Back in the 1990’s I admit to making a medical cultural
blunder that has remained indelibly etched in my mind. A patient of mine, a Chinese national was
experiencing a high postoperative fever.
Like any well-trained American clinician I followed protocol. I pulled off his blankets, made as many ice
packs I could (OK, they were crushed ice in rubber gloves) and proceeded with
my goal to make his bed equal to winter in Minneapolis. To my surprise, his response was not relief
but horror and sat up and threw all my hard work to the floor. Speaking no
Chinese I could not understand his concern and was further perplexed when he
started reaching for the hot tea brought earlier by his family. It was
only years later when I was researching cultural issues in medicine that I
learned that hot blankets and hot tea are remedies for fever in traditional
Chinese medicine (TCM).
While this experience lasted but a short time and at incurred
little to no obvious monetary cost, there was a blow to the trust between
myself and my patient. This could have
been avoided by more knowledge on such cultural and geographical nuances.
Fast forward 20 years.
Our entire industry is interacting globally. From selling and running trials to mobility
of patients across borders, such understanding of local and cultural mores, practices
and issues is critical for conducting business on multiple fronts. That
said there are various matters that require careful consideration. Most often the focus is on reimbursement and
overall health system issues. Akin to my
own experience with the patient described above, many of these go much deeper
to the institution and individual clinician level. For the past 10+ years, Snowfish has worked
globally with multinational and local companies and have paid special attention
to the micro-issues. When they are
addressed most effectually, this is how companies can make a real difference. Our
experience has identified a number of information tidbits which have proven to
be crucial to the success of global healthcare business.
Learning: Don’t
assume a product used in one country is equally compatible in another.
A major German company with a device used to deliver
intraoperative radiation to treat breast cancer launched in the U.S. with
surprisingly low penetration despite a very successful European launch. The company was clearly interested in
understanding the root cause. With thorough
analysis and comparison of the two markets, Snowfish found that this failure
was related to differences in physician responsibilities, patient flow, as well
as systems in place for intraoperative tumor biopsy and pathology services.
First off, in Germany radiation oncologists were found to
get involved much earlier in the treatment planning process, i.e., before
surgery. Therefore, the radiation
oncologists were far more instrumental in the use of this technology and the
adoption. Alternatively, patients
managed for breast cancer in the U.S. are less likely to see a radiation
oncologist until after surgery. Therefore
most of the decisions about which treatment device falls upon the surgeon, who
is not focused on the radiation component of treatment. Even if the surgeon is supportive of the
particular type of radiation therapy, multiple logistical issues posed by many
U.S. hospitals added additional changes that impeded adoption including the time
to receive the initial pathology report and the overall patient flow. Clearly, three major components were
different, physician targets, pathology process, and operating room flow. The cumulative impact slowed adoption of an
innovative product. Had the company
fully analyzed upfront the various country anomalies the U.S. adoption could
have been smoother.
Learning: Medical specialties do not always translate
across geographies.
For particular therapeutic area knowing the target specialties
to focus upon is not always the same across countries. One example is the specialty of angiology. Referred to as “vascular medicine” in the
U.S, angiologists play a critical role in the treatment of various vascular
diseases in a number of countries including the UK and the Netherlands. Adding to the complexity is for conditions
such as hypertension where in the U.S., clinical cardiology and nephrology take
the lead, angiologists are integral in the diagnosis and management. Furthermore, unlike the other specialties
mentioned, angiology will also perform catheter-based interventions. Even within the European Union (EU) the role
of the angiologist will vary significantly, so much for the EU being one
integrated market. If key specialties
such as these are missed, serious gaps with respect to clinical trial evidence,
product specifications, targeting and KOL engagements will occur.
Learning: Geographic clinician challenges are often
unrelated to disease or reimbursement and need to be understood
A recent project brought us full circle, back to China. Health care reform measures and entry of many
into the middle class have resulted in an explosion of patients into China’s
healthcare system. With this has come
new-found stress for an already over-stretched clinician workforce. Couple that with growing violence against
them by patients and you have a situation that is unsustainable for the long
term. Recent reports have highlighted attacks against physicians and other
health care workers by patients who claim wrongdoing. While it is not clear if these patients are
just misinformed or have unrealistic expectations the results are ultimately
devastating to China’s healthcare system and their patient’s well-being.
There is no simple solution to the situation given other
related challenges such as variability in medical education, role of
government, the disparity between urban and rural environments/services and
prominent role of TCM. Nevertheless, such information regarding the state of
the clinician can be very useful to better ensure more effective engagement and
clinical value delivery.
Conclusion
Snowfish has worked on multiple products developed at the
world-wide level. It is very important
to take into consideration the various factors in the planning stages that could
affect adoption. We have pointed out
critical factors such as varying physician treatment responsibilities, product
design, hospital processes, and cultural issues. A company cannot be complacent and simply
focus upon regulatory, reimbursement and distribution and expect a successful
product launch. A company needs to fully
understanding and assess a country’s micro-environment. To borrow a phrase from a former Speaker of
the U.S. House of Representatives, Tip O’Neill, “all politics is local” I might
add so are successful world-wide product introductions.
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