Briefing Meeting: 'Medical Education - The Bottom Line'

Over 80 delegates packed the meeting room at Altana Pharma in Marlow where Altana Managing Director Steve Glass welcomed them to the latest PM Society Briefing Meeting - testament to the interest in the topic of medical education.

Three speakers were there to investigate how, in the light of the ABPI Code of Practice ban on activities which include promotional elements, medical education can be made to help boost the bottom line.

Introducing the event Steve Clark, member of the PM Society Education Sub-Committee, said that the subject had been requested by many members in a previous survey. He said that medical education represented a 'big spend', and as such it had to be directed appropriately. When well done, it can add real value, he commented.

(from left) Steve Clark - PM Society, Philippa Mallaband - Chandler Chicco Agency, Steve Glass - Altana, Paul Underwood - Pharma MI, Eric Walsh - Takeda UK

The first speaker was Eric Walsh, Regional Account Director at Takeda UK. He started with a searingly honest view of how the discipline could be viewed in a cynical light: generating demand for the product about to be launched, promotion "with the product name omitted", as well as the much-documented accusations of disease-mongering, or as he put it, "a product looking for a disease".

"My gran could tell you more about erectile dysfunction than bunions," he said. "That's because it's everywhere."

A less cynical view - and one that supports the whole concept of medical education - is that it provides accurate and relevant information to inform patient management decisions, and importantly, does that with evidence, which is derived from robust and rigorous research and experience.

Eric cited the example of his own father, who after many years with the same GP, has recently switched to a younger doctor, who for the first time is being open with him about his health. He now knows why he has to take certain medication, and understands better his own conditions - because the GP is sharing the knowledge which they in turn are receiving through properly targeted and executed medical education campaigns.

So how can medical education be differentiated from promotion? Eric had a clear view on this: "The reader - patient or healthcare professional - should be left better informed about the condition, the management opportunities and the choices they are free to consider. If this doesn't happen, then in my view it's not medical education."

One common form of medical education is the Clinical Network, a format which in theory promises to fulfil the proper role of education and building more integrated care, but which, according to Eric, is more difficult to achieve in practice. He quoted a definition of a Clinical Network from Beyond Boundaries: A Guide to Diabetes Networks, which he said summed up what they were all about:

"Networks within the NHS are not new and have existed informally in different formats for some time. Over the last five to ten years there has been an attempt to develop and formalise clinical networks. The aim is to try and deliver more integrated care across organisational boundaries that reflect the whole spectrum of patient needs.

"Single and multi-professional clinical groups have existed for some time because they have a common interest [for example that shared by the industry and the HCP, or even the GP and 'my dad', according to Eric Walsh]. They are means of being able to share and learn as well as promoting evidence based practice.

"[Clinical networks provide] connections across disciplines which provide integrated care across institutional and professional boundaries, raising clinical quality and improving the patient experience.

"This highlights that clinical networks need to be at the centre of planning, commissioning and delivery of clinical care, whilst putting the patient at the focus of it all. Involving the service user in the process will shape and improve services around patient experience."

All of which is unarguable, says Eric Walsh - but how can the industry's involvement in these and other medical education initiatives be differentiated from promotion? And how closely can the industry stick to such a rigid definition when it is operating in vastly different markets, where one size clearly does not fit all?

Eric was clear in his support for the general principles and aims of the ABPI Code of Practice. "We need an infrastructure, and I do believe that the ABPI gives effective self-regulation. Sometimes it gets in the way, but the fact is that we have to act within a set of rules."

The focus of medical education activity is shifting, and rightly so, he says. Whereas a simple Therapy Area Focus might have been the starting point (with the pharmaco obviously focussed internally on the product), real and effective medical education has to focus on the customer, and more than that, on the Patient Outcome.



That could mean the most efficacious and safe product - but not necessarily, given the 'one size doesn't fit all' situation. For example, a better patient focus might be achieved by selecting a less efficacious treatment with fewer side effects, especially where this means that the patient will be more inclined to actually take the medication. "It all depends on the patient, and must be driven by them, in an informed way," says Eric.

So whose agenda needs to drive such programmes? Unquestionably those of the healthcare professional and the patient, says Eric. "If you can't answer the question with this answer, you should ask yourself what you're doing."

That means extending medical education into new areas. "Let's provide education and support that will improve health outcomes," exhorts Eric. "Let's make patients better than they are now in a way they understand - like my dad. This needs to be delivered by the healthcare professional; there must be clear blue water between medical education and promotion."

That means creating programmes that enhance understanding, that are evidence-based, patient-centric, are not intrusive into the time of both patients and HCPs, and that build a true partnership - only possible if the provider is giving, not taking.

But the key question for the pharma company is: does it work? Will it contribute to the bottom line? The extent to which it does will be driven by the individual company's circumstances, its mission and philosophy, the product profile and its life cycle stage, and by the requirements of HCPs and patients.

"Clearly your return on investment will be determined by what you measure," concluded Eric Walsh. "Are you looking for improved contribution, improved patient outcomes, or both?"





Creativity has a huge role to play in medical education's effectiveness, according to the second speaker, Philippa Mallaband of the Chandler Chicco Agency, who presented a fascinating case study showing how an unusual approach could achieve both credibility and impact, with a measurable effect.

Starting from the standpoint that successful medical education must include elements of communication and PR, Philippa introduced a case study for UCB Pharma product Equasym XL™, introduced as a treatment for ADHD in 2005. In a market where there is little product differentiation, Equasym XL's USP is its duration of effectiveness - around eight hours, or in other words a school day.

Philippa said that UCB pharma took the decision to follow the path of a bold and creative campaign, adding, "You have to ask what creative medical education actually means. The changes to the ABPI code means adapting and being more flexible. Customers are much more savvy today, and adept at tuning out of selling messages."

In this market, the customer (HCPs, rather than a patient or consumer audience) have very high levels of knowledge. Being secondary care HCPs, psychiatrists and paediatricians, they are genuine experts in how ADHD affects and impacts the lives of children. As Philippa put it: "what don't they know?"

So a traditional launch was not going to be enough. A way had to be found to show the target market something 'new' beyond the brand profile and data - this latter something that such an informed target group would anyway take for granted.

Because UCB Pharma was going to be a new entrant in this market, marking out a territory would mean building relationships to generate respect, support and partnership.

The approach that Chandler Chicco adopted was to attempt to 'emotionalise the subject, creating a medical education campaign with a 'School Days' theme, and a 'Hearts and Minds' strategy.

Central to the campaign was a play called 'Could do better, must try harder', supported by various campaign-linked printed collateral, including a research report entitled 'School Report', a 'Stories from the Chalkface' report, and a series of 'Talking Points' guides.

All of this linked into the common thread of School Days, and a strong internal communications was undertaken to ensure that the product team all bought into the concept.

The decision to use drama, or 'theatre based learning' to an expert audience was a bold one, and the execution had to be carefully undertaken. "It was important that we executed the idea with care and attention," said Philippa. "Creativity has to go alongside responsibility."

To this end, the script was comprehensively researched using expert consultants, and then professionally written, cast and produced. Message management was carefully considered to ensure that it was clinically valid, accurate, realistic and not over-stylised.

The script told the story of one child living with ADHD, and those around him. It was subsequently adapted as a screenplay for a DVD production.

Alongside the play came a 'School Report', which gave an additional insight into the real stories of children living with ADHD and their parents, gathered via extensive research. Using a combination of quantitative and qualitative, it included myth busting sections, and the whole visually complemented other aspects of the campaign.

The 'Stories from the Chalkface' report was aimed at assisting customers in their management of children within the modern school environment, aiming to shed new light on the subject for the target audience.

"The HCPs we were dealing with were very sophisticated in their knowledge of the condition, but this report was about helping them get under the skin of the lives of patients," said Philippa. "Like most people who left school a long time ago, the HCPs didn't actually know what goes on in school nowadays."

The final part in the jigsaw was aimed at helping customers facilitate difficult conversations with teachers. Entitled 'Talking Points', they were designed to meet the unmet need of communication, not just between doctors and teachers, but between parents and HCPs, as well as parents and teachers.

Philippa outlined what she thought had made the campaign a success. "We were thinking more about brand loyalty than directly about the bottom lines," she said. "It was about building relationships for the future."

With this in mind, the success factors included: not being led by the competition, but striking out on a bold track; having a clear strategy, and sticking to it; getting the research done; making a commitment to innovation; working in close collaboration with the agency to develop creative solutions; and recognising the need for rock solid third party collaboration and consultation along the way, recognising that if it wasn't authentic the audience would be lost quickly.

Finally, the campaign took a responsible approach and ensured high standards and transparency. "This was vital, because we were deliberately emotionalising the condition," explained Philippa. "This was not a way of disguising brand messaging. The customers were too savvy and would have seen through such an approach, with the lost credibility the end result."

The reaction from the audience was very positive, not just from the obvious customer group of HCPs, but also from a wider audience of nursing, psychiatric and educational opinion leaders.

Philippa concluded by asserting that transparency, reliability, clinical validity and good execution were all vital to a successful medical education campaign. "Taking a more human approach to a condition is a good idea that allows creativity," she said.

Assessing just how successful and effective a medical education campaign has been was the focus of the third speaker at the briefing, Paul Underwood, Director of Analytics at Pharma MI. He took the position that assessing RoI on medical education programmes was as important as any other investment.

"Medical education, as with any programme, is an investment decision," he said. "When deciding what activities to invest in you are allocating scarce resources. The most effective way of doing this is via the return on investment of different projects."

But, he said, because medical education programmes are non-commercial, the benefit is normally indirect, and thus difficult to measure. They are more likely to change the return on other marketing activities, rather than deliver direct return in themselves, which makes measurement potentially difficult.

However, claimed Paul, although the analysis is difficult and sometimes ambiguous, this potential for ambiguity can be reduced.

The first thing that is needed is good quality information. What are the parameters you have set for success - number of programmes placed; patients enrolled, commercial activity, etc. Paul stated that sometimes perceived failure came not from the design of the programme, but in its implementation - put simply, what was intended to be done wasn't done.

Furthermore, data is often poorly or inconsistently gathered, making meaningful measurement difficult.

Clear definitions of the programme objectives are of course vital. You need to know what the outputs, both direct and indirect, that you are trying to affect with the programme. These outputs should be defined in the key objectives of the activity, whatever they are: sales/market/share growth; patient throughput; formulary status improvement; speakers and KOLs generated and used; and even commercial activity generated, if access is the objective.




Paul cautioned about the 'Pilot Effect', in which pilot studies used to asses the viability of investing in a medical education programme tended to perform better than the programme which followed. This is because pilots tend to be run by the most motivated individuals who have an interest in seeing the project succeed, and so sometimes select the 'best' candidates.

So the design of any pilot needs to reflect the actual situation, and whilst pilots can be useful in assessing the correct measurement parameters to evaluate the potential RoI, the full roll-out will seldom perform as well. However, because of this very tendency, pilots can be a useful place to learn the critical success factors for the programme, which need to be replicated in the full roll-out if that too is to perform.

When it comes to analysis of the data gathered, there are problems to be overcome as well. The first is that the granularity of the output data may not match the input programme - in other words, there may not be a clear consequence stream between inputs and outputs. Additionally, as we have seen, the collected data, and the way in which it is collected, may be less than robust.




What's more, because many medical education programmes are designed to increase the return of other commercial investments (other marketing activity), it's difficult to measure the direct effects of the medical education programme: what Paul calls the 'indirect multiplier effect'. So relationships between medical education inputs and sales - and thus bottom line - are very complex.

Paul then introduced three types of analysis, each with its advantages and drawbacks.

Using 'Variation from Historic Projections' works best geographically, with a forecast of expected performance being used to compare the expected and actual outcomes - showing the effect of the intervention during that period. But, he warned, because there is a margin of error, it is important that the impact of the programme is considerably bigger than the 'confidence interval' (i.e. margin of error) of the projection. This approach has the advantage of being reasonably cheap and straightforward, but it does not disentangle what elements of the programme work and which don't work, nor can it measure how well the programme has been implemented.

The second approach is 'Multivariate Regression'. This is a technique for assessing the impact of multiple independent variables - but that independence is vital, and frequently the variables are inter-related (or 'have multicollinearity', as Paul put it). To attempt to distil out the key variables, it is necessary to hypothesis test multiple scenarios - and if the time period is large, this variable can swamp all the others. This type of analysis is generally time consuming and expensive, and requires considerable statistical expertise.

The third approach is to use data mining techniques. By using complex statistical software, you can 'mine' for relationships in the data. Paul introduced some of the techniques which can be used, including rule induction and neural nets, all of which have the advantage of being able to handle large data sets without hypothesis testing. This approach also handles 'fuzzy' data better than normal statistics. Although data mining is complex, time-consuming and expensive, and the results quite challenging to interpret, this technique does at least attempt to evaluate the complex relationships that exist between variables.

Paul's conclusion was a good summary of the points made throughout the evening. He questioned the motives behind measurement - as it costs in terms of time, effort and money to undertake evaluation, the reasons for doing so need to be clear. Whichever approach is taken will require clear programme objectives and good data collection.

In the end, measuring the impact of medical education programmes on the bottom line will never give a cut and dry answer. No matter how sophisticated the analytical techniques used, a measure of human interpretation and judgement will still be needed.

We would like to reiterate our thanks again to Altana for hosting the briefing and providing a delicious buffet for delegates.

Held on: 18/09/2006