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Cutting-edge delivery

Medical education must move with the times to maintain its effectiveness

bladeA recent report from the Healthcare Communications Association (HCA) showed that 58 per cent of surveyed agency members are seeing an increase in medical education (med ed), and about a third is seeing an increase in PR, with a corresponding third seeing a decrease.

Historically, a significant proportion of med ed was delivered by a large number of boutique agencies – with specialist, scientifically-qualified personnel, logistics and event management resources. Today, almost every major healthcare communications agency at least claims to deliver med ed services, and a number have set up, or are in the process of setting up, specialist teams. A simple job search on PMLiVE shows that there are over twice as many med ed jobs as there are jobs in PR, supporting what many agencies have felt for some time: everyone is now doing med ed.

Today, med ed has morphed into something very different to what it was a few years ago; in fact, it is almost unrecognisable when compared to programmes in the 1980s and 1990s. Updated regulations, media scrutiny, barriers to access and even guidance from physician bodies such as the recent Royal College of Physicians' (RCP) report, have changed forever med ed programme delivery. Fundamentally, modern med ed needs to meet the same commercial goals, but it is increasingly delivered in a more scientifically-equitable manner.

Arguably, the need to target multiple outcomes is making med ed more complex. These outcomes include: long-term corporate relationships with key opinion leaders (KOL) and non-clinical stakeholders; partnerships of care that improve practice and management (within which prescription therapies may only be a small part); national and local market access, beyond formulary adoption and changes in perceptions from stakeholders – not just clinicians – but also administrators, purchasers, managers, advocacy groups and even policymakers.

Medicine launches: then and now

Four years ago, a new medication saw over 150 key clinicians attend a national launch event, hosted by the four globally recognised opinion leaders. Yet for the launch of one of its competitors in 2008, the top opinion leaders advised holding a series of local roadshows around the UK instead, hosted by up-and-coming physician chairs. This was not because the therapy was unwarranted or the clinicians were uninterested, but because now it is just too hard to justify time out of clinic and top KOLs are booked at least six months in advance.



Medical education growth
With shrinking pharma budgets, the lack of significant new global blockbusters, and the patent expiry of many of the world's best selling medicines, why is med ed growing?

The obvious reasons are:
• Reduced salesforce effectiveness, because of poor clinician access, increased competition, market access challenges and clinician fatigue
• Growth in hospital-focused therapies (both newly-promoted portfolios and late-phase pipelines hold proportionately more hospital-based or hospital-driven medicines)
• Lack of internal resources and expertise as pharma streamlines the workforce and marketing teams are forced to become more generalised
• Increasingly complex and high barriers to entry, with new and existing options having to justify their existence as well as their line and scope of use against cheaper generic alternatives
• More stakeholders, influencers and decision makers to reach and persuade
• The need to justify marketing budgets by demonstrating clear and more immediate return-on-investment (RoI) from marketing tactics
• Regulatory restrictions on traditional PR activities, causing a shift to unbranded med ed/continuing med ed (CME).

Key challenges
KOL relationships have become the subject of increased scrutiny and additional regulation. The practices of sponsoring clinician conference attendance, providing med ed meetings and the use of honoraria have all been criticised by the media, both consumer and medical.

Though industry's conduct in this area is now more clearly defined, following the publication of new Association of the British Pharmaceutical Industry (ABPI) guidelines in summer 2008 (see Pharmaceutical Marketing's June 2008 article "Cramping your style?"), concerns remain among the media, the medical profession and the government. The release of a working party report by the RCP in February 2009, called Innovating for Health: Patients, physicians, the pharmaceutical industry and the NHS, highlights the need for even greater clarity on industry's role and regulations. It also called for more transparency and communication about the industry's relationships with medical professionals.

The report makes a number of recommendations that, if implemented, would see an even greater change in today's med ed programmes (see box 1). In particular, the recommendation of concern is: "The ABPI and its members should establish a pooled fund to invest in medical education. Such a fund would unlink financing from a single company, diminishing the perception of undue commercial influence and bias." (Paragraph 3.42)

This recommendation could effectively mean the end of the majority of med ed programmes – both those that contain a branded/product element and fully unbranded/CME projects. Interestingly, similar concerns in the US have resulted in a sea change in the way med ed is conducted there, with a complete separation of brand communications from education. In the US, separate, dedicated agencies undertake CME on behalf of a company – through separate budgets or grants. The recommendation above would move things on several steps, but I remain sceptical about whether the industry would fund such an initiative – at least to the extent that med ed programmes are now supported.

Regardless of whether any of these recommendations is implemented in the short term, one issue that does need to be addressed, by both agencies and companies, is saturation. The proliferation of med ed meetings and the increased use of KOL advocates has left jobbing clinicians overloaded with a choice of educational meetings/events and KOLs too busy to run them. With the schedule of domestic and industry conferences and restrictions on non-clinic time, it is becoming harder to attract the right number and quality of delegates, and to deliver top faculties.

Box 1: Recommendations from Innovating for Health: Patients, physicians, the pharmaceutical industry and the NHS

• The RCP and the Faculty of Pharmaceutical Medicine should promote and apply the Seven Principles of Public Life among their fellows and members, and advocate these principles to the Academy of Medical Royal Colleges and the profession as a whole through the General Medical Council (GMC). (Paragraph 2.27)
• New ways should be found to reduce the reliance of postgraduate medical education on sponsorship by pharmaceutical companies and the wider biomedical industry.
• Alternative sources of sustainable funding should be sought – for example, through the royal colleges and Department of Health. In doing this, the implications for individual organisations such as royal colleges and specialist societies should be considered carefully. (Paragraph 3.40)
• In rewriting the relationship between medicine and the pharmaceutical industry, and in the spirit of a more balanced and mutually respectful partnership, all gifts to doctors, including food and travel, become untenable and should end. (Paragraph 3.41)
• The ABPI and its members should establish a pooled fund to invest in medical education. Such a fund would unlink financing from a single company, diminishing the perception of undue commercial influence and bias. (Paragraph 3.42)
• Any honorarium or fee, commercial or otherwise, paid to a doctor should be declared on a publicly-accessible database. If the work being remunerated is completed in NHS time, that fee should be paid to the doctor's host institution to reinvest in the NHS. If the work is conducted outside NHS time, this payment should simply be made transparent. We urge the RCP, the Academy of Medical Royal Colleges and scientific societies to adopt this recommendation quickly. We urge employers to implement it in collaboration with professional bodies. (Paragraph 3.43)
• The ABPI should work harder to disseminate and implement its Code of Practice. We propose that the ABPI should organise an annual conference for medical professionals and policy makers to review the part that pharmaceutical companies play in shaping doctors' attitudes and behaviours. (Paragraph 3.44)
• Doctors should take more seriously their responsibilities to report violations of the ABPI Code of Practice to the PMCPA, together with their responsibility to monitor their own and colleagues' alignment with the principles set out by the GMC in “Good Medical Practice”. (Paragraph 5.27)



Finding the cutting edge
How do med ed programmes need to evolve? There are a number of trends emerging, which have had varied success and can go some way towards answering this question, for instance:

1. Go digital: online education websites have sought to address both the challenge of getting physicians to attend meetings and also to deliver greater RoI from med ed programmes. In fact, there are a number of professional bodies and scientific societies, such as the Royal College of Nursing, that are developing educational sites and are looking for industry sponsorship. Though the adoption and use of these sites varies by profession and therapy area, digital CME may not always be the best route for education. In particular, where peer-to-peer experience sharing is required, face-to-face interaction is still considered more effective.

2. Go local: there have always been representative-run lunchtime and evening meetings. Now, increasingly, national one- or two-day meetings are being replaced by regional, or even local, med ed meetings. The challenge is in making them local enough to encourage attendance and regional enough to deliver numbers and RoI. In a number of areas in the UK, particularly north of the border, geography dictates overnight stays or travelling long distances, which hamper the concept of truly local meetings.

3. Template and cascade: developing a template programme and holding a centralised event to train local opinion leaders who then cascade the content to their colleagues. This can be a cost-effective method of reaching many of the target audience. However, there may be issues with consistency of content and delivery. This can reduce the spontaneity and put the cascade in danger of becoming staid. Logistical support may be needed for all the local meetings, reducing cost effectiveness.

Med ed needs to innovate beyond changes in format or delivery. It must reflect the changing environment for education and the changing responsibilities of healthcare professionals with the NHS. Typically, successful programmes contain one or more of these elements:

• Involvement of a broader stakeholder base than traditional clinician groups
• Greater integration into overall marketing and communications
• Inclusion of hot topic educational elements that are distinct from branded aspects
• Content beyond therapies and management, and even beyond the immediate remit of the target audience
• Mixed programme formats, beyond didactic plenary sessions, and additional delivery methods and meeting outputs that extend the impact and reach of programmes beyond the initial meeting.

Pharma and agencies need to continue evolving in order to sustain the credible and effective delivery of creative med ed content. The increase in advocacy programmes must be accompanied by an equivalent increase in innovation, before saturation is reached and before the medical profession, which is already questioning our practice, begins to question the value of programmes as well.

The Author
Sam Barnes is a director at dna medical communications, a member of the Interpublic Group of Companies
To comment on this article, email pm@pmlive.com

15th June 2009

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