Hive Health

Sitting down this week with a group of nurses led me to give some thought to the types of work they do and the role they have.

Nurses have long been considered the ‘touchy feely ones’, with GPs dealing with the pragmatics of  prescription and referral. As the UK system evolves it increasingly requires a different, more-doctor-like-nurse, with changes in responsibility, remit and patient influence. Resulting in less time to do what is often considered a foundation of nursing – care. Alongside this evolution, sits a fundamental patient requirement to still have ‘caring’ held high. I believe we still need to place value on someone who is willing to sit and explain what we have missed, didn’t understand or are just worried about. It strikes me that these two requirements can be often at odds.

Our role as communications guys needs to evolve to help bridge this divide between the demands of the structure and that of the patient. In the old days it was enough to target this group as an advertising audience, whereby we would fight for share of voice in the b2b journals. We spent time defining key messages, and shouting them, thinly veiled ad ideas, carrying key messages, kept front of mind, alongside a hope that they would somehow be spewed up during the all important consultation.

In this new world, we need to leap forward and try to understand them not as consumers of journals, and message parrots, but as partners and conduits to driving a better patient experience. This requires a very different approach, and a need to evolve from top down parasitic paternalism to sharing values of partnership, respect, and mutual understanding. I think we  need to ask ourselves - how might our brands catalyse their talent? Rather than how best might we use them to our advantage.

I’ve worked on a host of POM to P switches, most now launched, some not and some still to come. This article indicates very well the inate disconnect I believe that the medical fraternity has with pharmacy. I think it also clearly highlights the relationship Doctors think people have with their health and with them as Doctors.

Over 70% of doctors oppose the switch of Flomax (tamsulosin). The vast majority saying that there is a risk of pharmacists missing underlying issues. I passionately believe that Pharmacy have a critical role to play in providing care on the high street. Having done much work with pharamcists as a group, I also know that they themselves worry about missed or underdiagnosis.

The reality is there are huge sways of the population who do not present to Drs, who do not recognise symptoms as problematic until pointed out to them and are either in denial or too scared to present to a Dr. Men in particular are great avoiders. Switch provides an opportunity for patients to enter the healthcare system in an accessible, non-scary and anonymous way. If I were a betting man I suspect brands like Flomax being available over-the-counter will encourage them to open a dialogue with healthcare professionals, recognise that actually what they thought was normal is not, and who knows get seen earlier by GPs not later when Pharmacy refers on. Certainly I know from previous switches that there has been an increase in prescriptions, suggesting more patients presenting in surgery too. I think Drs should be asking themselves some critical questions such as “who do we trust more, Pharmacists or patients?” “Do I welcome that they are in the system somewhere or nowhere?” Its time to accept patients decide and the more access points to health they have, the more knowledge we can give them, the better for all.

Those of us on the industry side of healthcare may dismiss today’s news as another headline doing damage to an industry that delivers benefit to millions. But in claiming “The difference in improvement between patients taking placebos and patients taking anti-depressants is not very great”, lead researcher Professor Irving Kirsch raises some undeniably challenging questions.

For one thing, the “effect” is not limited to mental health trials. One RCT in patients with acute duodenal ulcer (Lanza et al. 1994) consisted of three treatment arms: the then-new drug lansoprazole (Zoton/ Pravacid), an older drug, ranitidine (Zantac) and placebo. As per experimental law, the 44 patients receiving placebo had the same diagnosis as the other patients and were examined alongside them. After two weeks about a third of the placebo patients were healed, and after four weeks just under half of them were healed.

Here’s another in angina: (Boissel et al 1986) 35 patients with severely limited functional status were treated for 6 months only with placebo and short-acting nitroglycerin. The placebo dosage was blindly titrated over this time until an “optimal” response was seen. Twenty seven of the 35 patients showed substantial improvements over this period. Overall the number of angina attacks dropped from 10.3 to 2.4 a week with a corresponding decrease in nitroglycerin tablets used. It seems unlikely that these people would have simply gotten better had they stayed at home and had no treatment. But, with inert treatment in a clinical trial, they did get better.

Let’s not forget that a placebo isn’t necessarily a tablet. In two studies (Cobb et al, NEJM 1959. Dimond et al, J of Cardio. 1960) surgeons were only informed once in the operating room which patients were to have a complete internal-mammary artery operation, and which were to receive sham surgery. Both studies showed that most of the patients were much better after “surgery” regardless of whether they had actually received it or not.

These examples of a high response rate in a placebo arm are not uncommon. For centuries, it has been known that sick people frequently get better when administered an inert intervention by a healer or medicine man. It’s hard to account for the substantial improvement in these patients.

Increasingly, the term “placebo effect” has been a dismissive one, given to justify a response that cannot really be understood. To me, it seems that at some point the role of the patient’s ‘mind-over-illness’ must be considered. Indeed, the word “placebo” is being challenged by medical anthropologists, who ask how placebos, an inert substance by definition, can have any effect at all. If it does something, it is not inert. There must be something else at play driving this change.

Daniel Moerman in his excellent book Meaning, medicine, and the “placebo effect”, suggests a very different approach to this problem. He uses the term “Meaning response” and defines this as “the psychological and physiological effects of meaning in the treatment of illness”. The meaning response can be applied to most of the results traditionally attributed to placebo effect. As a definition it gathers the elements of the non-physiological into treatment success, aiming at a better understanding of this phenomenon.

Once you acknowledge that treatment ‘meaning’ exists alongside mode of action and plays a role, it’s only a short distance to another important realisation. This is directly relevant to us: by understanding meaning in the eyes of the end user, we can feed this insight into the HCP strategy. Adapting and optimising our communications can only help drive a better brand experience, a better consultation and perhaps better outcomes.

What do you think?

A recent post about the rise of the informed patient attracted some insightful comments. Dr J got me thinking about knowledge, responsibility and a few things in between.

Patient education is a good thing and we need more of it. The EMEA roadmap for 2010 promises more access to accredited medical information. Ideally this will help override the reams of flimsy information that, as Dr J points out, are in abundance.

I think the EMEA have their work cut out for them. How much information do people need for a start? Is it OK to broadcast an advert simply telling people to be more active, or do we need a clearer link to the real consequences of obesity? And what if we overload people with information – will we scare them into doing the wrong thing? Will they just stop listening?

What really alarmed me was Dr J’s comment that, even when patients know their onions, they often balk at decision time. Perhaps we know enough, but we’d still like to blame someone else if things don’t work out. Or is it the other way round – are we being urged to take more responsibility for our treatment, but don’t have enough insight to make decisions?

There’s a great take-out from this: We must be on the ball if our minds are boggling with the same question that patients’ are. What we all want to know is: how do we embrace patient empowerment without compromising medical integrity?

Looking forward to your thoughts on this one.