How To Harness Word Of Mouth in the Pharmaceutical Industry

By George Silverman
President and Founder, Market Navigation, Inc..

Copyright © 2008, Market Navigation, Inc.

In 1971, Ron Richards and I invented Word-of-Mouth Seminars -- often erroneously called "Peer Influence Groups.” . They have evolved into what is widely acknowledged to be the most effective marketing method ever developed for the pharmaceutical industry. Enormous amounts of money are being spent on them, sometimes wisely, sometimes not.

A few years have gone by since the publishing of my book, The Secrets of Word-of-Mouth Marketing: How to Trigger Exponential Sales Through Runaway Word of Mouth. I thought this would be a good time to review the current status of word-of-mouth seminars in the pharmaceutical industry and give you some insight into how to harness it most effectively.

How it started

In about 1970, in an effort to research word of mouth for clients, I was putting together prescribers and non-prescribers in telephone focus groups (you can read more about this technique in an article on our web site www.mnav.com/H2ResWom.htm), I noticed an interesting phenomenon: One or two physicians who were having good experiences with a drug would sway an entire group of skeptics. They would even sway a dissatisfied group of ex-prescribers who had had negative experiences!

As a psychologist who had specialized in group dynamics, I was completely baffled. I knew that this was completely contrary to the then-current beliefs about peer influence and group pressure. In theory, eight or 10 people who had had negative experiences should have completely clobbered the one or two who were having good experiences. This just did not happen, ever, in dozens of sessions!

I started probing why the skeptics were turned around. The answer was enough to fill my book, literally. But it’s easily summarized: you can’t argue with success.

If a physician has used a treatment successfully on a significant number of patients, the physician who has had negative experiences is usually faced with one of three explanations:

(1) either the one who has had positive experiences has been extraordinarily lucky,

(2) he/she has different kinds of patients or

(3) he/she is using the drug differently.

If the successful physician has used the drug on a significant number of patients, typically a dozen or two, the first hypothesis (luck) is wiped out. A few simple questions about the nature of the successful physician’s patients usually eliminate the possibility of different patients. That leaves the third explanation (using differently), which is usually correct: Physicians who are successfully using a particular treatment have mastered such things as diagnosis, patient selection, explaining the treatment to the patient, managing the patient’s expectations, correctly administering the medication, titrating dosage between symptoms and side effects, and correctly following up. As a result, the right patients are getting the right drug in the right way, at the right time, and are maintained on the drug in an optimal way. The physician is likely to have a very positive view of the drug, because it is working out in practice.

So, when the unsuccessful physician hears any of these things that are different from the way he is practicing, his ears perk up and he has something new to try. His conclusion is usually that he has not been administering the drug properly or has not instructed the patients enough on what to do and what to watch for, and he is usually correct. Someone who has not used the drug at all hears the practical tips and suggestions for using the drug successfully, instructing their patients through tried and true patient educational materials pioneered by the experts, and is usually much more comfortable trying the drug. Paradoxically, even hearing about side effects and adverse reactions and how they were handled is also reassuring. If the person who was using the drug successfully is an expert—a clinical investigator for instance—the case for using the drug is that much more compelling. If a typical practitioner corroborates the successful experience, the non-users will know that the drug also works out in non-expert hands.

Remember, physicians want the drug to work. To you it is a product. To them, it is a potential tool, a successful outcome, an actualization of their professional goals. They want another tool in their armamentarium. While they necessarily are strongly skeptical in order to protect their patients, they are also intensely hopeful that a drug will work out.

Gradually, over the years, Ron and I realized that we had harnessed word of mouth. It was now a medium, called word-of-mouth teleconferences, which would go on to create some of the largest sales jumps in pharmaceutical history. But at the time we did not fully understand its power, or how to optimize it. That took another couple of decades.

That’s what I’d like to summarize now.

Just how powerful is word of mouth? Why is it so powerful (the answer seemed obvious, but wasn’t), how can it be optimized, and how can we take full advantage of its power?

If you let me explain this in some depth, I promise you that you will be able to apply it to the real world with much greater effectiveness, yielding measurable sales results.

Just how powerful is it?

The average physician sees more than 500 commercial messages a day on average: journal ads and radio/television commercials, Web banners, e-mail spam, commercial messages in newsletters, salespeople, brochures, etc. A trip to a medical conference will often yield several thousand exposures a day. A single magazine or medical journal will yield dozens. How often does a physician act as a result of a commercial communication? Once every several days or weeks. In other words, after seeing many, many thousands of commercial communications. Even then, it is usually triggered by a decision he or she has already made as a result of talking with colleagues, consulting a local specialist, or distilling information from the literature.

How often does a physician act as a result of a recommendation of a respected colleague or trusted expert? We have learned from extensive feedback that physicians act about once out of every three times. So we are talking about a ratio of many thousands to a handful. So, word of mouth is between hundreds and thousands of times more powerful than conventional marketing!

This analysis, of course, completely ignores the quality of the action taken. A commercial communication usually results only in finding out more information, usually from noncommercial sources such as word of mouth. A word-of-mouth interaction is much more likely to result in the physician actually trying, adopting, and advocating the product. The analysis also ignores second-order word-of-mouth effects: colleagues who pass the word on to colleagues, who pass the word on to their colleagues, and so forth. This is an especially important issue in this current climate, where doctors are teaming up into large practices to increase their leverage with the managed care organizations. This tendency toward mega mulitispeciality practices multiplies the effect that word of mouth can have because physicians now have even more opportunity to communicate.

When we first realized this, we were stunned. This means that your entire sales force making calls for an entire year may not be as effective as one trusted expert recommending your product at a conference. A few word-of-mouth teleconference seminars may have greater and faster impact than your entire month’s or even year’s advertising!

What about the widely held belief that it takes about 6 to 10 sales calls to get a doctor to prescribe a drug? It is an illusion. The salesperson is reminding the physician about the drug, giving some information and perhaps stimulating some curiosity. In between the sales calls, however, the physician is talking with colleagues, or reading journals, or attending conferences. It is this independent third-party input and corroboration that really convinces the physician to change his or her prescribing habits. At some point, the decision is made and the salesperson comes in with samples that the physician now decides to accept and give out with a prescription. The salesperson walks out on Cloud Nine thinking that he has convinced the physician.

By the way, in case you are wondering, we are not advocating the abandonment of salespeople and advertising, although both are becoming dramatically less effective. But we are advocating their use for the things that they are effective at:  Providing initial information, samples, and opportunities for physicians to connect to word of mouth channels and programs.

Why is word of mouth so powerful?

Word of mouth is more credible than your most sincere salesperson. It is able to reach more people, faster, then advertising, direct mail, and even the Internet, because it can spread like wildfire. It breaks through the clutter and the noise better than anything:

“Even those deaf  to the bragging cries of the marketplace will listen to a friend,” as the world’s most successful dentist, Paddi Lund (also a brilliant marketer who you can read about in my book) put it.

Even more important than its credibility, reach, speed and ability to break through the clutter, is its ability to get people to act. In study after study of physicians, word of mouth has been shown to be what is known as the proximal cause of prescribing — the most recent thing that happened just before the first prescription was written. In other words, the prescribing trigger.

So how then do we harness word of mouth?

Not so fast. First, there is a lot more about this strange and powerful force than is generally understood. We have to know the nature of the beast before there is any chance of capturing it, taming  it, harnessing it, and directing its power. Then, and only then, can we learn how to speed it up, change its direction, and turn it into a stampede toward the product.

Stalking the beast: what is this strange creature?

Word of mouth is one of those things that everybody thinks they understand, yet realize soon that they are talking about a different part of the elephant.

By “word of mouth” we  mean informal communications about products, services or ideas between people who are independent of the company providing the product or service, in a medium independent of the company.

In contrast, advertising is a communication of a message that you originate, in a medium that you own or rent. A sales message is a “company line” delivered by a representative of the company. Word of mouth is originated by a third party, transmitted in a way that is somehow independent of the party being talked about. So in word of mouth, both the message and a medium are perceived to be independent. In that sense, good public relations is actually one form – by no means the only form – of word of mouth. Other forms are: personal discussions among peers or with experts, teleconferences, e-mail, conferences, rating and advisory services (such as the Medical Letter), Website discussions, list groups, and on-line rating services. One of the key elements here is the fostering of people-to-people communication, over the traditional one-sided reliability on passive absorption of information that is disseminated by the company.

What makes word of mouth so powerful?

It is this independence that gives it much—though, as we will see later, by no means all—of its power. If you ask most people why word of mouth is so powerful, they will tell you that it is because of its objective, independent, “no axe to grind” nature. Why is that so important? Because a decision maker is more likely to get the whole, undistorted truth from an independent third party then someone who has a vested interest in promoting your point of view. It is this unique credibility that gives word of mouth much of its power.

That explains why unsupervised word of mouth is often negative. It is the only place where the decision maker is likely to hear about the negatives of the product. So when physicians ask a colleague about a product, they are likely to ask, “Had any trouble with X?” Because they know that it is the only source of information where they are likely to get a straight answer.

So word of mouth can be a positive force because of its credibility, but often destructive because of its negativity.

The unknown reason why word of mouth is so powerful

But there is another reason why word of mouth so powerful. This reason is even more important and useful than word of mouth’s independent credibility. It takes some explanation.

When the physician is deliberating about prescribing a product, he reaches a point where he wants to try the product. Why? He wants to get real world, but low risk, experience in his situation. Up until then, everything is abstract, somewhat removed from the real world. He has to know how the product “will actually work out in the real world.” He needs experience.

There are only two ways to get experience: directly or indirectly. Now you would think that direct experience—actually trying the product—is the best teacher. But it is the most costly in time and risk of failure. Also, the physician cannot afford the time and risk to try a new product directly too much, so his sample tends to be small.

Indirect experience—that is, hearing about other physicians’ experience—is actually much better in many ways: someone else is spending the time and taking the risk. The physician can pool the experiences of several other physicians so as to have a greater sample. If the trial fizzles, their reputations are damaged, not hers. Its actually a way of trying a new drug on some other physicians’ patients”

All in all, indirect, vicarious experience is the better deal. Of course, it is not an either/or situation. The physician might try the product a little herself and also talk with others.

Talking with others about the product, comparing experiences and helping each other sort it out is one form of word of mouth. In fact, it is the most powerful form of this most powerful marketing force. It happens just at the point of maximum involvement, just when they are thinking about trying the product, just when they are making their crucial decisions about the product: Will it work? In my situation? Should I make a major commitment here? How should I interpret any negative experiences?

To summarize: the thing that gives word of mouth most of its power is the fact that it is an experience delivery mechanism. And it is successful experience that triggers trial and adoption behavior more than anything else.

It is experience that salespeople and advertising are least equipped to deliver. All they can do is pass along secondhand hearsay (an interesting word isn’t it?).

Let me give you a quick example. Let us say a new drug comes out which holds considerable promise. Physicians see ads, talk to the salespeople from the company and may even read the studies. That is how they know that the drug holds promise. But how do they know it will work out in actual practice? How do they sort out the conflicting claims made by the competition? They try it on a few patients who have not responded well to existing drugs. These, of course, are the patients on whom the drug is least likely to be effective, but it is easiest to justify trial in these cases. Physicians typically try a drug on about five of these refractory patients. One gets better, one stays the same, one gets worse, one has other possibly unrelated complications, and one moves to Florida.

These results are uninterpretable, so he has to wait for five more low risk situations in which to try the drug. This typically goes on for years, until enough experience accumulates so that physicians can talk with each other and share success stories, tips, and suggestions for coping with problems, and other experiences that make the pool large enough for physicians to form reliable opinions. Then, and only then—after a few years have elapsed—the chain reaction reaches critical mass and explodes into enough word of mouth to cause to drug to grow rapidly into full usage, sometimes in a matter of months.

It is the time it takes to accumulate enough favorable experience—and to communicate that experience—to make a reasonable decision that determines a product’s success and the speed with which it is accepted. It is the content, speed, and sources of word of mouth that mediate the process and act as the accelerator or brake on the speed of adoption.

So, to summarize: speed of experience gathering determines the speed of product adoption. Word of mouth determines speed of experience gathering. Therefore, word of mouth determines speed of product adoption.

Other reasons why word of mouth is the most powerful persuader in the marketplace

There are some other reasons why word of mouth is so powerful. Even though you already know most of them, seeing them all summarized in one place will probably make you realize why word of mouth is even more powerful than most people recognize. Space restrictions only allow me to list them. They are fully explained in the book.

• It is more relevant and complete.
• It is the most honest medium.
• It is customer driven.
• It is a mysterious, invisible force that determines if your product will live or die.
• It feeds on itself, like a breeder reactor, and eventually explodes or fizzles.
• It is unlimited, spreading far and wide without inherent limits.
• It sometimes takes only one influencer to start a stampede.
• Word of mouth becomes one of the product’s attributes (e.g., the one that [fill in your favorite expert] uses, recommended by …)
• The source of word of mouth is extremely important.
• It is spread most rapidly spread through opinion leaders to their spheres of influence.
• Word of mouth saves time and money for everyone — healthcare professional, company and patient.

Examples of word of mouth programs and campaigns

Products are routinely made or destroyed by word of mouth. Some examples:

Laradopa®: the story of L-Dopa had enough drama to inspire a film, Awakenings. No surprise then, that it stands as an extremely powerful word of mouth case study.

At its inception, Laradopa was viewed with high hopes by the medical community. It promised to remedy dopamine deficiency that was causing devastating effects in the brains of Parkinson’s disease sufferers. As with many “miracle drugs” however, there was the problematic issue of side effects.

Word of mouth threatened to destroy this product before it had barely gotten off the ground: the scuttlebutt among physicians was that the side effects of L-Dopa were far worse than the symptoms it was meant to treat. Sales plummeted to one-fifth of their previous level.

Hoffman La Roche engaged me to develop a program teaching physicians how to use the drug effectively. Physicians’ negative word of mouth was revealed through focus groups. Then, group seminars with a prominent neurologist determined how physicians could learn to put L-Dopa to good use.

Through teleconferenced seminars, doctors were taught that all they needed to do was fine-tune the dosage and the promise of the drug would be fulfilled. Sales of L-Dopa jumped more than tenfold. There had been four competing manufacturers in the market, prior to our sessions. Two of them pulled their product off the market, reeling from the aftershocks of the powerful seminars.

An antibiotic: in this case, Market Navigation’s teleconferenced word-of-mouth seminars were used to transform a superior, but unheralded product, into a dominant market force. A new class of antibiotics was introduced. The first version of this antibiotic to reach the market was extremely successful. It seems that physicians were simply too comfortable with the existing drug to bother switching to it, taking an “if it ain’t broke, don’t fix it” attitude. They had not been swayed by the improvements offered.

That all changed when Eve and I implemented word-of-mouth seminars and doctors listened to four clinical investigators who explained the new frontiers in antibiotic use, and why the benefits of the drug were so important. It took the word of the mouth of respected professionals who included leading experts and clinical investigators to move the doctors into action, and the product into its rightful position as the market leader.

An anti-ulcer medication: Gastroenterologists were favorable towards this superior anti-ulcer and heartburn medicine. They knew it worked well, but a prominent “black box” warning in the prescribing information gave them cold feet. What they needed was a positive signal from the most influential experts in the field, giving them the green light to use it.

Eve and I conducted a series of teleconference seminars with the most respected and influential specialists in the country, together with world-class clinical investigators. The information that came from these sessions convinced enough physicians to be a major factor in setting into motion the largest sales jump in pharmaceutical history. The numbers exploded from 300 million dollars to 1.3 billion dollars in a few months, and continued from there.

For thirty years, the approach I’m describing has caused multifold, record-breaking sales jumps in for many dozens of pharmaceutical products. But we have only understood the extent and reasons for its power in recent years.

What word of mouth can teach us about the rest of direct marketing.

As you can see, we tend to approach all marketing from the perspective of word of mouth and how it can accelerate the decision process.

It is what will go down the word of mouth channel—and be amplified by it—that should drive advertising and sales, not the other way around. This is a paradigm shift. It is the Copernican Revolution of marketing: Traditional marketing revolves around word of mouth, not the other way around.

We are suggesting that you keep whenever orientations and perspectives have worked for you in the past, such as advertising and/or sales perspectives. In addition, however, we urge you to look at all of your marketing as a word of mouth generating system. If, for most products, it is the word of mouth that triggers the sales, is it not important to look at what triggers the word of mouth? What if all elements of marketing, such as sales, advertising, direct mail, etc., were not oriented toward directly persuading people to use the product? Instead, what if all your marketing elements were organized around causing people to talk about the product in a way that would get them to use more, and get their friends and colleagues to use more?

Sometimes the “long way ‘round” can be the fastest. In fact, we would argue that going after word of mouth directly is not the long way around. It is what happens anyway: marketing leads to word of mouth, which leads to sales. Why not try organizing and integrating everything around word of mouth, since it is the central part of the mix?

There are many ways to accomplish this, such as word-of-mouth seminars, some high quality dinner meetings, customer advisory groups, experts roundtables, sponsored conferences, courses, sponsoring of clinical research, web sites, CD ROMs, discussion groups, list groups and many others. There are even ways to use advertising and the salesforce to encourage and spread word of mouth.

You’re probably saying, “But we do all these things already.” But these techniques, and dozens of others that can trigger massive amounts of word of mouth, are usually used piecemeal. They need to be organized into a systematic campaign, so that each element supports and is additive to each of the other marketing components. The campaign should be organized around a deep analysis of the decision process, where the barriers and friction points, and what specific word of mouth is needed to open the floodgates.

How to harness word of mouth.

Here’s how you do it: 

• Systematically analyze the decision processes of the various decision makers in your marketplace.
• Lay out the stages and steps they go through in making an adoption decision.
• Simplify: Find the friction points, bottlenecks, obstacles and barriers that slow down people in this process.
• Use your armamentarium of word-of-mouth techniques to specifically blast through these bottlenecks to make the right decision simple, easy, fun and fast.
• Build another factory to handle your increased sales.

What we are urging you to do is to consider a total, systematic approach. What if all parts of your marketing were focused singlemindedly on one goal: getting people to talk favorably about your product in ways that address your most serious sales barriers? When you look at a marketing system from this perspective—as a word of mouth generation system—you will see it in a whole different light that reveals many opportunities.

For instance, as you look at your marketing communications, you will see elements that could not possibly generate word of mouth. Or, if generated could not survive from one person to another. You will see how truly boring your promotional pieces really are. Who would want to talk about what you are telling them? Most pharmaceutical communications are either completely uninteresting to the physician, or unconvincing. Most messages from salespeople are tolerated in order to get samples.

The pharmaceutical industry is still essentially promoting their drugs the way they did when George grew up in the 1950’s and 1960’s in his father’s drugstore: Giving doctors the “details” about drugs they had never heard of or new details about existing drugs. Hitting them time and time again, repetitiously with the same message from ads and salespeople. Increasingly, doctors and patients are much better informed and have access to better information than “details.” Direct to consumer advertising attempts to respond to the recognition that patients want to be better informed, but what are you doing to increase word of mouth among consumers? What are you doing to motivate and enable your high writers to convince colleagues to avail their patients of the superiorities of your drugs, and the patients to tell others?

Wake up. This is the age where many people in your marketplace know more about your drug than you do. And they’re talking with each other through a variety of means. Are you actively participating in the loop?

We cannot even begin to give you a flavor for how many more opportunities could be gained, and how much more effective most marketing mixes could be made if they were viewed from the perspective of word of mouth. It is routine to be able to increase sales multi-fold (yes, 2-5 times!) by making word of mouth the center of your marketing efforts, rather than a serendipitous byproduct.

How can it be optimized? How can we take full advantage of its power?

A few words of caution: Just as nuclear power is thousands of times more powerful than conventional power, word of mouth is thousands of times more powerful than conventional marketing. Both have the potential of being extremely beneficial or extremely hazardous.

The most dangerous thing you can do is to introduce blatant advocacy into any kind of word-of-mouth event. Remember, people are talking with their colleagues and trusted experts in order to get objectivity, fair balance and unbiased information. Many word-of-mouth seminars whether they are teleconference seminars or dinner meetings, are thinly disguised sales pitches. Either a representative of the company or an expert delivers the “party line.” This can cause a momentary blip in prescribing behavior, until the next company comes along and buys the physician dinner.

We caution you to apply these methods to products that are genuinely superior, or superior for a particular indication. If not, your efforts will be either ineffective or will backfire. People will feel manipulated and violated (with good reason). Contrary to popular opinion, marketing is not about manipulating people. It is about putting out the best possible product and helping your customers come to the best possible decision.

We believe, looking back on a 30+ year career in the pharmaceutical industry, that we have reached a “tipping point” in this industry that we love so much. Either the pharmaceutical industry is going to continue to waste outrageous and increasing amounts of money in extravagant, inefficient — notice, we are not saying “totally ineffective”— marketing and get further regulated. Or it’s going to take the lead and become champions of the truth, actively participating in health-care professionals’ and patients’ information exchange, using word of mouth to efficiently and responsibly bring the wonderful advantages of its products to those who can most benefit from them. Your choice.

George Silverman is President and Founder of Market Navigation, Inc., Nanuet, NY, (www.mnav.com)  a word of mouth marketing consulting company. He has written “The Secrets of Word-of-Mouth Marketing: How to Trigger Exponential Sales Through Runaway Word of Mouth” AMACOM, Spring 2001, and “Speed THROUGH Market: How to Dominate Your Market by Helping Your Customers Move Faster,” (Publisher and dates now being finalized).

Ron Richards is President of ResultsLab in San Francisco (www.resultslab.com), a company that specializes in multiplying the results of web site

The Secrets of Word-of –Mouth Marketing; How to Exponentially Increase Your Sales through Runaway Word of Mouth,” AMACOM.  Click here to view on Amazon.

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