements.  

For example, physicians are, across the board, understandably interested in making the best use of their time possible. The pandemic found doctors having to quickly adapt to telemedicine, to new in-office safety procedures, to staff outages due to sickness, etc., thus causing a newly sharpened interest in getting full value out of every practice minute invested in an activity. Interestingly, for some physicians, this interest translates into a preference for traditional in-person PSR visits. As these physicians see the situation, they can control the length of personal visits by communicating through body language and, if necessary, pivoting on their heels and walking away when a PSR has overstayed his or her welcome. 

Conversely, other physicians prefer virtual presentations based on the same interest in controlling their schedules. For them, virtual presentations are preferable since they are prescheduled, allowing the physician to set aside the appropriate amount of time for such an engagement and to fit it into their schedules without PSRs being allowed to show up without an appointment, thus interrupting the physician’s workflow.

Physicians are increasingly intolerant of social chatter and other “wasted time.”

Quite simply, most doctors are looking for the efficient presentation of important new information and/or for the delivery of services that can help them help their patients. There needs to be a quid pro quo for the time the physician invests in any engagement. Period!

Physician segments are emerging that differ significantly in terms of their preferred interactions with pharmaceutical companies.

While some doctors eagerly looked forward to the return of the “good old days,” replete with PSR personal visits, copious supplies of samples and lunch provided for the office staff, others welcomed the advent of virtual details, considering them to be much more efficient than personal visits. Also frequently encountered are hybrid physicians who prefer longer, sit-down discussions, quite often with medical science liaisons (MSLs) for the introduction of a significant new product, while seeing virtual details, typically with PSRs, as being more efficient for less in-depth discussions. Many physicians report that they value the MSLs’ ability to answer more complex questions than can the PSR. They are often frustrated by PSRs’ inability to get into a more clinical, case-based discussion, while MSLs have more latitude to address physicians’ practical questions.

Underlying these differences, we have found that physicians are looking for PSRs, and more generally pharmaceutical companies, to play different roles in their practices. On the one hand, physicians in primary care, solo practice and in more rural settings appreciate both the new information and the samples that PSRs provide. On the other hand, physicians in academic practices often rely on their colleagues for the exchange of new information rather than on PSRs, whose visits are in some cases blocked by institutional policies. These same physicians often have little use for samples, which are in many cases also forbidden by the academic institutions in which they practice. The result is that designing engagement programs for such physicians can be especially challenging. This is a situation where pharmaceutical companies need to engage these high-level HCPs/key opinion leaders not through PSRs but through establishing their interactions with company MDs and PharmDs and other sources of clinically useful information.

We would be remiss if we did not report that while most physicians want to avoid social chatter with their PSRs, as discussed above, a relatively small segment of doctors exists who genuinely and enthusiastically value their friendships with some of their PSRs. Such social bonding does not occur overnight. Rather, the doctors who reported such friendships tend to be older, thus permitting them to have been serviced by a stable cadre of PSRs who had provided them with good service “for years.” In these same practices, it is important to note, the doctors also identified younger “pass through” PSRs who were seen only once or twice before disappearing. 

Most physicians view their engagements with the pharmaceutical industry as being product-focused not company-focused.

Despite many pharmaceutical companies’ belief in the importance of corporate image, most doctors honestly report that in general, they have little awareness of who makes what. Thus, when they speak about a PSR, they not infrequently call her “the (product) rep,” NOT “the (company) rep. Relatedly, physician perceptions of categories of pharmaceutical companies are often rather simplistic, e.g., big companies (Merck, Pfizer, etc.) vs. small companies.

Our conversations with physicians in the 2022 iteration of our ODM project revealed that the association of corporations with their products, let alone the development of anything resembling loyalty to a company, does not happen automatically as the result of routine product promotion. Rather, something heroically above and beyond routine exchanges is typically required for physicians to take note and respond to this perception. Here, Pfizer’s work on COVID-19 vaccines is seen as heroic enough to earn it special mention by physicians in terms of corporate image. Little support was heard from physician comments, however, for the notion that this image was resulting in corporate loyalty or increased use of other Pfizer products.

Several other examples of outstanding behavior on the part of pharmaceutical companies were heard in the current round of conversations. One neurologist, for example, was quick to identify Biogen as a company that is “doing a great job” for him. Why? Simple! The Biogen financial assistance program for patients is seen as being generous, easy to access and transparent. The upshot of this, the doctor went on to explain, is that if there are two virtually equivalent products and Biogen makes one of them, his positivity toward that company will make him choose its product.

Another and very different cause for a physician to become corporately aware and loyal was found in our conversation with an office-based dermatologist. This doctor reported that he is an active participant in the speaker programs of several pharmaceutical companies. Such participation, we found through conversations with other physicians in our project, understandably often weds a physician to the companies for which he or she is a frequent and regular speaker.

But this doctor offered further explanation of the power of participating in such activities. In the two weeks prior to our conversation, the doctor reported that he had participated in two Zoom speaker training programs. One of these was five hours long. He received a check for $5,000 for his participation in that seminar. The other was eight hours and resulted in him receiving a check for $8,000. In case we had missed the point, he went on to note that put together, these two sessions had netted him a total of $13,000. Not surprisingly, he had no difficulty in recalling what two companies had provided this largesse. Equally unsurprising is the fact that several other physicians reported to us that they are far more prone to participate in programs for which they are compensated.

A segment of physicians exists whose engagement with pharmaceutical companies revolves mainly around food.

As we saw in the findings of ODM v1.0, v2.0 once again has found a segment of physicians who routinely hold PSR-sponsored lunches in their offices three to five days each week. Such sessions have typically involved the entire office staff, permitting physicians, nurse practitioners, physician assistants and nurses alike to enjoy a convenient lunch and to be exposed to the message delivered by the PSR. Such lunches are valued by physicians, who see them as a great way to reward, at no cost to them, their hardworking and typically underpaid staffs. 

Even during the height of the COVID-19 pandemic, when no PSRs were allowed into physicians’ offices, the use of Uber Eats to deliver lunch and a computer set up in the lunchroom to permit the PSR to deliver her message via Zoom or a similar platform got the job done for this segment. Now that offices are largely opening back up, most lunch-dependent practices have returned to in-person sessions.  

However, the pandemic has fundamentally changed the promotional opportunities these luncheon encounters provide. More specifically, prior to the pandemic, a luncheon buffet was typically arranged by the PSR. The staff would come into the room at the appointed time and sit down to eat their lunches together. This setting allowed the PSR to make a quality presentation and to have the staff participate in a discussion so that everyone left with a shared understanding of the message that had been delivered and how it applied to treatment in that office. Post-COVID-19’s arrival, the rules have fundamentally changed. Now food is preordered by individual staff members and comes prewrapped. The result? The PSR only gets a minute or two to interact with individual staff members as they come in to pick up their lunches and there is absolutely no opportunity for group discussion of the presentation’s contents. Thus, it could be cogently argued, the majority of the promotional essence of the luncheon encounter has been stripped away.  

Moreover, since physician offices that host such lunches typically do so three to five times each week, with PSRs from multiple companies competing for available slots, it can also be argued that no company is gaining a reputational advantage through lunch sponsorship.

Understood as habitual

At the bottom line, approaches like the ODM project help us learn that an individual physician’s engagement pattern with pharmaceutical companies is best understood as habitual. Doctors are not making engagement decisions on a one-off basis but rather are developing predictable, habitual patterns of behavior. They are anxious to participate in some forms of engagement and to avoid others. 

As a closing note, the work reported above constitutes more findings of an initial investigation than of a study. Small sample sizes, and the conversational research style employed, inherently limit generalizability of findings. However, the search for insights as to how the pharmaceutical industry should deal with fundamental shifts in physician engagement patterns and preferences needs to start somewhere. Through the work reported to date, and through other aspects of our ODM project, we are looking to produce the following outputs: a better understanding of the psychology of physician engagement; a lexicon of the dimensions on which physicians’ utilized/preferred engagements can be profiled; and a series of physician personas that characterize segments of physicians based on their habits of engagement. These and other insights will be essential in helping pharmaceutical companies to respond to the rapidly changing field of physician engagement.