Pharma Field Force Excellence

FFE 2013 - the annual flagship event of MedicinMan - is less than 7 days away. Two important issues are being called up for discussion this FFE - Business Intelligence and Employee Engagement and their contribution to Field Force Productivity.Engagement of the Field Force lies at the heart of our work at MedicinMan (See MedicinMan May 2013). When employees are fully engaged, they are happier with their jobs and contribute more to the organization. Which is why we have a full panel discussion on the relationship between Employee Engagement and Field Force Productivity at FFE 2013. On the panel are industry thought leaders and long-time patrons of MedicinMan.At MedicinMan, we think we have a good understanding of what Employee Engagement looks like. Over the 20-odd issues released, we have read stories of individuals rising to great heights in their lives and careers because they were meaningfully engaged in their work as Medical Reps and Front-line Managers.Not in the least, our own work in delivering high-quality content and constantly improving the magazine since inception - all at zero cost to the reader - is testimony to what belief in one's vision and mission can produce. Participation by Pharma Professionals at the highest levels of industry in FFE 2013, is an affirmation of our beliefs and work.If you haven't booked your spot at FFE, don't panic, we still have a limited number of seats available. Please go to the registration on page 28. -MM

MedicinManField Force excellence

TM

June 2013 | www.medicinman.net

FFE 2013.Saturday, 8th June 2013 | Courtyard Marriott, Mumbai

http://medicinman.net

OppOrtunities& Challenges

Field Force Productivity:

the #1 learning opportunity for Senior Managers to enhance Field Force Productivity.

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MedicinManField Force excellence

Saturday, 8th June 2013 | courtyard Marriott, Mumbai

1. What the Doctor Wants from the MR..............4Doctors want MRs who are knowledge workers, willing and able to partner with him to better serve his patients.Dr. Aniruddha Malpani, MD

2. The Marks of a True Professional.....................8A True Professional is one who has achieved a high standard of “Personal Quality” in everything from dressing sense to professional knowledge and inter-personal relationships. Rachana Narayan

3. Paradigm Shift..................................................11How Pharma companies can survive and thrive in the New DPCO era.Sharad Virmani

4. The Single-Minded Success of Sachin Tendulkar..............................................................15What Gen-Y can learn from the cricket-or-nothing attitude of the Little Master.RM Saravanan

5. Catch People Doing Things Right ..................18FLMs must proactively engage their team in doing the right things and doing things right. K. Hariram

6. Building Sales Teams from Scratch................21Every team goes through the stages of Forming, Storming and Norming before they can start PerformingAnup Soans

7. Observational Research in Healthcare..........25Javed Shaikh & Shafaq Shaikh

8. Patient Reported Outcome Measures in Pharmacoeconomics...........................................29Mahendra Rai & Nishkarsh Likhar

Contents (click to navigate)

MedicinMan Volume 3 Issue 6 | June 2013

Editor and Publisher

Anup Soans

CEO

Chhaya Sankath

COO

Arvind Nair

Chief Mentor

K. Hariram

Advisory Board

Prof. Vivek Hattangadi; Jolly Mathews

Editorial Board

Salil Kallianpur; Dr. Shalini Ratan; Shashin Bodawala; Prabhakar Shetty; Vardarajan S; Dr. Mandar Kubal; Dr. Surinder Kumar

International Editorial Board

Hanno Wolfram; Renie McClay

Executive Editor

Joshua Soans

MedicinMan Academy:

Prof. Vivek Hattangaadi, Dean, Professional

Skills Development

MedicinMan ChangeMakersSaurabh Kumar

Make a difference in Pharma. Join MedicinMan ChangeMakers. Write in to our editor to find out more: [email protected]

Letters to the Editor: [email protected]

4

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4 | MedicinMan June 2013

What the doctor WaNtS FroM the Medical reP

Dr. Aniruddha Malpani, MD is the Medical Director at Malpani Infertility Clinic in Mumbai.

“

”

Sneaky underhand sales techniques just do not work. Just like you don’t like

pushy salespeople, neither do doctors! if you want the doctor to listen to you,

you need to earn his trust and respect. how can you do this? remember that

doctors are experts. they take pride in their scientific knowledge base. They

are impressed by representatives who are knowledgeable and well-informed.

Many doctors will be happy to use representatives as a valuable source of continuing medical education, but you

need to earn his respect in order to do so.

One of the most challenging tasks for you as a healthcare field force executive is to engage with doc-

tors. Physicians are perhaps the most im-portant component in pharmaceutical sales because they write the prescriptions that determine which medicines will be used by patients. Influencing the physician is the key to pharmaceutical sales and traditionally this was done by encouraging sales repre-sentatives to create a personal relationship with the doctor. Medical representatives call upon physicians regularly, and hope to influence his prescribing by providing drug information, free drug samples, and freebies such as pens and pads. You hope to build a relationship with the doctor, which you can leverage to influence him to write your brand. This is still the prevalent model today; but is broken for many reasons.


What the Doctor Wants from the Medical Rep | Aniruddha Malpani, MD

the good news is that there are now excellent

resources available online, which you can use to ensure you are

well-informed about medical advances . Many

are free – for example, MedlinePlus and google

Scholar. if you keep yourself

updated, you can offer to act as a research assistant

for your doctor. doctors are busy people and may

not have time to search the medical literature

themselves. if you can do this for them, they will see

you as a valuable ally!

For one, many doctors do not see representatives anymore. They feel that they simply eat into their precious time without adding any value to their practice. Thus, I will only see representatives once – and will request them to email me if there is information they want to share with me. If I find it of interest, I will give them an appointment to make a presenta-tion. This allows me to maximise my productivity- and ensures that I don’t waste the representative’s time either!

Sneaky underhand sales tech-niques just do not work. Just like you don’t like pushy salespeople, neither do doctors! Don’t insult their intelligence by trying to flatter them or manipulate them – doctors are not stupid! Sales ploys such as “closing the physician”, “ challenging them”, and “getting them to commit” can turn them off and this is one of the reasons many doctors refuse to see pharma representatives. Don’t damage your relationship with the doctor!

Sadly, most reps have become cynical. They feel doctors respond only to flattery , freebies and in-ducements. This is why they focus on polishing their social skills, in order to try to make the doctor a friend. While this works, this is a very short-term strategy, which is likely to fail over time. Doctors do not consider representatives to be their peers – they will often just treat them as a source of freebies.

How successful a representative you are will depend upon how well you can talk to the doctor. If you want the doctor to listen to you, you need to earn his trust and respect.

How can you do this ? Remember that doctors are experts. They take pride in their scientific knowledge base. They are impressed by repre-sentatives who are knowledgeable and well-informed. Many doctors

will be happy to use representa-tives as a valuable source of con-tinuing medical education, but you need to earn his respect in order to do so.

This is why you need to update your personal medical and scien-tific knowledge base if you want to command the doctor’s respect and attention. How can you do so? It’s important that you take the initia-tive –don’t wait for your company to teach you. If you do so, this is a great opportunity for you to stand out from your peers!

The good news is that there are now excellent resources avail-able online, which you can use to ensure you are well-informed about medical advances . Many are free – for example, MedlinePlus and Google Scholar. If you keep yourself updated, you can offer to act as a research assistant for your doctor. Doctors are busy people and may not have time to search the medical literature themselves. If you can do this for them, they will see you as a valuable ally! Can you help them to prepare a presentation for a conference? Or help them to publish an article in a medical journal ?

Can you do a PubMed search ? Why not ? Teach yourself – don’t expect to be spoon fed . You can always ask your company’s Med-ical Services Dept for help if you are stuck! You can offer to email your doctors with the latest infor-mation. If you become the “go-to expert” in a particular niche, your doctors will turn to you if they want more information!

The doctor should not just see you as a salesman, but as a well-wisher and ally! What value can you add to his life? Can you show him how to use medical productivity apps for his mobile? Can you help him to create his own website? Can you help him to use Facebook and LinkedIn?

“


What the Doctor Wants from the Medical Rep | Aniruddha Malpani, MD

if you invest in educating yourself, the satisfaction you will get from doing

your job well will increase enormously! this will

boost your self-esteem – and as you start to respect

yourself, your doctors will respect you as well.

the good news is that as specialists become busier, representatives are going

to be able to find more opportunities to be of

service to them.

Times are changing – and you need to change with them! Med-ical representative compensation has historically been sales-based: sell more drugs, make more mon-ey. Doctors know a rep is incen-tivized to sell more to make more. However, global leaders such as GSK are aiming to remove finan-cial incentives from the equation. Pharma reps still receive a mix of salary and bonus, but GSK has replaced individual sales targets with new targets measuring the overall performance of the sales team and feedback from custom-ers. This new system also evaluates a rep’s scientific knowledge as well as the ability to communicate that information. Other pharmaceutical companies will soon follow GSK’s lead. How-ever, why wait for your company to do so? You should take the initiative and do this of your own

accord – for purely selfish reasons!

Remember that there is much more to life than just counting the number of boxes of medicines you have sold! You need to be engaged and in order to enjoy your job, you need to add value and believe that you are doing something con-structive with your life.

If you invest in educating yourself, the satisfaction you will get from doing your job well will increase enormously! This will boost your self-esteem – and as you start to respect yourself, your doctors will respect you as well. The good news is that as specialists become busier, representatives are going to be able to find more opportunities to be of service to them.

Start to think of how you can contribute to making the world a healthier place, by helping the doctor to do a better job! -aM

“

MiSSiNg SoMethiNg iMPortaNt?

You can access all past issues of MedicinMan at: http://medicinman.net/archives.

Be sure to SuBScriBe on our website (top-right corner: www.medicinman.net) to stay up-to-date with us.

http://medicinman.net/archives/

http://www.medicinman.net

the most exciting part of the conference: FFe 2013 begins with the ceo roundtable. Pharma leaders have the opportunity to interact freely and set the tone of the event. Participants have the opportunity to interact directly with the ceos during Q & a.

Sujay Shetty,Partner & Lead,Pharma & LifeSciences, PwC.

Shakti Chakraborty,

Group President,Lupin.

Ganesh Nayak,COO & Executive

Director,Zydus Cadila.

Bhaskar Iyer,Divisional VP,

India Commercial Operations, Abbott

hosted by www.MedicinMan.net. organized by Knowledge Media venturz.

www.kmv.co.inHigh-Engagement CME for Brand Building

Presented by:

Facult yLess than 7 Days to Go.

ReGisteR now!

Saturday, JuNe 8, 2013 | courtyard Marriott, MuMbai

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ceo rouNdtable:Field Force Productivity: oPPortuNitieS & challeNgeS

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FFE 2013 REgistRation on PagE 28

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The Marks of a True Professional.a true Professional is one who has achieved a high standard of “Personal Quality” in everything from dressing sense to professional knowledge and inter-personal relationships.

Rachana Narayan is a Trainer at A Menarini India Pvt. Ltd.She has previously worked in Medico-Marketing Dept. at

Torrent Pharmaceuticals.

Let me confess that I am not writing this as an expert in grooming nor do I possess some technical

qualification for the same. Yet, very often I have been suggested to pen down my thoughts on grooming and presentation and making that first impression the best one. Grooming is actually the result of the ethics, habits and discipline that people acquire over the course of many years from their parents, family, friends and learning, that makes them different from others. The degree to which a person varies in their inter-personal and presentation skills depends not only on their educational background but also on the trans-regional exposure a person has received during her/his lifetime.

To me grooming is a very narrow term, that in isolation cannot trigger the desired result. It may lead to grabbing attention but attention without respect may be dangerous at times. So, I prefer to call it ACHIEVING PERSONAL QUALITY, which is a broader term and always leaves room for improvement.

Achieving quality in self, just like in any other product, does not come spontaneously. In fact it needs a lot of understanding, rehearsals, learning from past experiences and eliminating harmful personality aspects. To me, some of those aspects of personality, which will render satisfactory Personal Quality for self as well as others, come from following:

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“

The Marks of a True Professional | Rachana Narayan


1Dressing Sense: Appropriate dressing as per body type and oc-casion is a must to grab apprecia-

tive attention. In professional business settings, it needs to be more orthodox. The more you are covered, the better for you. Dressing should make you feel comfortable and confident. Selection of colours as per skin type is an art and comes with trial. In case of doubt, plain light colours are always best and white and black always tops the list for any skin type. In sales especially, dress-ing has a direct correlation with sales results.

Ornaments and jewelery should be minimal and delicate. Pearl necklaces or gold chains with small diamond pendants give authentic professional look to ladies. One could also go for lightweight imitation jewelery match-ing with dress colour.

2 Gestures: A confident gesture with pleasant smile and good eye contact is the first aspect of

grabbing attention. Openness to other’s thoughts makes a person reliable and trustworthy. It’s always the innermost desire of every human being to be heard and that one quality makes the person Mr./Mrs. Dependable. As per a study, smiling, as a positive gesture of acceptance, has been shown to increase sales success rate by 20%.

3 Personal Hygiene: This is one aspect without which even the highest standards of etiquettes

fail to leave a mark. Cleanliness and good body odor, even though they may not provide any added advantage, will be a big turn-off if neglected.

4Tone of voice: Tone of voice is always neglected but voice modulation helps in creating an

impression that lasts even after the per-son has gone. This is one of the aspects which may help salesmen to create a lasting impression. All good speakers have mastery in this.

5 Communication Skills: As per the research done by Adler R., it has been estimated that 70%

of our time is spent communicating –

writing, speaking or listening. Hence, spending that time judiciously is very important. In order to communicate effectively, Harvard Business Review recommends communication to have three elements: credibility, emotional connection and logic. Communication which instills trust, provides emotional need satisfaction and is backed by logic always stands out and creates a positive image of the person. This also leads to a higher closing ratio in sales.

6 Knowledge: A good image is built on the foundation of sound knowledge. Knowledge

here is not restricted to the product and processes alone. It also includes having command over the language, information about the environment and the customer. Knowledge enhances competency, boosts the confidence and provides the intellect to handle queries efficiently.

7 Personal and inter-personal relationships: It is now a proven fact that it is not only knowledge

but also people skills that take a person to the top. A survey from the Menlo Park done in 2011 found that 48 % of workers be-lieved that being courteous to co-work-ers can greatly affect a person’s career and accelerate advancement. Another research from Harvard University, the Carnegie Foundation and the Stanford Research Institute linked 85% of job success to people skills. Thus, a person without good relationship skills with colleagues cannot achieve success in the long run.In today’s era of social networking, people skills have come to acquire a much more important role. We are nothing but the impression we leave on others. Whether we want or not, we are always in the process of creating an impression about ourselves. There are people judging us and spreading the message that ultimately decides our success with them and in life.Hence, concentrating on the small aspects of PERSONAL QUALITY can create a big impact on life. Joyce Broth-ers, rightly said, “A strong, positive self-image is the best possible prepara-tion for success”. -Rn

We are nothing but the impression we leave on

others. Whether we want or not, we are always in

the process of creating an impression about ourselves. there are

people judging us and spreading the message that ultimately decides our success with them

and in life.


Key Questions for discussion:1. What is the role of business intelligence in enhancing Field Force Productivity?2. can accurate business intelligence lead to an optimized Field Force structure?3. can business intelligence help Field Force optimize physician targeting?

Facult y

buSiNeSS iNtelligeNce For Field Force Productivity

Vikas Dandekar, India Bureau Chief, Elsevier Business

Intelligence

Salil KallianpurCommercial Head -

Classic Brands Center of Excellence, GSK

Dr. Viraj SuvarnaMedical Director,

Boehringer Ingelheim

Ameesh MasurekarFounder Director - AIOCD Pharmasofttech AWACS


8


Presented by:

www.aiocdawacs.com

PaNel diScuSSioN

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Less than 7 Days to Go.

ReGisteR now!

http://medicinman.net/ffe13


Finally the tiger has come out of cage.

The New Drug Policy came into force on 15 May, 2013.

The Government of India, on May 16, announced the New Drug Policy, which brings 348 drugs and 652 formulations in the Essential Drugs List thus reducing their cost by about 25-30%.

What this means for MNC’s & Pharma Majors is:

Ø Volume Erosion

Ø Shrinking Profits

Ø Increased Operating Cost to Sales Ratio

The impact of this price reduction could be around 40-60% for many products promoted by MNC’s and pharma majors in India.

Incidentally all MNC’s and pharma majors have high MRP’s and sizeable volumes for most of their products which fall in these 27 therapeutic segments and therefore they are expected to take a severe hit in turnover and profits.

By conservative estimates, the expected erosion in turnover of MNC’s and pharma majors could be 12% to 20% and the expected erosion in profits around 20% - 25%.

To top this off will be the additional pressure from the pharma retailers where the margins have been reduced from 20% to 16%. This powerful lobby would be pressur-izing Pharma Companies for more freebies to compensate their margin loss.

In recent years, most of the MNC’s and pharma majors have expanded their field force to capitalize by maximizing their volume share of these key brands from rural markets The Rural Markets mainly support these Key Brands.

Now with reduced prices and profits it will become difficult for them to sustain many of these markets.

Sharad Virmani is Vice President, Marketing and Sales at Comed Chemicals and Pharmaceuticals.

[email protected]

how to survive in the New-dPco era.

P r D Ga aM

iS h F TI

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Paradigm Shift: How to Survive in the New DPCO Era | Sharad Virmani

The pressure will also mount on urban markets to compensate these volumes through other products.

Race will now begin to build new big brands which fall outside this list of essential drugs.

Rising operating costs to sales / profits would be the key con-cern.

outsourced Field Force - the New Paradigm.It’s time to change business tactics.

To cut down the rising costs and optimize profits, the best available alternative for MNC’s and pharma majors is to use outsourced field force.

The Advantages of using Outsourced Field Force:

1 Cut Operating Costs: improving market access and pene-tration at lower cost.

Ø Manpower can be employed at 30-40% less salaries com-pared to internal employees.

Ø 20-30% lesser daily allowances compared to internal em-ployees.

Ø Decrease internal headcount. Ø Reduced overheads. Ø Reduced fixed costs.

2 Grow Share of Voice - Increase Revenue:

Ø Promote brands which are in essential drugs list. Ø Parallel promotion of key brands with different brand

names to optimize market share. Ø Target niche segments. Ø Promote matured brands – leaving the company field force

to focus on new products. Ø Target new customer degments – no customer overlap. Ø Promotion at retail counters to maximize gains from brand

equity – capitalizing on the OTC appeal of the product.

3Flexibility for upsizing or downsizing quickly as needed – a Commercialization risk mitigation strategy against future

unexpected events, such as pipeline disappointments, negative FDA action and competitive threats.

4 Eliminate fixed payroll and benefits costs.

5Reduce legal expense and exposure due to the Outsourced firm covering Human Resources issues.

This is the right time for MNC’s and big pharma companies to explore CSO (Contract Sales Force) in India.

The big question is which out-sourced business model to use:1. Regional Franchisees or

2. MNC-managed Contract Sales Organizations (CSOs)

to cut down the rising costs and optimize profits, the

best available alternative for MNC’s and pharma ma-

jors is to use out-sourced Field Force.


Paradigm Shift: How to Survive in the New DPCO Era | Sharad Virmani

regional FranchiseesRegional Franchisee’s are State operators – mainly well-to-do C&F’s.

Shortcomings of regional franchisees are: Ø Infrastructure issues. Ø Cash mobility. Ø Manpower not willing to work under franchisee as they do

not have credibility and national presence. Ø High Attrition rates. Ø Lack of a professional culture and environment. Ø Short-term commitment.

Shortcomings for Companies working with Local Franchi-sees:

Ø Cumbersome multiple window operation with state-wise contracts.

Ø Monitoring from multiple windows is a problem. Ø Resource sharing through multiple points – increased over-

heads costs. Ø Dilution of message.

The Best bet is:

MNc-Managed cSo (contract Sales Force)Benefits:

Ø Professionalism – accountability and commitment. Ø Single contract. Ø Prior experience of managing CSO operations in multiple

countries Ø Single window operation / single command. Ø Confidence and job security of employees. Ø Uniform message. Ø Established infrastructure. Ø Credibility and national presence. Ø Single point resource sharing – reduced overheads for

parent company. Ø Cost economy. Ø Cash inflow and financial security. Ø Long term commitment. Ø Lower attrition rates.

Time has come for MNC’s and big pharma companies to change their paradigms, shift gears and explore the emerging opportu-nity of contract sales force business to leverage business advan-tage and optimize profits. -SV

eMPloyee eNgageMeNt:a NeW ParadigM iN Field Force Productivity.

Facult y

K. Hariram,Former MD (retd.),

Galderma India.

Amlesh RanjanAssociate Director,

Sanofi

Deep BhandariDirector, Marketing and

Sales Excellence, UCB

Moderator:Anup Soans

Editor, MedicinMan

S. MohanGM & Head, Training & Development, Ranbaxy


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Pharma’s Premier Branding Event

“Pharmodeling for healthcare: KaM & Market access” Session lead: Amlesh Ranjan, Assoc. Director, Sanofi

“role clarity for Field Sales Managers to enhance Field Force Productivity” Session lead: K. Hariram, Former Md (retd.), galderma india

Presented by:

PaNel diScuSSioN

Power Session 1

Power Session 2 :

BRAND DRIFTwww.branddrift.com

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I’m sure, there are many talented cricketers but in terms of longevity, records and adaptability to changing needs of the game, Sachin Ten-

dulkar scores over everyone.

How is Sachin Tendulkar able to play for 23 long years with the same intensity? How is Sachin able to have all the world records? How is this master blaster able to adapt to the changing needs of the game? These are questions I keep asking myself. I had received many answers earlier. But today, I had a realization, which transformed me much.

I realized that many cricketers, when they were try-ing to make it to the Indian Cricket Team, probably had a back-up option in their mind. There is a pos-sibility that their sub-conscious mind would have told them – “Play cricket. Do your best to get into the Indian Cricket Team. In case, you miss a career

“if there is no cricket, then there is no life for me.” Sachin Tendulkar’s cricket-or-nothing attitude is what has set him apart from other cricketers.Here’s what Gen-Y can learn from the little Master.

the SiNgle-MiNded SucceSS oF SachiN teNdulKar.

RM. Saravanan is a corporate trainer and author of the books - ‘Reveal Your Genius’ and ‘The Winning Edge. He was formerly

Manager - Training at Chiron Panacea Vaccines.

[email protected] | revealyourgenius.co.in

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The Single-Minded Success of Sachin Tendulkar | RM Saravanan

in cricket, don’t worry, as you can take up a corporate job, since you are well educated or you have an option to take care of your family business.”

Whereas for Sachin Tendulkar, there was no option and his dominant thought would have been – ‘I will play cricket. If there is no cricket, then there is no life for me’.

Since there was no back-up option for Sachin, he could bring an insatiable passion and hunger to his game and that made him one of the most complete batsmen of the century.

Success flows like a waterfall to all gifted players, but the same success will flow like tsunami to a man, who doesn’t have an option of failure in his mind. I realize today that having an option is the first step towards under-utilizing oneself.

It is a fact. Let us see few examples to understand this:

A sales professional, who thinks of only ‘one target’, will invariably achieve, as well as surpass the target compared to the sales professional, who thinks ‘2 targets’ - option 1 and option 2.

A working professional, who thinks ‘I’ll grow in this organization’, will invariably grow in the organization compared to the professional, who thinks ‘I’ll grow here or there or elsewhere’.

An employee, who wants to be an entre-preneur, will be successful in his venture sooner or later if he resigns from his job and demonstrates single-minded focus in his business, compared to a person who continues to be an employee but parallely starts a business and thinks that if he gets success in business, then he’ll quit his job.

An organization, that thinks that it can groom its employees as they are the future, will continue to develop strong professionals and in the process, retain

their employees as compared to an organization, which keeps back-up can-didates ready if someone resigns. They will never be able to develop people, as they are already thinking that people may leave.

Do you feel not having options is stressful? It may be stressful but that is a positive stress. The moment one has more than one option, he is sending a clear signal to the Universe that he is not confident of achieving the first one.

Having options is like tying a bicycle to your bike and thinking that if the bike breaks down, then you’ll take the cycle. It is not possible to travel at full speed in such a manner. If you tie a bicycle to your bike it will actually make you travel more cautiously.

There is one more reason why having one option or one goal will help im-mensely. When you have only one focus, you send a message to the Universe that you have faith in this goal, in this ven-ture, in this organization etc. And it is a fact of life that faith never fails.

Let’s throw the options away. It is enough that we played safe so far. When we have one goal and one focus, we will entually achieve it. Even if we fall short, what is the worst that can happen to us? Anoth-er solution will automatically come in search of us when we needed it. Let us trust and step forward in the direction of our dreams confidently.

I would like to end this article with the quote of Swami Vivekananda:

“Take up one idea. Make that one idea

your life; dream of it; think of it; live on

that idea. Let the brain, the body, muscles,

nerves, every part of your body be full

of that idea, and just leave every other

idea alone. This is the way to success, and

this is the way great spiritual giants are

produced.” -RMS

When you have only

one focus, you send

a message to the

Universe that you

have faith in this

goal, in this venture,

in this organization.

And it is a fact of

life that faith never fails.

“

”

ageNdaSaturday, JuNe 8, 2013 | courtyard Marriott, MuMbai

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08.30 - 09.20 Networking Breakfast

09.30 Keynote Address: Shakti Chakraborty, Group President, Lupin

10.00 CEO Roundtable Moderator: Sujay Shetty, Partner & Lead, Pharma & Life Sciences, PwC Panel Members: Shakti Chakraborty - Group President, Lupin Ganesh Nayak - COO & Executive Director, Zydus Cadila Bhaskar Iyer - Divisional VP, India Commercial Operations, Abbott

11.30 Panel Discussion: ‘Business Intelligence for Field Force Productivity’ Moderator: Vikas Dandekar - India Bureau Chief, Elsevier Business Intelligence Panel Members: Ameesh Masurekar - Founder Director, AIOCD Pharmasofttech AWACS Salil Kallianpur - Classical Brands Centre of Excellence, GSK Dr. Viraj Suvarna - Medical Director, Boehringer Ingelheim

13.00 - 14.00 Lunch

14.00 Panel Discussion: ‘Employee Engagement: The New Paradigm in Field Force Productivity’ Moderator: Anup Soans, Editor, MedicinMan Panel Members: Deep Bhandari - Director, Marketing and Sales Excellence, UCB K. Hariram - Former MD (retd.), Galderma Amlesh Ranjan - Assoc. Director, Sanofi Mohan Sheshadri - GM & Head, Training & Development, Ranbaxy

16.00 Power Session 1: ‘PharModeling for Healthcare: KAM & Market Access’ Amlesh Ranjan - Assoc. Director, Sanofi

16.30 Power Session 2: ‘Role Clarity for Field Sales Managers to Enhance Field Force Productivity’ K. Hariram - Former MD (retd.), Galderma

17.00 Closing Remarks


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Let us look at a very familiar scenario. In the quarterly cycle meeting there is an analysis of number of calls, visit frequency and call

averages. The concerned sales person whose call average is low is put down in front of everybody and virtually ripped apart. Most often the concerned FLM is also included in this exercise in front of his own team members or the FLM is in for a surprise with regard to this revelation. The Sales Manager, feels that he has done his job and his ego is satisfied. The ritual continues quarter after quarter with minimal impact on sales.

Do the managers concerned realize the purpose behind such an activity? Have they achieved their purpose? Do they know that this has an impact on the day to day revenue generation for which they are responsible? By doing this have they changed the behaviors of those concerned? Is there any coaching done with regard to this? Million dollar questions, I suppose.

Among the most important role of line managers is the willingness and ability to inspect performance according to expected standards, and the commitment to reinforce what is learned through feedback, consistent messages and coaching.

If you don’t inspect what you expect, you no longer

CaTCh PeoPle DoinG ThinGs riGhT*.

K. Hariram is the former MD (retd.) at Galderma India. He is Chief Mentor at MedicinMan and a

regular [email protected]

*Title borrowed from Ken Blanchard.

E

Catch People Doing Things Right | K. Hariram

have the right to expect it. Inspecting what you expect is simply holding people accountable for those behaviors, actions, attitudes and decisions that contribute to results. Every line manager has access to data of those where expectations have been set.

So monitoring and giving periodic feedback for course correction and the immediacy of action helps in avoiding ritualizing such things. The results will follow. Also, the sales team member gets projected in proper light in front of middle and senior management team. A sense of pride, self esteem and sense of accomplishment gets reinforced. This also provides opportunity to CATCH PEOPLE DOING THINGS RIGHT (Kenneth Blanchard).

Here are four ways to ensure consistency in expecting and inspecting:

1. Set clear expectations (not vague ones like ‘improve call average, meet more frequently’ etc)

2. Teach, train and educate them.

3. Reinforce the training in meetings, assignments, coaching etc.

4. Inspect (monitor) regularly whatever you expect and redirect immediately. -KH

“the Sales Manager who berates his team, feels that he has done his job and his ego is

satisfied. The ritual continues quarter after

quarter with minimal impact on sales.

Abdul Basit Khan

Ajay Kumar Dua

Amlesh Ranjan

Amrutha Bhavthankar

Andris A. Zoltners

Anthony Lobo

Aparna Sharma

Arvind Nair

Atish Mukherjee

B. Ramanathan

Chayya Sankath

Craig Dixon

Devanand Chenuri

Venkat

Dinesh Chindarkar

Dr. Amit Dang

Dr. Aniruddha

Malpani

Dr. Hemant Mittal

Dr. Neelesh Bhandari

Dr. S. Srinivasan

Dr. Shalini Ratan

Dr. Surinder Kumar

Sharma

Dr. Ulhas Ganu

Geetha G H

H. J. Badrinarayana

Hakeem Adebiyi

Hanno Wolfram

Hitendra Kansal

Iyer Gopalkrishna

Jasvinder Singh

Banga

Javed Shaikh

Jitendra Singh

John Gwillim

Jolly Mathews

Joshua Mensch

K Hariram

K. Satya Mahesh

Ken Boyce

Mahendra Rai

Mala Raj

Manoj Kumar

Mayank Saigal

Milan Sinha

Mohan Lal Gupta

Neelesh Bhandari

Neha Ansa

Nishkarsh Likhar

Noumaan Qureshi

Parveen Gandhi

Pinaki Ghosh

PK Sinha

Prabhakar Shetty

Vivek Hattangadi

Rachana Narayan

Rajesh Rangarajan

Ralph Boyce

Renie McClay

Richa Goyel

Richard Ilsley

RM Saravanan

Sagar S. Pawar

Salil Kallianpur

Salil Kallianpur

Sally E. Lorimer

Sandhya Pramanik

Sanjay Munshi

Shafaq Shaikh

Shalini Ratan

Sharad Virmani

Shiv Bhasin

Spring Sudhakar

Subba Rao Chaganti

Sudhakar Madhavan

Tony O’Connor

V. Srinivasan

Varadharajan K.

Vijaya Shetty

Vishal V. Bhaiyya

Vishal Verma

Vivek Hattangadi

William Fernandez

Our Authors

MedicinMan invites contributions from Pharma professionals on topics related to Field Force Excellence. See: www.medicinman.net/author-guidelines for more information.

FFE 2013 is India’s premier event for Field Force Excellence by MedicinMan.

The old methods of increasing field force num-bers will only mean increasing inefficiencies. Moreover, arbitrary targets and unachievable incentives has made the field force wary and weary and attrition is at an all time high.

The Challenges faced by Pharma in India is manifold:

• Patent expiration and fewer blockbusters

• Stringent regulatory compliance

• Intense competition and

• Heightened cost pressures

This, coupled with social activism, decreased face-time with Doctors, and commoditization of the market, make questions of Field Force Productivity all the more important.

In these circumstances, the urgent questions for senior pharma managers are:

1. What are Pharma CEOs thinking about the role of Field Force in the changed market sce-nario?

2. What is the role of Business Intelligence in enhancing Field Force Productivity?

3. How to attract and retain Gen-Y talent? What is Employee Engagement?

4. What is PharModeling? How can KAM (Key Account Management) lead to increased Field Force Productivity?

5. How can Role Clarity of Field Sales Manag-ers lead to increased Field Force Productivity?

Every year at FFE, MedicinMan brings togeth-er industry thought-leaders to deliberate on the most pressing issues facing the Pharma Field Force in India.

Join us at FFE 2013 to learn, share and set the agenda on Field Force Excellence for the year ahead.

WHo SHoulD ATTEND: Senior Managers in Sales and Marketing, Training, HR, SFE, SFA and other Field Force related functions.

WHy ATTEND: Do not miss out on this oppor-tunity to learn about the best practices in Field Force Excellence from industry thought leaders, network with industry peers and pharma deci-sion-makers and take home an action-plan for Field Force Excellence in 2013.

RegisteRwww.medicinman.net/ffe13-registration

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BuilDinGsales TeaMs froM sCraTCh

One of the key functions of a Front-line Manager is to act as the glue that holds MRs together as a team for a common

purpose and objective. The FM must understand the process and dynamics of transforming a group of strangers into a single, cohesive unit. FMs must understand the personality traits of MRs and be able to harness the strength of each personality

Understanding the four distinct stages of Forming, Storming, Norming and Performing will enable new FMs to be effective team-builders. In addition, Rapport-building, Communication skills, Empathetic leadership and Coaching skills are needed to build sales teams.

Among the most important role of line managers is the willingness and ability to inspect performance according to expected standards, and the commitment to reinforce what is learned through feedback, consistent messages and coaching.

understanding the process of team-formation can avert much distress for the FlM. each team goes through stages of ForMiNg, StorMiNg, and NorMiNg before they can start PerForMiNg. this knowledge is of vital importance to the team manager.

E


Building Sales Teams from Scratch | Anup Soans

ForMiNg: A sales team may be formed to launch a new division or to achieve a specific marketing/strategic objective. The first stage for any team is to come together. At this stage, the team can perform only routine tasks. It is possible to function for years at this level, doing the same things in the same ways and remaining as a group of individuals, like the Indian tennis duo Leander Paes and Mahesh Bhupathi. FMs must foster FORMING by being empathetic, asking probing questions, active listening, discovering the personalities of his MRs, and doing things together. FMs must take the lead in FORMING the purpose, goals and directions for the team.

StorMiNg: At this stage, conflicts erupt, as MRs seem to become uncooperative, raise objections, and become frustrated and hostile. MRs become angry at each other as well as at the whole idea of working together as a team. While this may make the FM feel like a failure, it is actually a major step forward. If the team is to survive, workable solutions must be found by accommodating differences. Useful skills at this stage are patience, consensus-building, flexibility, and an ability to see past the STORMING clouds to the goal.

NorMiNg: Eventually, the storm blows over and the team enters a period of calm. Solutions to problems and conflict seem possible. A unique set of NORMS for teamwork appears. These NORMS may be outside the official rules, but the team members accept them. The danger at this stage is for good ideas to be withheld because people do not want to stir things up. After all, things have barely settled down after the storm. Useful skills at this stage are trust, a willingness to take risks, innovation and the ability to recognise and measure progress.

PerForMiNg: At this stage, disagreements are resolved amicably in a win-win manner. MRs become confident and trust their FM and feel safe to take risks. New ideas and ways of solving problems are pursued. Activities that will help the team remain productive without getting stuck include taking calculated risks, disagreeing constructively, and seeking out challenges.

Teams do not remain permanently at the Performing stage. A Storm can erupt at any time. The pressure of the need to perform or an unexpected loss of a major business account such as a large institutional deal can trigger a storm. Losing or gaining a new MR always returns the team to the Forming stage. Changing FMs can also have the same effect. Successful teams usually recover from setbacks and get back to Performing quickly. However, when a team drops into a previous stage, it must work its way back through all the intermediate stages again, without skipping any of them.

To produce PERFORMING teams, FMs must focus on three critical areas:

1Clear purpose and measurable goals: Teams need a unifying purpose. Develop a common

purpose for your team that unites you and your MRs. Make each MR write down the team’s goal and compare the results. It may surprise you to discover that there are as many versions of the goal as there are MRs. Instead of forcing your version on the MRs, make each MR re-define his statement to reflect the goals clearly.

2 Interdependence and Pride in belonging: All team members must recognise and accept their

interdependence. Teams must have an interdependent working relationship in order to exist. Otherwise, all you

eventually, the storm blows over and the

team enters a period of calm. Solutions

to problems and conflict seem

possible. a unique set of NorMS for

teamwork appears. these NorMS may

be outside the official rules, but

the team members accept them.

“


Building Sales Teams from Scratch | Anup Soans

Anup Soans is the author of “HardKnocks for the

GreenHorn”, SuperVision for the SuperWiser Front-line

Manager” and “Repeat Rx”.

He is a facilitator of Learning and Development Programs for Managers and

Medical Reps at India’s top Pharma Companies

Contact:

[email protected] +91-93422-32949

this article has been extracted from the book

“Supervision for the SuperWiser Front-line

Manager” by anup Soans. the book is widely used as a

learning and development resource by India’s top

pharma companies.there is a special 1+1 Free offer currently available on

the book. See page 24 for details.

will have is a group of individual performers, like the Indian cricket team a great team of individuals on paper, but poor in collective performance. Interdependency happens when team members depend on each other to produce a combined output that is superior to their individual performance. FMs must build pride in the team. How does a small country such as Sri Lanka or South Africa produce such a fine cricket team?

Taking pride means being committed to winning and not taking loss as a matter of Karma. When the team wins, every member must feel joyful about it, as this is essential to winning the next time too. MRs who contribute to the success of other members must be recognised and rewarded suitably.

3 Commitment and Accountability: MRs must be committed to mutual goals.

Without commitment, the team’s performance suffers. Individual MRs must be given specific assignments for which they must be held accountable. A lack of commitment to team effort negatively affects enthusiasm and reduces effectiveness. Ask MRs to describe what frustrates them in trying to be committed to the team, without accusing them of not being committed. Remove barriers that prevent them from acting on their commitment. Hold MRs accountable for the tasks entrusted to them. Goals and plans must clearly reflect organisational objectives to ensure the support of senior managers for your team’s success.

Ultimately, the team’s success is dependent on the talents, abilities and attitudes of its members. FMs must actively seek out MRs who have the right combination of talent, intelligence,

abilities and attitude, to give them a competitive advantage on the field.

Talented MRs are intelligent people with abilities and the attitude to achieve pre-determined sales objectives. While recruiting, FMs must take stock of a candidate’s talents in terms of performance potential, the ability to handle a variety of customers and other factors. MRs must be assessed not only on intellectual skills, but also soft skills such as emotional intelligence, creativity, the ability to work in a team, and the willingness to learn and share.

coNcluSioNCompanies generally look for talent only at higher levels of management. Today, pharmaceutical companies require talented FMs and MRs who have the ability to look at problems from different perspectives and a high degree of creative and non-linear thinking to achieve business results. Intense competition and the consequent need for speed make the top-down management approach ineffective. Decisions need to be made at the field level. As pharmaceutical field sales get more and more challenging, FMs along with their senior managers have to identify, incubate and develop teams of talented MRs who can make better and faster decisions that address the needs of the doctor/customer effectively.

While it may be easier to manage average performers through mediocre management skills, the imperative for modern-day FMs is to upgrade their abilities constantly and be able to attract and retain talented MRs whose breakthrough performances can be models for other MRs. -AS

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Please pay through bank transfer to SB account no. *07141000006761* of “Anup Soans” HDFC Bank, Mosque Road, Frazer Town Branch, Bangalore – 560005. RTGS/NEFT IFSC: HDFC0000714 and inform by email and SMS - [email protected] | +91-93422-32949.

Or you can send a cheque favoring “Anup Soans” to:Anup Soans101 - North Forte Apts;22, North Road,Cooke Town,St. Thomas Town P.O.Bangalore - 560084

Field Force excelleNce toolS For iNdividualS aNd corPorateS


In an observational study investigators observe subjects and measure variables of interest without assigning treatments to the subjects. The treatment

that each subject receives is determined beyond the con-trol of the investigator1.

Observational research methods are employed within a number of different scientific disciplines used in the pharmaceutical industry, for example, epidemiology, pharmacoepidemiology, statistics, health economics and outcomes research, and survey research. However, methodologies and terminology differences exist across those disciplines. The terms epidemiology, pharmacoep-idemiology, observational, outcomes, noninterventional, nonexperimental, real-world, and registry are used inter-changeably in association with observational research2.

aPPlicatioNS oF obServatioNal reSearch.Observational research is an integral part of clinical development, life cycle management, and drug safety surveillance evaluations. Observational research is not a scientific discipline in itself, but a methodology central to a number of scientific disciplines. On the drug develop-ment and life cycle management continuum, companies frequently use observational research studies to:

Ø Define patient populations suitable for clinical trials.

Ø Define the natural history of a disease and patients’ responses to treatment.

Ø Standardize outcome measurements.

Ø Provide help in the design of long-term clinical out-

Knowledge for the Field Force Series- eMergiNg areaS iN healthcare -

obServatioNal reSearch iN healthcareUUUUUUUUUUUU

Javed Shaikh is a Consultant (HEOR, Pricing, Reimbursement and Market

Access) at Capita India, Mumbai.

[email protected]

Shafaq Shaikh is an Associate (HEOR, Pricing, Reimbursement

and Market Access) at Capita India, Mumbai.

[email protected]

E


Observational Research in Healthcare | Shafaq Shaikh & Javed Shaikh

come trials, to increase oppor-tunities for patient follow-up.

Ø Improve patient-reported outcome measures for clinical trials.

Ø Contribute to drug safety evaluations, including risk management strategies and effectiveness evaluations of risk minimization activities.

Ø Evaluate the comparative effectiveness between approved products under conditions of usual care.

Ø Identify health care resourc-es and costs associated with treatment.

Ø Identify drug utilization pat-terns for approved treatments.

obServatioNal reSearch MethodS.The three key, and most com-mon, epidemiologic observational research study designs, found in virtually all epidemiology and phar-macoepidemiology reference text books are3:

1. Cohort study

2. Case-control study

3. Cross-sectional study

1. Cohort Studies

These are the best method for de-termining the incidence and natural history of a condition. The studies may be prospective or retrospective and sometimes two cohorts are compared.

Prospective cohort studies: A group of people is chosen who do not have the outcome of interest (for exam-ple, myocardial infarction). The investigator then measures a variety of variables that might be relevant to the development of the condition. Over a period of time the people in the sample are observed to see whether they develop the outcome

of interest (that is, myocardial infarction).

In single cohort studies those people who do not develop the outcome of interest are used as internal con-trols. Where two cohorts are used, one group has been exposed to or treated with the agent of interest and the other has not, thereby acting as an external control.

Retrospective cohort studies: These use data already collected for other purposes. The methodology is the same but the study is performed post-hoc. The cohort is “followed up” retrospectively. The study period may be many years but the time to complete the study is only as long as it takes to collate and analyse the data.

Salient Features:

Ø Cohort studies describe inci-dence or natural history.

Ø They analyse predictors (risk factors) thereby enabling calcu-lation of relative risk.

Ø Cohort studies measure events in temporal sequence thereby distinguishing causes from effects.

Ø Retrospective cohorts where available are cheaper and quicker.

Ø Confounding variables are the major problem in analysing cohort studies.

Ø Subject selection and loss to follow up is a major potential cause of bias.

2. Case-Control Studies

A case-control study identifies patients on the basis of an outcome of interest, using either incident or prevalent cases, and is generally considered to be a retrospective study design. Cases are defined as patients who have experienced the

references

1. Porta M (editor). a dictionary of epidemiology. 5th.

edition. New york: oxford university Press, 2008.

2. black, N. education and debate: Why We Need

observational Studies to evaluate the effectiveness of

healthcare. bMJ 1996; 312:1215-1218.

3. Mann, cJ. observational research Methods. research

design ii: cohort, cross-sectional and case control Studies.

emerg Med J, 2003; 20:54-60 doi:10.1136/emj.20.1.54.

in an observational study investigators

observe subjects and measure variables of

interest without assign-ing treatments to the

subjects. the treatment that each subject re-ceives is determined

beyond the control of the investigator.

“

”

Observational Research in Healthcare | Shafaq Shaikh & Javed Shaikh


outcome of interest, for example, a disease under study (e.g. atrial fibrillation), or an adverse event of interest (e.g. veno-occlusive dis-ease). Controls are selected on the basis of being free of the outcome of interest and representative of the source population from which the cases arise. Exposures are then assessed by looking backwards in time at patients’ medical records or patient interviews. The case-control design is often used to identify and characterize the etiology of rare diseases because of its efficiency in terms of its ability to inform with respect to cost and time.

Salient Features:

Ø Case-control studies are simple to organize.

Ø Retrospectively compare two groups

Ø Aim to identify predictors of an outcome.

Ø Permit assessment of the influ-ence of predictors on outcome via calculation of an odds ratio.

Ø Useful for hypothesis genera-tion.

Ø Can only look at one outcome.

Ø Bias is a major problem.

3. Cross-sectional Studies

In a cross-sectional study, individ-uals are assessed at a single point in time with respect to an exposure of interest and outcome under study. The distinguishing feature of a cross-sectional study is the inabil-ity to establish a time sequence of events between exposure and outcome; therefore, cross-sectional studies cannot be used for causal as-sessments. However, they are useful in the effectiveness evaluations of risk management strategies and as-sociated risk minimization activities. The cross-sectional study design is

also useful for survey research, and in knowledge, attitudes and practic-es (KAP) studies of patients and or health care providers.

Salient Features:

Ø Cross sectional studies are the best way to determine preva-lence.

Ø Are relatively quick.

Ø Can study multiple outcomes.

Ø Do not themselves differentiate between cause and effect or the sequence of events.

SuMMaryThe use and scope of observational research studies within the pharma-ceutical industry has increased over past decades to include clinical, pa-tient-reported, economic, and other health outcomes endpoints, thereby giving value to multiple stakehold-ers for as many different purposes. Unlike randomized clinical trials, observational studies allow for the evaluation of the use and effects of healthcare products (including drugs, biologics, devices, vaccines) under conditions of usual care in a real world setting.

Globally, the use of real-world data in demonstrating the value of medical technologies is increasing-ly relevant to reimbursement and market access decision making. Whether prospective, retrospective or cross-sectional, observational research has a critical and growing role to play in driving a better un-derstanding of the health outcomes of medical technologies, and sup-porting appropriate product use in everyday clinical practice. -SS & JS

globally, the use of real-world data in demonstrating the

value of medical technologies is increasingly relevant to

reimbursement and market access decision making. Wheth-er prospective, retrospective or

cross-sectional, observational research has a critical and

growing role to play in driving a better understanding of the

health outcomes of medical technologies, and supporting

appropriate product use in everyday clinical practice.

“


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PaTienT rePorTeD ouTCoMe Measures in PharMaCoeConoMiCs

A patient-reported outcome (PRO) is a direct subjective assessment by patients about aspects of their health, including symptoms, function,

emotional well-being, quality of life, utility, and satisfac-tion with treatment. PROs evaluate the impact and func-tional implications of the disease or treatment to reflect their interpretation of the experience, which is influenced by their internal standards, intrinsic values, and expecta-tions of the patient.

The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being. The WHO’s International Classification of Functioning, Disability, and Health (ICF) was developed to provide a standard language and framework to describe and mea-sure health and health-related states. Within the ICF sys-tem, health outcomes are classified according to the effect upon body function, body structure, limitations in activi-ties, and limitations in participation. Health outcomes that measure body function include measures of physiological functions of body systems (e.g., ejection fraction, glucose level, depression, pain, etc).

Health-related quality of life (HRQoL) instruments mea-sure the broad concept of health (physical, mental, and social well-being) by inquiring into the extent of difficulty with activities of daily living (including work, recreation, and household management) and how difficulties affect relationships with family, friends, and social groups, capturing not only the ability to function within these roles, but also the degree of satisfaction derived from doing them. HRQoL instruments often contain items that measure body function (e.g., pain, depression, anxiety) and limitations with activities and participation.

Economic analyses include methods to evaluate different effects (death, effects of stroke on HRQoL, effect of reduc-tion in acne on HRQoL) in the same metric. One way to create the same units is through the concept of preferenc-es. Utilities and values are different types of preferences.

Whether dealing with utilities or values depends on how questions on measurement instruments are framed; are participants being asked to consider outcomes that are certain (values) or uncertain (utilities).

The Standard Gamble is the classical method of measuring utility, based directly on the axioms first presented by von Neumann and Morgenstern (utility theory) that describes how a rational individual “ought” to make decisions when faced with uncertainty. The Time Trade-Off2 is a measure of values. It asks participants to imagine living their lives in their current health states and to contrast this with the alternative of perfect health in exchange for a shorter lifespan (preference-based measured). The administrator provides alternatives of years of life in the present health state versus years of life in perfect health.

Patient-reported outcome measures provide information gathered directly from the patients about their experiences with the disease and its treatment. Because of the unique perspective offered by patient-reported instruments, direct measurement of health from the patient’s perspective is popular and has replaced more objective measures as the primary outcome of interest for a broad spectrum of clinical conditions. To make wise management decisions, patients and clinicians need to know the magnitude of the effect of treatments on a variety of outcomes, including patient-reported outcomes. Investigators must choose an informative method to present their findings to enhance the interpretability and applicability of their results in a clinical setting. -MR & nL

References:1. Von Neumann J, Morgenstern O. Theory of Games and Economic Behaviour. Princeton, NJ: Princeton University Press. 1944.2. Torrance GW, Thomas WH, Sackett DL. 1972. A utility maximization model for evaluation of health care programs. Health Serv Res 7(2):118–33.

Mahendra Rai & Nishkarsh [email protected]

E

Training that

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training that is relevaNt and grabs the atteNtioN of the participants, appealing to EMOTIONS and firing the INTELLECT to bring about chaNge in MiNdSet and behavior on the Field leading to VALUE CREATION in the DOCTOR’s chaMber and rePeat rx for the company.

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