Welcome to Analysis of ROI for Pharmaceutical Promotion

Don't Forget The Gatekeepers
by Thomas C. Pizor

Executive Summary
DTC promotion may persuade the consumer to ask for a prescription, but no sale takes place without that prescription actually being written. Like some of our other authors, Thomas Pizor cites studies that indicate that such endorsement of patient requests is by no means automatic. To make DTC succeed, therefore, the prescriber has to remain a central figure in the marketing plan. Mr. Pizor concludes with five suggestions for doing so successfully.

As other articles about direct-to-consumer advertising in this issue make clear, DTC is here to stay, and now holds an important place in pharmaceutical marketing efforts. But as so often happens when something is new and popular, the enthusiasm for DTC may have led to an over-reaction, and it may well be time for a reassessment.

The point is this: no matter how effectively an ad communicates to consumers, let's remember that these are ads for prescription drugs. The Physician's Desk Reference carries 3,200 pages of six-point type describing all of the side effects, contraindications, and interactions which make these products different from all the other products that consumers might want to buy. No matter how effectively a DTC campaign persuades the consumer to choose your brand, there is no sale without the approval of a prescribing physician, nurse practitioner, or physician assistant.

Prescribers are the educated and informed intermediaries. They worked hard to obtain their medical degree and to maintain their accreditation. Their responsibility is to ensure that the right diagnosis is made and that the right prescription gets written. Since they stand between the consumer and your drug, it seems intuitive that DTC promotion of Rx-only drugs will work only when the prescriber is treated as a central figure in the marketing plan. Which raises the critical question: how do physicians feel about DTC?

The professionals' verdict
Surveys asking doctors' opinions about DTC show that some doctors feel better about it than others (see "What we've learned from 11 years of strategic studies" by Tom Marcinko, page 52). Urologists see benefit in campaigns for Hytrin, Cardura, and Proscar which have educated men about the symptoms of BPH (benign prostatic hypertrophy), encouraging a typically recalcitrant audience to come forward and seek treatment. Podiatrists also look with favor, because DTC campaigns have brought in thousands of people who can be successfully treated for toenail fungus.

Other physicians, however, are not as impressed. Sixty-one percent of doctors in an IMS/POL survey said they wished that DTC would decrease or go away entirely. But whether or not doctors like DTC, the critical question from the advertisers' point of view is whether it works. When Patient Care magazine surveyed primary care physicians on the subject of DTC advertising in December 1997, an average of 25 percent of respondents reported that they had received requests from their patients, with slightly higher responses from solo practitioners (29 percent) and from physicians with ten or more years in practice (27 percent). But will they prescribe what is requested? While 36 percent said it is "very likely" and 54 percent said they would consider the patient's request, that means that nearly two-thirds of doctors will require additional work on the advertiser's part to justify the appropriateness of the prescription and to persuade them to prescribe the brand (see "Cheers and concerns for DTC from a family physician" by Michael O. Fleming, M.D., p. 74, for a report on doctors' perceptions of DTC published in the Journal of Family Practice).

Why worry what doctors think?
Consumers may be persuaded by DTC promotion and even ask their physicians for the promoted brand, but keep in mind that according to the annual Gallup poll, doctors and pharmacists continue to rank as the most trusted professions, alongside clergy. (Advertising practitioners, incidentally, rank at the bottom, along with car salesmen!)

More importantly, the physician can thwart, with a single comment or stroke of the pen, all of the investment of a DTC campaign. One of the reasons doctors are upset with DTC promotion is that they have not always been included in the message. That IMS/POL survey cited previously, for example, showed that 73 percent of sales reps rarely mention a DTC campaign. Having been both a detail rep and a product manager, I know that it is hard to get the pharmaceutical sales force to deliver a uniform message, but journal advertising is under the control of product managers, and rarely if ever do I see it being used to assure that the message about DTC reaches the prescriber.

Lee Weinblatt, CEO of the PreTesting Company, said, "... the worst mistake we have observed is that some advertisers have taken money for DTC away from professional promotion, forgetting that the physician is still the gatekeeper." As such, the doctor has the choice whether or not to write a prescription, as well as to prescribe something other than the promoted product. What is the value in a consumer campaign that results in a prescription for a competitor's brand?

Physicians are apt to be less antagonistic about DTC advertising when they are included in the communications loop. Most of the negative feedback from physicians stems from lack of communication, along with their perception that DTC ads tend to over-promise, leaving it to the doctor to risk patient resentment by setting the record straight. The issue, then, is how best to communicate to physicians. Here are some key points to build a concomitant program to reach prescribers:

•	Primum non nocere. First, do no harm. That's the first-level lesson a student learns in medical school and it's good advice for today's product manager evaluating the role of DTC for his/her brand. Choose DTC as you would any tactical solution -- evaluate what it can do to benefit the brand. No campaign message or campaign medium is justified if it is going to undermine the brand's equity built over years of investment in professional promotion.
•	Demonstrate the value of your DTC campaign in terms professionals can appreciate. Show them how your campaign can help by bringing untreated patients in to see them, or motivating patients to continue with therapy.
•	Let professional messages complement consumer messages. The copy platform and graphics should work together for all those times the patient will not remember the brand name but might remember the art or headline.
•	Budget adequately to reach professionals. While only some advertisers have actually canceled physician advertising when embarking on a DTC campaign, many more have failed to adequately and consistently fund their medical advertising budget. The investment in developing and maintaining an effective professional campaign is only a fraction of a consumer campaign. Why cut corners?
•	Reach professional audiences with impact and efficiency. PERQ/HCI has long documented the power of print promotion in conjunction with detailing to deliver increased prescriptions, share, and ROI. Since DTC is the largest financial commitment a product manager can make for his or her brand, it only makes sense to depend on these proven media to reach the only people who can, at the moment of truth, actually write a prescription. As I began by saying, DTC is here to stay. As a medical publisher I have no quarrel with that -- in fact I welcome any strategy that can help our advertisers do a more effective job of promoting their products. I would add only this reminder: health professionals are, rightly, often referred to as gatekeepers. DTC promotion can lead the patient up to the gate. But only the prescriber can turn the key.

Reference: Pizor TC: A medical publisher reminds us: don't forget the gatekeepers. Medical Marketing & Media 1998;33(11):65-67.