Education and information for prescribers and users

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Education and information for prescribers and
users

• Dr Peter Mansfield Founder, Healthy Skepticism
• www.healthyskepticism.org
• peter_at_healthyskepticism.org
• GP, Dept of GP, University of Adelaide

Porto Alegre 14 October 2005
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Tools for rational use of medicines
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A jigsaw with many dilemmas
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Topics

• Where I come from
• Get the message right
• Communicate the message the right way
• With adequate resources
• just a superficial coverage of what I think are
  the most important points.

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Muito Obrigado !

• The traditional owners
• The organisers and support staff
• The sponsors
• The tax payers
• My family
• My team
• The translators
• The audience

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Where I come from
Brazil area 8.5M km2 popn 175M Australia
area 7.7M km2 popn 19M
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Willunga
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Healthy Skepticism

• Countering misleading drug promotion

www.healthyskepticism.org
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Healthy Skepticism

• Philosophy Accepting claims that are justified,
  rejecting those that are not, whether it suits
  us, or others, or not.
• Methods Research, education and advocacy.

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1. Get the message right

• The naïve believe everything but the astute
  consider every step.- Proverbs 1415

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Steps to getting the message right

• A1) Minimise bias.
• A2) Set priorities.
• A3) Ask the right question.
• A4) Dont misplace the onus of proof.
• A5) Focus on the best evidence
• A6) Tell the truth, without ambiguity or
  overconfidence.
• A7) Tell all the relevant information without
  oversimplification.
• A8) Tell only information that is relevant
  without distractions or unnecessary detail.
• A9) Get feedback and evaluation and act on it.

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2 types of right message

• The right contenteg For indication A drug X is
  better than drug Y.
• - easy but learning limited
• The right processeg A medium quality systematic
  review suggests that
• - dilutes content but enables learning that is
  useful for other situations

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A1) Minimise bias.

• This is the foundation!!!
• Bias ? Wrong message ? Harm

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Types of bias

• Commercial Corruption
• Unintended commercial bias
• Lack of evidence (funding bias, publication bias
  etc)
• Poor quality evidence
• Overconfidence bias
• Consistency bias

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• One main problem with our thinking and decision
  making is is that much of it suffers from a lack
  of active open-mindedness We ignore
  possibilities, evidence and goals that we ought
  to consider, and make inferences in ways that
  protect our favoured ideas.
• Baron J. Thinking and Deciding. 3rd Edn
  Cambridge University Press 2000

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Types of experts

• Content experts
• May be biased
• Process experts
• Older ones may not be able to explain their
  processes
• Hypothesis
• Best, least biased work is done by young people
  with process skills given time to learn the
  content and feedback, not control, from old
  experts.

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A2) Set priorities

• Severe
• Common
• Community concern
• Easy to improve
• Morley D. Paediatric priorities in the third
  world.

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A3) Ask the right question.

• Otherwise you will get the wrong answer.
• Example
• Celebrex vs old anti-inflammatory drugs
• Or
• Celebrex vs less selective anti-inflammatory
  drugs (not diclofenac (Voltaren))

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A4) Dont misplace the onus of proof.

• Dont assume that current beliefs are correct
  until proven otherwise.
• Dont assume that new products are better until
  proven otherwise.
• Put the onus of proof on those who make claims
  that they benefit from.

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A5) Focus on the best evidence

• Often there is no high quality evidence.
• Use the best evidence available and disclose that
  there is uncertainty.
• Use your disclosure as an opportunity to teach
  about critical appraisal processes.

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A6) Tell the truth, without ambiguity or
overconfidence.
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A7) Tell all the relevant information without
oversimplification.
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Omission

• 16 drug rep visits to Melbourne GPs 64
  drugs Roughead (1995)
• Warnings 5
• Precautions 15
• Special groups (pregnancy) 3
• Adverse effects 27

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A8) Tell only information that is relevant
without distractions or unnecessary detail.
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A9) Get feedback and evaluation and act on it.

• So as much as we might not like to receive
  negative feedback, customers who complain are
  giving us a gift.
• Customer complaints are one of the most available
  and yet underutilized sources of information but
  can be the foundation for quality improvement.
  This is no small gift!
• Barlow J, Møller C. A complaint is a gift. Using
  customer feedback as a strategic tool.
  Berrett-Koehler Publishers. San Francisco 1996

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Groupthink
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Examples

• International Society of Drug Bulletins
• la revue Prescrire www.prescrire.org
• Butlletí Groc www.icf.uab.es/informacion/boletines
  /bg/asp/bg_e.asp
• Books
• British National Formulary
• Australian Medicines Handbook
• Others
• Therapeutic Initiative www.ti.ubc.ca
• Healthy Skepticism www.healthyskepticism.org

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Example

• Healthy Skepticism www.healthyskepticism.org
• Message ? ? ?
• Communication ?
• Resources ?

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2. Communicate the message the right way

• Go to the peopleLive among themLearn from
  themPlan with themWork with themStart with
  what they knowBuild on what they have
• - Dr YC James Yen, Credo of Rural Reconstruction

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Steps for good communication

• B1) Understand the audiences starting point.
• B2) Learn from drug companies.
• B3) Get and act on feedback and evaluation.

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B1) Understand the audiences starting point.
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If your audience feels content

• Focus their minds on a problem
• then
• Show that what you want them to do is a good
  solution.

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B2. Learn from drug companies

• As an advertising man, I can assure you that
  advertising which does not work does not continue
  to run.
• If experience did not show beyond doubt that the
  great majority of doctors are splendidly
  responsive to current prescription drug
  advertising, new techniques would be devised in
  short order.
• Garai PR. Advertising and Promotion of Drugs.
  in Talalay P. Editor. Drugs in Our Society.
  Baltimore John Hopkins Press 1964.

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Do not copy drug companies

• You wont have the resources
• The industry spends perhaps around 10 of its
  revenues on conducting clinical trials, and then
  another 30 promoting its products.Mehta V.
  Batten down the hatches in 2005. Scrip World
  Pharmaceutical News 2005 3025 57
• Drug companies are effective but not efficient
• Drug companies do not have much credibility

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Controlled trials since the 1920s

• An advertiser "may try twenty-five letters, each
  with a thousand prospects. He learns what results
  will cost. Perhaps the plan is abandoned because
  it appears unprofitable. If not the letter which
  pays best is the letter that he uses. Just as men
  are doing now in all scientific advertising."
• Hopkins CC. My life in advertising (1927)
  Scientific advertising (1923). Chicago. NTC
  Business Books 1996

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Promotion is a mirror to our souls

• Now can you think what the Mirror of Erised
  shows us all?
•   Harry thought. Then he said slowly, It shows
  us what we want whatever we want
• Yes and no, said Dumbledore quietly. It shows
  us nothing more or less than the deepest, most
  desperate desire of our hearts.

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Respect /Self esteem
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Power
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Doctors are human

• Medical men are subject to the same kinds of
  stress, the same emotional influences as effect
  laymen.
• Physicians have, as part of their self image, a
  determined feeling that they are rational and
  logical, particularly in their choice of
  pharmaceuticals.
• The advertiser must appeal to this rational
  image, and at the same time make a deeper appeal
  to the emotional factors which really influence
  sales.Smith MC. Principles of pharmaceutical
  marketing. Philadelphia Lea Febiger 1968

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Motivations

• Burnt out Dodo
• Caring Bunny
• Conservative Sheep
• Entrepreneurial WolfBranthwaite A, Downing T.
  Marketing to doctors the human factor. Scrip
  Magazine 1995 March32-5

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Shortcut reasoning
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Mother Turkeys shortcut reasoning

• Appeal Cheep Cheep
• ?
• Reasoning If A says Cheep Cheep then A is my
  chick ? I should protect A.
• ?
• Conclusion I should protect A.

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Respectful Health Professionals shortcut
reasoning

• Appeal Expert X recommends Therapy A1
• ?
• Reasoning If an expert recommends A then A is
  superior? I should use A.
• ?
• Conclusion I should use A1

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Appeal to Authority

• Informal logical fallacy
• Argumentum ad verecundiam (Appeal to modesty)
  Locke (1690)
• When there is a range of expert views who does
  industry fund?

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• Just as a practiced driver can change gears with
  little or no conscious awareness an expert
  decision maker can make decisions with little or
  no conscious awareness.

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• When we use shortcut reasoning with little or
  no conscious awareness then we are vulnerable.

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New is better

• Usually correct when choosing computers and
  fresh fruit

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Ratings of new drugs by Prescrire 1981-2003.

• Bravo0.24

A real advance2.68
An advantage7.56
? Helpful15.85
Not new66.63
Judgementreserved 4.25
Not acceptable 2.79
Industrial interests versus public health the
gap is growing. Prescrire International April
2004137071-76
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Use multiple media

• Publicity
• Advertising
• One to one visits
• Meetings
• Reminders

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Example

• DATIS (Drug and Therapeutics Information Service)
  no website
• Message ?
• Communication ? ?
• Resources ?

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3. With adequate resources

• Where your treasure is, there your heart and
  thoughts will be also.- Luke 1234
• It is easier for a camel to go through the eye
  of a needle, than for a rich man to enter into
  the kingdom of God.- Luke 1825

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Steps for getting adequate resources

• C1) Win political support.
• C2) Focus resources where they will do most good.

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C1) Win political support.

• Collaborate with a wide range of groups who stand
  to benefit from your success.
• Enroll others, especially people who are better
  at enrolling others than you are.

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Example

• National Prescribing Service www.nps.org.au
• Message ?
• Communication ?
• Resources ? ? ?
• Funding 2003/04 AUD 33 M BRL 56 M

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C2) Focus resources where they will do most good.
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Opinion leaders
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Topics

1. Get the message right
2. Communicate the message the right way
3. With adequate resources

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Healthy Skepticism

• Countering misleading drug promotion

www.healthyskepticism.org