ZEST insights

Steven Lewis of ZEST Digital, sister company to ZEST Healthcare, has written an interesting post on the increasing level of online discussion amongst consumers about pharmaceutical products. Medicines Australia’s Code of Conduct prohibits pharamceutical companies contributing to that discussion. The reality is, however, that patients are giving each other unqualified medical advice. Should the Code change to allow pharamceutical companies to take part in the conversation?

This opens up a whole can of worms. Steven’s article is here.

In essence, a brand manager’s job is devoted to educating doctors about the merits of their product in the hope the doctor will decide to start routinely prescribing it. Vast amounts of money are spent trying to achieve this. So a brand manager could be forgiven for thinking the task is done once a doctor starts using the product. But as we shall see, this is just clearing the first hurdle…

We talk to a lot of doctors. Whether GPs or specialists, these educated people all share a genuine desire to achieve the best health outcome they can for their patients. And the other thing they all share is a belief that all their patients are compliant. Every single one of them!

Call me a sceptic, but I am doubtful that even the most diligent of doctors with endless time to spend with their patients achieves total compliance across his or her entire patient population, with their various socioeconomic backgrounds, differing belief systems and range of forgetfulness. The BMJ thinks this is doubtful too.¹

Why does this matter? It matters because if a doctor doesn’t think that non-compliance is an issue for their patients, when a drug they prescribe fails to have the desired effect they will respond by changing the dose or even the medication.

This results in the doctor having a false understanding of the benefits of the drug and a sub-optimal health outcome for the patient, with the possibility of an increased financial cost to the health system and the patient. It also unjustly erodes trust in the pharmaceutical representatives who have invested so much time in educating the doctor about the product.

And the reality? Research has indicated that half of the medications prescribed for people with chronic conditions are not taken.² The BMJ believes this gap between perception and reality is likely to be due to a “difficulty for health professionals in acknowledging that it is the patients’ agendas and not their own that determine whether patients take their medicines.”¹

In other words, the doctors are making the effort to educate patients about the importance of compliance and assuming because they have done so it must be happening – but they’re not taking into account the patient’s views of health and care and if necessary readjusting the goal of treatment (or as we’d say in Med Ed-land, they’re not incorporating adult-learning principles into their consults).

The World Health Organization believes that the language used could be the start of the problem.³ The word “compliance” means the patient is doing as he or she is told by the doctor; that the patient is subordinate in the relationship. To tackle this imbalance a WHO report recommends adopting the term “adherence” rather than “compliance”. It suggests this is a less judgmental term and just indicates whether or not the patient’s behaviour is in agreement with recommendations from the healthcare provider, without the hierarchical connotation.

But really, is this anything more than sugar-coated compliance? It doesn’t require any change in the doctor’s approach to managing their patient. So compliance is the same and the brand manager’s return on investment is diminished.

But it’s not all doom and gloom. In the next post we’ll discuss the “concordant” model, the paradigm shift it represents in healthcare provider–patient relationships, and why brand managers should know about it.

1. Marinker M, Shaw J. Not to be taken as directed. BMJ 2003;326:348–9.
2. Haynes RB, McKibbon A, Kanani R. Systemic review of randomised trials of interventions to assist patients to follow prescriptions for medications. Lancet 1996;348:383–6.
3. World Health Orgnisation. Adherence to Long Term Therapies: Evidence for Action. 2003.

Unless there are any surprise last-minute announcements when the RACGP officially unveils its vision for the 2008–2010 triennium it’s probably fair to say there’s nothing controversial about their revamped framework.

As Linda states in her recent post, the gist of it is that they have put their heads together and identified the main reason for making continuing education for doctors compulsory – namely better outcomes for patients (you can’t fault the logic). To achieve this they’ve loaded more points into the more rigorous category 1 activities, which encourage doctors to consider their own clinical practice in depth and – hopefully – make changes for the better.

Now worth 40 points this emphasis on category 1 activities seems set to get the thumbs up from GPs – but if this means less interest in lowly category 2 activities like dinner meetings will there be fewer opportunities for pharmaceutical companies to support GP education? And will the “better” doctors opt to get their points through category 1 with category 2 meetings becoming predominantly the domain of the knife and fork brigade?

While time will tell, I think these changes actually create more opportunity for pharma to support educational activities. All the old activities are there but now we see some new additions, notably the EBM Journal Clubs, which have to be an excellent way for company representatives to build relationships with their doctors by helping them out with their meeting logistics.

I strongly believe excellent category 2 events will still be well attended. At an educational meeting I attended last weekend the GPs I spoke with acknowledged that there was a great deal of competition for their time, most saying they had a choice of several CPD meeting invites each week. But they asserted that “hooks” like the venue and even points were secondary to the quality and content of the meeting. “They would say that!” you could argue, but the sentiment seemed genuine. So I think what is true in this current triennium will be true in the next: If your educational activity is interesting enough and of a high quality they will come.

The new RACGP QA&CPD triennium has been designed to elevate the importance of active learning and quality improvement outcomes in the education program, and this will affect how activities are structured from next year.  

Major program changes include the increased emphasis on Category 1 activities, which will now attract 40 CPD points per event, and the mandatory inclusion of patient safety outcome objectives into all educational events.  Two new Category 1 activities have been introduced into the program - the Rapid PDSA cycles and EBM Journal clubs – increasing opportunities to deliver engaging educational programs to GPs. In addition, all GPs must undertake a CPR course during the new triennium. 

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