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Healthy Skepticism Library item: 16546

Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.

 

Publication type: book

Sawaya L
The Persuasion Report Orleans, Canada: Reticulum 2009
https://cp.experthost.com/ssl/18/reticulum.ca/books_s3.php


Abstract:

The Persuasion Report covers a very large number of subjects related to the science of persuasion and sales. You will learn about the following topics and more:

A brief historical review of the science and art of persuasion.
An overview of Physician Behavior. The complexity of physicians’ behavior. The need for physicians to juggle several roles (patient advocates, gatekeepers or cost controllers, self-employed professionals…). The role of uncertainty in physicians’ decision making. The repetitive and mundane aspects of physicians’ work. The heterogeneity and lack of standardization in physicians’ work. Physicians’ prescriber profiles. The need for improvements in physicians’ clinical performance. The difficulty in changing physicians’ behavior.
Why are physicians resistant to change and so hard to persuade? The long list of reasons: Inertia, physicians’ distrust and scrutiny, physicians’ ‘automatic vigilance’ and motivated skepticism, poor pharmaceutical marketing and sales strategies, the pharmaceutical industry’s poor image among some physicians, the conservative nature of the medical culture, physicians’ growing familiarity with persuasion techniques, the actions of the purists among physicians, the actions of several kiss-and-tell or loose-lips reps, the actions of governments and third-party payers, the various barriers to rep access, physicians’ stress and burnout, information overload and time pressures, physicians’ ‘reactance.’
Factors that might render physicians susceptible to persuasion: resistance is a limited and finite resource, physicians do respond to ‘economic’ incentives, Medicine’s dependence on industry money, physicians’ need for samples, pro-industry physicians or apostles, physicians’ poor training in clinical pharmacology and statistics, physicians’ fear of committing Type I errors, the educational value of pharmaceutical marketing, physicians’ curiosity and quest for lifelong learning, the appeal of the new, bias denying and physicians’ illusion of invulnerability, poor counter-detailing and anti-marketing activities, physicians’ preference for people as sources of information.
The sources of reps’ persuasive powers. Reps’ credibility as a persuasion tool. The primary and secondary dimensions of credibility. The role of reps’ knowledge and expertise. Reps’ trustworthiness as defined by physicians.
Reps’ friendliness as a persuasion tool. The persuasive powers of likeability. Likeability boosters (ingratiation, impression management, contact, cooperation and propinquity, similarity with the target…).
Reps’ attractiveness as a persuasion tool. Why and how does attractiveness work? The dark side of attractiveness. Sex appeals.
Humor as a persuasion tool. The benefits of humor in interpersonal exchanges, in education, in business settings and in Medicine. Why and how does humor work? Tips for the effective use of humor.
Gifts as persuasive tools. How and why do gifts work? Patients’ gifts to doctors. Reps’ gifts to doctors.
Free food as a persuasion tool. How does food work in persuasion? A growing medical backlash against free food.
Structuring and delivering your message. Climax or anti-climax orders of presenting your (sales) arguments. One-sided versus two-sided messages. Implicit versus explicit conclusions or sales messages.
Delivering your message. Speech markers (speed of speech, speech power, language intensity…). Non-verbal communication cues: kinesics, haptics, proxemics, chronemics.
Maintaining a conversation. The two-minute presentation. The newspaper method. The triple.
Repetition as a persuasion tool. How does repetition work? The mere exposure theory.
Framing your message. Framing as used by doctors. Framing as used by reps and marketers. The contrast effect.
Stories as persuasion tools. How do stories work? Examples, analogies, metaphors, testimonials and props as persuasion tools.
CME as a group persuasion tool. Physicians’ CME habits. From CME to CPD. Principles of adult learning. Social loafing, group learning and CME. The audience effect. Physicians’ references groups and opinion leaders. Feedback as a persuasion tool.
Typologies of persuasion techniques. Emotional versus rational appeals. Fear appeals, popularity appeals, and scarcity appeals.
The Elaboration Likelihood Model. The central and peripheral routes to persuasion.
Clinical trials as persuasion tools. Factors limiting the persuasive powers of clinical trials. The influence of the medical and general media on physicians’ perception of clinical trials results.
Evidence-based medicine. Persuading with evidence. The pros and cons of clinical practice guidelines.
Sequential persuasion techniques. The foot-in-the-mouth technique. The door-in-the-face technique. The foot-in-the-door technique. The three C’s: consistency, commitment and cognitive dissonance. The less-leads-to-more effect.
Omega persuasion strategies. Sidestepping resistance to change. Confronting resistance directly. Addressing resistance indirectly. Focusing resistance. Distracting resistance. Disrupting resistance. Consuming resistance. Using resistance to promote change.
Persuasion techniques doctors hate: pimping, hard close, nagging, begging, shaming, threatening… Counter-persuasion techniques used by doctors.
Persuading the reps. Team selling. Visiting with a manager. Tips for better territory designs.
The ethics of persuasion. Lies make us human. The ‘wool pullers.’ Typologies of lies. Deception, paltering, amplification and attenuation, hype and puffery claims. Coercion and compliance gaining.

Persuasion is among the oldest of human experiences –and one of the oldest fields of academic study. It is a major component in interpersonal communications and the lubricant of commercial exchanges. As such, the study of persuasion is a prerequisite for the mastery of various disciplines and human activities, including psychology, sociology, communication, rhetoric, pedagogy, marketing, sales, public relations, negotiations, politics and warfare.
Most of what we know about persuasion has been put forward by social psychologists. Social psychology is the scientific field that seeks to understand the nature and causes of individual behavior and thoughts in social situations. Social psychologists study how we think about and interact with others. A large part of their work focus on conducting basic research on persuasion and developing the theoretical frameworks of this fascinating field.

How do social psychologists define persuasion? According to some, persuasion “involves one or more persons who are engaged in the activity of creating, reinforcing, modifying, or extinguishing beliefs, attitudes, motivations, and/or behaviors within the constraints of a given communication context [1].” A shorter definition describes persuasion as “the use of communication to change another person’s attitude (i.e., that person’s evaluation of an object or a thought).”

A brief historical review

Aristotle is considered the Western world’s first great persuasion theorist. He devoted several books to the subject of “rhetoric,” which he defined as “the faculty of discovering in a particular case what are the available means of persuasion.” [Today, of course, the term has come to be associated with specious reasoning and overly stylized but fallacious arguments, or “empty rhetoric”].

Most of Aristotle’s writings on persuasion have survived the test of time. His insights and observations, though made more than 2,300 years ago, are still considered valid. The Greek philosopher described three concomitant routes for changing the mind of another person:

Ethos: focuses on the speaker, and stresses the importance of the communicator’s reputation, credibility, trustworthiness and expertise.
Pathos: stresses the role of words and proper language in arousing the interest of the audience, creating excitement about the message and appealing to the emotions of the listener.
Logos: puts the emphasis on the nature of the message and the need for using logical arguments, rational explanations, proofs and demonstrable evidence.
In modern times, it was Carl I. Hovland who significantly advanced the study of persuasion. During the Second World War, this young Yale professor was recruited by the U.S. government, and was asked to assess the susceptibility of Prisoners of War (POWs) to brainwashing and to devise ways for countering enemy propaganda aimed at undermining the troops’ morale.

When war ended, Hovland returned to Yale and established the “Yale Communication and Attitude Change Program.” There, with his coworkers and students, he experimentally manipulated a large number of variables and measured their impact on changing a recipient’s attitude. Some of these variables included the recipient’s prior position on an issue, the recipient’s self-esteem, the credibility of the source, the extremity of the position advocated, the order of presentation of arguments, whether one or both sides of the issue are presented, whether the conclusions of an argument are explicitly stated or are left to the recipient’s inference, whether the recipient actively attempts to reproduce the arguments for someone else, whether the recipient is induced to think of counter-arguments, whether the presented information is designed to stir the recipient’s emotions (especially fear), and the time that has elapsed since the information was presented. Many of his experiments’ findings are also still valid today, as we shall see throughout this book.

More recently, another social psychologist, Robert B. Cialdini, PhD, managed through a series of books to popularize the topic of persuasion and to move it from its academic quarters into the vast world of Business. Since 1984, his books have sold more than a million copies and have been translated into twenty languages. Cialdini’s research and writings focused mainly on six persuasion techniques: reciprocation, commitment and consistency, social proof, liking, authority, and scarcity. In later chapters, we will see how these approaches might work in a medical setting and among a physician audience.

In the past decade, Eric S. Knowles, PhD, further expanded our understanding of persuasion by considering its antithesis: resistance. In “Resistance and Persuasion,” a book he co-edited in 2004, he analyzed the nature of resistance to change and demonstrated how it can be reduced, overcome, or even used to promote persuasion. I will shed more light on Dr. Knowles’ work, especially his ‘Omega persuasion strategies,’ in later sections of the book.

Today, there is a thriving persuasion industry made up of a host of private and public companies, independent consultants, books, tapes and training seminars that cater to marketers, salespeople, politicians, educators, public health officials and to all those seeking to influence other people’s attitudes and change their behaviors. This report reviews the major persuasion techniques and theories, discusses their pros and cons, and supplements them with examples from the medical and pharmaceutical worlds.

Physician behavior is resistant to change

Changing physicians’ long-held patterns of behavior is complex, difficult, costly and unpredictable. As the following examples demonstrate, physicians are famous for frustrating the best efforts of marketers, educators, regulators, and hospital administrators:

Researchers reviewed 26 published studies of interventions designed to influence the prescribing behavior of physicians [45]. They found that the interventions’ success rates varied all the way through from 1% to 99%!

Another systematic review of 102 randomized controlled trials showed that single interventions have modest or negligible effects when used alone [46]. For example, programs that solely address physicians’ knowledge, such as traditional continuing medical education and passive dissemination of guidelines, are insufficient to change practice behavior. However, multifaceted interventions that combine several change strategies can lead to significant changes in physician behavior and health outcomes.

The August 2005 issue of the Journal of Health Policy reported that a key cost-cutting strategy employed by HMOs for 15 years was simply not working. HMOs sought to restrain drug costs by ensuring that a medical group will make money if member doctors prescribed within the drug budget set by the insurance company, and will lose money if member doctors over-prescribed. The failed strategy also included hiring pharmacists for expert advice, using ‘physician profiling’ to compare doctors’ prescribing patterns, and publishing guidelines and protocols that specify what each drug should be prescribed for, at what dose and for how long.

Back in 2001, the State of Pennsylvania stopped its counterdetailing program (designed to offset the effects of pharmaceutical marketing) after realizing that, although it had some effect, “it was labor intensive, costs a lot of money, and it didn’t have any staying power [47].”

Physicians will thwart the launch of most new drugs and prevent them from becoming instant ‘blockbusters.’ IMS Health examined 4,225 drug launches in several international markets and found that only 35 of them managed to dominate as the first or second market leaders within two years, in two or more countries [48].

Business professors Mizik and Jacobson [49] studied the effects of rep visits and distribution of samples on the generation of new scripts. They focused their research on three drugs:

a) Drug A, which had sales between 0.5 to 1 billion dollars, had been on the market for 3 years, and was competing with 12 drugs in its category.
b) Drug B, with sales of over 1 billion, 11 years on the market, and 18 competitors.
c) Drug C, with sales of under 0.5 billion, 6 months on the market, and 11 competitors.

The researchers were able to access a database containing 24-month information on the number of new prescriptions issued for a drug by a given physician, the number of rep visits and the number of samples left by reps. Using statistical modeling and operations research methods, they then assessed the effect that changes in the amount of detailing and sampling had on the number of additional new prescriptions.

Their research indicated that for inducing one (1) additional new prescription of Drug A an additional 0.64 rep visit and 6.44 samples were required; for Drug B, 3.11 rep visits and 25.39 samples were needed; and for Drug C, 6.54 rep visits and 73.05 samples were in order.

The authors concluded that physicians are not ‘easy marks,’ and acknowledged that while rep visits and sampling do have an effect on new prescriptions, the magnitude of the effect is only modest.
Furthermore, most physicians seem to recognize that they are hard to persuade and are cognizant of the fact that they rarely change their ingrained behavior. The following verbatim comments made by three U.K. physicians neatly illustrate physicians’ insights in that regard [50]:

“… You are influenced by other colleagues and superiors when you’re going through training and I think gradually as time goes on, you become… more set in your ways. I think it’s harder and harder for pharmaceutical companies and FHSA advisors to influence you because … as time goes on you actually tend to use the drugs more and more and you become familiar with, you become familiar with the doses and so you … you tend to write the same drugs over and over again. So perhaps we become more conservative as we get older as well.”
“I don’t think that changes that were introduced post 1990 (new national GP contract) have had much effect … or an impact on my prescribing habits. As I see it, the situation as far as prescribing and treatment is concerned, on a one to one basis, I haven’t changed my views, irrespective of prescribing figures and so on. I see a patient who has a need … and I address that need and I try to provide as constructively … as comprehensively for that need and that’s the issue that presents to me whenever a patient sits on that chair.”
“I would say (I am) a conservative prescriber really, I never really prescribe a drug that’s fresh onto the market, because that’s just my nature. I always go for a tried and tested drug … I think it’s easy to be caught out by a new drug that comes onto the market and finally after it has been used for a while, problems start to ensue and you then realize there could be other problems involved … It’s very unusual for a new drug to break into my own personal formulary.”

Reactance

Putting pressure on physicians and forcefully asking them to comply with a request will almost always be perceived as an attempt to limit their personal or professional freedom, and will often lead to reactance or negative attitude change.

Reactance, as first described by Brehm back in 1966 [5], is caused by external threats to one’s freedom of choice. When a person senses that someone else is limiting his or her freedom to choose or act, an uncomfortable state of reactance results, creating motivation to reassert that freedom.

In particular, people dislike being warned that they should not do something. In one experiment for instance, college students’ interest in a movie nearly doubled when it carried a warning that the show contained violence. In another study, people were more likely to say they’d like to taste cream cheese samples carrying a high-fat warning label than they were to taste samples without the warning label. And, as Mark Twain remarked:

“Adam was but human…He did not want the apple for the apple’s sake, he wanted it because it was forbidden. The mistake was in not forbidding the serpent; then he would have eaten the serpent…”
Two sets of factors determine the amount of reactance. One set concerns the freedoms that are threatened. The more important and fundamental the freedoms, the greater the reactance to loosing them. A second set of factors concerns the nature of the threat. Requests that are perceived as arbitrary, blatant, direct, and demanding will create more reactance than legitimate, subtle, indirect, and delicate requests. Furthermore, social psychologists point out that when the pressures applied on us to change our attitude are excessive, we tend to change our attitude in a direction exactly opposite to that being imposed on us.

The reactance concept helps explain why government, healthcare planners and third-party payers rarely succeed in altering physicians’ behavior through heavy-handed tactics. Pharmaceutical reps take heed! Herewith a few examples from the physician world to illustrate these points:

In the early 1990s, German authorities threatened office-based physicians with financial sanctions if they were to exceed a government-imposed budget for drugs prescribed in an outpatient setting. Physicians reacted by significantly reducing their prescription volume (more than the government had hoped for) but greatly increased the number of patient referrals to specialists and the number of hospital admissions where the drug budget did not apply [6]. In a similar fashion, a few years ago a U.S. Medicaid program limiting reimbursement for prescription drugs succeeded in reducing the number of drugs prescribed but was associated with increased admissions to nursing homes.

In the late 1990s, the Nova Scotia Department of Health ordered doctors to use an elaborate coding system for submitting their patient claims and billings to the provincial payer. Here is how some physicians reacted to this measure:
“We only use 5 of the 40,000 billing codes. The Department of Health is so far removed from the physician that this is a serious problem.”
“There are so many codes that there is even a code for patients being hit by something falling from outer space… If I can’t find a code, I have my assistant bill for an upper respiratory infection, which makes for a very tainted population data in Nova Scotia.”
“It’s incredibly time-consuming for staff. Data will be unreliable because now physicians just stuff in whatever seems to be a relevant code.”

In 2002, the government of Quebec, faced with a shortage of physicians and overcrowded emergency rooms, passed Bill 114 forcing doctors, regardless of their training, to cover shifts in the ER. The bill stipulated that if physicians did not comply and failed to turn up for work as ordered, they could be fined up to $5,000 per day, and if they performed any medical services on that day they will not be paid for those services. The legislation was adopted after a man died in an ambulance that was turned away from a closed emergency room near his home. While the majority of the population welcomed the new law, physicians bitterly resented it and likened it to a military draft. Physicians’ strong opposition and reactance eventually led to the law’s repeal.

In 2006, the province of Newfoundland decreed that all physicians, except some specialists, must take a mandatory physician education program and become a ‘designated prescriber’ before they can prescribe certain Alzheimer’s drugs. Again, most physicians resented this ‘draconian measure.’ Though exempted from taking the course, geriatrician Dr. Roger Butler neatly summarizes why he and his colleagues disagree with the government directive:
“We are not opposed to education. We are opposed to it being mandatory. The message this sends is that government here is going to get more closely involved in the management of our practice. We fear this will become a common practice when a new drug is added to the provincial formulary…”
Obviously, physicians loathe administrative meddling. The most dangerous aspect of administrative interventions, according to doctors, is that it is possible to achieve the desired changes in practice but to harm patients nonetheless. Another potential adverse effect of administrative interventions is their contribution to the ‘hassle factor’ that increasingly burdens practitioners. Greco and Eisenberg stress these points again [7]:

“Many efforts to change physicians’ behavior are imposed by outsiders who may not share physicians’ personal and professional concerns…Physicians will oppose changes they perceive as threatening to their livelihood, self-esteem, sense of competence, or autonomy. Thus, interventions that decrease physicians’ decision-making authority, reduce their income, challenge their professional judgments, or appear to compromise patient care are likely to fail…Involving physicians in the effort to effect change should make change less threatening. It seems especially important that physicians perceive the proposed changes as beneficial to patients (or at least not harmful)…”
In a similar fashion, physicians are advised not to elicit reactance among their patients during their provision of medical care and counseling. For example, in the April 2005 issue of the journal Vaccine, Dr. Kumanan Wilson reminds his colleagues that categorical assertions by doctors about the necessity of vaccinating children can be counterproductive and risk alienating parents:

“Suspicion about vaccines lie deep in the belief system of certain individuals and can be as strong as religious faith. Challenging them appears to more firmly entrench these people in their positions. Dogmatic insistence by some physicians, such as refusing to take on kids whose parents won’t agree to all childhood vaccines, could backfire. Instead, doctors must adopt an approach that is respectful of parents’ beliefs, and must be prepared to listen to parents and determine if there are effective ways to address their concerns.”

Physicians’ poor training in clinical pharmacology and statistics

Most medical schools do a poor job in preparing their students for skillful drug prescribing. For example, in 1994, U.K. medical students received a median 61 hours of teaching related to pharmacology, clinical pharmacology, and therapeutics. Since then the amount of teaching has fallen even further, and clinical pharmacology courses have disappeared entirely from many medical school curricula, driven in part by the drop in the number of pharmacologists and clinical pharmacologists. By contrast, nurses seeking to obtain the Postgraduate Certificate in Prescribing from the University of Liverpool are required to complete a training course of 162 hours of theory and 90 hours of practice [9].

This is some of what the head of the British Pharmacological Society had to say in 2006 about the poor training of medical students, a problem certainly not confined to the United Kingdom:

“…Prescribing is becoming increasingly difficult, and the inherent risks of adverse reactions and interactions have increased. Modern drugs are pharmacologically complex, the population is ageing, and the use of polypharmacy is increasing. The root cause of prescribing errors among final year medical students is the lack of an integrated scientific and clinical knowledge base. Tomorrow’s doctors need a firm grounding in the principles of pharmacology and clinical pharmacology, linked to practical therapeutics, so that they can weigh up the potential benefits and harms of treatment; understand the sources of variability in drug response; base prescribing decisions on sound evidence; and monitor drug effects appropriately…” (Jeffrey K Aronson, MD).
Poor training in clinical pharmacology leads to poor prescribing and sometimes-fatal medical errors, as we saw in an earlier chapter. It also creates a sense that prescribing is not a top priority for practitioners. This cavalier attitude, which I have personally encountered in some of my marketing research interviews with doctors, is troublesome given the extent of pharmacological interventions in medical practice. IMS Health figures shows, for example, that more than 65% of patient visits to a doctor office end with a prescription of some sort.

Doctors also have trouble interpreting the statistical figures they come across while reading medical papers. As an illustration, researchers tested psychiatrists’ understanding of several statistical concepts, such as regression analysis, standard deviation, p-value, validity, relative risk, odds ratio, t-test, two-tailed t-test, chi-square, Kendall’s tau, Worsley method, logit analysis, Pearson’s coefficient, and ANOVA [10]. They found that respondents understood only half of the statistical concepts tested, and more than 80% of them thought there should be a simplified statistical tutorial in every medical journal to make interpretation of data easier. The author of the study wrote:

“In the doctor community, it’s well known that people don’t understand statistics well…If physicians don’t fully understand the statistics in medical journals, they’ll take what they read at face value, which calls into question their ability to practice evidence-based medicine…”
Other doctors concur. Dr. Kevin Barraclough candidly explains why most doctors do not read research papers and attributes it to physicians’ apprehension of statistics [11]:

“…Of all the areas of mathematics, probability, and its inscrutable daughter statistics, are the most slippery to grasp. Yet authors routinely drop large chunks of this extremely difficult stuff into papers that are supposed to be there to illuminate practice for doctors. But most doctors, including myself, don’t understand it. It comes across as a sort of dishonest sleight of hand that is also patronizing. It may be obvious to the professor and his acolytes but to mere mortals (who after all are the ones who actually see the patients) it merely seems like obscuring jargon…”
Dr. Richard Smith takes this line of reasoning a step further. In a BMJ editorial [12], he candidly explains why most readers of medical journals are not capable of critically assessing the scientific merits of an article or a study, and why they have to rely on the opinion of the editors in that respect:

“Some doctors are scientists –just as some politicians are scientists, but most are not. If doctors are not scientists then it seems odd to supply them, as medical journals do, with a steady stream of original scientific studies…The inevitable consequence is that most readers of medical journals don’t read the original articles. They may scan the abstract, but it’s the rarest of beasts who reads an article from beginning to end, critically appraising it as he or she goes. Indeed, most doctors are incapable of critically appraising an article. They have never been trained to do so. Instead, they must accept the judgment of the editorial team and its peer reviewers…”
Taking into consideration physicians’ poor training in clinical pharmacology and statistics, sales reps strive to present information in a simplified and easy-to-digest format when they are making their sales pitches.

Patients’ gifts to doctors

Gifts from patients to doctors are quite common in all cultures. Surgeons tend to receive more gifts than medical specialists because of the more tangible nature of their interventions. Doctors usually do not reciprocate, since patients’ gifts are often given in return for an identifiable medical act, i.e., the doctors ‘gave’ first [5].

A few sociologists go as far as seeing patients’ gifts as a “tip for more than standard service [5].” Surprisingly, some physicians seem to concur with this interpretation:

“…with public health insurance plans and the fee schedules, the situation changed completely. Doctors had no more discretion to charge. Fees were set and extra billing was not permitted. Many patients offered to pay extra, but this was not allowed. Perhaps presenting gifts was their way of demonstrating their appreciation…”
Dr. Morris Charendoff (The Medical Post, December 16, 2003).
Yet, most physicians are rather ambivalent about receiving gifts from patients – much more so than about accepting gifts from pharmaceutical companies or their reps. This is an example of doctors’ ambivalence in that respect:

“Gifts from patients often make me feel a bit uncomfortable… Not that I feel my contributions are undeserving, but sometimes I suspect the donors feel they have purchased a higher level of service than that accorded to ordinary mortals…” Dr. Hugh Mackenzie (The Medical Post, September 16, 2003).
Some physicians, mostly psychiatrists, advise against accepting any kind of gifts from patients. Classic psychoanalytical teaching states that gifts from patients should never be accepted because they conceal unconscious (erotomanic and other) motives and might lead easily to the breach of the professional patient-doctor boundary.

In the United Kingdom, the 2001 General Medical Council’s Good Medical Practice code warns doctors against actively soliciting gifts or charity contributions from patients (but fails to tell doctors how to react if gifts were offered freely):

“You must not encourage your patients to give, lend or bequeath money or gifts which will directly or indirectly benefit you. You must not put pressure on patients or their families to make donations to other people or organizations.”
Several ethicists equally fear that gifts may violate the ethical principles of equity and justice [6]. By accepting gifts, doctors might be prone to shortchanging some patients and giving preferential treatment to those bearing gifts (for instance, by devoting more time and effort to their case, or by bending certain rules like moving them up the waiting list or providing them with a favorable medical report). They also point out that favored patients may inadvertently experience a few disadvantages, mostly because the doctor who becomes a ‘friend’ or develops a liking for the patient will no longer be impartial and may sacrifice critical judgment (for example, by being quick to dismiss a diagnosis of cancer or a sexually transmitted disease).

Other physicians call for a more pragmatic approach to the question of accepting gifts from patients. These physicians point out that refusing a gift risks offending the patient and may seem petty when the gift is small. They believe that culturally-appropriate gifts of low monetary value are relatively ‘safe.’ Nonetheless, they urge their colleagues to remain vigilant and reflect upon the meaning of certain gifts [7,8]. Authors cite several examples where patients try to send a specific message with their choice of a particular gift: a man relapsing into mania may bring an extravagant gift; a dying elderly widow might say ‘goodbye’ with one, as might a suicidal patient; an erotomanic patient might send her doctor a single theatre ticket; and a disgruntled patient may give his doctor a medical textbook! The following comments echo the advice of these pragmatic doctors:

“There are certainly some times when the therapist has to be cautious. Patients may be trying to curry favor, make themselves liked or even seduce the therapist. If a patient tries to give a very expensive gift, gives a gift after only a few sessions or frequently comes bearing presents, it is important to discuss the meaning of the gift with the patient.

However, gifts are not necessarily given as bribes to ensure special treatment but may just be a way for the patient to feel more equal by being allowed to show appreciation for valuable service. Turning down such a present may only serve to make the patient feel belittled and inferior.” Drs. Michael Paré and Gail Robinson (The Medical Post, November 8, 2005).

“The most appropriate advice is to take nothing for granted and reflect upon the gift and its timing. A polite refusal may be preceded by reference to the ethics of medical practice or could emphasize that declining a gift does not equate to rejecting the patient. Whatever the outcome, a thank you note is appropriate. Keeping a record of all gifts offered or received and discussing the matter openly with colleagues promotes transparency.” Dr. Sean Spence (BMJ, December 24, 2005).

How does food work as a persuasive tool?

Free food facilitates access to the target person, saves time for both the persuader and the persuadee, increases the likeability of the persuader, and engages the reciprocity rule. It also works in a more subtle way by simply associating the communicator and his message with a pleasant experience.

The latter effect was first uncovered in research conducted in the 1930s by psychologist Gregory Razran. Using what he termed the ‘luncheon technique,’ Razran found that subjects became fonder of the people and things they experienced while they were eating. In one of his experiments, Razran presented subjects with some political statements they had rated once before. After all the political statements had been presented, Razran found that only some of them had gained in approval. It turned out that these were the statements shown while food was being eaten.

Razran’s insight was that there are many other physiological or normal responses to food (besides salivation), including good and favorable feelings. Therefore, it is possible for communicators to attach this pleasant feeling or positive mood closely associated with good food to any communication (political statements being only one example).

More recent research hints to the biochemical effects of certain food or beverage ingredients on the human brain. A 2006 study published in the European Journal of Social Psychology showed, for example, that moderate doses of caffeine (the amount of two cups) can make people more likely to change their minds when presented with a persuasive argument. According to the research authors, that happens because caffeine increases and facilitates the mental processing of the message.

How does repetition work?

As we have mentioned in a previous chapter, we tend to react initially with mild discomfort to anything or to anyone new. But, with repeated exposure we become desensitized and our anxiety decreases. After frequent contacts with a new stimulus, the stimulus becomes more familiar and less threatening, which in turn leads to habituation, and eventually to a gradually more positive evaluation of the stimulus.

Similarly, the more times an opinion is heard, the more comfortable the recipient will become with it. In a vacuum, where no or few competing opinions are present, familiarity also seems like popularity. In some instances, that can give recipients a misplaced sense that the opinion is more widespread than it actually is.

Although not always a panacea, repetition can act as a very powerful persuasive tool when used properly. Certain conditions enhance the effect of repetition on liking and persuasion, while others act to limit its usefulness [4]. Here are some of the points and nuances to consider about repetition and the mere exposure theory:

The mere exposure effect is enhanced when the stimuli are presented for shorter periods of time. Also, repetition works better when the message is presented in a heterogeneous, rather than a homogeneous, exposure context. For example, when a word like ‘afworbu’ appears with different types of words, it is evaluated more favorably than when it repetitively and monotonously follows itself.

Repeated exposure is more suited for stimuli or messages that are complex. According to psychologists, complex stimuli gain in ‘hedonic valence’ or perceived attractiveness over the course of a number of exposures. By contrast, simple stimuli begin to bore people after fewer exposures. Similarly, increasing the frequency of exposure to an already familiar stimulus is unlikely to increase the likeability for the stimulus much further. For example, citizens are usually quite familiar with their country’s flag and (in most instances) have positive attitudes toward it. Showing them the flag a few more times would probably do little to enhance their positive evaluations of it. Similarly, if a doctor is already prescribing a drug and is happy with its performance, exposing him to repetitive messages about the drug will unlikely cause him to rate the drug any higher.

TV ads seem to best incorporate the principles of the exposure-affect relationship listed above: they are typically fairly complex and interesting (albeit with relatively simple messages), fairly brief (15 to 30 seconds), and presented in a heterogeneous exposure context (i.e., broadcast in various TV programs and episodes, and interspersed with other advertisements and announcements).

Mere exposure exerts particularly strong effects when the stimuli are neutral or unfamiliar, rather than intrinsically pleasant or unpleasant. This principle holds true, for instance, in U.S. election campaigns where political newcomers and individuals holding low-visibility states offices (e.g., lieutenant governor, secretary of state) competed and where candidates who spent the most money on advertising were most likely to win the election [5].

When the objective of a promotional campaign is to create short-term maximum awareness (e.g., for a seasonal product or a limited-time offer), a burst of closely-timed exposures would be appropriate. On the other hand, if the goal is to create long-term awareness and enduring likeability, spread-out exposures will usually yield better results.

The effects of repetition vary according to the recipient’s level of involvement in the search for information. Learning and information search under a situation of ‘low involvement’ occur when the individual has little or no motivation to learn about a given product (e.g., the doctor has little interest in or use for a given drug, the product’s use and indications fall outside the doctor’s specialty or expertise, or the product carries very little risk). In ‘high involvement’ learning, the consumer, or the doctor in our case, is very motivated to carefully search for and assess relevant information (e.g., the doctor has many patients who are resistant to existing drugs, or the drug has serious potential risks).

Under conditions of low involvement, repetition alone is unlikely to produce strong retention of learned material. Conversely, in high-involvement situations, two or three exposures to a stimulus (like an ad or a sales message) may be sufficient for later recall. Among children, a single exposure to a commercial can produce a full effort in the direction of obtaining the advertised toy.

According to the May 2007 issue of the Journal of Personality and Social Psychology, repeated exposure to one person’s viewpoint (e.g., a single rep) can have almost as much influence as exposure to the same viewpoint but coming from several people (or different reps).

Repetition creates familiarity. However, familiarity might at times breed contempt. In fact, repeated exposure to a stimulus enhances positive feelings up to a point, but after a certain number of exposures, ratings of the stimulus will begin to decline [6]. This is the classic inverted U curve. Social psychologists call it tedium, advertising researchers call it wear-out, and physicians simply call it boredom and overkill. As evidenced by the following physician verbatim comments, the excessive and indiscriminate repetition of pharmaceutical sales messages is a major source of physician complaints, aggravation, and sometimes dislike of or even hostility toward reps:
“ I Just get bored when some of the reps come in so often telling me the same thing.”
“Rep goes over the same studies over and over again; excessive repetition of the same information and great waste of time.”
“I don’t appreciate a rep detailing me on a familiar medication when there were no new indications or studies about its effectiveness.”
“I am tired of spending time with reps who have nothing new to say. Often they keep talking when you already know the product (and are informed as such).”
“Drug X and drug Y reps are broken records. It seems their knowledge is limited to the product monograph. I can read that myself.”
“Company X reps are very aggressive; barge into office; visits too frequent with nothing new to say. I now refuse to see them.”
More often than not, the indiscriminate and excessive repetition of the sales message and the quest for a larger share of voice will translate into a higher noise volume and restricted rep access. Furthermore, the literal repetition of the same message erases the perception that the message is personal and tailor-made to the individual physician. The challenge facing pharmaceutical reps (and their managers and trainers) is how to properly calibrate the rate of message repetition and how to keep that message fresh…

Sidestepping Resistance

There are a number of tactics for circumventing and diminishing resistance. We take a look at a few of them:

a) Redefining the relationship
An effective maneuver to overcome resistance is not to raise it in the first place. Sales reps might attempt to avoid resistance by redefining the sales call as a free consultation. Thus, an insurance agent calls not to sell you an insurance policy, but to help you assess the ways your assets might be at risk, and to see how your need for protection might have changed over the past several years. Similarly, the ‘consultative selling’ theorists advise salespeople to redefine all sales pitches as a cooperative interaction, beginning by exploring the interests and needs of the buyer to see if a mutually acceptable basis for doing business can be established.

A properly-devised ‘consultation’ has many advantages. First, it implies that both consultant and target are working cooperatively on the target’s goals. The target or ‘consultee’ feels he is in charge and, therefore, has less need to be wary. Second, a consultancy defines the situation more as a ‘joint’ relationship, which shifts attention away from a commercial exchange to developing a common plan. Third, a consultancy implies a longer-term relationship with more occasions for interaction than a sales call, and more future opportunities to reciprocate or repair any inequities that may result from the interaction.

Informational or educational messages generate less resistance than sales and marketing messages. For example, a 2006 study by the Rocket Science Group of 40 million e-mail messages sent by hundreds of different companies found that the most likely ones to be opened were those that avoided a seductive marketing appeal in the subject line and were factual if not boring. Ten of the 20 most successful messages included in the subject line the words ‘newsletter,’ ‘news,’ or a synonym such as ‘update.’ None featured an overt promotional offer. By contrast, the least successful ones had pitches like “Last Minute Gift? We Have the Answer,” and “Valentine’s Day — Shop Early and Save 10%.”

In the pharmaceutical field, a credible pharmaceutical rep can position herself as a ‘CME consultant’ – not a detail person, but rather a ‘knowledge agent’ who is committed to keeping her doctors well informed and up to date. Most doctors in fact would be open to this eventuality. An article in the Journal of Continuing Education in Health Professions emphasizes, for example, that “a doctor’s interaction with a sales professional should be less a sales event and more of an opportunity for the doctor to exercise his or her abilities as a learner [1].”

Also, some marketers and sales reps are tempted to disguise their sales message as a marketing research exercise in order to sidestep physicians’ resistance to sales pitches. This is how one rep describes two of her ‘launch-targeting tricks:’

“…I use the testing approach after a product launch has begun and I’m ready to provide a full detail. Here’s the idea: Tell a doctor you’re going to practice your detail, give your detail and then ask what he or she thought of it. This accomplishes two very important things: One, it really does test your detail and lets you know what, if anything, is wrong with it, and two, it forces the provider to listen enough to provide honest feedback…”
“…I did two monthly displays, 30 days apart, in a subspecialty clinic but I didn’t display anything. Instead I gave out great pastries and carried a clipboard. When they asked me what I had for them, I replied, ‘Well, nothing. My company is new in this field and I’m just collecting some information on how you treat this disease in the real world. Tell me something…’ Would you believe it worked? After the second display, I was frequently stopped in the halls of the hospital by these specialty doctors…” Jan Michell in ‘Pharmaceutical Representative’ (July 1997).
b) Reversing the relationship
Social psychologists have described persuasive attempts as an interaction between two people who cast each other into specific roles, such as ‘persuader’ versus ‘persuadee,’ ‘expert’ versus ‘novice,’ or ‘teacher’ versus ‘learner’ [2]. An influence agent can disable the target’s resistance by reversing the relationship and casting the target in the role of an ‘expert’ or ‘teacher.’ Thus, the car salesman can say to the resistant customer, “Well, you drive for a living, so you know what an advantage it is that this car has the best braking system of any vehicle in its class.” Ascribing the ‘expert’ role to the customer places the customer in a double-bind. To keep his status as an expert, the customer has to agree with the salesperson.

Here is how this pharmaceutical rep was able to turn the tables and reverse the doc-rep relationship [3]:

“My invitation explained that this was the first-ever ‘Detail the Rep’ program, and I promised not to detail the doctor. I included a product brochure and asked my customers to review it before attending. When they arrived, they were supposed to briefly detail me based on what they had read about my product.

I held the program in a local restaurant. Although there was a blizzard that night and road conditions were poor, 18 customers (out of 50 invited) attended. I was amazed at what I saw. My most important targets walked up to me and gave full product details without missing a word. Some were even a little nervous, hoping to get their detail just right.

At one point, two doctors who share the same office told me they had discussed the program earlier that day. They described how each had tried to find out what the other was going to say in his detail, but neither would disclose it to the other for fear that his ideas would be stolen.

I walked away that evening feeling like I had cured a major disease! In a sense, I found a way to penetrate customers’ resistance to my message. I watched as they told me everything I had been trying to say to them about my products…”
c) Depersonalizing the interaction
This technique calls for taking the recipient out of the interaction while preserving the message. Thus, instead of saying “You too should contribute to this charity,” a fundraiser might say, “Everyone should contribute to this charity.” Likewise, a pharma rep might say, “More psychiatrists should prescribe this antidepressant for longer periods of time,” instead of “You should prescribe this antidepressant for longer periods of time.” Depersonalizing the request makes it less threatening and less likely to infringe on one’s personal freedom As such, it generates less reactance on the part of the recipient.

Therapists often devise stories and parables to depersonalize their encounters with resistant patients. The narratives are usually about apparently unrelated external events or inconsequential people in the form of “I once knew someone who suffered from…” However, the content and resolution of each story are carefully crafted to mirror the patient’s plight and to identify a path out of his predicament. Because the story ostensibly is not about the patient, it is not intimidating and does not engage the resistance that would be sparked by an explicit discussion and prescription for the patient’s medical condition.

Similarly, sales reps might use stories of real and imaginary customers to depersonalize a delicate interaction with their client and make a salient point in a non-threatening way, by saying something like, “I recently met a psychiatrist who did not really believe in adjunctive therapy for depressed patients, and…”

d) Minimizing the request
The foot-in-the-door technique is a classic example of minimizing overall resistance. As we have seen earlier, the technique calls for making a small, initial request that raises relatively little resistance before moving to larger and larger requests.

e) Raising the comparison
Another way to minimize resistance to an original offer is to introduce a contrasting offer that will make the original one seem more attractive. The salesperson might say, for example, “While you are considering this L model, I just want you to have a look at this top of the line ELX model.” The new comparison becomes an ‘anchor’ or reference point from which the original offer is judged. A high anchor can reduce resistance to the price by changing the implicit comparison price from zero (not buying the product) to some higher value (the high anchor price). The door-in-the-face technique mentioned earlier can be construed as an Omega strategy that works by ‘raising the comparison.’

f) Pushing the decision into the future
Many people tend to predict the future in an optimistic fashion. Of course, they are going to exercise more, eat healthier foods, save for retirement, volunteer at the local food bank, and vote in the upcoming municipal elections! The more distant a choice is, the more it is driven by hope and ambition. Thus, offers and requests generate less resistance and are more likely to be accepted if they required future action rather than immediate commitment, e.g., “Buy now, don’t pay a cent for 30 months!” “Could you help me move in six weeks?” “Doctor, I would like to invite you to our upcoming Saturday morning CME event to be held in three months from now.”

There are at least a couple of explanations for why people are more inclined to commit to do something in the future as opposed to right now: the ‘planning fallacy’ and the ‘temporal construal’ theories.

According to the ‘planning fallacy’ theory [4], most people tend to ignore past relevant experiences and greatly underestimate the effort and time required for completing a task (like writing a book or painting a house).

According to the ‘temporal construal’ hypothesis, distant future situations are construed (or interpreted) at a higher level than are near future situations [5]. As such, people focus on the general, abstract, and central features of events in the distant future, but on specific, concrete, and secondary features of events in the near future. Consider, for example, a physician who is pondering whether to attend a CME event some time in the future. If the event is one year from now, she is more likely to focus on abstract aspects, such as how interesting the topic is and what new things she might learn. On the other hand, if the event is two weeks from now, she is more likely to focus on concrete issues or specific obstacles, such as childcare arrangements or travel costs.

g) Predicting the future
Instead of directly asking people to do something (and in the process inevitably strengthening their resistance to the request), one can simply ask them to predict what they would do if someone were to ask them to do it. In a classic study from the 1980s, psychologists directly asked a group of people to devote an afternoon to a charity some time during the upcoming semester [6]. Less than 3% complied with the researchers’ demand. However, when the researchers asked another group of participants to predict what they would do if someone requested them to help for an afternoon, 40% predicted that they would agree to do so. A couple of weeks later, when participants who had made predictions were called and asked to volunteer their time, 38% complied. These were practically the same people who had predicted that they would help if asked.

Similar outcomes have been achieved for a number of socially desirable behaviors, like agreeing with requests to sing the Star-Spangled Banner, to vote in elections, to recycle, and to eat healthy food [7]. Those experiments convincingly proved that, once a prediction is made, the likelihood of subsequently agreeing to a full-blown request would greatly increase.

The ‘predicting the future’ technique has some similarities with the foot-in-the-door technique, and might owe its success to the commitment and consistency principles, as well as the impression management imperative.

Pharmaceutical reps can try using this tactic by asking physicians to predict how many of their patients might benefit from using their drug, instead of closing their sales by directly asking physicians to ‘please prescribe my drug to the next 10 patients.’

h) Imagining and explaining hypothetical future events
Even the simple act of imagining oneself engaging in a future behavior can sidestep resistance, and can lead to a higher compliance rate with a later request regarding that behavior. In one experiment, social psychologists asked a group of subjects to imagine themselves subscribing at a later date to a cable television service and enjoying the benefits of the service. When approached a month later, these subjects were significantly more likely to agree to sign up for the cable service than were people who simply received information about the service but did not imagine using it [8].

One possible explanation for these findings is that subjects were more likely to feel as if they had come up with the idea and benefits of cable television rather than being ‘fed’ those from a biased salesperson.

Similarly, imagining or anticipating regrets can also be used as an effective persuasion technique. Life insurance agents and funeral home operators typically ask potential customers to imagine the regret they would feel (ostensibly after their death) and the anguish they would cause if they were to pass away leaving their families with no proper financial coverage or pre-paid funeral arrangements.

Counter-persuasion techniques used by doctors

Pharmaceutical sales reps should be aware of the counter-persuasion tactics used by doctors, and should adjust their approach accordingly. Physicians might resort to one or more of the following tactics in order to influence reps and resist persuasion:

Banning reps from visiting
Or strictly controlling their access. These are among the most commonly used counter-persuasion techniques. As a result, a large chunk of a rep’s time and efforts has to be devoted to overcoming these obstacles.

Remaining silent
Silence is probably the most difficult form of resistance to overcome since it gives the persuader no feedback about the effectiveness of his persuasive attempts. Silence might also signal a passive-aggressive personality.

Some physicians will sit though the entire rep presentation without saying a word. They would respond to the rep’s statements with silence, and refuse to answer his or her questions. Even their body language might be difficult to decipher. Some would occasionally add little interjections or other distracting noises, such as “Hmm”, “I see,” or “OK, keep going.”

Acquiescing
Agreeing, or pretending to agree, with the rep’s statements can serve to shorten the rep’s visit, and to instill a false sense of confidence in him or her.

Digressing
Some physicians will purposely go off on a tangent in order to disrupt the rep’s presentation and flow of arguments. They will talk about sports, the weather, the markets or their travel plans, but not about the drug detailed. Digression takes up the rep’s selling time and prevents him or her from pitching his product persuasively.

Disrupting
Physicians might deliberately disrupt the flow of the rep’s sales pitch. Disruptions can take several forms: answering the phone, talking to a nurse, eating a snack, or excusing themselves to go to the bathroom. Even coughing, scratching or attending to various other body parts can be distracting for the sales rep.

Interrupting
Physicians are notorious for interrupting the speech of their patients. And, many will intentionally do the same to reps. They would use interruptions as a counter-persuasion ploy, and a way to assert their authority or superior position. These physicians might choose one or more of the following interruption techniques:

A ‘power interrupt,’ by starting to speak whenever they want and interrupting reps in mid-sentence, for example.
A ‘touch interrupt,’ by physically touching the rep on his arm or shoulder, for instance.
An ‘identity interrupt,’ by mentioning the rep’s name, e.g., “Joe. Listen. Let me make this clear…”
A ‘disinterest interrupt,’ by indicating a lack of interest in what the rep wants to discuss or claiming that his assertions are impractical, e.g., “Look. This might be important to you, but it’s of no value to the patients I see…” or “No. I am not willing to talk about how I treat hypertension. What I want to know is …” or “Before you go on any further… The concept might be nice, but it won’t work in the real world…”
A ‘disagreement interrupt,’ by forcefully disputing what the rep is saying, e.g., “No, no, no! That is completely wrong. The right approach is…”
Asking for more data
Many physicians will claim, truthfully or not, that they do not have enough information to start prescribing a new product. They will ask for more clinical trial results, articles, reviews, and other literature. Some will question the research methodology and ask for minute statistical details. Asking lots of relevant and less relevant questions (e.g., splitting hairs) can serve to distract the rep, use up his time and deflect his persuasive attempts. Some physicians will go as far as ‘pimping’ the rep and grilling him or her with legitimate or trick questions.

Asking for more time
Many physicians, as a matter of personal policy, refuse to prescribe a new product immediately after its launch, regardless of the quantity or quality of evidence provided by the rep. They prefer to wait until the drug has been on the market for a year or two, or until it is covered by most drug plans.

Faking anger, blaming the rep, and verbally attacking him
Some physicians try to throw reps off-track by appearing annoyed over some minor detail, by taking slight about some small things reps said, or by berating them for not knowing some ‘important facts.’ A few physicians might even ask for some concessions when reps try to calm them down. Others will play the blame game and hold reps or their companies responsible for their own misfortunes, as shown by the following verbatim comments collected in anonymous physician surveys:

“Drug X rep misrepresented the safety and use of medication resulting in my inappropriate use and subsequent problems with the College of Physicians and Surgeons.”
“I was told drug X had no effect on diabetes. A patient went into severe hyperglycemia and had to be hospitalized.”
“One rep forgot to inform me that his drug was a MAO-inhibitor; my patient ended up in intensive care.”
The blame or anger can lead to verbal attacks and hurling abuse at reps. Attacks can be at a personal level or aimed at reps in general. At times, attacks are directed at the rep’s ‘ridiculous and irrational’ arguments or ‘pathetic’ persuasive attempts, as in the following examples:

“Don’t you ever use those high-pressure sales techniques with me!”
“I can see your company has brainwashed you thoroughly. Do you think I would be taken in by such facile arguments?”
“I am sick to death with you sales people treating me like I am a moron.”
“I know you have to say that, but I don’t like it. Your company has some stupid rules that I am sure you don’t like either.”
“Well, you would say that, wouldn’t you?”
Complaining and Escalating
Dissatisfied physicians might complain about a rep’s behavior to his manager, might call his company’s head office, or might report his action to various government agencies. Others might threaten the reps of doing so in order to gain more concessions.

Grabbing the moral high ground
Some physicians might accuse a rep of being dishonest or unethical for suggesting something they perceive as illegal or inappropriate, e.g., “Are you suggesting that I should prescribe your drug just because you bought me lunch?” Crying foul and stating that they would never do such an immoral thing can be a convenient way for physicians to dismiss reps’ requests and thwart their persuasive attempts. Also, taking a moral high ground puts the doctor in a position of superiority and forces the rep to retreat and seek some kind of forgiveness.

Referring to a higher authority
Physicians can

 

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