Dr Jones, you have given us examples of the use of biotechnology in specialist areas such as breast cancer; are there any areas where you predict short-term widespread use of these technologies?
There will certainly be a great market for biotechnology in treating common and minor ailments in the future. One example is that it may be possible for instance for patients in a nursing home to cough on to a diagnostic chip that can recognise if they are suffering from a bacterial or viral infection. The chip can then also decide what treatment is right for that person according to the genetic make up of the infection and the patient, and can therefore then avoid the need to consult doctors and pharmacists for common ailments.
This method of diagnosis is ‘high tech’ but not ‘high touch’ – in other words it is very fast and efficient, it delivers a simple diagnosis, but it is at the expense of the human touch. It goes without saying that if you are being diagnosed with something serious, like cancer, you need a face to face consultation with a doctor.
Where this technology can be really useful though, is for patients who need long term therapy like HRT, contraceptives, diabetes therapy etc. In these situations, after the doctor has made the diagnosis and chosen the treatment, it will be possible for the routine monitoring to be done at home, electronically – this already happens in the case of diabetes, with blood glucose monitoring. The idea is that a robotic electronic doctor monitors the patient’s progress and contacts the patient if something starts to go out of synch. This could be an opportunity for drug companies to liaise more directly with patients, the drug could be delivered every month to the patient’s home, and an electronic copy of the treatment record kept by the pharmaceutical company. This could lead to disintermediation of some of the traditional players involved eg. pharmacists – the relationship could begin to be a three way one, between the patient and the drug company and the prescriber. As long as this is handled ethically, the drug company could take certain actions, such as they could inform the patient that their therapy is coming to an end, and either instruct the patient to visit their doctor, or inform them that their next supply is on its way. The drug company could also help monitor compliance, by getting the patient to check how many tablets they have actually taken against how many were prescribed.
This will cause a lot of competition for the selection of the therapy, as the first prescription will be the vital one for the pharmaceutical company to obtain. Representatives will therefore need greater understanding of disease management programmes, and the technology involved which links patient to company to prescriber.
If this is the way it goes, will it change the skills set required of those on the road to promote products?
In life generally, change is not a choice, and that is very true of the pharma industry. The kind of products I learned about in college hardly exist these days. There are some drugs that are now over 20 years old now, some of the generics are still valuable, but all the money and time we’ve spent on medical research means that new drugs are very different, and the changes and progression is bound to continue. For instance the treatment of chronic myeloid leukaemia, was extremely crude, until about 10 years ago, and despite clever drugs, death was inevitable. Suddenly, along comes a product that actually starts to switch off the accelerated phase of cell growth, and it actually reverses it and provides a cure. That’s the first in a whole new series of drugs, but it requires the medical representative to have a sophisticated understanding of genomics, of physiology, and to understand the context of the patient which means a very different working relationship for the representative.
Will we see more of a peer to peer type consultation, with doctors being sold to by other medics?
Certainly, pharmaceutical physicians have a very important educational role in informing prescribers – but if their reputation is to survive, they have to remain very objective. That means that more than ever, they must make truly informed choices. This is a different skill to the various questions that representatives have to deal with about managing disease; I actually don’t think there will be much change in the basic skills set of the representative in terms of his knowledge of physiology and pharmacology, drug activity etc, that’s still fundamental.
However a more continuing and updating educational profile will be needed as the new technology and new distribution systems and structures come in. What I am saying is that there will be big changes to the way that healthcare has been delivered in the past, where the doctor is god and the nurse is the assistant, and where the pharmacist is possibly motivated by cash. This doesn’t have to be the way forward. Patients have the right to be included in decisions about their lives. More and more, the informed patient will become the empowered patient. The patient therefore becomes a partner in decisions about their future care, so they need to be able to ask questions of the doctor, such as ‘Why are you giving me that particular medicine? Is it right for my genetic profile? Or are you trying to save money because you need to give someone else a hip replacement?’ That dialogue can’t take place in the classic seven minute interview with a doctor, and it can’t easily take place in pharmacies, because you can’t have an intimate conversation across a counter. Doctors and pharmacists are not in the home environment, and are not able to get a feel of how well the patient is coping. Such interaction can however take place with a nurse because she’s often in the home environment, and so nurses are going to be extremely important to this industry and representatives have to develop a very strong focus on that role. The critical point is that nurses have more time with the patient. For example if you’re diagnosed with Parkinson’s disease, the physician will usually get the diagnosis over fairly quickly, but the patient will spend much longer worrying what this is going to do to their life. It will be the nurse who will spend much longer with them, and will know their home circumstances more intimately. They are likely to have a degree of influence in the choice of treatment, which makes the nurse a very key player for the pharmaceutical representative.
The role of the pharmacist will certainly change. Pharmacists have a role to play in their high street environment, but increasingly they want to be prescribers. My concern about that is that they will not have easy access to the full medical record of the patient, so how can you make a decision about switching a therapy unless you have all the information?
The other problem is that if they are going to get paid more for prescribing a more expensive product, isn’t that a perverse incentive? What I think will happen is that pharmacists will become very specialised, and they will go through more training courses beyond university and specialise in an area, for example diabetes, schizophrenia and individual patients will be linked to them. Whether they will do that in the health clinic rather than the high street remains to be seen. This all means that representatives will have to cultivate relationships with these rather more specialised pharmacists as a totally new element of healthcare prescribing.
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