Understanding the Humanity in Physician Prescribing Behavior
By John Burke SVP, Planning, Ogilvy Health
Understanding the behaviors of our customers is central to the effectiveness of any ad campaign, and pharma is no different. What is all too common however is that we assume we understand these behaviors instead of looking at them with an open mind. Data from the IPA and ThinkTV1 illustrates this conundrum where advertising practitioners consistently assign their own behaviors to consumers, skewing perception and diminishing the ultimate effectiveness of our work. And, with so little (known) empirical data on what actually drives prescribing in any given therapeutic category, this becomes even more prevalent when we seek to understand the actual behavior of physicians.
How often have we heard “well, physicians are people too” as an argument to ensuring that our work retains an emotional bent? Well yes, that is true, they are not robots, wild dogs, or sharks with lasers on their foreheads. Physicians are indeed human (we love you, physicians!). This mantra, while true, often obfuscates the real influences that drive physicians to prescribe. It often leads to a conflation of patient emotion with physician prescribing behavior. A dangerous proposition. Why?
Because physicians are agents. Proxies. “They are the chooser, and not the user.”2 And, while there are gradient levels of patient influence, say between specialists vs. generalists, in dermatology vs. cardiology, or in advanced vs. newly diagnosed conditions, physicians are ultimately the decision makers. They write the scripts; the patients take the medicine.
Armed with this truth in our pockets, we, the ad people, will often pendulum swing from “physicians are people too” to the assumption that physicians are only swayed by rational and fact-based evidentiary messages. You see this in almost every prelaunch disease awareness, and post-launch HCP branded campaign. Doctors are somehow the inhuman humans, only using their rationality and not their hearts.
As with everything, truth tends to live in the middle. And the middle is, for many, not a comfortable place to exist. It takes work and an open mind to embrace. There is no room for assumption or anecdotal information. Our customer’s success depends on a full understanding of the biopsychosocial environment within the clinical practice.
As it turns out, compelling data does exist to help give us a glimpse into what is really driving physicians to prescribe. In fact, there are nearly 10 existing models of physician prescribing behavior that we can learn from, built and researched between 1972 (Knapp and Oeltjen) and 2017 (Murshid and Mohaidin).3 And, just as in FMCG, there are some disparities and commonalities within these models and the data they produce. What follows below are the three most relevant commonalities that exist across all of these models and numerous other sourced studies.
1. Rational Messages Are Not Enough
Whether we practice it or not, we have heard this a thousand times. And as it turns out, it’s true. As reported in 19 peer analyzed papers,5 “experienced emotion is an aspect of clinical reasoning and clinical decision making.” And, “emotional responses of anxiety, stress, fear, and empathy were evident with clinical decision making.”5 This is evidenced in the skin responses of practitioners,10 and across a variety of other quantitative and qualitative techniques reported within the studies.
Interestingly, “some physicians required facilitation to be made aware of this emotional aspect of their response after initially denying they were influenced.”6 This often surfaces as “intentional exclusion,”7 perhaps due to perceived professional or regulatory pressures on their practice. Nonetheless, the emotion is physiologically present, and can therefore be harnessed in our work.
The effects of rational-based messages on prescribing decisions are well known,8 that is not in dispute. It is how we blend those important messages of efficacy, disease pathophysiology, MOA, or whatever we need to functionally communicate within an emotional wrapper that is aligned with what physicians are actually experiencing. And this means more than just using Getty stock images to make a connection. There is real emotion present and we should be tapping into it, smartly.
2. Reactivity Is Common in Prescribing Behavior
Assuming that physicians are out there visiting our websites and proactively seeking information on new drugs to prescribe is not backed up by the data. In fact, the research shows that physicians are more often than not “reactive recipients, rather than active searchers of new drug information, and mention little reference to objective, scientific drug information”4 in their prescribing decisions.
The information-gathering behavior of physicians has been shown as “opportunistic rather than based on an explicit process.”4 This reactive consuming of information can be most effectively addressed with proactive human-touch relationships—e.g., reps out consistently detailing to educate physicians and drive behavior change. In reality, data shows that the physician/rep relationship is overwhelmingly the principal resource for physicians to learn about new drugs2; more than two times any other reported source at 33%,4 and at 39% as a factor influencing new drug uptake. This again means that they are busy out there practicing, and that it is our job to get our messages out in front of them. Not wait for them to come to us.
Another critical aspect of consideration around the reactivity of prescribing decisions is patient influence. Research shows that it is the third most influential factor influencing drug uptake at 22%. Narrowly beat out by “suboptimal efficacy / adverse effects” in second at 25%, with again the rep relationship being first. Interestingly, in the over 616 reported incidents in the Prosser/Almond/Walley study, even “side effect profile” takes a backseat at 17% to “convenience and patient acceptability” at 20%. Further illustrating the emotional aspects and empathy underlying physician prescribing behavior.
Many generalists and specialists are aware of the prevalence of patient influence and have voiced their concerns11, 12 but the FDA, unlike the EU and Canada, has allowed DTC ads to continue to be influential in the prescribing behavior of physicians.
3. Clear and Consistent Communication Is Paramount
There is no single golden egg to changing physician behavior. That is something we must always keep in mind. Physician behavior is “multifactorial,”4 requiring a number of touch points with consistent and clear messaging across each one to create the cognitive shortcuts necessary for behavior change within the human brain. Laser-headed sharks might not require this, but our human physicians do.
This is well documented in a number of studies both in and out of pharma. Namely from Kantar/Millward Brown, who’s Link Database shows that message retention drops significantly when more messages are introduced.9
This is particularly relevant with physicians who are already time-strapped and prefer the input of non-peer reviewed sources (Pulse, GP, etc.) over scientific medical journals.4 Counterintuitive to what we might believe, physicians “cited lack of time, information overload, difficulty in interpretation and comprehension, irrelevance, and the importance of clinical experience as constraints to accessing scientific literature.”4
A FINAL THOUGHT
If I could suggest you take away one thing, it is this: physicians are indeed people too. It’s just a fact. They do not simply make rational decisions as so many HCP campaigns would have you believe. They are heavily swayed by a variety of sources, many of them influenced by other humans. And, when it comes to the all important moment of writing a script that first time, they are feeling a variety of emotions that we as marketers should be considering if we want them to keep writing and our businesses to keep growing.
A NOTE ON RESEARCH
Undoubtedly you will most likely enter into primary research at some point to better understand physician behavior in whatever therapeutic area you are engaged in. Each specialty is somewhat different, and each disease state has unique considerations that have to be taken into account when modeling behavior. In this light, it is very important to be reminded of a central fallacy in behavioral research in general: that any human is capable of explaining their own actions.
Whether it is authority bias, framing, or any other cognitive trap, all human beings will make assumptions on why they do what they do, but they are often wrong. This is evidenced by mountains of fMRI and brain imaging data13 and countless studies. To quote David Ogilvy, “People don’t think how they feel. They don’t say what they think and they don’t think what they say.” And this is just as true for physicians as any other human being.
One tactic I have found the most revealing when conducting in-depth interviews (IDIs) is to ask the physician how, or why, they think their peers are make prescribing decisions. I have found their responses to be more honest and reflective of their own behavior than asking them directly. Give it a try!