Key Opinion Leaders
I would give them all the information that I wanted them to talk about. I would give them the slides. They would go through specific training programs on what to say, what not to say, how to answer to specific questions, so that it would be beneficial to my company.— Former sales representative (quoted in Moynihan 2008: 1402)
The term “key opinion leader” descends from work on structures of influence in such domains as politics, fashion, culture, and medicine, by the sociologist Paul Lazarsfeld and his students (e.g., Katz and Lazarsfeld 1955). As the term itself suggests, pharmaceutical companies engage key opinion leaders (normally “KOLs”) primarily to influence others, to lead opinions in the directions that the companies prefer: KOLs are key mediators between pharmaceutical companies and physicians. For this reason, relations between the companies and KOLs are ideally, from the point of view of the companies, part of general “KOL management” (a standard phrase) plans.
There are different kinds of KOLs. High up in the ranks of prestige, and paid accordingly, are researcher KOLs. These are usually academics with significant research profiles, whose value to pharmaceutical companies might stem from any number of activities. As discussed already, they might be engaged by publication planners to serve as authors on medical journal articles stemming from company- led research. In addition, they might contribute to research by recruiting patients for trials, by responding to invitations to conduct trials on specific topics, or by initiating their own trials. They might be consulted on any of medical, marketing, or research issues. And finally, researcher KOLs are often paid to speak to other researchers, patient groups, or to physicians at continuing medical education sessions, with the eventual goal of increasing sales. One speaker at a 2012 meeting on KOLs, enthusing about a new approach to network analysis, says, “So it’s really very, very interesting and starts to give us the tool and the power to be able to actually look at these network maps and start to think about the implication in terms of the things that we are doing commercially.” A marketing firm writes in overview: “Interacting with qualified investigators, physicians experienced in regulatory reviews, well-known and respected speakers, and highly published authors will help to efficiently manage tasks within the critical path of the product and disseminate the message of the product to the end prescribing audience” (InsiteResearch 2008).
These well-known physicians and researchers are not usually hired simply to present a company’s script but are chosen and/or brought on board with care. Independent agencies identify KOLs who could serve the pharmaceutical companies’ needs and may design communication plans for companies to build relationships and knowledge with their prospective collaborators. The KOLs are nurtured through seminars, close contact, advisory boards, and publications.
At lower levels of prestige, but equally valuable to pharmaceutical companies, are ordinary physicians, either general practitioners or specialists, who are paid to speak to other physicians. They become part of the “speakers bureaus” for particular drugs and give talks in clinics over lunchtime or after dinner, with other physicians assembled by sales representative around a buffet lunch or a pleasant dinner (Reid and Herder 2013). More occasionally, they may speak at community events, again organized by sales representatives. In this context, KOLs effectively become salespeople, as well as conveyors of scientific information: according to a Merck study, the return on investment from KOL-led meetings with physicians was almost double the return on meetings led by sales reps (Hensley and Martinez 2005). It is common for drug companies to measure prescriptions before and after KOLs’ talks—companies buy prescription data from health information services companies, which buy it from pharmacies—and they expect an increase (Moynihan 2008). One marketer speaking at a 2012 conference on KOLs essentially defined promotion in these terms: “you have a key opinion leader engagement with a group of doctors, and you measure sales before and after the engagement.”
KOLs do more than sell, though. Both physician and researcher KOLs, but especially the latter, may be engaged for larger marketing activities, paving the way for later sales efforts. For example, they may be engaged first to learn about and then speak on diseases, rather than drugs:
Another common objective...is to educate the marketplace and drive awareness of a particular disease state, mechanism of action, or existing treatment alternatives. A goal within this objective may be to successfully engage with key opinion leaders by completing a set number of advisory boards. (CampbellAlliance 2011)
Marketing involves a full range of activities with the goal of coordinating products, distribution networks, and demand (e.g., Applbaum 2004). With this in mind, pharmaceutical companies might not only want to communicate with physicians and others about their products but also to create awareness of new opportunities and approaches and interest in and concern about particular conditions and to introduce fears about alternatives. For all of such goals, KOLs are excellent conduits.
The marketing company InsiteResearch (2008) argues that the term “KOL management” is the right one for interactions with KOLs. Drawing on a dictionary definition, the company argues that, in general, management should involve “handling, direction, and control,” precisely what is needed to make KOLs effective. Thus a speakers bureau program begins with a training session, to ensure that speakers are well versed in the positive aspects of the product and able to speak effectively about them. For example, Wave Healthcare claims on its website:
It’s vital that advocates are able to communicate and influence colleagues with clarity and conviction. To ensure speakers are at the top of their game, we have developed a communication skills programme for clinicians. (Wave Healthcare 2011)
Another such firm, KnowledgePoint360, which owns Physicians World Speakers Bureau, offers programs for training speakers, and its promotional material appears to treat KOLs and employees in the same terms: “Whether it is for external resources, such as speakers, or internal staff, including sales representatives and medical science liaisons, a robust training program is critical to the long-term success of any pharmaceutical, biotech, or medical device company” (KnowledgePoint360 2010; see also Carlat 2007). Pharmaceutical companies work with physicians to make them “product champions” and pay them generously for their lectures (Moynihan 2008).
Typically, physician KOLs are nominated by sales representatives, who have a sense of their abilities. Sales reps will know “what’s their stage presence?” argued one company employee making a presentation at a 2014 conference on speakers bureaus. They will also know if “he looks good in a tie,” suggested another pharmaceutical company manager at the same conference—who quickly disavowed that kind of recommendation, because it doesn’t relate to the KOL’s knowledge or communication skill and so might be looked at askance by regulators.
Though physician KOLs’ main role is to communicate facts and views to other physicians, with the goal of increasing sales, pharmaceutical companies might sometimes recognize the value of having speakers who are also customers. One company manager, addressing the audience at a 2011 KOL management conference, raises the specter of an investigation of a speakers bureau program: “When you say ‘I need 700 to 1000 speakers in this activity’, the questions [that are] going to get pushed back to you in investigations are, ‘Why do you need so many? How many is each speaker going to do? Why did you need a thousand?’” His concern here is that investigators will conclude that speakers’ fees are inducements to prescribe or payments to receive (rather than transmit) advertising messages. That would constitute illegal marketing.
After physician KOLs have been trained, they become part of a speakers bureau for a company and wait to be offered engagements. As already mentioned, sales representatives handle all of the details: transportation is arranged, the time and place are set, invitations are sent and resent, and the equipment is set up and the food laid out. All that the KOL has to do is to make the presentation. Most of the time, that is straightforward. In the USA, speakers are not permitted to adjust the prepackaged PowerPoint slides or to deviate from their scripts when doing what are known as promotional talks, the bulk of the engagements. Says one psychiatrist, who earns large sums in speaking fees:
So if I am doing a promotional program for a company, I have to use the slide deck that they provide me—I am not allowed to alter it in any way and every word in that slide deck is basically reviewed by their own internal counsel... .
In addition to the slides and the scripts, answers to standard questions also are scripted, and speakers are trained not to answer any questions in ways that might either be illegal or run against company interests.
The KOLs are sometimes aware that they are being used by pharmaceutical companies, though they find ways to defend their actions. One endocrinologist interviewed is quite critical of the industry and especially of its role in promotional talks, though he gives them regularly. “The reason for giving the promotional talks is to help the company sell its drug—I mean that’s basically—that’s what a promotional talk is.” A hospital-based hematologist echoes this point but manages to find educational value despite the problems. “The honest answer is that promotional talks are not really for educating so—and I give plenty of promotional talks—... but some speakers are better than others at bending it into an educational talk.” The value of their work in terms of education is echoed by others. Every single one of the KOLs interviewed for this project invoke education as a reason for speaking on behalf of companies, even when they are doing purely promotional speaking. In interviews, KOLs take pride in their teaching, and teaching is how they frame even promotional talks. “I am educating fellow physicians. I spend my day educating patients, I spend some of my evenings educating fellow physicians,” explains one.
But in this context, it is the pharmaceutical companies’ preferred messages that are being communicated. As we have already seen, pharmaceutical companies produce large quantities of data, shaped and arranged to support their interests. When KOLs serve as authors on company manuscripts, they give their weight to the establishment of that knowledge in the medical community as a whole. But pharmaceutical companies are not content to let that knowledge sit in medical journals, where it does little good. While there are senses in which KOLs are providing something like education, often involving scientific information, the education they are providing has been shaped and created by the companies for which they are working. KOLs do distribute knowledge.
If done correctly, then, KOL management will spread knowledge, change opinions, and change prescribing habits—which will generate a good return on companies’ investment.