Pharma-sponsored medical education has always been about much more than just education, yet with greater transparency, changing learning styles and increased influence of expert patients, what does the future hold for pharma's wider interactions with healthcare professionals?

Medical education serves a whole host of purposes, says Kirsty Mearns, chief business development officer at healthcare communications agency Havas Just::. "At its simplest form, it is a cascade of information that can be about a medicine or more widely about a therapy area or where medicine fits in the treatment journey. However, for me, medical education covers so much more ground; it's about making connections with customers."

Alan Sumner, head of corporate affairs at Boehringer Ingelheim UK has seen med-ed evolve over his career. "When I began as a sales representative the relationship was very one-directional and transactional, but the customers I meet now are looking for solutions to their challenges. We know that it is important to align ourselves and have the right people on the ground to understand the environment our customers are working in and to work together to identify challenges and tailor solutions that are beneficial to customers and patients as well as to us, as a company. This is a major change."

Another major change has been increased use of remote, on-demand and e-learning approaches, says Sumner's colleague at Boehringer and head of customer marketing, Paul Dunesky. "The format has evolved; traditional, face-to-face, real-time settings are now being complemented and enhanced by medical education on demand. We know how important it is to the customer to have education that is convenient. These are exciting times as we expand the way we think about how we provide content and present options to our customers."

Yet this trend, combined with the challenges thrown up by greater transparency around 'transfers of value' to HCPs, has created a problem, says Mearns. "In the traditional approach to med-ed, you have people in a room making and listening to presentations but the most valuable elements are the face-to-face conversations with customers that really help our clients understand their customers' working environment. With the changes we are seeing in the industry, we risk losing this connection with our customers, the healthcare community. If you stop having a conversation with someone you cease to understand their point of view and, in the long run, that would limit innovation and lead to the solutions that pharma offers being less meaningful to customers."

The answer to this issue is a long-term approach, says Dunesky. "It all comes down to providing options to our customers and an acknowledgement that face-to-face contact points only make up part of the overall experience around education. We must move away from the transactional, one-event or one-activity model. Just because someone has chosen an on-demand or digital solution, that's not to say you won't meet his or her needs with a face-to-face setting in the next instalment. It's human nature to want to keep your options open and, ultimately, if I've received education that enhances my experience with a company, I will feel satisfied."

Expanding the remit of medical education is essential, says Mearns. "I've worked on big medical education programmes where the emphasis was not on product but on patient pathways and soft skills training. By moving away from product, the conversation becomes richer and focused on how to manage a disease or condition in a much more collaborative way. This builds loyalty and leads to benefits such as improving access."

In the ever-shifting sands of healthcare, companies must always strive to find new ways of working, says Dave Hunt, chief executive of global healthcare communications group, Havas Lynx. "As an industry we need to be much more innovative, more creative. If you look at the ways that companies like Starbucks or Airbnb do things, they haven't just said 'let's choose another channel', they've completely shaken up their business model to deliver the service their customers need. In medical education, if that means we need to build healthcare professionals' capabilities, then that is what we should do."

Hunt points to other examples of innovative ways of working. "I came across the Khan Academy when I was looking for schools for my son. They invert the way people learn – rather than sitting in class learning a new topic then going home to do your homework, the homework comes first. By learning a subject in your own time in advance, it maximises your interaction with the teacher in the classroom, and you can start to interrogate a subject, debate it and really get to grips with it. That's how we should be approaching HCP education."

A popular example of a ground-breaking scheme in healthcare is Novartis' Crowdshaped, which won a host of accolades at the 2016 Communiqué Awards. "It was like a hackathon in COPD," says Hunt. "It brought together HCPs, patients, technologists, engineers, etc., to generate innovations to solve the challenges COPD patients face. It was not strictly a medical education initiative but it was phenomenally educational for the clinicians who took part."

Mearns agrees. "It was a fantastic example of industry partnering with clinical and patient communities to find practical solutions. It was looking at an entire disease, not just a single medicine, asking what unmet needs patients had and crowdsourcing ideas, even involving the patient community in assessing the outcomes afterwards. I sat on the Communiqué panel that judged one of the awards and it was the immediate and unanimous winner. We all thought it was the kind of programme we all should
be doing."

Soft skills

For Sarah Strachan, sales and marketing director at Hayward Medical Communications, with the rise of empowered patients and a cash-strapped NHS, healthcare professionals need even more from pharma. "We have been talking a lot about therapy-specific medical education and that's how the NHS is carved up and how pharma companies are structured, but there are programmes that transcend these silos. We know there is a huge problem around how HCPs engage with patients; they need good communications skills, they need to know how to ask open questions in order to widen the conversation, they need to know how you get that incredibly valuable piece of information the patient might not normally mention until they've got their hand on the doorknob leaving the consultation room. That needs to be part of the conversation earlier but doctors don't always know how to get that conversation going."

Only by empowering doctors can patients become empowered, says Hunt. "We talk a lot about the importance of a patient's subjective well-being, about their ability to get to grips with their condition and getting to a position where they can fight it. That starts with the interaction with the HCP, with empathy and sensitivity and the skills needed to ensure the messages are delivered effectively. Everything we do as an agency is aimed at improving patient outcomes – if building capabilities in empathy and sensitivity supports the treatment and recovery of patients, and improves outcomes, then it also drives commercial success."

Yet, in Mearns' experience, it can be tough to convince some companies of these links. "There is a disconnect between doctor and patient, and this is a big opportunity for everybody. But, if you tried to design a medical education programme around that, it would struggle to get through compliance approval because it's seen as a value-added service that has a transfer of value attached. The bigger picture can get lost in the detail, which is very frustrating as everybody loses. We need to try to look slightly outside the box but this frightens some people, who can always find ten reasons not to do something."

Healthcare professionals also need help building other capabilities, says Hunt. "It is no longer enough for them to just be experts in science. If we really want to push boundaries, we need to start building their capabilities when in tech, innovation and social. We have so much data emerging from patients in their interaction with their devices, information that could be incredibly informative when it comes to diagnosing and treating patients, but I'd be surprised if the broader healthcare community has the skills to make the most of that data."

How that capability-building education is delivered, however, also needs to change, he says. "We now have two types of HCPs. We have those who have lived through the digital revolution, who operated, educated and existed before the internet and the emergence of the digital technology. We also have people who have lived with a digital evolution, for whom digital is second nature, Millennial HCPs are digital natives and the way they learn is radically different. Their homework buddies are not their friends, they are Google and Wikipedia. The way they absorb and digest information is vastly different and we need to be much more cognisant of this fact when delivering medical education."

Disclosure dilemma

It is impossible to talk about medical education without the conversation inevitably turning to disclosure, especially the new requirement that pharma companies declare all 'transfers of value' to healthcare professionals. Yet, opinions vary on what the impact has been and
will be.

Hayward's Strachan has seen first-hand the impact on both pharma and HCPs. "On the NHS side, people are thinking more about whether to get involved with education programmes; they are more likely to discuss it within their organisations, even if it is in their own time. Pharma's response has varied but some have taken it to the extreme, stopping all funding for HCPs to speak and attend meetings, which has lessened the motivation for some HCPs to get involved."

Havas Just::'s Mearns has also seen the impact. "When it all started, there were some KOLs who were working with a lot of companies who started to say no, that they couldn't be involved, while others said they would do it for free because they didn't want their reputations clouded by a perception that money was the motivation not education. However, outside that top one percent of doctors, the people at the very top of their field, it doesn't even feature on their radar so it's not having an impact."

From the client side, Boehringer's Sumner welcomes transparency. "We hope that more HCPs will choose to disclose their payments in the future and we do everything we can to encourage that. My hope is that we will have a completely transparent relationship with HCPs, open for everyone to see because it's not something we should be shying away from, it's something we should be proud of. The work
we do with HCPs makes patients' lives better."

Yet his colleague, Boehringer's therapy lead for diabetes, Dr Will Spencer, predicts even stricter regulations to come. "For me it's too early to say what will happen next because there is a general lack of awareness among HCPs. Where is it going to go? Although I have no crystal ball, I wouldn't be surprised if there was a trend towards more guidance and directives from regulators. Whatever happens, this is a reflection of where we are as an industry and we have to work with it rather than against it."

Havas Lynx's Hunt is more bullish. "I couldn't be more of an advocate for complete transparency. When you pull down the shutters and start not being transparent, that's when you start to raise questions. And why? I'm incredibly proud to work in healthcare communications and I believe that what we do makes a difference to people's lives. I don't understand why the industry would have a chip on its shoulders about paying scientific leaders to talk about their subject of expertise. It's absolutely fair that they are compensated for their time given the years they have spent becoming an expert."

For some agencies, client companies are still too risk-averse. "What I'm hearing from some clients is that they are starting to realise that they have slightly shot themselves in the foot," says Mearns. "By trying to be whiter than white, and finding new models of education, they have lost the relationships and their understanding of their customers. Now they are coming to us to ask how they can get that back."

Agencies and clients need to act fast to make the most of emerging opportunities, says Strachan. "The NHS is so strapped for cash and at such a low point in terms of investing in its workforce that this is a fantastic time for the industry to be more involved in medical education. I wonder if we need an honest broker, an independent body that sits between the industry and the NHS to make everyone feel more comfortable. I don't think it exists yet; the ABPI is seen as too pharma and NHS education programmes are too NHS-focused. This could be an opportunity for medical education agencies if they can broker a new arrangement that all stakeholders can trust."

Trust, perhaps, holds the key, and pharma's reputation is rising, says Sumner. "The word trust is very important for where we're at right now. Looking back over the time span of medical education, when I first began there was far less trust in the information we produced and there is nothing more important in providing information than trust. If it's not from a trusted source then it's tarnished information. Today, there is far greater trust of pharma."

Yet, dispelling mistrust takes time, says Mearns. "The companies that produce medicines are world experts in them but they are not impartial and they can't provide a completely impartial viewpoint. Reputation is key and there is a huge opportunity for us to enhance reputation by working in partnership to improve the lives of patients and the efficiencies of the health system. We cannot overcome mistrust overnight but we should rise above it and be confident, brave and bold. We should stand up for ourselves and say what we think is right."