Diffusion of Innovation with Physicians

It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new ones. — Niccolo Machiavelli

Getting a new idea adopted is difficult, even when the advantages are obvious.

Innovation is not for the faint of heart.

Every medical device, biotech, pharma, and tech company goes through the exercise of answering “how do we speed up adoption?”

The answer is found in the innovation work compiled and pioneered by the late Everett Rogers and how innovation diffusion occurs.

Diffusion is a kind of social change.

It is the process in which an innovation is communicated through certain channels over time among the members of a social system.

What is “communication”?

Communication is a process in which participants create and share information with one another in order to reach a mutual understanding.

I mention this as many forget the simple definitions and thus overlook the first principles of technology adoption and diffusion.

For years I’ve written and spoken about the power of social media and how it has evolved to be the primary channel for innovation diffusion in healthcare. Recently I shook up our industry with my publication “The Death of Medical Sales.”

In this piece I want to cover diffusion and the role key opinion leaders have on social influence and adoption of a technology.

Pfizer’s Drug Diffusion

The Pfizer drug diffusion investigation is one of the most famous cases in explaining the paradigm of how innovation spreads.

The most noted impact of the Columbia University drug study was to orient future diffusion research toward investigating the interpersonal networks through which subjective evaluation of an innovation are exchanged among the individuals of a system.

The study illuminated the nature of interpersonal diffusion networks, suggesting the role that opinion leaders play in the takeoff of the S-shaped diffusion curve.

What the Columbia study clearly established was that innovation diffusion was a social process.

The market research department at Pfizer provided a grant of $40,000 to three Columbia University sociologists to conduct the drug diffusion study in 1954.

Pfizer originally wanted to know if the advertisements it purchased in medical journals were influential in diffusing the company’s new drug products.

The sociologists decided to convert the market research question into an important diffusion study of interpersonal communication networks.

A pilot study of the spread of anew drug was carried out among 33 doctors in a New England town (Menzel & Katz, 1955) with the main study conducted in four cities in Illinois (Peoria, Bloomington, Quincy, and Galesburg).

The drug study analyzed the diffusion of a new antibiotic, tetracycline, that had appeared in 1953.

The drug had been tried at least once by 87% of Illinois doctors in the study, who had been using two other closely related “miracle” drugs belonging to the same antibiotic family.

The new drug superseded an existing idea in that tetracyclines main advantage over earlier antibiotics was it had fewer side effects (Van den Buelte & Lilien, 2001).

The sociologists then interviewed 125 general practitioners, internists, and pediatricians in the four Illinois cities.

These were 85% of the doctors practicing in specialties where the drugs was important.

The 125 doctors sociometrically designated 103 additional doctors in other specialties as their network partners. The total sample of 228 doctors made up 64% of all medical doctors practicing in the four cities (Coleman et al., 1957).

An objective measure of each doctors time of adoption was obtained from the record of pharmacy prescriptions written by doctors of the study.

Pfizer’s Discovery on Innovation Diffusion

What Pfizer found was:

• Innovative doctors attended more out-of-town medical conferences than did later adopters.
• Innovative doctors have social networks that extend outside of their local system.
• Innovative doctors served wealthier patients and thus had a more wealthy medical practice.

The most important finding of the Columbia University drug study dealt with interpersonal diffusion networks.

Coleman and his colleagues (1966) found that almost all of the opinion leaders, defined as doctors who received three or more sociometric choices as social friends, had adopted tetracycline by month 8 (of the 17 month diffusion period).

At about this point, the S-shaped diffusion curve for the opinion leaders’ followers really took off.

One reason for the S-shaped curve is that once the opinion leaders in a system adopt, then they convey their subjective evaluations of the innovation to their many network partners, who are thereby influenced to adopt the new idea (Valente, 1995).

This point in time at which critical mass of doctors adopted, and the s-shaped curve took off, is a key factor in the diffusion process.

Key Opinion Leaders

Key Opinion Leaders are vital to any innovation diffusion to occur.

Opinion leadership is the degree to which an individual is able to informally influence other individuals’ attitudes or behaviors in a desired way with relative frequency.

This phenomenon took off broadly with the introduction of key opinion leaders on social media (i.e. influencers) and added a depth of complexity to innovation diffusion as the common person could have more influence than expected.

The same holds true for the medical world as many of the top key opinion leaders on social media are often not the heads of departments. Rather, they are a passionate individual who consistently shows up online, weekly and even daily, to add value through their content.

The behavior of opinion leaders is important to the rate of adoption of an innovation in a system. The innovation diffusion curve is S-shaped because once opinion leaders adopt and begin telling others, the number of adopters per unit of time takes off in an exponential curve.

Mass Media to Social Media

The Hypodermic Needle Theory is a linear communication theory which suggests that media messages are injected directly into the brains of a passive audience.

The hypodermic needle theory suggests a powerful and direct flow of information from the sender to the receiver. It suggests that media messages are injected straight into a passive audience which is immediately influenced by the message.

The theory suggests that the mass media could influence a very large group of people directly and uniformly by ‘injecting’ them with appropriate messages designed to trigger a desired response or to influence.

It suggests that we’re all the same and we all respond to media messages in the same way.

The media was seen as conveying messages to atomized masses of individuals (Katz and Lazarsfeld, 1955).

The power of media influenced historical events such as

1. Role of the Hearst newspapers in getting public support for the Spanish-American War
2. Power of Nazi leader Joseph Goebbel’s propaganda system during WWII
3. Influence of Madison Avenue advertising on consumer AND voting behavior in the United States

The model was eventually found to be too simple and mechanistic to give an accurate account of media effects. It ignored the role of opinion leaders.

Paul F. Lazarsfeld of Columbia, a pioneering mass communication scholar, directed research to provide an updated model that had opinion leaders.

In this Two Step Flow Model, the following occurs:

Step 1 (Informational) : Media transfers information to opinion leaders

Step 2 (Influence): Opinion leaders transfer information to followers with the spread interpersonal influence

What this model did not recognize was the role different communication sources or channels at various stages in the innovation-decision process. Everett M. Rogers highlights this in his book “Diffusion of Innovations” to show that individuals pass from:

1. Knowledge of an innovation
2. Persuasion
3. Decision to adopt or reject
4. Implementation
5. Confirmation of this decision

Mass communication channels are primarily knowledge creators, whereas interpersonal networks are more important in persuading individuals to adopt or reject.

The mistake many companies make is assuming that mass communication channels (aka social media) are both knowledge creators AND persuasion networks.

They are not persuasion networks without the influence of opinion leaders.

This idea was hidden in the original two step model because the time sequence involved in an individuals innovation decision-making process was ignored. Such source/channel differences at the knowledge versus the persuasion stages usually exist for BOTH opinion leaders and followers.

Thus, opinion leaders are not the only individuals to use mass communication channels, as the original two step model suggested.

The adaptation of this model has gone through an evolution to what we see in social media today.

Influence of Social Systems

A social system is a kind of collective learning system in which the experiences of earlier adopters of innovation, transmitted through interpersonal networks, determine the rate of adoption of their followers.

Such learning in a social system can, of course, take a negative turn if the innovation is not efficacious in solving a problem.

If the new drug wasn't very effective in solving the innovative doctors’ problem, they would have quickly passed their dissatisfaction with the new drug along to peers.

Then the S-shaped diffusion curve would have displayed a much slower rate of adoption, or it might have reached a plateau and declined as a result of widespread discontinuance of tetracycline.

Thus the social system in which an innovation diffuses acts like a participatory democracy in which the aggregated individual adoption decisions of its members represent a consensus vote on the new idea.

In other words, social proof of the tribe selects a new standard.

A doctor’s position in the communication network of physicians in their community also had important consequences for the doctor’s innovativeness.

Individuals who were isolates, defined as doctors not connected to anyone else, required 9.5 months, on the average, to adopt tetracycline, while only 7.9 months were needed for non-isolates (Valente, 1995).

Being connected meant being innovative.

The doctors also had plenty of information about the new drug. Tetracycline had undergone randomized controlled clinical trials by pharma firms and universities prior to its release in the medical community.

The results of these evaluations were communicated

1. in medical journal articles to physicians and

2. by “detail men” aka pharma reps who contacted doctors and gave them reprints of the journal articles for free.

These promotional activities created awareness of the innovation in the medical community, but such scientific evaluation of the new drug were not sufficient to persuade the average doctor to adopt.

Subjective evaluations of the new drug based on personal experience of each doctor’s peers were key in convincing the typical doctor to adopt the drug with his/her own patients.

The crucial role of interpersonal network communication in the diffusion of tetracycline led James Coleman and others (1966) to investigate which doctors talked to whom.

Why had a respondent chosen one, two, or three other doctors (out of hundreds in the community) as his or her best friends?

A dyadic network analysis disclosed that religion and age were the main determinants of friendship links, with hometown and medical school attended also of some importance.

But the main reasons for person-to-person links in the medical community were professional affiliations, such as belonging to the same hospital or clinical as another doctor or participating in an office partnership.

The Columbia study showed the important role of interpersonal networks in the diffusion process.

More than anything else, it was the social power of peers talking to peers about the innovation that led to adoption of the new idea.

I end with this quote-

There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things….Whenever his enemies have the ability to attack the innovator, they do so with the passion of partisans, while the others defend him sluggishly, so that the innovator and his parry alike are vulnerable — Niccolo Machiavelli, The Prince (1513)

Innovation is not for the faint of heart.

Sharpen your mind, harden your heart, and open your eyes and ears.

Pay attention to what’s happening right in front of you.

Burn the boats. Good luck.