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Changing Doctors’ Practice Dynamics With Covid-19 And Beyond

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Unexpectedly, the answer to an onerous question surfaced just around a year’s time. In my article on this blog, written on April 08, 2019, I raised a question – “Would ‘Connected Healthcare’ Catch Pharma Players Off-Guard?” Interestingly, an unexpected and abrupt turn of events in the global healthcare space, including India, triggered by Covid-19 pandemic, signals an early dawn of an evolving reality, related to ‘Connected Healthcare’, in India.

Never ever, I reckon, the Government realized so well that continuation with a fragile public healthcare infrastructure is self-defeating for the country. Allocation of financial resources, at least 2.5 percent of the country’s GDP, for its rejuvenation – powered by AI-based modern digital technology, would help avoid overburden on the healthcare system. This will mean, saving more lives and also a significant reduction of morbidity, especially in a situation, like Covid-19 pandemic. Good health can propel good economy, more effectively.

That’s why, ‘connected healthcare’ – by effectively linking requisite ingredients of all health-related information that medical professionals and the patients would need, appears to be the new reality. This process is being facilitated by rapid acceleration of usage of various digital platforms, by both healthcare consumers and providers. Thus, it is becoming increasing clear now that leveraging digital technology with innovative mindset and a fresh pair of eyes, will be the way forward, in India, as well. It seems very likely, when considered from two angles:

  • What several research data reveals about an increase in usage of digital platforms by healthcare consumers and providers, before and during Covid-19 pandemic. Especially because, this struggle appears to be for a long haul.
  • Most countries are currently struggling to navigate through highly contagious Covid-19 outbreak and simultaneously trying to chart a workable pathway for avoiding similar eventualities in the future.

In this article, I shall try to focus on Covid-19 induced changes in doctors’ practice dynamics – based on research studies, while revisiting the subject on ‘connected healthcare,’ and its relevance now – also in the years ahead.

Research studies capture a new and growing awareness: 

The recent findings from the “Digital Doctor 2020” survey, which is a ‘21-country study of Doctors’ perspectives on digital and connected health, highlight some interesting points. This study was conducted just before the global outbreak of Coronavirus. Some of its findings were also deliberated inan article published in the PharmExec.com on April 23, 2020. The paper is titled, ‘How Prepared Were Physicians for the COVID-19 Digital Upswing? Some of the key points, as reported, are worth noting:

  • Although, the awareness of drug prescribers of different digital technologies related to healthcare is high, how these technologies work in healthcare was unknown to many doctors at the time of the Digital Doctor 2020 survey. It came out that clear benefit statements, will be welcomed when there is such a steep learning curve.
  • Regardless of face-to-face interactions still remaining preferred choice before the pandemic, online channels are on the rise and accelerating with COVID-19 lockdown.
  • Benefits of using connected health devices for patient management and treatment are widely recognized and is believed to play a key role in the future. The respondents agree, even their patients are now more interested in their own health data, as they are gaining control over their weight, diet and physical activities.

Highlighting that their research data over the last few weeks showing increasing usage of digital solution to respond and adapt to the new realities of Covid-19 pandemic, the author of the article concluded: ‘For a long time, digital solutions have often been considered an option; now they have become a necessity.’ To understand the emerging scenario, let us now look at the preferred communication channels of the doctors – pre-Covid-19 outbreak. 

Preferred channels of doctors pre-Covid-19 outbreak:

According to the Ipsos survey of pre-Covid-19 outbreak, face-to-face communication with Medical Representatives (MR) used to be the most favored channel of the doctors, as follows:

Channel Med. Rep Speaker Program Conf. E-detail Journal Ads Med. Liaison E-mail Direct mail Pharma website
Pref. % 35.2 11.7 10.0 8.4 8.4 8.8 8.4 5.0 4.1

However, on April 14, 2020, Ipsos shared the results of their interim research conducted, together with M360, among doctors, conducted during Coronavirus outbreak. The preliminary findings indicate, Covid-19 will permanently alter physician practice dynamics. A clear shift in the engagement model with them – away from in-person detailing, throws several significant questions on the traditional physician engagement template of the pharma players.

It also signals another fundamental change in the physicians’ practice dynamics, as Covid-19 seems to have changed practicality of having face-to-face communication between the representatives and doctors, as before. This situation makes ‘connected healthcare’ a reality – as we move deeper into the everyday- evolving scenario.

Some unexpected and significant changes surfaced in a month: 

The above research also flagged, the following two important changes, among several others, triggered by the Coronavirus outbreak:

  • The mean number of sales representative visits dropped from 15.7 before the Coronavirus outbreak to 1.3 in just the following month, during the pandemic 
  • Overall preference and effectiveness of e-detailing also improved, significantly, where any non-personal communication and interaction with drug companies, either through sales representatives or by others, were considered as e-detailing. 

This brings me back to the question, how are doctors feeling about this never before shift in their practice dynamics?

How are doctors feeling about a never before shift in their practice dynamics?

The ongoing research on this critical area captures a new reality, where many doctors, especially those who are not directly engaged in combating the Covid-19 pandemic, are clearly feeling a shift in their practice dynamics. Curiously, the new feeling of a shift also includes, the way these doctors interact with different drug companies, mostly through their Medical Representatives.

These inklings of the doctors are expected to get translated into some fundamental changes in the real-life situation, as we all sail through the life-changing time caused by Covid-19. Especially, considering the requirements of a new normal – social distancing, wearing a mask always while on outdoor, and several other norms as prescribed from time to time.

‘Connected healthcare,’ is expected to take its place on the center stage:

In this situation, ‘connected healthcare,’ which used to be more discussed than practiced, is expected to take its place on the center stage. It is necessary in the present situation for remote consultations, primarily for chronic ailments – for effective disease management and treatment. More so, as in the current situation individual health awareness of a large population, even in India, is increasing with an accelerated speed, perhaps more than ever before.

Thus, this is the right time to focus on ‘connected healthcare’, powered by AI-based digital technology. It has immense potential to help the Indian population getting immediate medical attention at a lower cost, with an improved access, for all. Though these are early days, it appears the ball has started rolling in the right direction, as the recent draft guidelines of the Indian Council of Medical Research (ICMR) indicates: ‘Patient can WhatsApp, SMS or email consent for Covid-19 clinical trials.’

Conclusion:

Still today, there is no sign of even temporary flattening the disease progression curve in India. As on May 10, 2020 morning, the recorded Coronavirus cases continue to climb sharply to 62,939 with 2,109 deaths, which is rising in India faster than most other countries. On May 07, 2020, AIIMS director again warned that Covid-19 pandemic is yet to peak in the country. “According to modeling data and the way our cases are increasing, it is likely that peak can come in June and July,” he added.

But is it getting worse? Despite stringent lockdown, there has been a surge in cases, which can also be attributed to higher levels of testing. However, from a doubling rate of 11.5 days on May 3, it has shortened to 10.3 days, which means that cases are doubling in quicker time. Each set of 10,000 cases is now increasing at a more rapid pace than the preceding set, highlighted an editorial of a leading news daily.

With a vaccine still elusive, the government had been banking mostly on the lockdown to break the chain of transmission of the virus. Meanwhile, the World Health Organization (WHO) has said: ‘Deliberately infecting healthy people with Coronavirus may speed Covid vaccine studies,’ reflecting more uncertainties in this area. It is also not likely that the country will cease to have any problems with its fragile public healthcare infrastructure and delivery system, even after flattening the disease progression curve.

Along with many other Covid-19 induced life-impacting changes, doctors’ practice dynamics are also expected to undergo a metamorphosis, lasting for an indefinite period. Consequently, I reckon, it’s about time, even for the pharma industry to voluntarily adopt ‘connected healthcare’ as a future way of life. One can get a glimpse of it in the Covid-19 clinical trial draft guidelines of the ICMR. Nonetheless, ‘connected healthcare’ comes with a clear signal of reducing the cost of healthcare and improved patient access, having the potential to effectively mitigate a sizeable part of the precipitated healthcare crisis, caused by Coronavirus.

By: Tapan J. Ray   

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Multifaceted Coronavirus Narrative Raises Multiple Questions

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Last night, amid the national lockdown, many people followed Prime Minister Modi’s video message, broadcasted on April 03 at 9 am for all, ‘to challenge the darkness of Coronavirus together – with a Diya, candle, torch or flashlight, at 9 pm for 9 minutes, from their respective balconies.’ That was the 12th day of 21-day lockdown, when the deadly microbe – Covid19 infected, tested and detected cases climbed to 3,577 in the country, with the death toll rising to 83. This is against 564 - the total number of confirmed cases in India when the lockdown commenced on March 24, 2020.

With all this, a mind-boggling narrative is developing at an accelerating pace. It’s not just about the rogue microbe – rampaging the world hunting for its prey. But also pans over multiple dimensions of its fallout, impacting virtually everything, for all. People of all sections of the society are participating, deliberating or debating on this issue, as the invisible camera of destiny rolls on. Unprecedented!

That’s the real world where, despite fear of an unknown future, most people prefer freedom of expression while playing a constructive role in containing the menace, collectively. We are witnessing a similar scenario – the world over. But, more in the democratic nations. Relatively enlightened citizens will always want to participate in this emerging chronicle, shaping the overall narrative and help sharpening the nations Covid19 policy further – instead of being passive onlookers.

Meanwhile, the objective of maintaining physical distancing during 21-day national lockdown period and beyond must be achieved, regardless of any public discord on its mechanics. This has to happen, primarily because of the TINA factor. Likewise, it’s also a prerequisite that the lockdown is handled efficiently, with meticulous advance planning, deft and dignified handling of any situation, by all and for all. That said, the good news is, newer scientific, evidence-based data are revealing more actionable pathways, in this multifaceted narrative.

A multifaceted narrative raises multiple questions:

As I wrote above, Covid19 narrative is multifaceted and not just one dimensional. It’s true beyond doubt: ‘If there is life, there is the world.’ But, that has to be a life with dignity, a life that help protect families and facilitates contributing to the nation, in different ways – enabling a scope of fulfillment of all.

In this article, I shall, explore some important facets of the evolving narrative on the Covid19 outbreak to drive home this point. In that process some very valid questions, as raised by many, also deserve to be addressed. Some of these include:

  • Covid19 is a war like situation where no questions are asked about the strategic details of a warfare, why the same is not being followed today? In a war some collateral damages are inevitable, why so much of noises now?
  • Why has Covid19 created a general panic with stigma attached to it?  
  • Panic is avoidable, but is the threat real. If so, why?
  • Why people violating national lockdown by migrating from the job location to respective hometowns – increasing the risk of the disease spread, must be brought to their senses mostly through the harsh measures?
  • In the absence of any vaccine or an effective curative drug, why all decisions of policymakers must be blindly accepted by all, during national lockdown and maybe beyond, as if there is ‘not to reason why, but to do or die?’

Let me now explore each of these questions.

A war like situation?

No doubt Covid19 is a war like situation, but with some striking dissimilarities between a conventional war and this war. A conventional war is fought by a well-trained and well-armed defense forces with already developed a gamut, against a known and visible enemy nation.

Whereas, the war against Covid19 is against an invisible and unknown microbe’s sudden attack, being fought in India by a limited army of health care professionals and workers. They fight this war, mostly without adequate or no battle gear, like Personal Protective Equipment (PPE), testing kits and ventilators, supported by a fragile health care infrastructure.

Moreover, in the conventional warfare, the type of advance information and intelligence that the Governments usually possess against the enemy nations, can’t be matched by any private domain experts.

Whereas, Covid 19 still being a lesser known entity to medical scientists, as on date, the remedial measures are still evolving. Only scientific-evidence-based data can create actionable pathways for combat, spearheaded by the W.H.O. Thus, most people expect the nation to comply with, at least, the current W.H.O guidelines for health-safety of the population.

Further, in the cyberspace, several latest and highly credible research data are available for all. These are being well-covered by the global media as a part of the narrative. Thus, unlike conventional warfare, external experts may know as much, if not even more than the Government on Covid19.

Some avoidable show-stoppers:

There are several such avoidable show-stoppers. For example, when one reads news like, ‘Delhi Government Hospital Shut As Doctor Tests Positive For Coronavirus,’ or something like, ‘Indian doctors fight Coronavirus with raincoats, helmets amid lack of equipment,’ alongside a jaw-dropping one, ‘India Sends COVID-19 Protective Gear To Serbia Amid Huge Shortage At Home,’ chaos in the narrative takes place.

In the tough fight against Covid19 menace, these much avoidable fallout may be construed as show-stoppers, if not counterproductive. Many may advocate to pass a gag order against revelation of such difficult to understand developments, and keep those beyond any public discussion. Instead, why not order a transparent enquiry by independent experts to find facts – holding concerned people accountable?

Why has the disease created so much of panic with stigma attached to it?

This is intriguing because, according to the W.H.O – China Joint Mission report on COVID-19, around 80 percent of the 55924 patients with laboratory-confirmed COVID-19 in China, had mild-to-moderate disease. This includes both non- pneumonia and pneumonia cases. While 13·8 percent developed severe disease, and 6·1 percent developed to a critical stage requiring intensive care.

Moreover, The Lancet paper of March 30, 2020 also highlighted, in all laboratory confirmed and clinically diagnosed cases from mainland China estimated case fatality ratio was of 3·67 percent. However, after demographic adjustment and under-ascertainment, the best estimate of the case fatality ratio in China was found to be of 1·38 percent, with substantially higher ratios in older age groups – 0·32 percent in those aged below 60 years versus 6·4 percent in those aged 60 years or more, up to 13·4 percent in those aged 80 years or older. Estimates of the case fatality ratio from international cases stratified by age were consistent with those from China, the paper underscored.

Even the Health Minister of India has emphasized, ‘around 80-85 percent of cases are likely to be mild.’ He also acknowledged: “My biggest challenge is to ensure that affected people are treated with compassion, and not stigmatized. This is also applicable for the health care workforce, which is working hard to counter this epidemic. It is through concerted, community-owned efforts, supported by the policies put in place by the government that we can contain this disease.” This subject, surely, needs to be debated by all, and effectively resolved.

Panic is avoidable, but does a real threat exist with Covid19?

As The Lancet paper of March 30, 2020 cautions by saying - although the case fatality ratio for COVID-19 is lower than some of the crude estimates made so far, with its rapid geographical spread observed to date, ‘COVID-19 represents a major global health threat in the coming weeks and months. Our estimate of the proportion of infected individuals requiring hospitalization, when combined with likely infection attack rates (around 50–80 percent), show that even the most advanced healthcare systems are likely to be overwhelmed. These estimates are therefore crucial to enable countries around the world to best prepare as the global pandemic continues to unfold.’ This facet of Covid19 also requires to be a part of the evolving narrative to mitigate the threat, collectively, with a robust and well thought out Plan A, Plan B, Plan C….

Violation of lockdown increases the risk manifold, but… 

There isn’t a shade of doubt even on this count, in any responsible citizen. Besides individual violation, recently a huge exodus of migrant laborer’s ignoring the lockdown raised the level of risk for others. This exodus should have been stopped at the very start, by better planning and with empathy and dignity by the law enforcing authorities, as many believe. Curiously, even the current Chief Justice of India (CJI) commented, on March 30, 2020: “The fear and the panic over the Coronavirus pandemic is bigger that the virus itself,” during a hearing on the exodus of migrant laborers from workplace to their respective hometowns, due to Covid19 lockdown.

To mitigate the risk, the CJI advised the Government to ensure calming down ‘the fear of migrants about their future, after being abruptly left without jobs or homes because of the 21-day lockdown to prevent the spread of Coronavirus.’ The Court felt, ‘the panic will destroy more lives than the virus.’ Thus, the Government should “ensure trained counsellors and community leaders of all faiths visit relief camps and prevent panic.”

The CJI also directed the Government to take care of food, shelter, nourishment and medical aid of the migrants who have been stopped. This appears to be the desirable pathway of preventing the migrant exodus, causing greater risk to people, requiring better planning, deft situation management with empathy and dignity, by the law enforcing authorities. However, individual violations, if any, can be addressed by intimately involving the civil society, against any possibility of the disease spread.

Whatever decision the policy makers take, must be blindly accepted by all:

In this area, all must first follow what the Government expects us to do. Maintaining strict compliance with such requirements. But, some people do ask, is it in total conformance with the steps W.H.O recommends following? At the March 30, 2020 issue of the Financial Times reported, the W.H.O’s health emergency program has outlined four factors that might contribute to the differing mortality rates in Covid19 outbreak:

  • Who becomes infected?
  • What stage the epidemic has reached in a country?
  • How much testing a country is doing?
  • How well different health care systems are coping?

Many members of the civil society are also keen to know these facts, and may want to seek clarification, if a gap exists anywhere. After all, Covid19 outbreak has brought to the fore, an unprecedented future uncertainty of unknown duration, involving not just life, but a sustainable livelihood and a dignified living in the future, for a very large global population, including India.

Conclusion:

There seems to be a dose of chaos in an otherwise reasonably controlled scenario. One option of looking at it as a pure law and order issue, which needs to be brought to order only with a heavy hand. The second option is to accept it as a golden opportunity to take all on board, by clearly explaining what people want to know – with reasons, patience, persuasion, empathy and compassion, as is happening in many countries.  Of course, without compromising on the urgency of the situation. This is a challenging task, but a sustainable one. Overcoming it successfully, will possibly be the acid test of true leadership, at all levels. However, the slowly unfolding narrative on the ground, doesn’t appear to be quite in sync with the second option.

In the largest democracy of the world, people want to get involved in a meaningful discussion on Covid19 crisis, collectively – based on evidence-based scientific data. Then, it’s up to the policy makers to decide what is right for the country and in which way to go. In tandem, fast evolving, multifaceted Coronavirus narrative, I reckon, will keep raising multiple questions.

As the disease spreads, the pathways of combating it decisively, is being charted by different experts, led by the World Health Organization (WHO). This is being widely covered by the mainstream global media, even in the din of a cacophony. Nonetheless, it is generally believed that a true relief will come, only after a vaccine is developed and made available and accessible to all sections of the world. Till such time a ‘hide and seek’ game, as it were, is expected to continue.

By: Tapan J. Ray  

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

 

Cacophony Over Coronavirus Lockdown

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Currently, the entire India is trying hard to comply with the 21-day lockdown of the country, as communicated by Prime Minister Narendra Modi to the nation at 8 pm on March 24, 2020. The very next day,  while addressing his parliamentary constituency of Varanasi via video, he said, “the Mahabharata war was won in 18 days but this war against Coronavirus will take 21 days.”

After this announcement most people’s life, as I myself can feel it, has changed as never before in the past. Unlike the West, in India most of us are too much dependent on domestic help, for routine chores of the family. How difficult these are, at least, I never experienced in the past. Will life, in its entirety, ever be the same gain?

In addition, shortages of most of the essential items were felt everywhere, be these vegetables, grocery items or medicines. Leave aside, the non-essential necessities. But, the bottom-line is, the lockdown has to be followed. There isn’t any other effective alternative to protect ourselves, those working for us to make our lives easier and comfortable, our respective neighborhood and thereby our country. In its midst, a cacophony over this decision is palpable, whatever may be the reason. Many are from highly credible sources.

Exploring various facets of the cacophony, this article will dwell on the question that will arise at the moment of truth – on or after April 15, 2020: What happened after 21-day lockdown of the entire nation. I shall try to focus on this question with the most relevant facts.

The Government’s rationale behind 3 weeks lockdown:

As explained by the Prime Minister and later by several Indian experts, the rationale behind the 21-day lockdown will include primarily the following:

  • The incubation period of Covid19 is around 5 to 14 days. This is also the potential transmission period of the microbe. Effective social distancing of all, may contain or even stop its spread.
  • As all viruses can sustain or exist only by replicating, they are completely dependent on a host cell for survival and can’t reproduce outside a cell. Social distancing may help in this area, as well.
  • Since, the world doesn’t have any vaccine for Covid19, as yet, prevention alternatives are limited.

Cacophony includes: Is complete national lockdown the only answer?

Several highly credible voices are asking: Is the complete lockdown of the nation the only answer? For example, Professor Vikram Patel at Harvard Medical School, wondered about the relevance of national lockdown in his article of March 26, 2020. He wrote, without any widespread community transmission of the disease, the Government might have staved off the worst without a sledge-hammer approach of national lockdown, which no country at India’s stage of the epidemic has imposed.

Elaborating the alternative approach, he suggested to intensify case finding approach through testing and contact tracing, quarantining those who are infected, physical distancing by everyone, graded travel restrictions, preparing the health system to cater to those who may need intensive care and protect health care workers. Even locking-down limited populations with community transmission will be prudent. When properly implemented these steps ‘could have stopped the epidemic in its tracks.’ Citing examples, he wrote, many of our Asian neighbors have done it successfully. Even China, the original epicenter of the epidemic, did not lock down the entire country.

According to other reports, as well, the countries, such as, Singapore, Germany, Turkey, Taiwan and China, have so far handled Covid19 much better than other countries in containing the pandemic. They all ‘refrained from imposing a complete, nationwide curfew-like lockdown.’ China did bring only the Hubei province under complete lockdown, but not the whole country. Scientists expect that Covid19 will exist despite lockdown – till an effective vaccine is developed and made available for all.

Are our doctors adequately protected against Covid19?

Today, even the doctors and other health care workers remain extremely vulnerable to the disease.  Even in AIIMS doctors, reportedly, are using masks and sanitizers made by themselves or buying them. There is already a shortage of Personal Protective Equipment (PPE), which doctors are worried about. PPE includes face masks, eye shield, shoe cover, gown and gloves. These can be used for only five or six hours before having to discard them. Even N-95 face masks cannot be used for more than a day or two. And there is an elaborate protocol in place, as well, on how to dispose them. As the report said, doctors fighting Covid19 asked: ‘Not just claps, give us personal protective gear.’

Further, the Huffpost article of March 20, 2020 had emphasized with details: “Staying home can be hard, but it’s not even an option for the health care workers and scientists on the front lines of our global effort to thwart the COVID-19 pandemic. They have to arm themselves to face potentially infected patients and deadly viruses every day.” This gets vindicated by a March 26, 2020 report. It brought to our notice that 900 people have been quarantined after a Delhi Doctor unprotected by PPE tests COVID19 positive.

Another news article reported: “A day after the entire nation flocked to their balconies to clap for the heroes in the medical field, who are working relentlessly to arrest the Coronavirus pandemic, doctors in Telangana and Andhra Pradesh were greeted with humiliation and assault.”

Cacophony expands to religious solutions and explanations:

With the panic on Coronavirus spreading, the cacophony also includes religious solutions to the disease. For example, as reported by Reuters on March 14, 2020, ‘Hindu group offers cow urine in a bid to ward off Coronavirus.’ Another YouTube video also shows: ‘Hindu activists in India drink cow urine to ‘protect’ themselves from Coronavirus.’ According to many there are many takers of such concepts, whether one likes it or not.

Intriguingly, a top film star with 40.7 million twitter followers twitted on March 22, justifying public clapping at 5 pm during ‘Janata curfew’ and attributing a bizarre reason to it: ‘clapping vibrations destroy virus potency,’ which he later deleted against strong adverse comment from the scientific community. However, a number of, apparently responsible people, a few of whom are also known to me, often comment – such things can happen and do happen in a vast country like India. It isn’t a big deal. The cacophony goes on.

Be that as it may, regardless of enthusiastic public clapping and availability of cow-urine based solutions – fighting deadly Covid19 of potentially infected patients – without PPE, I reckon, is quite akin to asking a professional army to fight a tough battle without having adequate battle-gear.

Level of India’s preparedness just before national lockdown:

To ascertain this, leaving aside other critical areas, such as, quarantine and isolation facilities, let me cite a few examples related to PPE and testing kits. A news that came just a day before the national lockdown, reported a Government official commenting on a textile material used for masks and other PPEs: “Currently, demand is for 8 lakh bodysuits and N95 masks of the material. Orders for these have been placed.”

However, the Directorate General of Foreign Trade (DGFT), reportedly, banned the export of textile material for masks and coveralls, under the Foreign Trade (Development) and Regulation Act, just recently. Interestingly, as Reuters reported on March 28, 2020, ‘India needs at least 38 million masks and 6.2 million pieces of personal protective equipment as it confronts the spread of Coronavirus.”

Further, when testing is the only acid test to diagnose Covide19 infection – as on March 19, 2020, India, reportedly, had tested 14,175 people in 72 state-run labs, which is regarded as one of the lowest testing rates in the world. This is because: India has limited testing facilities. Thus, only those people who have been in touch with an infected person or those who have travelled to high-risk countries, or health workers managing patients with severe respiratory disease and developing Covid-19 symptoms are eligible for testing. Whereas, according to W.H.O, “All countries should be able to test all suspected cases, they cannot fight this pandemic blindfolded”.

However, after declaration of the national lockdown, the Indian Council of Medical Research (ICMR) on March 25, 2020, reportedly, invited quotations from manufacturers for supply of 1 million kits to test patients suspected of suffering from COVID-19. After getting a glimpse of the cacophony over the national lockdown for Coronavirus supported by a few examples, let us see what steps the W.H.O advises for all countries to follow in this pandemic. 

The steps W.H.O recommends following:

On March 16, 2020, the Director General (DG) of the World Health Organization (W.H.O) said: “We have a simple message to all countries – test, test, test.” On that day, observing that more cases and deaths have been reported in the rest of the world than in China, as compared to the past week, the DG elaborated the following:

  • Although, there has been a rapid escalation in social distancing measures, like closing schools and cancelling sporting events and other gatherings, but, not an urgent enough escalation in testing, isolation and contact tracing – which is the backbone of the response.
  • Social distancing measures can help reduce transmission and enable health systems to cope with. Handwashing and coughing into your elbow can also reduce the risk for yourself and others. But on their own, they are not enough to extinguish this pandemic. It’s the combination that makes the difference. Thus, all countries must take a comprehensive approach.
  • The most effective way to prevent infections and save lives is breaking the chains of transmission. And to do that, you must test and isolate. You cannot fight a fire blindfolded. And we cannot stop this pandemic if we don’t know who is infected. We have a simple message for all countries: test, test, test. Test every suspected case.
  • If they test positive, isolate them and find out who they have been in close contact with up to 2 days before they developed symptoms, and test those people too. Every day, more tests are being produced to meet the global demand.

Curiously, even three months after the massive outbreak of the Coronavirus epidemic in China, India doesn’t seem to have procured enough PPEs for the doctors and testing kits to diagnose the disease. Besides, lack of advance preparation to create adequate quarantine and isolation facilities in the country make the situation even more complex to effectively deal with.

Other challenges and frugal options:

With eight doctors per 10,000 people in India, compared to 41 in Italy and 71 in Korea and one state-run hospital for more than 55,000 people, the general population has developed a much avoidable habit, over a period of time. It is quite likely, even in the event of getting flu-like symptoms, the majority may not go to doctors. Instead, may try home remedies or go to a retail chemist for drugs. Some may even resort to self-medication, until a full-blown disease surfaces, complicating the situation further.

Hence, only two options are left. One – for each individual to take care of personal hygiene and physical distancing, and second – for the Government to announce a national lockdown, through its second sudden and late evening order, effective midnight of the same day. This took almost everybody by surprise and possibly creating a widespread panic – not so much about the disease – at least initially, but more for regular availability of essential daily necessities – food and for many people – medicines, besides means for daily living of scores of families. This was further fueled by the gross lack of empathy by the law enforcers.

Conclusion:

As reported, if Covid19 continues to spread at its current pace, India could face between around 100,000 and 1.3 million confirmed cases of the disease caused by the new Coronavirus by mid-May, according to a team of scientists based mainly in the United States. It’s important to note that with just 6.8 tests per million, one of the lowest rates in the world, India has been criticized for not testing enough.

Moreover, besides panic and economic fallout of the disease, the long-term impact that Covid19 may have on the mental health of different people, for various reasons, will also need to be ascertained. As Professor Vikram Patel of Harvard Medical School said in his above article, ‘the deliverable is not how many people clanged pots and pans’ or how many obediently followed the Prime Minister’s advice of staying indoors. “The deliverable is how many people got tested, how many doctors have protective gear, how many ventilators the government managed to manufacture or buy overnight.” Another deliverable is isolation centers, temporary hospitals in indoor stadia and quarantine facilities that are fit for human beings, he added.

On November 24, 2020 – when 21-day national lockdown commenced, the total number of confirmed cases in the country were reported as 564. Just at the beginning of the 5th day of the lockdown on March 29, 2020, as I write this piece, as many as 1032 people have been tested positive for Covid19 with 28 deaths. Against the above backdrop, some critical points that surfaced while exploring the cacophony over the national lockdown, can possibly be wished away only at one’s own peril.

Nevertheless, under the prevailing circumstances, there was no other alternative for the Government, but to announce immediate national lockdown, which all should abide by, religiously. However, whether Coronavirus will be won in India with 21-day of national lockdown – just three days more of what the Mahabharata war took, as the Prime Minister expects, will start revealing from April 15, 20120 – as the moment of truth arrives.

By: Tapan J. Ray  

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

 

Pharma ‘Chatbots’: For Better Stakeholder Engagement

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The critical value of meaningful interaction and engagement with individual customers – responding to their specific needs, is fast drawing attention of many businesses, for sustainable performance excellence. The same is happening in the pharma industry, as well. Creative use of this process leveraging modern technological support systems, would also provide a unique scope of cutting-edge brand service differentiation, in well researched areas.

That, it is a very important focus area for the pharma players, is no-brainer. Nonetheless, what really matters most is the novelty in strategizing such interactions and engagements, especially with patients and doctors. I also wrote about it in my article, titled ‘Indian Pharma To Stay Ahead of Technology Curve,’ published in this blog on May 22, 2017. Over two years ago, I clearly indicated there that application of AI via digital tools, called ‘Chatbots’ – the shorter form of ‘Chat Robot’, is one of the ways that pharma may wish to explore this area.

Illustrating this point in that article, I mentioned that on March 05, 2017, a leading bank in India announced the launch of an AI-driven Chatbot named Eva, coined from the words Electronic Virtual Assistant (EVA), to add more value to their services for greater customer satisfaction. ‘According to reports, Eva is India’s first AI driven banking Chatbot that can answer millions of customer queries on its own, across multiple channels, immediately.’

In this article, I shall dwell on this interesting area, with a primary focus on pharma sales and marketing, and assess the progress made in this space, thus far, by several drug companies, including some Indian players. Let me start by recapitulating the basic function and purpose of ‘Chatbots’ in pharma.

Pharma ‘Chatbots’ – the function and purpose:

Simply speaking, pharma ‘Chatbots’ are also AI-powered, fully automated virtual assistants. Its basic function is to mimic one-to-one human conversation on particular areas, as desired by the user. Likewise, its basic purpose is to genuinely help and assist the customers who are in search of right answers to specific disease related questions, in a one-to-one conversational format, having a higher source-credibility.

In that process, ‘Chatbots’ can effectively satisfy the patients and doctors by providing them the required information, immediately. In tandem, pharma companies also reap a rich harvest, by developing not just a trust-based healthy relationship with them, but also in building a robust corporate brand – creating a long-term goodwill that competition would possibly envy.  

Effective customer satisfaction is an area that can’t be ignored:

In the digital age, a new type of general need is all pervasive, with its demand shooting north. This is the need to satisfy a voracious appetite among a large section of the population for all types of information, with effortless and prompt availability of the required details – as and when these come to one’s mind.

When such information need relates to health concern of a person, such as – available treatment options against affordability, or drug price comparisons – factoring in effectiveness, safety concern – exactly the same thing happens. Most individuals won’t have patience even to write an email and wait for an answer, even the wait is just for a short while.

In the current scenario, it will be interesting to fathom, how would a pharma company, generally, interact or engage with such patients, to further business and creating a possible long-time customer? Some companies have started responding to this need – effectively and efficiently, by providing easy access to information through ‘Chatbots’, created on advances AI platforms. But, such players are a few in number.

Can pharma also think of ‘Chatbots’, like ‘Siri’ or ‘Alexa’?

Today, several people are using standalone and branded Chatbot devices in everyday life, such as, Siri (Apple), Alexa (Amazon), Cortana (Microsoft) or Google Now (Android). Interestingly, many industries, including a few companies in pharma, have also started developing their own version of ‘Chatbot dialog application systems.’

Industry specific ‘Chatbots’ are designed to meet with some specific purpose of human communication, including a variety of customer interaction, information acquisition and engagement – by providing a range of customized services to the target group.’ ‘Siri’ or ‘Alexa’ or the likes, on the other hand, are all-purpose general Chatbots, though, for everyday use of individuals. Thus, the question that comes up, in which areas pharma companies can use Chatbots to add value to their interactions and engagements with patients, in general, and also doctors.

Where to use ‘Chatbots’ as a new pharma marketing channel?

Some of the findings on the application of ‘Chatbots’, especially in pharma sales and marketing, featured in the CMI Media publication in December, 2016. It found that drug companies have a unique scope to leverage this new sales and marketing – channel, by developing ‘Chatbots’ in the company represented therapy areas. Following are just a few most simple illustrations of possible types ‘Chatbots’ for interaction and engagement with patients, which can be designed in interesting ways:

  • That can answer all types of patient questions on specific diseases, educate them about the disease and available treatment options with details.
  • That allows patients or physicians to get all relevant information about the prescription drugs that they require to prescribe for patients to start treatment, including potential side effects, adverse events, tolerability, dosing, efficacy and costs, besides others.
  • Once a treatment option is chosen, a third kind of Chatbot can help with patient adherence to treatment, provide reminders when the treatment should be administered, explain how to properly dose and administer the treatment, and other relevant information.

Chatbots could also be useful for doctors and nurses:

As the above paper finds, ‘Chatbots have value for serving healthcare professionals as well, for example:

  • When, physicians and nurses want to understand the pathogenesis, pathophysiology, and/or progression of a specific disease in their patients.
  • Although, such content may also be available on disease state awareness sites, but branded Chatbots would make that content readily available in more of an FAQ format.
  • When health care professionals would like to get data around safety/toxicity, or information about dosing strengths, calculations, and titrations, while using specific brands.

Chatbots can also be effectively utilized by the drug manufacturer to gain deep insights into customer behavior across all touchpoints, to enhance end-to-end customer experience, as I wrote in this blog on July 02, 2018. The data created through this process, can also be put to strategic use to design unique brand offerings.

Need to chart this frontier with caution:

Pharma, being a highly regulated industry in every country of the world, with a varying degree, though, the ‘Chatbot’ development process should strictly conform to all ‘Dos’ and ‘Don’ts’, as prescribed by the regulators of each country. Each and every content of the ‘Chatbot’ should pass through intense, not just regulatory, but also legal and medical scrutiny. Yet another, critical redline that ‘Chatbots’ should never cross is the ‘privacy’ of any individual involved in the process.

Three critical areas to consider for pharma ‘Chatbots’:

Effective pharma ‘Chatbots’ are expected to get ticks on all three of the following critical boxes:

  • Meeting clearly defined unmet needs of patients in search of a health care solution or most suitable disease treatment options.
  • Brand value offerings should match or be very close to the targeted patients’ and doctors’ expectations.
  • Should facilitate achieving company’s business objectives in a quantifiable manner, directly or indirectly, as was planned in advance.

Pharma has made some progress in this area, even in India:

To facilitate more meaningful and deeper engagements with patients, some drug companies, including, in India, are using ‘Chatbots.’ Here, I shall give just three examples to drive home the point – two from outside India and one from India.

October 23, 2018 issue of the pharma letter reported, a study from DRG Digital Manhattan Research found, ‘Novo Nordisk and Sanofi brands rank best for the digital type 2 diabetes patient experience.’ The article wrote, about some pharma players ‘facilitating deeper engagement through the use of automated tools like Chatbots to triage inquiries and get patients the answers they need faster, and through interactive content like quizzes and questionnaires that pull patients in and help them navigate health decisions,’ as follows:

  • Novo Nordisk‘s diabetes website includes an automated Chat feature dubbed “Ask Sophia,” helping patients access disease and condition management information more quickly.
  • Likewise, Merck & Co‘s website for Januvia employs interactive quizzes to educate patients and caregivers.

Similarly, on November 23, 2018, a leading Indian business daily came with a headline, ‘Lupin launches first Chatbot for patients to know about their ailments.’ It further elaborated, the Chatbot named ‘ANYA’, is designed to provide medically verified information for health-related queries. The disease awareness bot aims to answer patient queries related to ailments,’ the report highlighted.

Chatbots – global market outlook:

According to the report, titled ‘Healthcare Chatbots – Global Market Outlook (2017-2026),’the Global Healthcare Chat bots market accounted for USD 97.46 million in 2017 and is expected to reach USD 618.54 million by 2026 growing at a CAGR of 22.8 percent.

The increasing demand for Chatbot ‘virtual health assistance’, is fueled primarily by the following two key growth drivers, the report added:

  • Increasing penetration of high-speed Internet.
  • Rising adoption of smart devices.

Conclusion:

With the steep increase of the usage of the Internet and smart phones, general demand to have greater access to customized information is also showing a sharp ascending trend, over a period of time. A general expectation of individuals is to get such information immediately and in a user-friendly way.

Encouraged by this trend, and after a reasonably thorough information gathering process, mainly from the cyberspace, many patients now want to more actively participate in their treatment decision making process with the doctors. This new development has a great relevance to drug companies, besides other health service providers. They get an opportunity to proactively interact and engage with patients in various innovative ways, responding to individual health needs and requirements, thereby boosting the sales revenue of the corporation.

The unique AI-driven technological platform of pharma ‘Chatbots’, is emerging as cutting-edge tools for more productive stakeholder engagement – so important for achieving business excellence in the digital world. The recent growth trajectory of ‘Chatbots’ in the health care space, vindicates this point.

By: Tapan J. Ray   

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Is Pharma Communication In Sync With Doctors’ Expectations?

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Not many pharma companies, especially in India, undertake any ongoing data-based analysis to gain insight on expectations and change in behavioral pattern of their customers, particularly doctors and patients. Many developments are taken as obvious, such as, when busy practitioners don’t want to give much time to a medical rep for brand detailing, if not any time, common spontaneous inference remains – ‘they are too busy.’ These responses are mostly without any data backup. Thus, meaningful efforts in finding ‘productive alternatives’ continue to remain elusive.

As making personal calls to some top medical practitioners becoming increasingly difficult, non-personal outreach for them tend to significantly go up. It often happens without any quantifiable assessment of how each of these targeted doctors is responding to even the non-personal outreach of the company.

That this is happening, was captured in a world-wide survey by ZS Associates in 2016. It highlighted: ‘The number of digital and non-personal contacts that the pharmaceutical industry now has with physicians exceeded its number of sales rep visits to doctor offices.’ It is worth repeating, this finding comes from a global survey.

Lack of insight in this area, could give rise to an avoidable disconnect between many pharma company’s core communication strategy, and what individual doctors would like to hear from them and in what way. Unless this issue is addressed sooner, it could be a strong invisible barrier to brands’ success, if not the image, too. Thus, in this article, I shall explore its implication, the key factors driving this trend, and most importantly, how to bridge this gap. Let me start with the well-established trend of increasing volume of non-personal contacts and hasten to add, by ‘non-personal’ I mean situations where a person is not physically present.

Increasing volume of non- personal outreach:  

In these days, personal interaction of medical reps with doctors, despite being traditionally important, is just one of the many channels for delivering requisite content to them. With increasing difficulty in getting top prescribers’ time, for effective brand detailing, many more non-personal channels are fast opening up.

Today, even in the Indian context, more than half of the total outreach volume of many drug companies, especially to such prescribers, are taking place through non-personal promotions. These include activities, such as:

  • Both, general and personalized e-mails
  • Mobile alerts to achieve various different objectives
  • E-detailing
  • Continuing Medical Education (CME)
  • Speaker program with associated arrangements and fees
  • Sponsoring medical events, seminars, symposia
  • Advertising in medical journals

Whereas, a little less than 50 percent of the total outreach by volume, still take place through in-person interactions with medical reps for brand detailing, as studies indicate. Interestingly, for known products, such contacts are often no more than just brand reminders.

The productivity of such calls needs to be measured and quantified, just as what is required for various non-personal channels, including digital – the contact volume of which is fast increasing for several companies. Curiously, despite this prevailing scenario and in some cases, a declining performance trend notwithstanding, higher promotional budgets continue to be available, based on hope and supported by optimistic forecasts.

The key reason attributed to this trend:

The article titled ‘What healthcare professionals want from pharma’, published in Pharma IQ on April 23, 2019 wrote about a key research finding on this subject. It emphasized, ‘only 46 percent of physicians worldwide are “accessible”- defined as meeting with a pharma sales rep in 70 percent of requests in the past year – a figure that has declined from 78 percent in 2008.’

On the same issue, the survey brought out two other important points:

  • 38 percent of physicians restricted MR access, and
  • 18 percent of physicians “severely’’ restricted MR access

The question that follows is, how much doctors’ time is taken by non-personal communication?

Doctors’ time taken by non-personal communication:

The above article also found: ‘These doctors estimate they receive more than 2,800 contacts from pharma reps each year via digital and non-personal marketing channel – contacts that consume an estimated 84 hours per year, or two full work weeks of their time.’ This level of “white noise” makes it imperative to rethink strategies for reaching prescribers, the article added.

What do doctors do with non-personal communication?

In this situation, understanding when doctors open doors to MRs, read promotional emails, commit to speaker events, and engage with other sales and marketing channels could be the difference between gaining market share by delivering a strong customer experience and failing to keep pace with a competitor. This was one of the key findings of ZS Associate’s 2017 Access Monitor study.

Thus, gaining insight on individual customer behavior for personalized customer engagement, would help create a cutting-edge competitive advantage for pharma players. With this acuity, astute pharma marketers would require prioritizing their focus on communication channels and platforms – alongside resource allocation for each.

Current resource allocation:

As reported in the above survey by ZS Associates, while marketing executives and doctors notice the increase in non-personal communications, pharma players, in general continue to allocate around 88 percent of their total sales and marketing budget to the sales force. This is despite non-personal communications – including digital, now comprising 53 percent of the total marketing outreach, as captured in this worldwide survey.

The survey findings do raise a point of caution as it says: ‘If pharma companies continue to increase investment in less expensive digital communications without considering customer preferences, physicians may feel overwhelmed and eventually ignore them.’ Thus, it will be important for drug companies understand doctors’ expectations in this area.

Pharma – doctor communication: Expectations and gaps: 

On the doctors’ front, there are two important developments that pharma marketers should take note of:

  • Core expectation of doctors is much clearer now:  As one of the above studies clearly indicate, the core expectation of all practicing doctors, from both personal and non-personal contacts with the drug companies, is to get the ‘news that they can use’, in their respective medical practices.
  • Availability of multiple expert sources/channels to fetch relevant medical information: The reality today is, medical representatives are no longer the only credible source for many busy practitioners to get useful medical information, not just for the molecule, but also for specific brands. ‘And with more choices, physicians increasingly prefer to learn about products on their own terms,’ as the above worldwide survey points out.

Hence, there exists a gap between how and what type of content busy practitioners expect from pharma companies and how and what the drug companies actually deliver to them. There isn’t an iota of doubt that this gap has to be bridged for making sales and marketing efforts more productive.

It demandsa deep insight into the way doctors gather medical information – based on real-time data analysis. This is critical, considering the role it plays for success in generating increased brand prescription support.

Acquiring insight into the way doctors gather medical information:

There are four key elements, I reckon, to acquiring insight into the way doctors gather medical information:

  • What each high-value medical practitioner considers as ‘the news that he/she can use’ in their practice, which would also help a company to generate increasing brand prescription support? Its answer should be the key driver for targeted content development.
  • How a doctor would prefer to receive it – as a personal or non-personal communication?
  • What would be each such doctor’s most preferred channel or platform to receive this message?
  • How to create an effective and measurable synergy between personal and non-personal communication for each important prescriber?

As too-much, too-frequent and too-many types of communication may often be counterproductive, delivering the right content, on the right platform, through the right channel for each top prescribers, would likely to pave the way for success in this effort.

Real-time monitoring to increase the strike rate is important:

This is relevant for both personal and non-personal communication and would include several areas, such as, after getting appointment of a top specialist, with great difficulty, what results follow after the interview concludes. Or after sending important and even personalized emails, how to monitor whether doctors are opening those, reading and acting upon, as intended.

This is no rocket science. There are ample mechanisms to make it happen. However, it is important to decide first, which of these means would suit a particular company the most, for effective implementation. That said, leveraging modern technology and constantly updating it, is the only way forward, for sure. While the task is difficult, but is certainly achievable – with the optimal mix of right resources and perseverance.

Conclusion:

When the expectation is, to build a strong pharma brand with a long-term success record, the only tool is effective communication of brand-value to target customers – in the right way, leading to tangible value creation for all. The source of communication being respective drug companies, one can be sure that it will be relayed to targeted receivers, such as doctors, patients and other stakeholders. However, none can be too sure whether the receiver will be willing to receive it the way it was planned by the source – and through the same channels.

Like many other industries, pharma customers are also becoming more selective in receiving, accepting and acting on medical communications, according to individual expectations and preferences. Several research studies have confirmed this emerging trend. Simultaneously, it is also getting revealed that most communication of a large number of drug companies are not quite in sync with doctors’ expectations. As a result, return per dollar/rupee spent on such communication is fast declining.

Thus, it’s time for a significant course correction – with a sense of urgency, as discussed above. No doubt, all pharma players have a strategy in place to make their brand communication effective. Nevertheless, what they should also focus on, is to align their communication with doctors’ expectations.

It is, therefore, imperative that pharma communication is made in sync with doctors’ expectations – not based on a couple of interviews with them, as it were, but by analyzing a massive pool of credible data, leveraging modern technology. Otherwise, high value prescribers may keep considering reps visit as ‘noise’ and remain indifferent to such outreach.

By: Tapan J. Ray     

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Are Cancer Patients Victims of Pharma’s Payment to Doctors – For Prescriptions?

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In pharma industry, people of all socioeconomic backgrounds have no other choice but to visit doctors, to seek their expert advice for medical treatment. Patients expect them to prescribe the right and most affordable medicines for desired relief. Ironically, it appears to be the general industry practice to favorably influence the prescribing decision of doctors of all kinds of drugs, irrespective of any tangible product superiority, and price. This practice has been a decade old general concern of many that still continues unabated, especially in India.

There is nothing wrong, though, in pharma companies’ influencing doctors with unique product and associated service offerings over others, intended to benefit patients. However, when any marketing activity goes against the general patient interest, or may be construed independently as short-changing patients, must not be condoned, the least by any government.

This article will discuss how this menace is not sparing even those cancer patients who can’t afford expensive drugs but want to survive. I shall start with an overall perspective and sign off with the prevailing situation in India.

Are such practices transparent?

Obviously not, as these take place under several benign names and guise, and is an open secret to almost all stakeholders, including many patients. In several countries, India excluded, the government or the legal systems have intervened to make the drug marketing process more transparent, often with strong punitive measures. Curiously, adequate space is constantly being created by some players to hoodwink all these.

Today, one can, at best put two and two together to get a feel of what could possibly be the reality. It still remains a challenge to exactly quantify as to what extent it is going on, and with what impact on common patients, who mostly pay out of pocket to purchase medicines. But the good news is, studies on this particular subject has commenced, a few examples of which I shall in this article.

Some common influencing tools:

Pharma companies’ influencing tools for favorable doctors’ prescriptions are, apparently, directly proportional to a doctor’s prescription generating capacity. Once a doctor is influenced by such mechanism, high product price becomes irrelevant, even for those who find the drug difficult to afford.

The form of influence varies from gifts carrying different price tags, advertising in specific souvenirs or journals, sponsoring medical symposia of doctors’ choice, to arranging company’s own ‘Continuing Medical Education (CME)’ programs in exotic places, with travel, boarding and lodging expenses paid by the company, sometimes including their spouses. Hefty speaking, consulting fees and research grants may also be among these influencing tools. All are commonly done through a third party to avoid easy detection.

Some evidences of drug companies’ payment to doctors:

May 02, 2017 edition of the Journal of American Medical Association, published a couple of survey findings that can be summarized, as follows:

  • About half of U.S. doctors received payments from the pharmaceutical and medical device industries in 2015, amounting to USD 2.4 billion
  • Such payments and gifts very likely encourage doctors to prescribe pricey brand-name drugs and devices pushed by sales representatives.
  • Chances of receiving a general payment depended on the doctor’s specialty — 61 percent of surgeons got a payment, compared with 48 percent of primary care doctors.
  • Pharma companies earned more than USD 60 billion in 2010 for brand-name drugs included in the study. Generic drugs are 80 to 85 percent less expensive, which means hospitals can save lots of money, if doctors start prescribing generics instead of brand-name drugs.
  • Doctors at academic medical centers were more likely to prescribe cheaper generic drugs than expensive brand-name drugs after their hospitals adopted rules that restricted pharmaceutical sales visits, the researchers said.
  • “Many doctors would say they can’t be bought for the low amounts we’re talking about, but the amounts actually aren’t that low. Many, many doctors are getting thousands of dollars. It’s hard to imagine that is not influential,” the article underscored.

Quantification of increased prescription:

Another interesting study analyzed the prescription pattern of cardiologists who were taken out for a meal by sales representatives of Pfizer or AstraZeneca– makers of two expensive branded cholesterol-lowering statins, Lipitor and Crestor. They found that payment to physicians increases prescribing of the focal drug by 73 percent.

It is noteworthy,during the time period examined, which was between 2011 and 2012, there were several equivalent, lower-cost generic statin drugs available in the market. The paper’s findings confirm the general belief that drug companies’ business practices do influence doctors prescribing behavior while treating patients, in favor of the high-cost targeted brands.

Any relationship between soaring cancer drug price and pay for prescriptions?

Dr. Peter Bach at the Memorial Sloan-Kettering in New York City, with the help of a ‘cancer drug price chart from 1965 to 2016 period, established that treatment cost with cancer drugs is soaring. In another article, on the same issue, Dr. Bach commented: ‘Market pricing does not ensure access to new innovation.’ He reiterated:‘Profit maximizing price is not welfare maximizing. This is a policy failure, not a market failure.’

So far so good. However, everybody was surprised when on October 02, 2018, The New York Times reported about the same Memorial Sloan-Kettering that: ‘Dr. Craig B. Thompson, the hospital’s chief executive, resigned in October from the board of Merck. The company, which makes the blockbuster cancer drug Keytruda, had paid him about $300,000 in 2017 for his service.’

The same report further detailed: ‘Dr. Thompson, 65, received $300,000 in compensation from Merck in 2017, according to company financial filings. He was paid $70,000 in cash by Charles River in 2017, plus $215,050 in stock.’ This does not seem to be a solitary example from this hospital, as ‘another article detailed how a hospital vice president held a nearly $1.4 million stake in a newly public company as compensation for representing Memorial Sloan Kettering on its board.’

The question that arises now, how would such behavior of doctors adversely impact cancer patients’ health-interest? This was evaluated in an interesting article, as below.

Evaluation of association between industry payment to doctors and their prescribing practices:

Financial relationships between physicians and the pharmaceutical industry are common. This was analyzed in detail with deft and expertise in yet another very recent research paper titled, ‘Evaluating the Strength of the Association Between Industry Payments and Prescribing Practices in Oncology,’ published in the ‘The Oncologist’ on February 06, 2019. Two critical findings of the study may interest many, which are:

  • The association between industry payments and cancer drug prescribing was greatest among physicians who received payments consistently (within each calendar year).
  • Receipt of payments for compensation purposes, such as for consulting or travel, and higher dollar value of payments were also associated with increased prescribing.

Its implication on cancer patients:

To ascertain its implication on cancer patients by combining records of industry gifts with prescribing records, the study identified:

  • The consistency of payments over time, the dollar value of payments, and payments for compensation as factors.
  • This is very likely to strengthen the association between receiving payments and increased prescribing of that company’s cancer drug.

The outrageous cost of cancer treatment with innovative drugs:

As I said in my previous articles, new cancer drugs are increasingly becoming more innovative with greater efficacy. The fact that the 2018 Nobel Prize in Physiology or Medicine was awarded to James P. Allison and Tasuku Honjo “for their discovery of cancer therapy by inhibition of negative immune regulation,” provides a testimony to the high quality of innovation involved in the discovery and development of cancer therapy.

This progress is excellent, unquestionably! But who is getting benefitted by these innovative cancer medicines? The headline of the article, titled ‘The Nobel Prize is a reminder of the outrageous cost of curing cancer,’ published by the Vox Media Vox Media on October 02, 2018, captures the prevailing reality, succinctly. Articulating, ‘The Nobel Prize is a reminder of the outrageous cost of curing cancer,’ the author further elaborates the point. The paper underscores, for the first time ever, we’re living in a moment when many of our most promising medical advances, such as cancer immunotherapy, are far out of reach for the vast majority of people who could benefit from them.

Innovative cancer drugs are pricey only for the high cost of innovation? 

Let me deliberate this point based on data. Quite expectedly, pharma industry never accepts that prescriptions are bought. But, when get caught, they retort that these are some aberrations, keeping their much-publicized argument unchanged in support of jaw dropping cancer drug prices. They argue, innovative drugs are brought to market after incurring R&D expenditure of over a billion dollars, if not more.

The Vox article quotes the CEO of Novartis, the maker of the immunotherapy drug Kymriah, saying that the R&D costs of the drug were about USD 1 billion. But many experts don’t buy this argument. The article echoed one such expert - Ezekiel Emanuel, a professor of medical ethics and health policy at the University of Pennsylvania’s Perelman School of Medicine.

The professor countered by saying: ‘That’s certainly a big investment, but it is much less astounding when compared with the drug’s anticipated revenue. Based on Kymriah’s list price, treating just 2,700 patients would allow Novartis to recoup its entire investment. Even with significant discounts for many patients, it wouldn’t take many treatments to turn a considerable profit.’

According to researchers at the University of Pennsylvania, the total cost for removing, reprogramming and infusing the cells into each patient is less than USD 60,000—just one-sixth of the USD 373,000 price tag. Production costs do not seem to be driving the stratospheric drug prices, the researchers commented.

Has any remedial action been taken by the industry or the doctors?

Except one report, I reckon, this practice continues virtually unabated, even today.

‘The above conflicts at Memorial Sloan Kettering, unearthed by The New York Times and ProPublica, have had a rippling effect on other leading cancer institutions across the country’, commented ProPublica on January 11, 2019. It reported: ‘The cancer center will now bar top officials from sitting on outside boards of for-profit companies and is conducting a wide-scale review of other policies.’

Further, Dana-Farber Cancer Institute in Boston and Fred Hutchinson Cancer Research Center in Seattle, both of whose executives sit on corporate boards, are among the institutions reconsidering their policies on financial ties, the article said.

Conclusion:

Although, in many countries, at least, some action has been taken by the governments to curb such practices by framing appropriate laws, in India it is virtually free for all types of situation, as prevailing in this area.

A recent news report aptly summarized the Indian situation. It highlighted: “While Prime Minister Narendra Modi recently mocked doctors in a public interaction in London for going on foreign trips sponsored by pharma companies, his government has been unsuccessful in bringing in a law to punish pharma companies that bribe doctors. The Uniform Code of Pharmaceutical Marketing Practices (UCPMP), prepared by the pharmaceuticals department (DoP) to control unethical marketing practices in pharma has been in the work since December 2014, six months after the current government came to power. More than three years later, the code is stuck in the Niti Aayog after the law ministry rejected DoP’s draft.”

With the above global and local perspective, I reckon, even if some changes take place in the developed world, India is unlikely to fall in that category, any time soon. Consequently, a large number of Indian patients may continue to fall victims of common pharma practice – pay to doctors for prescriptions. It doesn’t seem to matter even for cancer drugs.

By: Tapan J. Ray     

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Should Pharma-Doctor Communication Be Also Gender-Specific?

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Regardless of situations, while selecting a suitable doctor for patients, or for that matter, pharma companies engage with them for commercial reasons, their gender doesn’t matter much to many.

What one generally looks for is, whether they are General Practitioners (GPs), General Surgeons (GSs) or Specialists in various disease areas, such as cardiac, metabolic, bones and joints, cancer and so on. This has been happening, despite several research studies pointing out a number of important gender-based behavioral differences between most male and female doctors, often leading to a significant difference in patient outcomes.

Before proceeding further, let me admit up front that there may be some exceptions to this general scenario. For example, certain female patients may prefer being examined by the female doctors only. Similarly, a few drug companies may be tailoring the content and the process of their communication based on the target doctors’ age.

In this article, I shall try to focus on this area based on a number of important research findings. The objective being whether medical communications of pharma players should also factor-in the gender-specific nuances among male and female doctors. This is because, such differences impact clinical outcomes and happens irrespective of whether they are GPs or specialists. Let me kick-start the discussion with the following question:

“Does gender matter when choosing a doctor?”

This interesting point was raised in an article, titled “Should You Choose a Female Doctor?”, appeared in ‘The New York Times (NYT)’ on August 14, 2018. Let me put across the essence of it, quoting from some large research findings.

The August 21, 2018 study, titled “Patient–physician gender concordance and increased mortality among female heart attack patients,” published in the Proceedings of the National Academy of Sciences of the United States of America (PNAS). This study covered more than 580,000 heart patients admitted to emergency rooms in Florida between 1991 and 2010. After a thorough scrutiny, the researchers noted that:

  • The mortality rates for both women and men were lower when the treating physician was female.

Consequently, it appears, gender does matter, while choosing a doctor for better treatment outcomes. Nevertheless, just one illustration in this regard may not possibly be enough to drive home this point. Thus, let me quote from another important study. This one is a Harvard study that included more than 1.5 million hospitalized Medicare patients and arrived at similar conclusions, with the finding as stated hereunder.

Lower 30-day mortality under female internists than male counterparts:

This large study, published in JAMA Internal Medicine on February 2017 also concludes:Hospitalized patients who receive care from female general internists have lower 30-day mortality and readmission rates than those patients cared for by male internists.

“The difference in mortality was slight – about half a percentage point – but when applied to the entire Medicare population, it translates to 32,000 fewer deaths,” reported the above NYT article while commenting on this subject. I shall come to this finding in just a bit.

Why patient outcomes are different under the care of male and female doctors? 

To get an answer to this question, just as several other previous studies, the findings of the above issue of JAMA Internal Medicine also suggest more studies in this area. The aim is to zero-in on the key differences in practice patterns between male and female physicians, which may have important clinical implications for patient outcomes.

The researchers observed, understanding exactly why these differences in care quality and practice patterns exist may provide valuable insights into improving quality of care for all patients, irrespective of who provides their care.

Curiously, this question was answered in a 2002 study published in the JAMA that found female doctors spend more times with patients.

Female doctors spend more times with patients:

The paper, titled “Physician gender effects in medical communication: a meta-analytic review” wanted to find out why patient outcomes are different under the care of male and female doctors?This study was published in the August 14, 2002 issue of JAMA. It found, “Female primary care physicians engage in more communication that can be considered patient centered and have longer visits than their male colleagues.”The average difference in time spent with patients between male and female physicians is about 2 minutes, or 10 percent, per visit.

The researchers also found that female physicians engage in communication that mostly relates to the larger life context of patient conditions. It includes addressing psychosocial issues through related questions and counseling, greater use of emotional talk, more positive talk, and more active enlistment of patient input. From this perspective, they commented: When taken together, these elements comprise a pattern that can be broadly considered ‘patient-centered’ interviewing.

Would tailoring pharma communication accordingly fetch better dividend? 

Such highly similar findings, as evidenced by many reports, over a considerable period of time, add much credence to an important fact. These vindicate the concept that ‘patient-outcomes are better when cared by female doctors as compared to their male counterparts.’ In the pharma context, the subsequent question that surfaces: Can this finding be put to use while developing a tailor-made communication strategy with appropriate content for female doctors, harvesting a rich commercial dividend?

No doubt, before doing so, more data need to be generated and analyzed to corroborate the utility of the same in the pharma business. That said, the good news is, the work has already started in this area.

Some interesting recent findings on pharma-doctor interactions:

As reported by Fierce Pharma on October 26, 2018, moving towards this direction, CMI/Compas ventured into testing the water. It planned to find out whether drug companies should develop male and female doctor-specific communication strategy and content for more productive engagement with them. After an elaborate data analysis, CMI/Compas found the following:

  • As the most important source of new product information 59 percent of older-male-doctors rank pharma sales reps much higher. Whereas, only 46 percent of older-female-doctors’ think so.
  • 47 percent of older-male-doctors were most likely to see sales reps without any restrictions. Whereas, less than 40 percent of the other group saw reps without placing any hurdles to their visits.
  • Female physicians of all generations were found more likely to rank medical websites and online drug reference guides as more important tools than their male counterparts.
  • Women doctors are also likely to encourage patients using websites, electronic medical records and patient support programs more frequently than their male counterparts.
  • After receiving requisite information from pharma source, especially younger women doctors, are more likely:

- To change a patient’s treatment (20 percent).

- Try a new product (22 percent).

- Conduct more research using other sources (40 percent).

Conclusion:

These research findings do provide a fresh food for thought for the pharma strategists to ascertain whether a new ground exists to further hone the conversation between drug companies and the doctors. More specific point to ponder is, whether an avant-garde, as it were, customer-segmentation strategy be put to use, while devising a sharply focused communication and content for the male and female doctors, separately for each.

Coming back to where I started from: Should pharma-doctor communication be gender-specific? In my view, enough credible evidences, as captured in several large studies, send a clear signal towards an affirmative answer. Nevertheless, individual company would still be required to meticulously vet it out internally, for the best possible results.

By: Tapan J. Ray

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.

Antimicrobial Resistance: A Recent Perspective

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On January 23, 2018, at the World Economic Forum in Davos, Switzerland – the first independent analysis of pharmaceutical industry efforts to tackle antibiotic drug resistance, was published by the Netherlands based Access to Medicine Foundation.

The issue of Antimicrobial Resistance (AMR) was brought under focus by the World Economic Forum (WEF) not for the first time at Davos in 2018. Its 2013 Annual Report on global risks, also underscored the gargantuan health hazard that AMR poses to mankind. It said, we live in a bacterial world where we will never be able to stay ahead of the mutation curve. A test of our resilience is how far the curve, we allow ourselves to fall behind. It’s indeed a profound statement!

In that sense, the AMF analysis is important. More so, when the global population is virtually at the threshold of facing a situation very similar to pre-antibiotic era, where even a common infection used to pose threat to a life. And now, a fast-developing AMR to many effective antibiotics or even super-antibiotics, are making them almost redundant in many serious conditions. Consequently, around 700,000 people die every year only due to antimicrobial resistance, the world over.

The World Health Organization (WHO) also reiterated its grave concern in this area by a news release on September 20, 2017. It cautioned, “Antimicrobial resistance is a global health emergency that will seriously jeopardize progress in modern medicine.” Against that backdrop, in this article, I shall dwell on some latest developments in this area, both globally and also in India.

Dire need for newer antibiotics – but dry R&D pipeline:

At the very outset, let me flag another critical area that is intimately related to this concern. An article titled, “Where Are the Antibiotics?”, published by the AARP Foundation adds more to this growing concern. It writes, in an era when many breakthrough innovative drugs are curing some of our most deadly afflictions, the quest for meeting the unmet medical needs, seems to have shifted away from development of critically needed breakthrough antibiotics to effectively address AMR, for various reasons.

The author further highlighted that between the time penicillin was discovered in 1928, and the 1970s – 270 antibiotics were approved – a robust arsenal of powerful drugs that kept almost all bacterial infections at bay. However, since then, research into new antibiotics has declined dramatically. Today, just five of the top 50 big drug companies are reportedly developing innovative antibiotics – the article reiterates.  Nevertheless, some recent developments in this area can’t be ignored, either, which I shall touch upon in this discussion.

Global initiatives for a multi-pronged concerted action:

It is understandable that there are no magic bullets to address the fast-growing menace of AMR. It calls for a multi-pronged strategy with well-orchestrated concerted efforts for its effective implementation with military precision. Following are the three primary constituents who should lead from the front in the battle against AMR, as I reckon:

  • The world leaders
  • Each country, individually
  • Pharmaceutical industry, both global and local

The medical profession, including hospitals, nursing homes, the retail chemists and individual patients, also play a significant role to alleviate this problem, especially in India and other developing countries. But, I shall keep that as a subject for a separate discussion, altogether. Let me now touch-upon the first three constituents, one by one, as follows:

1. The world leaders’ initiative:

Realizing that failure to act on AMR will result in a global health and financial crisis, the world leaders met to address this growing menace. Accordingly, on September 21, 2016, the United Nations General Assembly (UNGA) passed a declaration aimed at slowing the spread of antibiotic-resistant superbugs. At this meeting in New York City, the top UN leaders successfully urged all governments to sign a political declaration to tackle the problem of AMR, both globally and in their respective countries. The joint declaration requires each country to develop a 2-year plan to protect the potency of antibiotics for both livestock and humans. The progress of the initiative for each country at the end of those 2 years will be evaluated. However, in this article, I shall focus only on the agreed human-specific actions, which include the following:

  • Antibiotics should be prescribed only when they are absolutely necessary
  • A massive education campaign about antibiotic resistance.
  • Greater monitoring of superbugs to understand the scope and magnitude of the problem.
  • Safeguarding current antibiotic stockpile.

The leaders suggested that people should be encouraged to help prevent the crisis from turning into a death sentence for millions, with the steps, such as:

  • Get available vaccines to prevent illness
  • Stop asking doctors for antibiotics when they have the cold or flu, as antibiotics treat neither
  • To urge their political leaders to commit to action in combating antibiotic resistance.

2. Country-specific initiatives:

In September 2016, just a year after the UNGA high-level meeting on AMR, an update by the United Nations Foundation reported that 151 countries out of 195 WHO member states have responded. The overall response includes the following, among others:

  • 85 percent of countries are developing or have developed National Action Plans (NAC).
  • 52 percent of countries have a fully developed plan with ‘One Health’ approach that seeks to unify human and veterinary medicine, agriculture, and food providers against the progression of AMR by reducing agricultural antimicrobial use.
  • 52 percent of Low and Middle-Income Countries (LMICs) have national-level measures in place on ‘Infection Prevention and Control (IPC)’ measures in human healthcare.

3. Pharmaceutical industry initiatives: 

I shall cite only the latest commendable developments in this area, as I see it. On Jan. 21, 2016 a document titled the ‘Declaration on Combating Antimicrobial Resistance’, was launched, again, as part of the World Economic Forum at Davos, Switzerland.

For the first time, 85 pharmaceutical, biotechnology, generic-drug, and diagnostic companies agreed on a common set of principles for global action to support antibiotic conservation and the development of new drugs, diagnostics, and vaccines. The document, outlining several critical measures the government and industry must take to increase antibiotic effectiveness worldwide, was also drafted and signed by nine industry associations spanning 18 countries.

Global progress assessment of AMR initiatives in 2018:

This brings me back to where I started from, while analyzing what happened in this regard a year after the above declaration was signed. On January 23, 2018, at the World Economic Forum in Davos, Switzerland – the first independent analysis of pharmaceutical industry efforts to tackle drug resistance, was revealed by the AMF. It found companies are developing new drugs, as well as dismantling the incentives that encourage sales staff to oversell antibiotics, setting limits on the concentration of antibiotics in factory wastewater released into the environment, and tracking the spread of superbugs.

In the AMR Benchmark, GSK and Johnson & Johnson lead among the largest research-based pharmaceutical companies. A separate ranking of manufacturers of generic antibiotics features Mylan, Cipla, and Fresenius Kabi Global, in the leading positions. While Mylan leads the generic medicine manufacturers, Entasis, reportedly, leads the biotechnology group. 

Twenty-eight antibiotics are in late stages of development:

The other key findings of the 2018 study include mention of 28 antibiotics that are in later stages of development, targeting pathogens deemed critical AMR priorities by the WHO, and/or US Centers for Disease Control and Prevention. However, only two of these 28 candidates are supported by plans to ensure they can be both made accessible and used wisely if they reach the market. Be that as it may, the benchmark finds room for all companies to improve in this space, the report indicated.

Some major initiatives in India:

The good news is, ‘The National Policy for Containment of Antibacterial Resistance’, with similar objectives, was put in place in India by the Directorate General of Health Services, Ministry of Health & Family Welfare, way back in 2011. Further, on March 20, 2015, to strengthen the surveillance of antimicrobial resistance (AMR) in the country, Indian Council of Medical Research (ICMR) had set up a National Antimicrobial Resistance Research and Surveillance Network (AMRRSN) to enable compilation of national data of AMR at different levels of health care.

Again, in February 2017, the Indian Council of Medical Research (ICMR)  has put a new ‘Treatment Guidelines for Antimicrobial Use in Common Syndromes’, to achieve the same objectives. Despite this, as many medical experts opine, a large number of General Practitioners (GP), including hospitals, nursing homes continued over-prescribing antibiotics. Alarmingly, considered as the last line of defense antibiotics by many doctors – Colistin and Carbapenem resistant infections have also been reported from several Indian hospitals. All this adds further fuel to the AMR fire.

Another matter of huge worry in India:

The February 04, 2018 article titled, ‘Threats to global antimicrobial resistance control Centrally approved and unapproved antibiotic formulations sold in India,’ published in the British Journal of Clinical Pharmacology, highlight serious hurdles for controlling antimicrobial resistance in India, which has had parliamentary investigations into the failures of the country’s drug regulatory system. The study was conducted by researchers from Queen Mary University in London, Newcastle University and Lakshya Society for Public Health Education and Research in Pune. Some of the key findings of the study are as follows:

  • Extensive use unapproved of fixed dose combination (FDC) antibiotics is contributing to the rising rate of AMR in India, which is already one of the highest in the world.
  • Out of the 118 of FDC antibiotics being sold in India, only 43 (36 percent) were approved by the CDSCO. These 118 antibiotic formulations are being sold in 3307 brand names and manufactured by 476 entities. Of these, 464 were Indian manufactures, and 12 were MNCs.

The authors recommend work on understanding why unapproved formulations are being prescribed by medical professionals.

Conclusion:

As the above AARP Foundation article highlights, like all living beings, bacteria constantly evolve to survive. While encountering a new antibiotic, they quickly find ways to evade it, and continue to live or exist. Some have even developed cell wall like virtually impregnable shields, as it were, keeping antibiotics out. Others pump antibiotics out when they get in. Several deadly bacteria have even devised ways to deactivate antibiotics.

The comments made in the article titled, ‘The Future of Antibiotics and Resistance,’ published by The New England Journal of Medicine (NEJM) on January 24, 2013, is also worth noting. It says, the converging crises of increasing resistance and collapse of antibiotic research and development are the predictable results of policies and processes we have used to deal with infections for 75 years. If we want a long-term solution, the answer is not incremental tweaking of these policies and processes. Novel approaches, based on a reconceptualization of the nature of resistance, disease, and prevention, are needed.

The bottom line still remains, AMR is a humongous threat to the global population, not just in India. While its awareness is gradually increasing, much more painstaking work remains to be done by all, both individually and collectively, to contain this global health menace. It’s our responsibility to protect the well-being of our future generations.

By: Tapan J. Ray  

Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.