MedicinMan October 2012

1. A BroadSpektrum Healthcare Business Media’s Corporate Social Responsibility InitiativeMedicinMan ~ FIELD FORCE E XCE L LE N CE ~ TM PHARMA | MEDICAL DE VICES | DIAGNOSTICS | SURGICALSVol. 2 Issue 10 www.medicinman.net October 2012EditorialMEDICINMAN–THE ACTION BEGINSA year into operations and things are moving at rapid in a highly professional manner even in challengingpace for us at MedicinMan. After pulling off Brand situations. Anthony Lobo has written on the lost art ofDrift 2012 and FFE 2012, we are now readying for listening – an increasingly important skill in a noisyBrand Drift 2013 and FFE 2013 in February 2013. world.The 1st Breakfast for the Brain was a grand success Prof. Vivek Hattangadi continues the second part of hisand there‟s a report on Page 10 by Amlesh Ranjan, Objection Handling – an excellent and comprehensivewho moderated the proceedings and coined the treatment of an important skills area for MRs andacronym, B4B. FLMs as well as training managers.The 2nd B4B will be held on Friday, 5th October at the Dr. Surinder Kumar has written on Decision Making –Courtyard Marriott, Andheri East, Mumbai from 0815 an important skill for aspiring and practicing managers.AM to 1000 AM. “10 Steps to Success” by V. Srinivas is a reminder forThe outcome of the 1st B4B - we now have Medicin- Medical Reps on the essentials of pharma field sales.Man Academy to conduct skill certification programs Dr. Amit Dang continues his series on Pharmacology,for pharma professionals from entry to senior levels in making this issue of MedicinMan a wholesome learn-sales, marketing, L & D, SFE, KAM etc; ing exercise to produce knowledgeable and confidentOur First Skill Certification Program for Pharma Sales field sales people.Trainers will be in December 2012 Finally, my third book, Repeat Rx is now available asDr. S. Srinivasan who was Sr. VP at Aventis will kick an eBook on Amazon.com, for reading on the Kindle,start our skill certification process as Dean, Medical iPad as well as the PC and Mac.▌Education of MedicinMan Academy. This issue has - Anup Soans, Editorthree articles by Dr. Srinivasan. We believe that everypharma field sales person must be knowledgeableabout common medical conditions and we begin thisissue with “Understanding CHF”. Let us know yourthoughts on this.This issue is power packed with articles from veteranslike Anthony Lobo, who has worked for 37 years as aMedical Rep and has demonstrated that one can work

2. Contents CLICK TO NAVIGATE. 17. High-flying Herbals Keeping a tab on the growing herbal4. The Ten Commandments of and natural remedies market Listening. Dr. S. Srinivasan A refresher on what it takes to be a good listener with practical tips. 18. SPECIAL FEATURE: Decision Making Anthony Lobo and Common Biases7. Handling Objections with A look at common cognitive biases that Confidence. (Part 2) plague pharma decision-makers and Four more techniques for Medical make good intentions go terribly awry Reps to handle objections from Dr. Surinder Kumar Doctors with ease Prof. Vivek Hattangadi 22. Pharmacology Essentials - Pharmaco-10. Breakfast for the Brain kinetics Parameters A report on the 1st Breakfast for the Concepts of volume of distribution, Brain hosted by MedicinMan at clearance, absorption, half-life, oral Courtyard Marriott, Mumbai. bioavailability explained Amlesh Ranjan Dr. Amit Dang12. Feedback - An Important Tool for 23. Boehringer Launches “Syrum” Coaching A look at the Facebook game launched How to constructively incorporate by Boehringer Ingelheim feedback into the coaching process John Gwillim K. Hariram 24. Infiltration - A Chronic Infection in15. Birth Pangs of Medico-marketing Pharma Field Sales A personal story on the initial days Products meant for sale in one territory of medico-marketing and learnings end up in another causing much frus- from the field. tration to the field force Dr. S. Srinivasan Hot on Linkedin16. Ten Steps to Reach the Summit 25. Understanding Congestive Heart Simple pointers for success in phar- Failure ma field sales A Field Force Knowledge Series V. Srinivasan Dr. S. SrinivasanEditor and Publisher: Anup Soans Chief Mentor: K. Hariram Advisory Board: Vivek Hattangadi, Jolly MathewsEditorial Board: Salil Kallianpur, Dr. Shalini Ratan, Shashin Bodawala, Prabhakar Shetty, Varadarajan S,Dr. Mandar Kubal, Dr. Surinder Kumar MedicinMan Academy: Dr. S. Srinivasan, Dean, Medical Education

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4. ← Home MedicinMan October 2012 >>> Listening Skills | Page 4The TenCommandmentsof Listening. Anthony Lobo eith Davis, the author of Organizational Behavior: Human Surely all of us believe that having heard so much for so Behavior at Work has dealt with Listening, and lists The Ten long, we must all be good listeners. Are hearing and Commandments of Listening as: listening the same? We have described listening as Ac- tive, and Passive. Pundits today harp on Aggressive Listening! #1. Stop Talking. # Listening is with the mind; #2. Put The Talker At hearing with the senses. Ease. # Listening Is Conscious; an Active Process Of Eliciting #3. Show Him That You Information, Ideas, Atti- Want To Listen. tudes and Emotions #4. Remove Distractions. # Listening is Interpersonal, Oral Exchange #5. Empathize With Him. A common fallacy is that since the objective is handed #6. Be Patient. down by a higher up it should be accepted without question. “Believe in my wisdom” is a cliché commonly used #7. Hold Your Temper. by managers to ram down unanimity. Coercion dis- suades active participation, and leaves the team uncon- #8. Go Easy On Argu- vinced that they are on the right track. Team mates would want to follow a leader not be herded by a ments And Criticism. commander. Yes, this manager might curry favor with the superior, but apart from not really carrying the team #9. Ask Questions. along, better ideas might stay buried with those who have them. An apt note for such managers: “it is better #10. Stop Talking! to shut your mouth and let others think you are a fool, that to open your mouth and confirm it”.

5. ← Home MedicinMan Ocotber 2012 >>> Listening Skills | Page 5 Common fallacies about listening are numerous, but as most Lawyers are on opposite sides; in a sales team every member is field sales people are compelled to sit through weekly meet- on the same side. To generate momentum and create maximum ings because the higher ups lack a clear idea of how to pro- impact, every team member must be convinced that the approach ceed, it would be fair to stick to the bugs in these meetings, to achieving the objective is right. A team leader is part of a team, and should not appear to function apart from the team. Based on as that is where most of the listening should happen. past experience members may vary approaches, still achieve success, or even surpass expectations. How to be an Aggressive # Listening is not my problem! Listener: # Listening and hearing are # You must want to listen the same # Admit biases, and accept re- # Good readers are good lis- sponsibility for understanding. teners # Encourage verbal participation, # Hearing what we expect to restrain the urge to judge . hear, than what is actually # Make notes, involve physically, said. avoid negative mannerisms. # Thinking about how to rebut # Recognize the focus of the the speaker, rather than ac- speaker, the main idea and de- cept his view. tails of the oral message. # Not paying attention, or Epictetus, a Greek philosopher (AD 55) is credited with some talking when we should be unforgettable pointers about listening, among which, I‟d like to listening. share two with you i) First learn the meaning of what you say, and then speak. # Listening skills are difficult ii) Nature has given to man two ears and one mouth, so that you to learn. may hear twice as much as you speak. A Few Barriers to Aggressive Listening: We hear so much, but have we learnt to listen? Listening twice as much as we speak might help us achieve twice as much. ▌ # No motivation. # Negative listening attitude. Anthony Lobo started life as a # Selective listening. Medical Representative in Warner Hindustan Limited in 1974, moved # Poor interpersonal relations into Parke Davis India Limited in 1985 consequent to a merger of the two companies, and Pfizer in 2002 To students of law, Latin legal maxims are like bullet points after another merger, retiring in 2011. of a power point presentation. „Audi alteram partem „ is a He has seen mergers and acquisi- Latin Phrase that literally means „Hear the other side before tions, their unpleasant side of internal you speak‟. change, secondary sale to primary dumping, and the transition from a demand generating to an over the counter pharmaceutical field force.

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7. ← Home MedicinMan October 2012 >>> Objection Handling | Page 7 Handling objections with confidence. (Part 2) Prof. Vivek Hattangadi e saw in the September 2012 Issue of MedicinMan that there is no such term as „objection handling‟. On the other hand, the actual term is „encashing the opportunities‟. Establishing a business relationship with a doctor is a lot like walking on a balance beam and, if you are able to handle the opportunities he gives you, you will be able to have a sus- tained relationship. Now let us look at why objections are raised in the first place. » You have neglected to present all of the prod- Whenever an objection is raised, it should be addressed im- uct benefits. mediately; or else it may be a lost opportunity; a lost prescription! Procrastinating may result in: » Benefits may have been presented, but not the right benefits. In other words, you may have » The doctor not listening further to our detailing. failed to probe for real needs. » The doctor may feel that we are hiding something. » Rapport hasnt been established with the doc- » The doctor may feel that even you perceive it as a tor. problem – that would be very dangerous. » The product has not been targeted to the right » The doctor may think that you are not able to answer doctor. Just imagine Colimex Drops being pro- because you do not know the answer, which is a poor moted to a cardiologist? reflection on you. If you do not have an immediate » Communication and body language are poor answer, assure him that you will find out and inform. that you don’t sound confident or knowledge- The worst scenario, it may appear that you are not interested able. in the doctor‟s opinion and you may lose him forever. » Extraneous reasons for which neither you, nor While handling objections: the brand nor the company are responsible. A. Be positive! » Use positive body language and smile. » Do not take objections personally. B. Listen - be an aggressive listener. » Ask questions, nod your head at appropriate times. » Show him that you are genuinely interested in what he says. Here are few more methods in addition to what we learnt in the September 2012 Issue.

8. MedicinMan Ocotber 2012 Handling objections with confidence. (Part 2) | Page 8 1. Deflection Method what to do. I too put a drop on my tongue mirrored him and made a face. “Yes, it‟s bitter. I shall definitely con- You can handle an objection by deflecting it, i.e. by vey this to our R&D” I said and then deflecting the changing the direction. First listen to what the doc- objection I asked him “But what do you feel about the tor says. Understand his concerns, which should concept behind Colimex Drops, like when at midnight also reflect in your body language. Then continue as a mother brings her child to you with burping, ab- if nothing had happened. You can tell him that you dominal gaseous distension with severe colicky pain?” will come back to his point later. It is possible you Dr. Rao looked at me and said “Yes, and this is a very won‟t have to. Give an excuse, such as not having common problem here. Mothers do not know the right information or having to talk to somebody else lat- techniques of breast feeding”. And then he went on for er. half an hour explaining that condition to me and how In the examples which follow, many are from my Colimex could be useful. In fact he was detailing Co- days when I was a medical representative with limex Drops to me. Finally he said “Tell your company Carter-Wallace. We had just introduced possibly to prepare a patient-education poster on the right way the most interesting and effective product in those to breast feed a child. And make sure that Colimex days for infantile colic, Colimex Drops. It contained Drops are available with all the retailers here. I do not dicyclomine (an antispasmodic) and dime- want a single prescription to come back”. thylpolysiloxane (an antiflatulent). I deflected the objection, yet acknowledged and accept- Doctors loved its efficacy, but the kids hated its ed his objection. He went on to become my Colimex taste – very bitter. Nevertheless, it was my favorite brand ambassador in Kalol. brand and always wanted it to be brand leader in my territory. 2. Empathy Method Once I was meeting a very influential doctor from In this method, first empathize with the doctor and tell Kalol, an ex-town of Ahmedabad, Dr. S.M. Rao. him that you understand how he feels. Then tell them He was a GP with dominant pediatric practice. I about another doctor who also felt the same way. Then was introducing Colimex drops to him. He liked the tell them how the other doctor found that things were concept. He opened the sample bottle and put a not so bad when he actually used it. drop on his tongue. “Aagh! It‟s very bitter!” he ex- I was meeting a well known pediatrician from Ahmed- claimed “I shall never prescribe Colimex Drops till abad Dr. Arvind Kothari who was reluctant to prescribe you change its taste.” Colimex drops because of its bitter taste. I said “I do I knew that dicyclomine had an inherent bitter taste understand how you feel about the taste of Colimex and there was no way to mask it. I was wondering Drops, and how the infants would respond to its taste. Even Dr. M.V. Dudhia (who was his teacher and HOD, Pediatrics, V.S. Hospital, Ahmedabad) felt the same way. But when he prescribes Colimex Drops, he tells the mother to keep the dropper at the back of the mouth and then administer Colimex Drops. Well, he told me that he receives so many phone calls from mothers thanking him for the relief he has given to the infant!” “Okay” said Dr. Kothari “is this what he does? Well, let me also try this technique too” and he went on to become a prolific prescriber of Colimex Drops. By empathizing with the doctor, you are in harmony and creating rapport for building long term relations.

9. MedicinMan October 2012 Handling objections with confidence. (Part 2) | Page 9 strong body language and make sure you take care of your 3. Curiosity tone. You should appear non-threatening and not in closing When a doctor says that he does not want to pre- mode. The doctor may well relent and give you the infor- scribe your product, you can become curious. Do not mation you need. just ask Why?‟ but express curiosity and interest. Diovol Suspension, an antacid, was our ace product. 4. Humor RCPA revealed that Dr. Vinod Rawal was a heavy When a doctor objects do not respond with negative emo- prescriber of Digene (from Boots), the most im- tions such as anger or frustration. Defuse the tension with portant competitor for Diovol Suspension. I met him gentle humor, maybe feigning shock or poking fun at your- regularly for about a year but not a single prescrip- self, BUT NEVER AT THE DOCTOR. Be careful not to tion for Diovol. Finally one day I asked him “Doctor, make the doctor the object of humor. just of out curiosity, could you please tell me why Another true episode, this time with Dr. Chinubhai Shah you have not prescribed Diovol? Tell me the reason who never prescribed Colimex Drops. One day I told him doctor and I shall be very happy.” “Well I think Colimex Drops will start crying if you don‟t Dr. Rawal smiled. “I believe you know Hoshang prescribe”. I took out a bottle of sample, showed the bottle Kanga, the medical representative of Boots? We and said “Dr. Chinubhai, Colimex Drops are already shed- studied together for 11 years in school. Forget about ding drops of tears – see this” Diovol Suspension as long as Hoshang is with Boots”. (This is the image of Colimex Drops sample pack then) “Thank you for mentioning the name Diovol Suspen- sion, doctor. At least now I know the reason”, I said Dr. Chinubhai burst out laughing and not with a smile. “I always thought my presentation was only started prescribing Colimex Drops but also took up an- poor or maybe you do not like me. I am relieved” He other product, Walamycin, outright too smiled, but the last sentence “…as long as he is Receiving an objection can be very frustrating. It is very in Boots” kept on reverberating in my ears. easy for emotions to leak out. By adding humor, you can I kept on persisting and one day during RCPA, I show that you are not offended by their refusal. BUT I RE- found a flow of prescriptions of Diovol Suspension PEAT, NO HUMOR ON THE DOCTOR! from Dr. Rawal. I was pleasantly surprised. I asked Well my message to all young friends, improve your com- the retailer what happened. He too smiled and told munication skills and speak with confidence. Your technical me that Hoshang has migrated to Canada. Persis- knowledge i.e. product knowledge will certainly go a long tence pays and if you know the reason why a doctor way in getting the confidence you need. ▌ does not prescribe your products, it will help you. But very important, in such cases, when trying to Caricatures © Vivek Hattangadi find the reason, complement your actual words with Prof. Vivek Hattangadi is a Consultant in Pharma Brand Management and Sales Training at The Enablers. He is also visiting faculty at CIPM Calcutta (Vidyasagar University) for their MBA course in Pharmaceutical Management. vivekhattangadi@theenablers.org http://in.linkedin.com/in/profvivekhattangadi

10. ← Home MedicinMan October 2012 >>> Report | Page 10 “Breakfast for the Brain” hosted by MedicinMan... Friday, 7th September, 2012 - Courtyard Marriott, Mumbai. Topic: Skill Certification for Pharma Field Force Amlesh Ranjan he First Breakfast for the Brain, let us call it B4B, started with some background information and purpose sharing to set the context and the tone for a quality interaction and exchange. Pharma in India, a crowded industry, with an increasing difficulty for meaningful differentiation, depends even more on its Field Force to make an impact on the key customers. Why call them Field Force? Why Pharma? Sandip, COO, Max mobile took off with these highly provocative questions. Varadrajan, Merck Serono talked about learning from other industries and creating benchmarks for training and certifica- First Line Managers have a critical role and their equation tion. Vidyut, USV emphasized on Grooming, Self Esteem with the field force often determines the gap between success and also need to simplify the message. Madhu, Zydus batted and failure. Newer roles like KAM and Specialty Reps are the for overall Capability. Dr. Srinivasan advocated the impossible answers to the emerging opportunities. We also need portance of making Medical knowledge and communication, to look at sales models focused on relationships, partnerships relevant. Nandkumar Shetty, ex-Zydus pushed for soft skill and value based selling. and full training. Smita mentioned training as a function of Keeping in mind the above, we will put a task force in place strategic importance. Dr. Nitin Malekar opined that a Medi- to work towards certification for the Pharma field force in cal Representative who is trained well is received and treated India. Chhaya Sankath will head the task force and we will well by the Doctors. Milind, Abbott spoke about the need for have the key professionals from the industry who will like to field based training combined with class room training. volunteer for this important project for the industry. Sagar, PwC mentioned the difficulties of the frontline roles Pharma‟s destiny is determined in the Doctor‟s chamber and and suggested to use certification as an effective filter and it is the Field force, whose Will, Knowledge and Skill drives also a business model which addresses the value chain in its the success. Thus Field Force Excellence is one of the most entirety. Ms. Balraj od Kingpins Management Consultancy strategic lever requiring all-round support and attention. put forth self-esteem, as a critical factor for field force. Ra- manathan, Ranbaxy urged all to make training practical. Someone has rightly said: Increasingly Lesser time from the Doctors, makes the job “In a commercial organization, You should either be sell- even more difficult. Overall there is a low value perception ing or, supporting someone, who is.” ▌ by the Doctors for the Medical Representative‟s visit. Can we help evolve the quality of Reps through a certification based training which measures up to set benchmark? Can we have the due balance between Knowledge and Skill on one hand and classroom and field based learning on the other? Amlesh Ranjan is Associate Director Number pressure often dilutes the drive for quality. Trade at Sanofi. management training is not imparted and the same can be very useful. The gap between the ground reality and the training needs to be bridged.

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12. ← Home MedicinMan October 2012 >>> Coaching | Page 12feedback—an importanttool for coaching. K. Hariram our call average is low”, “your total number of doctor To get the desired result, how to convey negative feed- coverage is below expectation‟, “your reports are always back? coming late”, “your sales is not up to the mark”, „your Do it without de-motivating or demoralizing the other KOLs‟ connect is very poor”. person Does this sound very familiar? » "Feedback is best given at the earliest opportunity. Though these statements appear like comments, they are » Give the feedback calmly and with a sense of guid- all, in fact, FEEDBACK. ance and correction. What is feedback? » Even negative feedback should focus on the positive In an organizational context, feedback is the information while still identifying areas for further growth and sent to an individual or a group about its prior behavior so better outcomes that they may adjust their current and future behavior to “Earlier, you were prompt in mailing your reports. But achieve the desired result. since two months, they are coming late, by a week. What could be the reason? If you are facing any problems, feel Feedback comes in three forms: free to share them with me so that I will see if I can help you to overcome the problems in future.” I. Negative feedback: Even a person doing an excellent job looks forward to appreciation. This is handed out through POSITIVE It describes a perceived negative behavior, without pro- FEEDBACK posing a resolution. It is used to point out what the sales person did not do or how much he did less than the ex- II. Positive feedback pected behavior, etc. All the examples mentioned as in- troduction are examples of negative feedback. By merely Applies to situations where the sales person did a good pointing out the negative behavior, the manager is not job. It consists of simple praise, but is even more power- going to achieve anything, other than de-motivating the fully reinforcing when the FLM specifically highlights sales person. why or how the sales person did a good job. So to be ef- Most often we come across this form of feedback, think- fective, describe the positive behavior. ing that we are being specific by pointing out only what “I thought you did a great job on the sales call. You were has not been done or what was wrongly done. We as- asking the doctor a lot of important, open-ended ques- sume that we are not wasting time nor beating around the tions to understand what he needed, rather than just talk- bush by doing so. In the process, we miss out the most ing about price and telling him about our product.” important angle…the human element, which looks for Another form of feedback, which helps by redirecting positive strokes and redirection for improved perfor- behavior, is CONSTRUCTIVE FEEDBACK. mance.

13. MedicinMan October 2012 feedback—an important tool for coaching. | Page 13 III. Constructive feedback Highlights how the sales person could do better next How to make feedback effective? time. It needs to be conveyed objectively with emphasis on specific, measurable and observable facts. » Come to an agreement about the Constructive feedback involves Identifying and com- issues municating the problem behavior and offering an appro- » Acknowledge the sales person‟s priate action plan. feelings “I‟d like to talk with you a moment; please come into my office. I have noticed that you have been in the office, » Focus on „ behaviors/skills and not rather than in the field, and this is a problem. Your re- the „person‟ sponsibility is to spend 90% of your time on the field » Give the specific picture of desired calling on doctors and retailers, and you are not doing that.” skill/behavior “Why I am pointing out this is because we are in a very » Suggest practical steps competitive market and your current doctor customers are being targeted by our competitors. You need to stay close » Balance negatives and positives: with them and always be providing value. We have talked provide constructive actions about you making at least ten doctor calls a day to bring » Verify with questions: ask for the in the revenue growth we are expecting of you. What can I do to help you?” sales person‟s recap Providing feedback is one of the FLM‟s most important » Jointly arrive at a plan skills. Positive feedback is used to reinforce desired » Invite the sales person to asses own behavior. Constructive feedback relates to areas in need performance first of improvement. It is important to provide your sales people with both forms of feedback in order to improve and » Offer support for future maintain quality performance. It establishes a connection between what sales people are doing and how their actions are perceived by others. » Providing feedback can improve sales people‟s morale It means conveying or sharing with your sales person and reduce confusion regarding expectations and current what he did in a specific situation, and also highlight the performance. impact of the same. This forms the basis for direction and » Feedback should NOT be limited to the times you do what is the expected action plan, as a way forward. Performance Evaluations. It‟s an ongoing process between the manager and his team. Remember: This is the 3rd article in a series on » Even though you, as a manager, may dislike giving “Coaching” by K. Hariram feedback, your sales people expect it and need it. » Most complaints are never about the necessity to improve, but how a manager inappropriately han- dled the situation. K. Hariram is the former » When correctly given, feedback helps improve per- MD of Galderma. formance while promoting professional and personal growth in the sales people

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15. ← Home MedicinMan October 2012 >>> Personal Growth Story | Page 15 Birth pangs of“medico-marketing” Dr. S. Srinivasan he year, 1975. The place: a doctors‟ meeting in Pune. I had reps‟ and inquisitive doctors, the more I felt like announc- just “re-migrated” to India after a few years of teaching cum ing to the pharma world of yore that I was not a medical research in CWRU School of Medicine, Cleveland, Ohio. I advisor but a medico-marketing manager, rubbing shoul- had also dared to change horses mid-stream as it were to join ders with no one but the guy in the field whatever his visit- the then-rare breed of pharma medical advisors to occupy a ing card said, and enjoying it all to the core and asking for cabin in the marketing head quarters of a big MNC-cum- an encore too. Indian pharma at that time. Mind you, new learning never happened (and it never hap- pens) unless you force yourselves into new situations and As the doctors‟ chat got warmer with a few gulps of the elixir new difficulties. While many medical advisors were happy of life, a prosperous looking GP asked me what I do to make a to intellectualize in the air-conditioned comfort of their living. When I said, medico-marketing, he literally choked on cabins, I relished the rough and tumble of the market his drink wondering what language I was speaking. “Where is place, come rain or shine, hell or high water. For instance, your clinic?” was his next question and when I said I had I would work myself into anti-competitive duels, take a none, he decided to ignore me for the rest of the evening as few punches but give back at least as many, if not more. though I am an aborigine from Swaziland. After coming home, the licking of the wounds was painful HO howlers. as well as insightful to say the least. Back in the head office, when I repeated the term medico- Many stories to tell. marketing, I was ridiculed by my medical boss whose visiting In the 37 years that went past since that Pune meeting of card said, Senior Medical Advisor, Medical Research Divi- doctors, I have gathered several stories which I hope to sion. When I protested that my research days were over when I share with you. I am sure, you have many good stories to left Cleveland, he sternly reminded me that the word research tell too and I am keen to hear them and learn a thing or had to be there for tax purposes, and rules are rules. two, right here, right now. The marketing head was very happy with me, though I never Before I say bye for now, let me give you a tip on medico- reported to him directly. I spent a whole lot of time with prod- marketing career building, or even life in general. Become uct managers and field managers, especially the first level, a good story teller and everybody will eat out of your riding pillion with them and drinking cutting chai by the road- hand. ▌Wanna hear more and tell more? Wait till next side and at times even gobbling chicken biryani for 5 bucks a month! plate en route to the airport. New learning. Dr. S. Srinivasan was Sr. VP at Aventis. He assumes Boy, did I learn a lot about our products that way. And what a responsibility as Dean, Medical Education of learning it was, well beyond the formidable board covers of MedicinMan Academy. Goodman & Gilman that we were told to swear by. The more I learnt totally new things about our products through „med

16. ← Home MedicinMan October 2012 >>> Steps to Success | Page 16 Ten steps to reach the summit. V. Srinivasan Step 1. Step 8. Active doctors coverage list, total number of Doctors, and Personal Order Booking (POB) must be booked every day specialty-wise breakup, should be exactly as per strategy. to ensure availability of products being promoted at all counters. Check for near expiry stocks at retail counters, and Step 2. ensure they are liquidated quickly. Right Doctor for right products chosen after thorough understanding of the potential of each Doctor, the brands he Step 9. is currently prescribing, etc. through proper RCPA. Review the state of affairs often, like product wise primary sales, secondary sales, conversion of Doctors, efforts put Step 3. in, etc. and then take corrective measures immediately wherever required. If you are provided with online reporting No compromise on efforts, i.e. call norms, frequency of system, then lot of analysis/status reports are available to visits, and exposure norms as per strategy, must be you at the click of a button, thus make the best use of tech- achieved month after month. nology for betterment. Step 4. Step 10. No deviations in working, from approved tour programme. Make earning of big incentive amounts a habit, rather than making a few hundred rupees extra through expense Step 5. statement. Sampling, Camps, Campaigns, Special promotions, etc. These ten commandments, if implemented in all sincerity, must be strictly executed as per strategy. should definitely take any Pharma Medical Representative to success. Line Managers, to taste same success, must en- Step 6. sure strict implementation of strategy, some of which are described above, by each and every Medical Rep in the Communication – i.e. detailing for each product – must be bang on target 100% as per strategy. team.▌ Step 7. V. Srinivasan has headed Sales Administra- Prescriber base (i.e. Number of Doctors prescribing the tion & HR functions in reputed Pharma products) should be as wide as possible. While it is under- Companies, with over 300 published articles standable that 20-30% of Doctors may be big volume con- on Pharma Management in India and abroad. He can be reached at: tributors, rest all should be contributing something worth- Email: shridhar1956@rediffmail.com while to the kitty. Mob: 8056168585

17. ← Home MedicinMan October 2012 >>> Market Insight | Page 17High-flying herbalsHigh- Dr. S. Srinivasan ost of you must be dealing largely with allopathic medicines where the rules of the promotional game Good news and bad news Getting into herbals is an attractive proposition for many marketing are pretty much set for decades, barring a few „zara heads, especially those who are crunched by price-controlled, branded hatke‟ strategies in recent times. Whether you are generics where the bottom line gets eroded too fast for comfort. The good selling the „original brand‟ or a branded generic or a news about herbals is that they are outside of price control and composi- generic-generic, your instincts and reflexes stay es- tional constraints, so you get to play with the top line to ensure a good sentially in the same ballpark. bottom line. But the same good news can turn bad if your competitor plays fast and loose on both counts and tweaks the composition and the Markets 2010 Projected 2015 price a bit too often for your comfort. Europe 35 70 North America 6.5 25 Clever play of terminology While we can‟t get into the details here, we should know how to use ter- China 4.0 12 minologies to our advantage. Depending on the situational need, a herbal India 1.5 3 can become, in promotional slant, a nutraceutical, a phytochemical, a cos- Others 13 30 meceutical, a complementary medicine, a traditional medicine, a wellness promoter, a natural balancer, and so forth. No matter what term your mar- Total 60 140 keting department chooses to use, you must be adept at communicating it Billion US$, SME Times News Bureau, 6 March, 2010 with conviction and confidence. But times are changing, and changing fast. Of late many of you must be feeling the heat of the fast- Rx route vs others As of now, most herbals are promoted through the „ethical‟ route of de- emerging herbal market which might well be throw- tailing leading up to a prescription that is dispensed by a chemist. This is ing a spanner in the works for some of your products, largely because it is the only game we know well, thanks to our decades- especially in the chronic therapy segments like arthri- long entrenchment in the prescription market. But all this can, and will, tis, asthma, psoriasis and so on. Without getting into change pretty fast. There are other options like DTC, OTC, OTX etc the whys and hows of how this happened, let us which converge as well as diverge depending on your convenience and acknowledge that gone are the days when the confidence level. „traditional‟ (read allopathic) marketers looked down upon herbals as uncouth country cousins not worthy In short, wait and watch and adapt as the herbal story is just unfolding. It of even half a nod as they are forced to look at the could well become a Pandora‟s box for the marketers as well as the con- size of this humongous market. sumers of healthcare in the not-too-distant future. ▌

18. ← Home MedicinMan October 2012 >>> Special Feature | Page 18 Decision making and common biases. Dr. Surinder Kumar Sharma ll of us, from a field representative to a CEO, frequently make various decisions, business as well as personal. These decisions are supposed to be rational and objective decisions made after carefully evaluating all pros and cons. Though all of us claim to be objective while making a decision, scientific research suggests the contrary. In spite of our best efforts to be objective and rational, our biases and thinking errors influence our decisions. Con- sequently, our decisions are frequently the outcome of our hunches, impulses, emotions, convenience, or limited experience, rather than a sound judgment. Everybody, regardless of age, gender, education, or intelligence, is prone to biases. advantage and helped survival of our species. Therefore, Bias, and the subsequent error in judgment, is the most heuristics have become an integral part of our cognition important reason of wrong, and sometimes catastrophic, (mental process). business decisions. While these strategies (heuristics, experience-based tech- First question that comes to our mind is why we, owner niques, or mental shortcuts) are of great help in our day-to- of an intelligent and rational mind, fall prey to biases? day efficient functioning, they can also lead to thinking Our forefathers had lived in a highly unpredictable errors, which adversely affect our judgment, and subse- world, where they needed to make quick decisions quently, business decisions. based on limited knowledge. Imagine a man in savan- Behavior research has firmly established that our many nas, who upon noticing a movement in a nearby bush, decisions, and some times the very crucial ones, are strong- immediately assumed it be to some dangerous animal ly biased. Daniel Kahneman, a psychologist, received No- and ran for his life. Such quick decisions, though many bel Prize in Economics for his work in this area. times having erred on the cautious side, paid by increasing their chances of survival. Though numerous biases have been identified, I will brief- Over a span of generations, our mind has developed ly discuss only some of the most common biases. strategies to make quick decisions based upon readily accessible though incomplete information such as past Conformation bias. personal experience, intuitive judgment, common sense, While making decisions, we assume that we have gathered educated guess, etc,. These strategies, also called heu- all relevant information and have based our decision upon ristics, shorten our decision making time and save us it. However, we tend to seek and collect information that from getting bogged down by details, and therefore are goes well with our preconceived notions or beliefs, and highly energy efficient. ignore or discount the information that is contrary to our This system, of taking quick decisions in an unpredicta- existing beliefs. We even tend to interpret the data in a way ble situation, has provided us with a great evolutionary that suits our pre-judgment.

19. MedicinMan October 2012 Decision making and common biases. | Page 19 We read books, watch movies, or socialize with people that support „our way of thinking‟. Unknowingly, we gath- er more and more evidence to support our assumptions, “Our mind is tuned to detect beliefs and views. and construct patterns from No wonder, most of us, as we age, tend to become more rigid, more judgmental, more obstinate; and unfortunately, the available information in more stupid. conformity with its pre-existing To simplify, we tend to give too much weight to the information that support our decision, and too little to the evi- knowledge and experiences… dence which contradicts it. Many times slowly occurring Examining all the available evidence with objectivity, dig- changes do not appear to be ging deeper into contradictory evidence, resisting tempta- tion to dismiss the uncomfortable information, maintain- of importance to us, and are ing intellectual honesty, and keeping a devil‟s advocate in not acknowledged until they us will help us to overcome this very common and most dangerous bias. become so obvious, and usually too late.” Bounded awareness or extreme focus bias. While making decisions, we frequently tend to overlook Status quo or comfort crucial information due to our extreme focus only on one aspect of the matter, especially when the information is zone bias. unexpected. When we make decisions, we have a tendency to prefer alternatives that perpetuate status quo, or ensure that we Our mind is tuned to detect and construct patterns from remain within our comfort zones. the available information, but it constructs or detects patterns only in conformity with its pre-existing knowledge A comfort zone is a behavior state in which a person oper- and experiences. Therefore, we are prone to miss or ignore ates in an anxiety-neutral, emotionally comfortable situa- an unexpected or a newly developing pattern, which in tion. reality may be very important for an accurate judgment. Most of us tend to avoid novel or challenging situations, Many times slowly occurring changes do not appear to be and make new decisions under these constrains. of importance to us, and are not acknowledged until they Conventionally, it is wiser to stick to the confines of one‟s become so obvious, and usually too late. reach, familiar, existing capability; but in the fast changing A drug company, too much focused on drug‟s efficacy or world, where new developments in technology are redefin- on making profits, may miss the magnitude of ing the norms and boundaries, staying at impact resulting from a „seemingly innocuous‟ the same spot could be fatal. adverse effect. One of the main reasons of organizations Many strategic-disasters, such as fall of Enron, failing to meet the market challenges is Challenger‟s crash, Polaroid‟s bankruptcy, have that the decision makers hesitate to make happened due to failure to recognize small, but decisions that challenge status quo. Per- haps the reason is if they maintain status crucial information. quo, they can always blame the market Thorough „threats and weaknesses analysis‟, a forces for their failure; whereas onus of keen eye on changing business environment, and taking an unconventional decision, if most importantly, taking an outsider‟s perspec- turns out to be a wrong one, will fall only tive, help us to avoid this bias. on them – organizational culture is to be blamed.

20. MedicinMan October 2012 Decision making and common biases. | Page 20 When meeting after meeting you are discussing the same issues, without arriving at a solution, you are perhaps avoiding tough decisions. Reflect if status quo will help you in meeting your objectives, or you need to change course. “Managers have a strong urge Ask yourself, „if today you start afresh, will you do this thing, in the same way? Or, will you do this thing at all?‟ to prove that their decision was And mostly change is not as traumatic as assumed; many times it is liberating - we often overestimate the effort need- right, and commit higher than ed to change. justified resources to influence Sunk cost or escalation the outcome.” of commitment bias. We have tendency to continue to support unsuccessful en- deavors, sometimes with an escalated commitment. Strange- impeccable record, given more weightage during perfor- ly, we not only tend to stick with the obviously gone-wrong mance evaluation, is one example of availability bias in projects, but we continue to further invest in such projects. business environment. By habit, more we invest in something (financially or emo- Many times, we end up tweaking our plans based upon a tionally), harder it is for us to give up that investment. sundry remark or some inconsequential information, only This sunk-cost fallacy resulted in continued involvement of because we came across it just before the review or meeting. USA in Vietnam in 60s-70s, and more recently in Iraq, Whenever an anecdote, or a single event, is used to „justify‟ where dollars spent and lives lost justified the continued an idea, it is the availability heuristic which is in play. involvement. One of the main reasons of getting sucked up by „sunk cost Basing your decisions on statistical data and logic helps bias‟ is - we are strongly conditioned not to waste. There- avoiding this bias. fore, we continue investing, because, otherwise, the sunk cost will have been „wasted‟. Anchoring Bias. Mind gives disproportionate amount of importance to the In business scenario, perhaps more important reason is, first information it receives – initial impressions carry undue managers have a strong urge to prove (or not mature enough to admit their mistake) that their decision was right, and weight relative to the information received later. commit higher than justified resources to influence the out- In other words, first-information learned about a subject come. strongly influences our future decision making and infor- To avoid Sunk Cost bias - take a fresh look at your project/ mation analysis. decisions at every milestone; get periodic evaluation by in- This bias is due to common human tendency to rely too dependent party; Be alarmed on hearing statements like „ heavily on one trait or piece of information while making we have already invested so much…‟; and most importantly, decisions. avoid creating a mistake-fearing culture in your organiza- This bias more frequently come into picture during negotia- tion. tions. During price negotiations, especially for services where benchmark is hazy, subsequent discussion is often Availability bias. based upon the first-price quoted by the service provider. We tend to base their judgments on information that is read- Similarly, sales expectations and investment plan of the next ily available to us. Especially the information that evokes year is prepared based on previous year numbers, rather than strong emotional reaction, is vivid, and is encountered re- on the market potential. cently, tends to be more available to our memory and color Evaluating everything with a fresh mind and, giving every our decisions. The availability bias creeps in due to our un- information, irrespective of when the information was re- conscious process that operates on the notion that "if you ceived, equal attention will help avoiding this thinking error. can think of it, it must be important." An independent bench marking, or creating internal stand- Recent behavior or one failure of a person, otherwise with ard for services, will help to cut a better deal.

21. ← Home | Page 16MedicinMan October 2012 Decision making and common biases. | Page 21 Halo effect bias. Bias blind spot. Halo effect is a bias when one overarching positive trait of a We are smart in picking up other‟s biases, but we fail to realize person drastically improves his rating for his other positive our own biases. traits as well. For example attractive people are rated better We are strongly biased towards our own capabilities and short- than real for their education, intelligence, friendliness and hon- comings. We overrate ourselves for positive attributes, and esty. underrate ourselves in undesired attributes. This effect works in a very wide range of situations – a hand- It is very difficult, and almost impossible, to get insight into some boy is considered more intelligent and better behaved, our own biases because biases work at the subconscious level. and a good looking criminal gets away with a lighter sentence. HB Shaw has aptly said, „It is not only the most difficult thing This effect creeps up in our mind due to difficulty of mind to to know oneself, but the most inconvenient one, too.‟ hold two conflicting ideas, beliefs, values, or emotions, simul- Though, being a devil‟s own advocate may help up to some taneously. Therefore, if a person is extremely good in one posi- extent, the best way to uncover your blind spots is to keep a tive trait, he is assumed to be good in other positive traits as critic near you. Kabir has said, “Nindak niyare rakhiye angan well. kuti chhabay, bin pani saaban bina nirmal kare subhay” A It is commonly acknowledged bias while hiring and fixing contextual translation is - Keep a critic very close to you, for compensations. However, it has even deeper implications - he purifies your mind. suggestions of a manager, who is successful in one department, Quick decision-making strategies (Heuristics) serve a very are given undue weightage while taking decision of a function- useful role in our day to day functioning. They are of great ally different department. evolutionary significance and have helped us in reaching the (A reverse-halo effect, called devil‟s effect, is also equally current level of perfection. However, when we have sufficient common, where a person with one undesirable trait is harshly time and resources to arrive at a crucial decision, falling back judged as overall scoundrel. One error by an otherwise great on these strategies prevents us from arriving at the best deci- person demonizes him and all good done by him are totally sion. forgotten - history is full of fallen heroes.) A little more knowledge, awareness, patience, and objectivity Want to overcome this bias – just be a little skeptical. during decision making will help us a great deal in minimizing our biases in our professional as well personal life. Remember, HIPPO effect. it is often the small changes that have the biggest impact. ▌ Though technically not a bias, HIPPO effect is a very important cause of wrong business decisions. HIPPO stands for the Highest Placed Person in Office (or Highest Placed Per- son‟s Opinion). Many good projects get scrapped or irrelevant tasks initiated, or otherwise nicely progressing project reworked; just because the HIPPO said so – your wish is my command, my lord. Though we believe ours‟ to be a rational and humane society, just look around – how many managers are being (professionally) killed or maimed, simply because they have antagonized the HIPPO? Many times it is due to the Halo effect bias on part of the sub- ordinates, or due to narcissism of the HIPPO – he does not know, what he does not know. Dr. Surinder Kumar Sharma is Head - Strategy & Business HIPPO should spend more time in encouraging others to give ideas/opinions and listening to them, rather than throwing ide- Development, TTK Healthcare. as. Final decision shall be best left to the experts in a particu- lar field.

22. ← Home MedicinMan October 2012 >>> Pharmacology for the Rep | Page 22Pharmacology essentials:pharmacokinetic parameters volume (14L)]. In general, the greater the V d, the greater Dr. Amit Dang the diffusibility of the drug. Most drugs bind to plasman the last issue, the term pharmacokinetics was discussed under the proteins such as albumin and α-1-acid glycoprotein. Vdfour headings of absorption, metabolism, distribution and excre- becomes clinically important as it is assumed that onlytion. Pharmacokinetic parameters are derived from the measure- unbound (free) drug is available for binding to receptors,ment of drug concentrations in blood or plasma. The key pharma- being metabolized by enzymes, and eliminated from thecokinetic parameters and their importance for the dose regimen and body. Thus, the free fraction of drug is important.dose size are shown in the Figure 1. These are bioavailability, vol- Clearance (CL) is used to describe the efficiency of irre-ume of distribution, clearance and elimination t1/2. versible elimination of drug from the body. It is the meas-Bioavailability (F) is defined as the fraction of the administered ure of the body‟s efficiency in eliminating drug from thedrug reaching the systemic circulation as intact drug. Bioavailabil- systemic circulation. More specifically, clearance is de-ity is highly dependent on both the route of administration and the fined as the volume of blood from which drug can be com-drug formulation. For example, drugs that are given intravenously pletely removed per unit of time (e.g. 100 mL/minute).exhibit a bioavailability of 100%, since the entire dose reaches the Clearance can involve both metabolism of drug to a me-systemic circulation as intact drug. However, for other routes of tabolite and excretion of drug from the body. Clearance ofadministration, the bioavailability is less than 100%. drug from different organs is additive. Renal clearance ofVolume of Distribution (Vd) is a hypothetical volume of fluid into a drug results in its appearance in urine.which the drug is disseminated. This mathematically determined Half-life of the drug (t1/2) is the time during which half ofvalue gives a rough indication of the overall distribution of a drug the drug is eliminated from the body. Half-life determina-in the body. For example, a drug with a Vd of approximately 13 L tion is very useful, as it can be used to evaluate the dura-(i.e., interstitial fluid plus plasma water) is probably distributed tion of action of the drug and for how long a drug is ex-throughout extracellular fluid but is unable to penetrate cells [as pected to remain in the body after termination of dosing,total body water (42L)=intracellular volume (28L)+ extracellular the time required for a drug to reach steady state (when the rate of drug entering the body is equal to the rate of drug leaving the body) and often the Volume of Distri- frequency of dosing. Clearance Absorption bution All these parameters help in deciding the dosing frequency and also the dose adjustment which is required in patients with renal or hepatic impairment. ▌ Half-life Bioavailability Dr. Amit Dang is Director at Geronimo Healthcare Solu- tions Pvt. Ltd. Dosing regimen: Dosing regimen: How often? How much?

23. ← Home MedicinMan Ocotber 2012 >>> Industry Insight | Page 23Boehringer Launches Syrum Jon Gwillim ogether with many pharma and digital professionals, I at- tended the launch of Boehringer‟s new Facebook game Pugh is also open about the fact that some core assumptions Syrum at the London Science Museum last week. With – including the game‟s functionality, core audience demo- waiters in lab coats and cocktails in test tubes, the atmos- graphic and the level of promotional spend within Facebook phere was convivial and full of icebreakers of various types. itself – are yet to be fully determined, and his attitude is refreshing: “this is a true experiment; we don‟t know where The Syrum game itself appears a significant step for phar- it will end.” ma‟s publicly-facing digital activities. In the intentions of its primary creator, Boehringer‟s John Pugh, the platform From my point of view, regardless of whether Syrum suc- wasn‟t built with product or therapy area awareness in ceeds or fails as a game-based initiative, it still provides a mind, rather – much as Farmville isn‟t intended to appeal to strong statement to the world about Boehringer‟s position an audience with an interest in farming – the game is meant as a pharma company with an outside-the-box approach and to be an entertaining mass-market way to highlight the val- a strong commitment to innovating for its audiences. uable work that the industry does. Perhaps more importantly, the very public nature of the As with any digital initiative, however, its success will be launch and publicly accessible success stats in the form of judged by its appeal to its target audience and this raises Facebook likes and Twitter followers for the game‟s mascot some interesting questions: is an educational game an ap- Professor Syrum will help the industry focus on what re- propriate strategy? Is the game actually fun and rewarding turns they really want (and should really expect) from their to play? And how will Boehringer ultimately judge the suc- digital initiatives – in this case, is the return to be found in cess of this very public initiative? enduring engagement with a generation of increasingly pharma-friendly gamers, or is it in the wider media cover- At the launch, I spent some time with John and discussed age of the initiative itself? Syrum‟s long gestation period and journey to get to the point of a successful beta launch. I was particularly interest- Only time will tell, but for now I need to get back to the ed in the development process itself. Was the game a prod- lab…▌ uct of the lean, agile, user-centred processes common to most of the Silicon Valley originated (or inspired) start-ups playing in both healthcare and wider sectors? Jon Gwillim is the Founder and CEO at PatientsCreate.com, the worlds first The length of the development process would seem to sug- patient centric crowdsourcing platform, gest this wasn‟t the case. Syrum was first announced on supported by regulators, pharma and Boehringer‟s Facebook page back in June 2011, and Pugh patient groups. It aims to empower pa- admitted to have preferred to have “done things differently” tients to help improve health outcomes. testing “with small groups on elements of the games”, but Join him on LinkedIn: uk.linkedin.com/ was prevented from taking this approach due to “technical in/jongwillim snags”. Nevertheless, in common with agile product development the game is apparently “set up in a modular way, so Email: jon@patientscreate.com elements can change.”

24. ← Home MedicinMan October 2012 >>> Hot on LinkedIn | Page 24 Infiltration–a chronic infection in pharma field sales. Ajay Kumar Dua nfiltration of products can be likened to a chronic infection, which has created the room for counterfeit products. A brand, which travels from one territory to the other, eventu- ally comes back to the origin. Infiltration is killing well- established brands by losing market share to competitors and counterfeit products. The root cause for infiltration is companies trying to achieve the sales by short-term means. Although this is being done at the lower level, the responsibility lies with top management. Some promotional tools that are responsible for Infiltration: 7. Companies not analyzing the secondary sales of HQs and not focusing on the secondary to primary sales ratio. 1. Unrealistic targets, which are not matching with market potential of territories and people. This gives undue sales Infiltration has other side effects, which affect companies in pressure to high volume HQs, which try to achieve targets the long term. through unethical means. This decreases attention on low  New field staff are not able to tackle this serious threat performing HQs that need corrective steps to improve the - they get frustrated and leave the company. skills of field sales people, distribution system etc.  HQs who get trapped in this malpractice continue to get 2. Companies giving large quantity of samples of estab- sales without putting in genuine efforts. lished brands. The practice of distributing samples and gifts has degenerated into a rat race among pharma companies, Established brands, which after price adjustment land in leading to using these inputs for adjustments in rates at wholesale „mandis‟, give rise to counterfeit products, dam- stockist level aging the sale of genuine brands of the company. Moreover these low quality counterfeit products reach in retail market, 3. Companies sanctioning special institutional rates of prod- which gives low response to the patient ailment, thereby ucts without verifying with the institutional distributors. spoiling the image of the company and product. This proves Lack of monitoring and verification brings the products into to be harmful in the long term for the company as a whole. the retail market and leads to price adjustment in one territory for sending the product to another territory. Infiltration is a serious problem that needs urgent attention from the top management as well as from field sales people 4. Companies sanctioning sponsorship budgets for activities to remedy the unethical and unhealthy practices that are like doctors meet, medical camps and CMEs without proper detrimental to patients, doctors, companies and sales people verification. This leads to using the sanctioned amount for in the long run.▌ adjusting the price of products in the market. 5. Monetary incentives to field staff – often field staff ma- nipulate the sales by adjusting the product price, by giving out of some percentage from the incentive, which they Ajay Kumar Dua is a senior Pharma might earn. Profesional. 6. Companies giving special rates for large quantity to dis- LinkedIn: in.linkedin.com/pub/ajay- tributors - this gives advantage to financially sound distribu- kumar-dua/14/520/996 tors who play on their margin and sell the products to other parts.

25. ← Home MedicinMan October 2012 >>> Field Force Knowledge Series | Page 25 Understanding congestive heart failure. Field Force Knowledge Series. Dr. S. Srinivasan eart failure is a condition in which the heart cant pump enough blood to meet the bodys needs. In some cases, the heart cant fill with enough blood. In other cases, the heart cant pump blood to the rest of the body with enough force. Some people have both problems. The term "heart failure" doesnt mean that the heart has stopped or is about to stop working. Nor is it the same as heart attack which is myocardial infarction. However, heart failure is a serious condition that requires medical care. The condition can affect the right side of the heart only, or it can affect both sides of the heart. Most cases involve As the heart grows weaker, symptoms get worse. The both sides of the heart. patient feels tired and short of breath after getting dressed Right-side heart failure occurs if the heart cant pump or walking across the room. Some people have shortness enough blood to the lungs to pick up oxygen. Left-side of breath while lying flat (called orthopnea) because the heart failure occurs if the heart cant pump enough oxygen lungs get more congested in that position which is re- -rich blood to the rest of the body. lieved by gravity while sitting up. Right-side heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and the veins in the neck. Right-side and left-side heart failure also cause shortness of breath and fatigue (tiredness). The leading causes of heart failure are diseases that dam- age the heart. Examples include coronary heart disease (CHD), high blood pressure and diabetes. Other causes are cardiomyopathy (disease of heart muscle), valvular heart disease, arrhythmias, congenital heart defects. These are described in greater detail elsewhere in this book. The most common signs and symptoms of heart failure are:  Shortness of breath or trouble breathing (dyspnea)  Fatigue (tiredness)  Swelling in the ankles, feet, legs, abdomen, and veins in the neck All of these symptoms are the result of fluid buildup in the body. When symptoms start, the patient may feel tired and short of breath after routine physical effort, like climbing stairs.

26. ← Home MedicinMan October 2012 >>> Field Force Knowledge Series | Page 26 Fluid buildup from heart failure also causes weight gain, A healthy diet also is low in added sugars and refined grains. frequent urination, and a cough thats worse at night and Refined grains come from processing whole grains, which when youre lying down. This cough may be a sign of acute results in a loss of nutrients (such as dietary fiber). Examples pulmonary edema, a condition in which too much fluid of refined grains include white rice and white bread. A bal- builds up in your lungs. The condition requires emergency anced, nutrient-rich diet can help the heart work better. treatment. Getting enough potassium is important for people who have heart failure. Some heart failure medicines deplete the potas- Diagnostic Tests. sium in the body. Lack of potassium can cause very rapid No single test can diagnose heart failure. Clinical history and heart rhythms that can lead to sudden death. physical examination play the major part in diagnosis. The Potassium is found in foods like white potatoes and sweet following investigations are performed in appropriate cases. potatoes, greens (such as spinach), bananas, many dried » ECG fruits, and white beans and soybeans. » Chest X-ray Fluid Intake » Echocardiography Its important for people who have heart failure to drink the » Doppler ultrasound correct amounts and types of fluid. Drinking too much fluid » MRI can worsen heart failure. Alcohol is bad for a failing heart. » Nuclear Heart Scan Other Lifestyle Changes » Stress test » Control obesity » Cardiac catheterization / coronary angiography » Physical exercise » BNP (Brain natriuretic peptide) blood levels raised » Quitting smoking » Thyroid function tests » Enough rest Treatment. Medicines The most important is to treat the underlying cause like high » Diuretics (water or fluid pills) help reduce fluid buildup blood pressure, valvular heart disease, congenital heart dis- in the lungs and swelling in the feet and ankles. ease etc. » ACE inhibitors lower blood pressure and reduce strain on the heart. They also reduce the risk of a future heart Lifestyle Changes. attack » Aldosterone antagonists trigger the body to get rid of A Heart Healthy Diet salt and water through urine. This lowers the volume of A healthy diet includes a variety of vegetables and fruits. It blood that the heart must pump. also includes whole grains, fat-free or low-fat dairy products, » Angiotensin receptor blockers relax blood vessels and and protein foods, such as lean meats, eggs, poultry without lower blood pressure to decrease hearts workload. skin, seafood, nuts, seeds, beans, and peas. » Beta blockers slow heart rate and lower blood pressure A healthy diet is low in sodium (salt) and solid fats to decrease your hearts workload. (saturated fat and trans fatty acids). Too much salt can cause » Isosorbide dinitrate/hydralazine hydrochloride helps extra fluid to build up in the body, making heart failure relax blood vessels so the heart doesnt work as hard to worse. Saturated fat and trans fatty acids can cause un- pump blood. healthy blood cholesterol levels, which are a risk factor for heart disease. » Digoxin makes the heart beat stronger and pump more blood. ▌

27. What do you expectyour FLMs and SLMs to be good at? What are you doing to ensure that they gain proficiency in the desired skills?The Half-Time Coach A Psychometric Assessment-based Feedback and Feed-forward Program for FLMs and SLMs 1. Management Games  Relearning by Reflection,  Feedback by Observation 2. Case Studies 3. Movie ClippingsThe Half-Time Coach is delivered by Anup Soans, Editor MedicinMan &Author of SuperVision for the SuperWiser Front-line Manager, HardKnocks for theGreenHorn and RepeatRx Contact: anupsoans@medicinman.net Ph. +91 93422 32949