Editor’s note: Michael Greenfield, M.D., is director of medical marketing research at Greenfield Consulting Group, Inc. and Greenfield Online, Inc., Westport, Conn.

Effective Rx direct-to-consumer (DTC) advertising is typically more difficult to create than traditional advertising of non-Rx products to consumers, since it has to achieve a delicate balance between attitudes and behaviors among two very different audiences - consumers and physicians. Think of the challenge this presents for pharmaceutical companies and their agencies when developing an Rx DTC advertising campaign. How much information do you release to the consumer? How compelling can you make your product relative to competitors’ products, before a physician-patient discussion turns into a debate, creating dissatisfaction and potential backlash among physicians?

Perhaps the most challenging part of achieving this delicate balance involves tuning the advertising in a manner that results in a positive -- or, in the worst case, neutral - reaction from physicians. In this regard, consider the following example of two radically different physician reactions to Rx DTC advertising.

"Advertising Rx drugs directly to consumers makes me uncomfortable. I end up wasting a great deal of time fielding phone calls from patients questioning the choice of the medication I have put them on. Moreover, in the office, I end up diverting time from my examination and diagnostic activities to correct misperceptions regarding their medication - misperceptions based on advertising they have seen. It doesn’t help me, and it doesn’t help the patient."

Contrast this physician’s point of view on the effect of direct-to-consumer advertising for Rx drugs with the following: "Done properly, DTC advertising can be helpful. Many of my patients are better informed, ask smarter questions, and end up feeling more confident about the drug therapy that I have prescribed. It has actually made my job easier."

The importance of achieving the delicate balance has grown geometrically. DTC advertising for Rx products was virtually nonexistent 10 years ago - today there are presently 26 pharmaceutical companies spending an estimated $1 billion annually on DTC advertising in the U.S.

Addressing the balance issue becomes even more critical as the Food and Drug Administration’s Division of Drug Manufacturer Advertising and Communications (DDMAC) begins to allow more information to be released to the public within the context of Rx DTC advertising. Achieving a balance between the two targets was not really much of an issue just a few short years ago. Rx DTC advertising that operated under the DDMAC guidelines of prior years often left consumers scratching their heads in puzzlement, unsure about what medical condition was being addressed (never mind forming an opinion about the drug’s superiority relative to competing brands). However, times have changed. And, while the result of this change is clearly positive -- consumers now can at least understand what medical condition the drug being advertised is supposed to address - these changes result in the need to achieve the delicate balance.

A closer look

To understand some of the dimensions of this balance, let’s take a closer look at the actual needs and issues of the various groups involved. Let’s start with consumer needs. Generally, the consumer is looking for marketing communications that inform them that a specific condition can be treated, and create a connection between the condition and a specific drug. The result: The consumer is now provided with sufficient information to engage in a physician/patient dialogue relative to his or her condition.

Physicians’ needs relative to Rx DTC advertising are somewhat more complex. Most physicians we speak with are generally comfortable with advertising that addresses the first consumer need noted above - the ability to treat certain conditions with drugs. In this regard, we hear physician comments such as "results in a more motivated, health-conscious patient," or "can create a more compliance-focused patient."

Now the issue that creates the delicate balance problem: While the physician is comfortable with a patient who has a point of view about treatment per se, he/she is generally less comfortable with advertising that speaks to a patient specifically about how to treat the condition. Understood through the physician’s eye, this need takes the following form: The doctor does not want to become simply the executor of the patient’s treatment requests. Specifically, requests that take the form of "how to treat" rather than simply a "desire to treat."

Without overstating the sensitivity of this issue, we have heard numerous physicians express the following grave misgivings about Rx DTC advertising. Comments include:

"It potentially results in our role going from determining what is best for the patient to one of having to debate with the patients about appropriate therapeutic modalities."

"It’s great to have an informed patient, but let’s be realistic - we are the ones who are best prepared to determine how to treat the patient - it is a waste of everybody’s time to have a patient trying to take on the role of the doctor."

It is important to be clear about exactly what physicians’ concerns are. Upon analysis, the issues being raised by physicians ultimately take the following form: While they are generally comfortable with a patient inquiring about the possibility of treatments for a particular condition, and even about a specific drug to treat the condition, they are not comfortable when patients enter their offices with an opinion about a drug’s relevance, either per se or relative to competitive products.

Create awareness

Thus, the crux of the challenge for the pharmaceutical marketer is as follows: Among consumers, the marketer needs to create some awareness that a medical condition is treatable, and needs to create awareness that there is a drug worth asking the physician about relative to this medical condition. But, in the eyes of physicians, the marketer would be well advised not to create a strong point of view among consumers about "how to treat" the condition. And, to make this an even more challenging marketing communications issue, some would argue that the marketer should go beyond simply creating positive consumer associations with the drug (such as communicating specific benefits/differentiating features), while at the same time avoiding alienating physicians - a tall order, to be sure.

So, how are Rx DTC pharmaceutical marketers and their advertising agencies supposed to achieve this delicate balance. Well, a large part of the answer involves the fine art of copywriting. Here, we can offer little guidance, since this is an art, not a science, and far beyond the purview of marketing researchers. Where we can provide some guidance, however, is in helping clients employ research techniques that will provide creatives with a deeper understanding of how consumers and physicians are responding to various pieces of communications. (Think of this as providing grist for the creative mill.)

To help marketers achieve the "delicate balance," we have found that qualitative research can be particularly useful. Below we have listed some general approaches along with some specific techniques that have proved helpful in developing marketing communications that motivate consumers and don’t alienate physicians.

  • Use an iterative approach: When developing marketing communications that must achieve the delicate balance, we have found it extremely helpful to go back and forth, and then back and forth again, between consumers and physicians. Within a qualitative context, this usually takes the form of presenting a "first take" on a piece of marketing communications directed to consumers, assessing their attitudinal and projected behavioral takeaway, and then exploring physicians’ reactions to both the advertising and to consumers’ response to the advertising. Then, based on physicians’ comfort levels with consumers’ responses, creatives have the option to then tweak the advertising if indicated. Then, we again present the new or tweaked advertising to consumers, again assess the attitudinal and projected behavioral response, and then assess physician comfort with the response. (Obviously, there are some situations which require little back and forth, and less tweaking is indicated.)

The relevance of an iterative approach involving a back and forth between consumer and physician flows from the very nature of trying to achieve a delicate balance between consumers attitudes and behavior (generated by advertising) and physicians’ comfort with these attitudes and behaviors.

  • Treating physicians as clients during the research process itself: While this may, on the surface, sound like heresy, it is actually an effective way of helping to achieve the delicate balance. Involving the physician in the development of Rx DTC marketing communications can work in a number of ways. Specifically:
  • Recruiting physicians to sit in the back room watching consumer focus groups. In this situation, we often employ two moderators - one in the front room, and one in the back room. As consumers in the front room are responding to a specific piece of communication, doctors in the back room are responding to consumers’ attitudes and projected behavior. This enables us to understand, in a very efficient manner, precisely where the potential problem areas (physician/consumer) lie in the marketing communications, how important they are, and, with a little input from creatives, how to address these issues.

A critical piece in this approach involves making certain that the initial qualitative effort with consumers is strongly focused on surfacing both the attitudes and projected behavior that result in exposure to the marketing communications being researched. In this area, we strongly recommend "flash" response techniques, which help surface reflexive and visceral takeaways from the advertising rather than intellectual interpretations. Use of flash techniques enables consumers to respond in a manner far closer to real world/in-market responses. The importance of getting to the reflexive/visceral response - rather than intellectual response - cannot be overemphasized. As we know only too well, in the real world, consumers generally do not spend a great deal of time studying and thinking about advertising. As such, it is critical to make certain that whatever qualitative techniques you use during your consumer phase of research are sensitive to this.

  • "House calls." This involves using pre-recruited pairs of physicians and consumers in the following manner: First, we expose consumers to Rx DTC advertising. Then, the physician enters the room to hear the patient’s thoughts and questions that are generated by the advertising. Then, the physician is debriefed (after dismissing the consumer) regarding his/her comfort level with the consumer’s response. Note: The "house calls" technique can be used either in a one-on-one situation or in a situation involving a group of consumers.
  • On-site research. This involves showing marketing communications to patients in the physician’s waiting room, and then debriefing the physician later in the day. This approach requires that the physician is willing to make very brief notes (after seeing each patient) regarding what kinds of questions surfaced, issues were raised, etc.

Looking to the future

In cases where there is a very low incidence of consumers who are targets for a particular drug, we are now using our database of Internet-user households as a vehicle for providing access to these hard-to-reach targets. This on-line capability allows us to assess the effectiveness of Rx DTC advertising at the patient/consumer level, including copy testing, compliance tracking, as well as measurement of ROI on DTC programs. We also use this medium to conduct on-line focus groups, enabling us to gain diagnostic insight with hard-to-reach targets.

The point of describing the techniques above is not to recommend any particular technique, but rather to illustrate that marketers and researchers have a relatively high degree of flexibility when it comes to involving consumers and physicians in research that is focused on achieving the delicate balance.

All indications are that Rx DTC advertising is here to stay, and will grow meaningfully for the foreseeable future. Pharmaceutical marketers (and their agencies) who understand that effective Rx DTC advertising must address the delicate balance issue, and who use research techniques to achieve this balance, will be the ones with the best chance of getting the greatest ROI on their marketing communications.