Erik Goldman05.01.03
Medical professionals currently represent only a small part of the overall market for nutraceuticals and natural products. However, by most accounts, it is one of the fastest growing and most dynamic segments of the market, with tremendous potential for future growth.
Do the math yourself: there are approximately 700,000 physicians in the U.S., not including chiropractors, naturopaths and other practitioners of "alternative" medicine. Assuming each of those doctors has 2000 active patient files or more, a company that wins the allegiance of even a small percentage of those physicians will vastly increase its customer base. Even if the majority of physicians do not sell dietary supplements from their offices-something some doctors find unethical and the American Medical Association has taken a position against-they can still make recommendations, which patients will likely accept.
The professional channel is still under 5% of the total natural products market. However, many industry watchers predict that will change in the coming years. According to Nutrition Business Journal, San Diego, CA, the growth potential of the practitioner market is strong-very close to double-digits. It is estimated that the practitioner market, which includes MDs, chiropractors, pharmacists, naturopaths, nurses, acupuncturists, dietitians, nutritionists and practitioners of Ayurveda or Traditional Chinese Medicine, will grow at a rate of 9-10% for the next two to three years.
In large part, this trend is being driven by consumer demand because they are concerned about the quality and efficacy of supplements and are very confused. Physicians have tremendous influence over patients' health practices and purchasing decisions, and it behooves supplement manufacturers to win them as allies.
According to The Natural Marketing Institute's (NMI) 2003 Health and Wellness Trends Report, physician recommendation was the most often cited major influence on an individual's decision to seek out natural products. A total of 85% of respondents said a physician's recommendation was a prime influence, and physicians have been the number one influence for the last four years.
However, when purchasers were asked what drove the choice of the product they ended up purchasing-in this case weight loss products-only 8% cited a doctor recommendation as the reason for their first or repeated purchase of a particular product.
If 85% of the general population views physician recommendations as a major influence on their decision to use natural products, but less than 8% of purchasers state that their doctors' recommendations drove the purchase, there is clearly a communication gap of some sort. Maryellen Molyneaux, president of NMI, attributed the gap to physicians' lack of knowledge about specific products. Speaking about the weight loss market, she explained, "Doctors tend to recommend weight loss in general, but they do not tend to recommend specific products." In large part, this is because doctors do not know very much about the products. This holds true of natural products in general, and it represents both a challenge and an opportunity for the nutraceuticals industry. Simply put, physicians will not recommend what they know little about.
Historically, the nutraceuticals industry has ignored the medical mainstream because companies have generally assumed that MDs, given their pharmaceutical orientation and lack of education in nutrition and natural therapeutics, would be indifferent at best, and hostile at worst. For the better part of the last 30 years, those assumptions were largely true. Likewise, mainstream MDs tended to view natural products companies as unscientific, unscrupulous and unregulated. Unfortunately, one need not look too hard at this industry to find examples of companies that fit a physician's worst assumptions.
The good news is that the relationship between doctors and the natural products industry appears to be changing, as MDs become more receptive to nutrition and preventive medicine, while nutraceutical companies become more sophisticated and scientific in their product development and marketing efforts.
Signs of the attitudinal shift within mainstream medicine are everywhere through the emergence of CAM (complementary and alternative medicine) course work in nearly all of the nation's medical schools; the proliferation of continuing medical education (CME) conferences related to CAM; the rapid growth of the American Holistic Medical Association, the American Academy of Anti-Aging Medicine, the American Academy of Medical Acupuncture and other professional groups; the publication of positive studies on supplements and natural medicine in conventional medical journals (including last summer's study in the Journal of the American Medical Association supporting routine multivitamin supplementation for adults) and greater federal funding for alternative medicine research, including a $100 million budget for the National Center for Complementary and Alternative Medicine (NCCAM) within the National Institutes of Health (NIH).
The reasons for the shift are numerous, but clearly the prime mover is public demand. Individual physicians have quietly been aware of alternative medicine for decades, and some were in the forefront of its practices. Consumer demand became blatantly obvious in 1993 after David Eisenberg, MD, and colleagues from Harvard Medical School published their landmark study in the New England Journal of Medicine, estimating that one-third of U.S adults were using some form of "alternative" medicine and usually not telling their physicians. (Eisenberg DM, et al. N Engl J Med. 1993;328:246-52.)
The numbers have clearly grown since then. In fact, in their 1998 follow-up study, Eisenberg's group reported that the prevalence of CAM use increased to 42%; total visits to CAM practitioners reached 629 million and exceeded total visits to primary care physicians and the American public was spending $21 billion annually on alternative medicine.
Mainstream doctors now recognize the need to know more about natural medicine. In a recent survey of Colorado physicians, 84% said they thought they needed to learn more about CAM to address patient concerns. "Education about CAM is a significant unmet need...and may help alleviate the discomfort physicians have when answering patients' questions about CAM," concluded author, Lisa Corbin Winslow, MD. (Arch Intern Med 2002; 162(10): 1176-81.)
In an earlier survey of Chesapeake region physicians, 70-90% of doctors considered CAM therapies to be legitimate medical practices and 70% expressed interest in training in multiple areas of alternative medicine. (Berman BM, et al. J Am Board Fam Pract. 1995; 9(1):70.)
Dynamics within the medical profession itself have also fostered changing attitudes. Since the mid-1980s, mainstream physicians have experienced loss of income due to cost cutting by insurers and Medicare/Medicaid. Doctors are frustrated by the loss of decision-making authority at the hands of HMO overseers. In addition, they are burdened by enormous malpractice insurance premiums and are well aware of the efficacy gap and side effects of conventional pharmaceuticals. They are also increasingly troubled by drug company hype.
Further, the demographics of medicine have changed. Fully 50% of all recently graduated MDs are women. Doctors who trained during the height of the 1960s "counterculture" revolution are now in their peak professional years and have assumed positions of authority. Many beliefs and practices once considered "alternative" such as yoga, vegetarianism and meditation, are increasingly part of mainstream American culture. Many conventionally trained MDs are moving toward holistic medicine because they truly desire to be healers rather than "prescription-stampers."
Companies that reach out to MDs find it can be very rewarding. For example, Louis Trachtenberg, a New York, NY, Metropolitan area professional sales representative for Standard Process, says that while roughly 75% of the practitioners he services are chiropractors, and only 25% are MDs, it is the MDs who actually move more product on a per practitioner, per month basis. Representatives from other companies report a similar pattern.
But marketing to healthcare practitioners is not easy, especially for companies striving to capture market share among conventionally trained MDs. It requires a much greater commitment of time, energy and money than does marketing in the more straightforward retail channels. To reach health professionals, a scientifically credible message and a sophisticated presentation are essential.
Some product categories are a much easier "sell" for the professional market. Those that have strong science, well defined mechanisms of action, long histories of use, low risk of adverse effects and address common day-to-day clinical syndromes are the ones being adopted most quickly. These include omega 3 fatty acids, CoQ10, folic acid, niacin, probiotics, glucosamine/chondroitin, soy isoflavones, minerals and "letter" vitamins. These are generally easy for even very conventional doctors to understand.
Homeopathy, Chinese herbal medicine, growth hormones and glandular products will have a harder climb, as will extremely novel ingredients. But it is not impossible. For example, several years ago, lutein and lycopene were completely unknown to most physicians. Today, however, the vast majority of doctors at least recognize these antioxidants.
While physicians may be accepting of certain ingredients and product categories, they may not be committed to any particular brand. In order to win market share, manufacturers must convince practitioners that their products are unique and backed by science. According to Dale Kriz, a marketing consultant, "You need to have something that is unique, not just another 'me-too' product. Every company claims that theirs is 'the one.' With practitioners, you really have to prove it. The bottom line is, you have to have science behind your products. Without the science, it is going to be a tougher sell to practitioners."
Beyond the cost of the marketing materials-remember, physicians are used to seeing multimillion dollar messages designed by some of the advertising world's top firms-there are other challenges to breaking into the mainstream, including organizational bias against natural products on the part of some medical associations.
As in any marketing effort, it helps to know the psychology of your target market. If you want to sell to physicians, you have to know how they think. One of the key features of doctors as a profession is their pride in being knowledgeable. Simply put, doctors don't like to be ignorant. One does not make it through the grueling ordeal of medical training unless one has a strong thirst for knowledge and an ability to learn quickly.
Secondly, doctors tend to be conservative in embracing change. They tend to practice defensively and cautiously in large part for fear of getting sued. The concern is legitimate: if a doctor recommends a supplement product and there is an untoward serious side effect, the litigators won't come knocking at your corporate office, but you can bet they will pay a visit to the MD.
Thirdly, most doctors are also genuinely concerned for their patients' safety and well being. Most medical professionals went into the field with a real desire to help their fellow human beings. A strong, ethical, well-reasoned scientific message builds the sense of security that physicians need in order to get behind a product or modality.
Marketing to medical professionals implies educating them. The success of pharmaceutical companies is in large measure due to their recognition early in the 20th century that their future would depend on educating professionals on how to use their products. They built and funded medical schools and continue to fund medical research. They fund ongoing continuing medical education and work closely with professional organizations. In effect, their commitment to medical education was so total that conventional medical education, and in turn conventional practice, became almost synonymous with prescribing drugs. The pharmaceutical giants built their product delivery system through education and outreach. While I would not advocate that the nutraceuticals industry try to parrot "Big Pharma," it doesn't hurt to understand a few moves from their playbook.
Recently, it seems, a number of nutraceutical companies are taking notes from "Big Pharma." Last year, Thorne Research made a $500,000 contribution to the Southwest College of Naturopathic Medicine in Phoenix, AZ, for the endowment of a chair in environmental medicine. Gaia Herbs made a similar donation to Southwest to establish a botanical medicine clinical research program. Some companies have become extremely sophisticated in their educational and informational outreach to physicians. For instance, Metagenics posts a monthly electronic newsletter to practitioners called, Meta eNews, which provides scientific literature reviews, quick "primers" on general natural product categories and specific updates on the company's new products.
One of the most impressive campaigns, however, recently came from Sigma-Tau, the Italian fine chemical and ingredient supplier. After a series of Italian studies showed that L-carnitine could improve sperm count, motility and morphology, the company decided to brand its L-carnitine fumarate/acetyl-L-carnitine as a finished product called Proxeed. Last year, the company exhibited Proxeed at a number of conventional medical conferences, including the annual meetings of the American Society for Reproductive Medicine and the American Urological Association, as a low-cost natural intervention for infertile couples. Sigma-Tau's promotional materials for Proxeed are well designed and scientifically grounded. The Proxeed exhibit booth, which drew enthusiastic attention at both conferences, was as sophisticated as those from any of the neighboring drug company giants. The only thing that distinguished Proxeed as a nutraceutical rather than a pharmaceutical was the tiny DSHEA disclaimer statement.
While there has clearly been progress in bridging the gap between medical professionals and the nutraceuticals industry, by and large, the industry has done a poor job overall in presenting the benefits of dietary supplements to the medical community.
It is indeed true that it would be hard to compete with the massive spending of the drug giants-a large pharmaceutical company probably spends more on an exhibit booth and support materials at a single major medical conference than most supplement companies spend on marketing for an entire year. But the issue is broader than financial concerns. Several observers have noted that in general, the industry has not perceived itself as part of healthcare as a whole.
With the exception of the DSHEA legislation and other issues that have direct and immediate impact, the nutraceuticals industry has been conspicuously absent from healthcare policy-making and are seldom involved in any of the legislative processes that shape healthcare.
This is partly due to historic rifts-the previous unwillingness of mainstream medicine and policy makers to take the industry seriously. But if DSHEA taught us anything it is that policy makers will listen to an industry with massive popular support in its corner. With the healthcare system at large tottering on the brink of total collapse, it is high time the nutraceuticals industry brings its public support and prevention orientation to the table.NW
About the author:
Erik Goldman is editor-and-chief of Holistic Primary Care, New York, NY. He can be reached at 212-406-8957; Fax: 212-406-8959; E-mail: erik@holisticprimarycare.net.
Do the math yourself: there are approximately 700,000 physicians in the U.S., not including chiropractors, naturopaths and other practitioners of "alternative" medicine. Assuming each of those doctors has 2000 active patient files or more, a company that wins the allegiance of even a small percentage of those physicians will vastly increase its customer base. Even if the majority of physicians do not sell dietary supplements from their offices-something some doctors find unethical and the American Medical Association has taken a position against-they can still make recommendations, which patients will likely accept.
The professional channel is still under 5% of the total natural products market. However, many industry watchers predict that will change in the coming years. According to Nutrition Business Journal, San Diego, CA, the growth potential of the practitioner market is strong-very close to double-digits. It is estimated that the practitioner market, which includes MDs, chiropractors, pharmacists, naturopaths, nurses, acupuncturists, dietitians, nutritionists and practitioners of Ayurveda or Traditional Chinese Medicine, will grow at a rate of 9-10% for the next two to three years.
In large part, this trend is being driven by consumer demand because they are concerned about the quality and efficacy of supplements and are very confused. Physicians have tremendous influence over patients' health practices and purchasing decisions, and it behooves supplement manufacturers to win them as allies.
According to The Natural Marketing Institute's (NMI) 2003 Health and Wellness Trends Report, physician recommendation was the most often cited major influence on an individual's decision to seek out natural products. A total of 85% of respondents said a physician's recommendation was a prime influence, and physicians have been the number one influence for the last four years.
However, when purchasers were asked what drove the choice of the product they ended up purchasing-in this case weight loss products-only 8% cited a doctor recommendation as the reason for their first or repeated purchase of a particular product.
If 85% of the general population views physician recommendations as a major influence on their decision to use natural products, but less than 8% of purchasers state that their doctors' recommendations drove the purchase, there is clearly a communication gap of some sort. Maryellen Molyneaux, president of NMI, attributed the gap to physicians' lack of knowledge about specific products. Speaking about the weight loss market, she explained, "Doctors tend to recommend weight loss in general, but they do not tend to recommend specific products." In large part, this is because doctors do not know very much about the products. This holds true of natural products in general, and it represents both a challenge and an opportunity for the nutraceuticals industry. Simply put, physicians will not recommend what they know little about.
Meeting Halfway: Mainstream MDs Reckon with Nutraceuticals
Historically, the nutraceuticals industry has ignored the medical mainstream because companies have generally assumed that MDs, given their pharmaceutical orientation and lack of education in nutrition and natural therapeutics, would be indifferent at best, and hostile at worst. For the better part of the last 30 years, those assumptions were largely true. Likewise, mainstream MDs tended to view natural products companies as unscientific, unscrupulous and unregulated. Unfortunately, one need not look too hard at this industry to find examples of companies that fit a physician's worst assumptions.
The good news is that the relationship between doctors and the natural products industry appears to be changing, as MDs become more receptive to nutrition and preventive medicine, while nutraceutical companies become more sophisticated and scientific in their product development and marketing efforts.
Signs of the attitudinal shift within mainstream medicine are everywhere through the emergence of CAM (complementary and alternative medicine) course work in nearly all of the nation's medical schools; the proliferation of continuing medical education (CME) conferences related to CAM; the rapid growth of the American Holistic Medical Association, the American Academy of Anti-Aging Medicine, the American Academy of Medical Acupuncture and other professional groups; the publication of positive studies on supplements and natural medicine in conventional medical journals (including last summer's study in the Journal of the American Medical Association supporting routine multivitamin supplementation for adults) and greater federal funding for alternative medicine research, including a $100 million budget for the National Center for Complementary and Alternative Medicine (NCCAM) within the National Institutes of Health (NIH).
Why the Shift?
The reasons for the shift are numerous, but clearly the prime mover is public demand. Individual physicians have quietly been aware of alternative medicine for decades, and some were in the forefront of its practices. Consumer demand became blatantly obvious in 1993 after David Eisenberg, MD, and colleagues from Harvard Medical School published their landmark study in the New England Journal of Medicine, estimating that one-third of U.S adults were using some form of "alternative" medicine and usually not telling their physicians. (Eisenberg DM, et al. N Engl J Med. 1993;328:246-52.)
The numbers have clearly grown since then. In fact, in their 1998 follow-up study, Eisenberg's group reported that the prevalence of CAM use increased to 42%; total visits to CAM practitioners reached 629 million and exceeded total visits to primary care physicians and the American public was spending $21 billion annually on alternative medicine.
Mainstream doctors now recognize the need to know more about natural medicine. In a recent survey of Colorado physicians, 84% said they thought they needed to learn more about CAM to address patient concerns. "Education about CAM is a significant unmet need...and may help alleviate the discomfort physicians have when answering patients' questions about CAM," concluded author, Lisa Corbin Winslow, MD. (Arch Intern Med 2002; 162(10): 1176-81.)
In an earlier survey of Chesapeake region physicians, 70-90% of doctors considered CAM therapies to be legitimate medical practices and 70% expressed interest in training in multiple areas of alternative medicine. (Berman BM, et al. J Am Board Fam Pract. 1995; 9(1):70.)
Dynamics within the medical profession itself have also fostered changing attitudes. Since the mid-1980s, mainstream physicians have experienced loss of income due to cost cutting by insurers and Medicare/Medicaid. Doctors are frustrated by the loss of decision-making authority at the hands of HMO overseers. In addition, they are burdened by enormous malpractice insurance premiums and are well aware of the efficacy gap and side effects of conventional pharmaceuticals. They are also increasingly troubled by drug company hype.
Further, the demographics of medicine have changed. Fully 50% of all recently graduated MDs are women. Doctors who trained during the height of the 1960s "counterculture" revolution are now in their peak professional years and have assumed positions of authority. Many beliefs and practices once considered "alternative" such as yoga, vegetarianism and meditation, are increasingly part of mainstream American culture. Many conventionally trained MDs are moving toward holistic medicine because they truly desire to be healers rather than "prescription-stampers."
Marketing to Practitioners: High Hurdles, Huge Growth Potential
Companies that reach out to MDs find it can be very rewarding. For example, Louis Trachtenberg, a New York, NY, Metropolitan area professional sales representative for Standard Process, says that while roughly 75% of the practitioners he services are chiropractors, and only 25% are MDs, it is the MDs who actually move more product on a per practitioner, per month basis. Representatives from other companies report a similar pattern.
But marketing to healthcare practitioners is not easy, especially for companies striving to capture market share among conventionally trained MDs. It requires a much greater commitment of time, energy and money than does marketing in the more straightforward retail channels. To reach health professionals, a scientifically credible message and a sophisticated presentation are essential.
Some product categories are a much easier "sell" for the professional market. Those that have strong science, well defined mechanisms of action, long histories of use, low risk of adverse effects and address common day-to-day clinical syndromes are the ones being adopted most quickly. These include omega 3 fatty acids, CoQ10, folic acid, niacin, probiotics, glucosamine/chondroitin, soy isoflavones, minerals and "letter" vitamins. These are generally easy for even very conventional doctors to understand.
Homeopathy, Chinese herbal medicine, growth hormones and glandular products will have a harder climb, as will extremely novel ingredients. But it is not impossible. For example, several years ago, lutein and lycopene were completely unknown to most physicians. Today, however, the vast majority of doctors at least recognize these antioxidants.
While physicians may be accepting of certain ingredients and product categories, they may not be committed to any particular brand. In order to win market share, manufacturers must convince practitioners that their products are unique and backed by science. According to Dale Kriz, a marketing consultant, "You need to have something that is unique, not just another 'me-too' product. Every company claims that theirs is 'the one.' With practitioners, you really have to prove it. The bottom line is, you have to have science behind your products. Without the science, it is going to be a tougher sell to practitioners."
Beyond the cost of the marketing materials-remember, physicians are used to seeing multimillion dollar messages designed by some of the advertising world's top firms-there are other challenges to breaking into the mainstream, including organizational bias against natural products on the part of some medical associations.
Doctor Psychology 101
As in any marketing effort, it helps to know the psychology of your target market. If you want to sell to physicians, you have to know how they think. One of the key features of doctors as a profession is their pride in being knowledgeable. Simply put, doctors don't like to be ignorant. One does not make it through the grueling ordeal of medical training unless one has a strong thirst for knowledge and an ability to learn quickly.
Secondly, doctors tend to be conservative in embracing change. They tend to practice defensively and cautiously in large part for fear of getting sued. The concern is legitimate: if a doctor recommends a supplement product and there is an untoward serious side effect, the litigators won't come knocking at your corporate office, but you can bet they will pay a visit to the MD.
Thirdly, most doctors are also genuinely concerned for their patients' safety and well being. Most medical professionals went into the field with a real desire to help their fellow human beings. A strong, ethical, well-reasoned scientific message builds the sense of security that physicians need in order to get behind a product or modality.
Marketing to medical professionals implies educating them. The success of pharmaceutical companies is in large measure due to their recognition early in the 20th century that their future would depend on educating professionals on how to use their products. They built and funded medical schools and continue to fund medical research. They fund ongoing continuing medical education and work closely with professional organizations. In effect, their commitment to medical education was so total that conventional medical education, and in turn conventional practice, became almost synonymous with prescribing drugs. The pharmaceutical giants built their product delivery system through education and outreach. While I would not advocate that the nutraceuticals industry try to parrot "Big Pharma," it doesn't hurt to understand a few moves from their playbook.
Pro-Line Nutraceuticals Learn from 'Big Pharma'
Recently, it seems, a number of nutraceutical companies are taking notes from "Big Pharma." Last year, Thorne Research made a $500,000 contribution to the Southwest College of Naturopathic Medicine in Phoenix, AZ, for the endowment of a chair in environmental medicine. Gaia Herbs made a similar donation to Southwest to establish a botanical medicine clinical research program. Some companies have become extremely sophisticated in their educational and informational outreach to physicians. For instance, Metagenics posts a monthly electronic newsletter to practitioners called, Meta eNews, which provides scientific literature reviews, quick "primers" on general natural product categories and specific updates on the company's new products.
One of the most impressive campaigns, however, recently came from Sigma-Tau, the Italian fine chemical and ingredient supplier. After a series of Italian studies showed that L-carnitine could improve sperm count, motility and morphology, the company decided to brand its L-carnitine fumarate/acetyl-L-carnitine as a finished product called Proxeed. Last year, the company exhibited Proxeed at a number of conventional medical conferences, including the annual meetings of the American Society for Reproductive Medicine and the American Urological Association, as a low-cost natural intervention for infertile couples. Sigma-Tau's promotional materials for Proxeed are well designed and scientifically grounded. The Proxeed exhibit booth, which drew enthusiastic attention at both conferences, was as sophisticated as those from any of the neighboring drug company giants. The only thing that distinguished Proxeed as a nutraceutical rather than a pharmaceutical was the tiny DSHEA disclaimer statement.
Nutraceuticals and the Future of U.S. Healthcare
While there has clearly been progress in bridging the gap between medical professionals and the nutraceuticals industry, by and large, the industry has done a poor job overall in presenting the benefits of dietary supplements to the medical community.
It is indeed true that it would be hard to compete with the massive spending of the drug giants-a large pharmaceutical company probably spends more on an exhibit booth and support materials at a single major medical conference than most supplement companies spend on marketing for an entire year. But the issue is broader than financial concerns. Several observers have noted that in general, the industry has not perceived itself as part of healthcare as a whole.
With the exception of the DSHEA legislation and other issues that have direct and immediate impact, the nutraceuticals industry has been conspicuously absent from healthcare policy-making and are seldom involved in any of the legislative processes that shape healthcare.
This is partly due to historic rifts-the previous unwillingness of mainstream medicine and policy makers to take the industry seriously. But if DSHEA taught us anything it is that policy makers will listen to an industry with massive popular support in its corner. With the healthcare system at large tottering on the brink of total collapse, it is high time the nutraceuticals industry brings its public support and prevention orientation to the table.NW
About the author:
Erik Goldman is editor-and-chief of Holistic Primary Care, New York, NY. He can be reached at 212-406-8957; Fax: 212-406-8959; E-mail: erik@holisticprimarycare.net.
