The rule of seven touches

Dr. Atul Gwande tells the story in his New Yorker column of asking a pharmaceutical rep how he persuades “notoriously stubborn” doctors to adopt a new drug he’s promoting.  The rep’s response:

“Evidence is not remotely enough, however strong a case you may have. You must also apply the rule of seven touches.”

“Personally ‘touch’ the doctors seven times, and they will come to know you; if they know you, they might trust you; and, if they trust you, they will change.”

That’s why, explained Dr. Gwande, this drug rep stocked doctors’ closets with free drug samples in person.  Then he could poke his head around the corner and ask questions like:

“So, how did your daughter Debbie’s soccer game go?”

Eventually, this can become:

“Have you seen this study on our new drug? How about giving it a try?”

As marketing guru Mark Holloway has written, one of the clichés out there in the marketing world is that it takes at least seven touches to convert a cold customer to a sale. He adds:

“This is actually true. Basically the more touches or contact you can have with a prospective customer in as many ways as possible, the more likely you are to build strong relationships and in turn sell your product or service.

Dr. Jeffrey Lant’s own “Rule of Seven” states that you must contact your buyers a minimum of seven times in an 18-month period for them to remember you.

Jay Abraham also cites seven as the number of times you have to contact someone and ask for a sale before you get a “Yes!”

As the drug rep in Dr. Gawande’s story had recognized, human interaction is the key force in overcoming resistance and speeding change. And that’s why, according to the journal, Public Library of Science Medicine, pharmaceutical companies spend a staggering amount of money each year on marketing directly to prescribers, trying to persuade them to prescribe their (and only their) brand name drugs to patients.*

And as the Wall Street Journal reported, that’s about $12 billion annually just for what Big Pharma calls “detailing” – the industry term for sending sales reps to meet with doctors, nurse practitioners, physician assistants and other drug prescribers. Spending on detailing was highest for statins (such as Pfizer’s Lipitor), antidepressants (like Forest’s Lexapro) and antipsychotics (like Bristol-Myers Squibb’s Abilify). In each of those categories, branded drugs are competing against generics for a very big market.

But drug rep visits to physicians, despite Big Pharma’s claims, are not about “educating” ignorant docs about the latest studies on the magical superiority of their drugs over those manufactured by their competition.

Rather, they are all about building relationships.

And relationships work to sell drugs. Last year, the world’s 12 largest drug companies made a net profit of about $80 billion on revenues of $435+ billion. (Seven of the 12 are headquartered in the U.S.: Johnson & Johnson, Pfizer, Abbot Laboratories, Merck, Wyeth, Bristol-Myers Squibb and Eli Lilly).

Speaking of relationships, later in his New Yorker article, Dr. Gawande interviews an Indian nurse and asks her why she has listened to a younger, less experienced trainer’s suggestions on delivering babies safely.

At first, the older nurse rejected the ideas of the younger nurse. Even though she knew the ideas to be sound, the older nurse had many reasons why they could not be implemented in her setting. But the training nurse stayed around, and over time built a relationship with the older nurse – one not based on a judgmental stance at a distance, but through close-up human interaction, through the seven touches method.

The senior nurse’s explanation to Dr. Gawande of this shift in relationship was poignantly simple:

“She was nice. She smiled a lot. It wasn’t like talking to someone who was trying to find mistakes. It was like talking to a friend.”

So the closer that drug reps can get through their seven touches to their prescriber friends, the better their sales numbers will be.

And as New Hampshire physician Dr. Kevin Pho wrote in his always-enlightening blog KevinMD, there’s another type of pharmaceutical sales rep whose actions remain largely unregulated.

“These reps have unfettered access to the top academics of all fields of medicine, are invited by medical societies to give keynote addresses, routinely publish articles in the best journals, and offer advice about medications that is accepted as gospel by doctors everywhere. 

These reps have medical degrees, and some have become millionaires by taking fat payments from drug companies. They are “the hired guns of medicine”.

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By the numbers

  • Amount drug industry spent on marketing directly to doctors last year: $12 billion
  • Drug industry’s research & development budget compared with marketing budget: 1:2
  • Ratio of drug reps to doctors in North America: 1 to 2.5
  • Favorable change in a doctor’s prescribing habits after less than one minute with a sales rep: 16%
  • Prescribing change seen after three minutes with a sales rep: 52%

Source: Pharmedout.org “Why Lunch Matters”

* Gagnon M-A, Lexchin J. The Cost of Pushing Pills: A New Estimate of Pharmaceutical Promotion Expenditures in the United States. PLoS Med 5(1): e1. doi:10.1371/journal.pmed.0050001

See also:

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11 thoughts on “The rule of seven touches

  1. “Personally ‘touch’ the doctors seven times,”

    Ooh! That could get a drug rep in BIG trouble depending on the genders and other things. LOL

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  2. In Gwande’s article, he discusses aids and obstacles to adoption of a broad range of medical practices, including washing of hands, and concludes that human interaction is key. Through human interaction, not online prompts, the Indian nurse learns practices that genuinely aid infant survival.

    Over many years I watched the pharma reps come in and out of the busy family practice we relied on. It was headed, at the time, by a man who went to college on athletic scholarship, still-fit but middle-aged (which meant that he was about five years older than my own age at whatever time.) And those reps were almost invariably attractive somewhat younger women in perfectly fitted suits; their skirts were only-a-little-bit-short and they always stayed on the other side of his desk. But he definitely called them by first-name and once a month each rep hosted an enormous and delicious staff lunch.

    My mother worked for a much larger clinic in the Midwest and she often brought home leftovers from those drug rep lunches, at least one per week. When she was getting ready for her annual medical mission to Central America, the drug reps gave her boxes and boxes of samples; a few even brought her children’s clothing and old glasses for the mission, and they always stopped by after she came back to look at her pictures.

    My dentist’s office is in a large medical building, so I frequently share the elevator with drug and medical supply reps. I know them at a glance: well-dressed and attractive young (but not-too-very-young) people, many of them women, with excellent rolling cases. They appear to enjoy their calls, and why shouldn’t they? It’s all about making contact, and, frankly, I’m really good at that too. It’s ridiculous for docs to claim that it doesn’t influence them.

    I also have known docs-for-hire who, for a month at a time, travel the world (most notably parts of China) to demonstrate the virtues of a certain brand of medical equipment. in one case, research was already showing that the demonstrated use of equipment contributed to long-term damage to cartilage, but this doc sure looked forward to his trips.

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    • Thanks Kathleen for sharing your perspective. As I wrote here, McGill University’s Dr. Ashley Wazana’s research on drug company influence found that doctors who “occasionally” attended Pharma-sponsored meals were 2-3 times more likely than other doctors to request that the sponsor’s drug be added to a hospital formulary; doctors who “often” ate these meals were 14 times more likely to do so.

      Dr. Robert Cialdini wrote The Book on this fascinating subject: Influence: The Psychology of Persuasion. Highly recommended, especially for docs who insist that drug reps and drug money have no impact whatsoever on them….

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