E-learning as an innovative platform 

for medical doctors in South Africa 

 

 

Student: Terence Pillay 

Supervisor: Laurence Beder 

 

 

A research report submitted to the Faculty of Commerce, Law and 

Management, University of the Witwatersrand, in partial fulfilment of the 

requirements for the degree of Master of Management specialising in 

Strategic Marketing 

 

Johannesburg, 2020 



i 

ABSTRACT 

E-learning could be an innovative continued medical education platform for 

medical doctors in South Africa, especially now with the COVID-19 pandemic and 

its effects on physical contact between pharmaceutical companies’ 

representatives and doctors. This study aimed to determine and develop a more 

effective way to reach and provide accurate, credible education for all doctors 

using an e-learning platform as an alternative to representative visits. 

This research involved a quantitative study, deploying a survey to a sample of 

456 doctors in South Africa via an online platform.  

The results arising from the analyses to prove the three hypotheses were 

statistically significant, and all were accepted. In summary doctors in South Africa 

valued their relationships with medical representatives, but simultaneously 

questioned the credibility of the education received from the representatives. 

Many doctors accessed the internet for their own education as one of their 

channels of education.  

In view of the research findings, an innovative e-learning platform is proposed to 

deliver continued medical education to all doctors and to allow for best practices 

sharing across the medical fraternity in South Africa. 

  



ii 

DECLARATION 

I, Terence Pillay, declare that this research report is my own work except as 

indicated in the references and acknowledgments. It is submitted in partial 

fulfilment of the requirements for the degree of Master of Management in 

Strategic Marketing at the University of the Witwatersrand, Johannesburg. It has 

not been submitted before for any degree in this or any other university.  

 

T. Pillay 
__________________ 
Terence Pillay 

 

Signed at Ascot, Berkshire, United Kingdom 

 

On the 29th day of August   2020 

 

  



iii 

DEDICATION 

This report is dedicated to Lena Pillay who never stopped motivating and 

reminding me of the journey I started and why I had to finish it. She allowed me 

to be me. Thank you for lending yourself to me and for being the spine as I wrote 

this chapter of our life. 

 

  



iv 

ACKNOWLEDGEMENTS 

My heartfelt and sincere appreciation goes to the following key instrumental 

people who made this research report a success: 

 Mr Laurence Beder, my supervisor. Your words of motivation, patience 

and coaching that we will get through, helped me to breathe a little more 

and press on; 

 My mum and dad for an indescribable gift. ‘Go for it, Dream Big!’ will 

always resonate with me; 

 Noah Liam Pillay and Gianna Cara Pillay who afforded me the time to 

focus on what needs to get done, ‘Oh the places we will go’; and 

 Zak Ahmed Baig for saying ‘YES’. 

 

  



v 

TABLE OF CONTENTS 

ABSTRACT ...................................................................................... I 

DECLARATION ............................................................................... II 

DEDICATION ................................................................................. III 

ACKNOWLEDGEMENTS .............................................................. IV 

TABLE OF CONTENTS ................................................................. V 

LIST OF TABLES ........................................................................ VIII 

LIST OF FIGURES ......................................................................... X 

CHAPTER 1: INTRODUCTION ....................................................... 1 

1.1 PURPOSE OF THE STUDY ............................................................................ 1 

1.2 THEORETICAL BACKGROUND TO THE STUDY ................................................. 1 
1.2.1 DIFFUSION OF INNOVATIONS MODEL ........................................................................ 1 
1.2.2 TECHNOLOGY READINESS INDEX ............................................................................. 2 

1.3 CONTEXT OF THE STUDY ............................................................................. 2 

1.4 PROBLEM STATEMENT ................................................................................ 6 
1.4.1 SUB-PROBLEM 1 .................................................................................................... 6 
1.4.2 SUB-PROBLEM 2 .................................................................................................... 6 

1.5 SIGNIFICANCE OF THE STUDY ...................................................................... 7 

1.6 DEFINITION OF TERMS ................................................................................ 8 

1.7 CONTRIBUTION OF THE STUDY ..................................................................... 9 

CHAPTER 2: LITERATURE REVIEW ........................................... 10 

2.1 INTRODUCTION ........................................................................................ 10 

2.2 DIFFUSION OF INNOVATIONS MODEL ........................................................... 10 

2.3 TECHNOLOGY READINESS INDEX ............................................................... 14 

2.4 DETAILING TO HEALTHCARE PROFESSIONALS .............................................. 22 

2.5 BARRIERS TO INNOVATIONS ...................................................................... 27 
2.5.1 RELATIVE ADVANTAGE .......................................................................................... 29 
2.5.2 COMPATIBILITY .................................................................................................... 29 
2.5.3 COMPLEXITY ........................................................................................................ 30 
2.5.4 TRIAL-ABILITY ...................................................................................................... 30 
2.5.6 OBSERVABILITY ................................................................................................... 30 

2.6 DETAILING REPRESENTATIVES ADDING VALUE TO CME OF DOCTORS ............ 32 



vi 

2.7 ACADEMIC DETAILING TO IMPROVE CLINICAL DECISION-MAKING .................... 39 

2.8 E-LEARNING AS A SOURCE OF DETAILING AND EDUCATING DOCTORS ............. 45 

2.9 E-LEARNING AS A SELF-DIRECTED EDUCATIONAL TOOL FOR DOCTORS .......... 53 

2.10 EFFECTS OF THE COVID-19 PANDEMIC ..................................................... 56 

2.11 CONCEPTUAL MODEL OF ANALYSIS ............................................................ 61 
2.11.1 HYPOTHESIS 1 ..................................................................................................... 62 
2.11.2 HYPOTHESIS 2 ..................................................................................................... 62 
2.11.3 HYPOTHESIS 3 ..................................................................................................... 62 

2.12 CONCLUSION OF LITERATURE REVIEW ........................................................ 62 

CHAPTER 3: RESEARCH METHODOLOGY ............................... 66 

3.1 INTRODUCTION ........................................................................................ 66 

3.2 RESEARCH METHODOLOGY ....................................................................... 66 

3.3 RESEARCH APPROACH / PARADIGM ............................................................ 66 

3.4 RESEARCH DESIGN .................................................................................. 69 

3.5 POPULATION AND SAMPLE......................................................................... 70 
3.5.1 POPULATION ........................................................................................................ 70 
3.5.2 SAMPLE AND SAMPLING METHOD ........................................................................... 70 

3.6 THE RESEARCH INSTRUMENT .................................................................... 70 

3.7 PROCEDURE FOR DATA COLLECTION .......................................................... 72 

3.8 DATA ANALYSIS ........................................................................................ 72 

3.9 VALIDITY AND RELIABILITY ......................................................................... 73 
3.9.1 EXTERNAL VALIDITY ............................................................................................. 74 
3.9.2 INTERNAL VALIDITY ............................................................................................... 74 
3.9.3 RELIABILITY ......................................................................................................... 75 

3.10 LIMITATIONS OF THE STUDY ....................................................................... 76 

CHAPTER 4: PRESENTATION OF RESULTS ............................. 77 

4.1 INTRODUCTION ........................................................................................ 77 

4.2 DEMOGRAPHIC CHARACTERISTICS OF THE RESPONDENTS ........................... 77 
4.2.1 GENDER .............................................................................................................. 77 
4.2.2 HOME LANGUAGE ................................................................................................. 78 
4.2.3 PROVINCE OF PRACTICE ....................................................................................... 79 
4.2.4 PRACTICE SECTOR ............................................................................................... 80 

4.3 DESCRIPTIVE STATISTICS .......................................................................... 81 
4.3.1 ATTITUDE TOWARDS DETAILING REPRESENTATIVES ................................................ 81 
4.3.2 SOURCE OF INFORMATION FOR DOCTORS .............................................................. 83 
4.3.3 E-LEARNING BEHAVIOUR OF DOCTORS .................................................................. 84 

4.4 FACTOR ANALYSIS .................................................................................... 85 

4.5 RELIABILITY ANALYSIS .............................................................................. 87 

4.6 TESTING FOR DIFFERENCES BETWEEN GROUPS .......................................... 88 
4.6.1 DOCTORS’ GENDER .............................................................................................. 88 
4.6.2 DOCTORS’ PRACTICE SECTOR ............................................................................... 90 

4.7 CORRELATION ANALYSIS ........................................................................... 90 



vii 

4.8 MULTIPLE REGRESSION ............................................................................ 94 
4.8.1 PREDICTION LEVEL OF EDUCATION ........................................................................ 94 

CHAPTER 5: DISCUSSION OF RESULTS ................................... 95 

5.1 INTRODUCTION ........................................................................................ 95 

5.2 DEMOGRAPHIC PROFILE OF RESPONDENTS ................................................ 95 

5.3 HYPOTHESIS TESTING .............................................................................. 95 
5.3.1 HYPOTHESIS 1 ..................................................................................................... 96 
5.3.2 HYPOTHESIS 2 ..................................................................................................... 97 
5.3.3 HYPOTHESIS 3 ..................................................................................................... 98 

5.4 CONCLUSION ......................................................................................... 100 

CHAPTER 6: CONCLUSIONS AND RECOMMENDATIONS ...... 102 

6.1 INTRODUCTION ...................................................................................... 102 

6.2 CONCLUSIONS OF THE STUDY ................................................................. 102 
6.2.1 E-LEARNING PLATFORMS DELIVER ACCESSIBLE, CREDIBLE EDUCATIONAL CONTENT TO 

ALL DOCTORS .................................................................................................... 102 
6.2.2 FACE-TO-FACE DETAILING CONTRIBUTES TO CREDIBLE VALUABLE EDUCATION TO 

DETAILED DOCTORS IN THEIR CLINICAL DECISION-MAKING PROCESS ...................... 103 
6.2.3 THE POSITIVE RELATIONSHIP BETWEEN FACE-TO-FACE DETAILING AND E-LEARNING 

PLATFORMS CONTRIBUTE TO THE EDUCATION OF DOCTORS .................................. 104 

6.3 IMPLICATIONS OF THE STUDY ................................................................... 105 
6.3.1 THEORETICAL IMPLICATIONS ............................................................................... 105 
6.3.2 MANAGERIAL IMPLICATIONS ................................................................................ 106 
6.3.3 COVID-19 IMPLICATIONS ................................................................................... 106 

6.4 RECOMMENDATIONS FOR FUTURE E-LEARNING ......................................... 107 

6.4 SUGGESTIONS FOR FUTURE RESEARCH.................................................... 108 

REFERENCES ............................................................................ 109 

APPENDIX A – RESEARCH INSTRUMENT ............................... 118 

APPENDIX B – RESEARCH COVER LETTER ........................... 122 

APPENDIX C – FACTOR ANALYSIS AND RELIABILITY .......... 124 

APPENDIX D – CORRELATION ANALYSIS AND MULTIPLE 
REGRESSION ANALYSIS .......................................................... 126 



viii 

LIST OF TABLES 

Table 1: Gender distribution ............................................................................. 77 

Table 2: Home language .................................................................................. 78 

Table 3: Province of practice ............................................................................ 80 

Table 4: Practice sector ................................................................................... 80 

Table 5: Agreement scale: Attitude towards detailing representatives ............. 82 

Table 6: Mean and standard deviation: Attitude towards detailing representatives

 ......................................................................................................................... 82 

Table 7: Agreement scale: Source of information ............................................ 83 

Table 8: Mean and standard deviation: Source of information ......................... 84 

Table 9: Agreement scale: E-learning behaviour ............................................. 84 

Table 10: Mean and standard deviation: E-learning behaviour ........................ 85 

Table 11: KMO and Bartlett test results ........................................................... 86 

Table 12: Factor analysis results ...................................................................... 87 

Table 13: Cronbach’s alpha values .................................................................. 88 

Table 14: Gender t-test results ......................................................................... 90 

Table 15: Sector t-test results .......................................................................... 90 

Table 16: Correlation analysis: Attitude towards detailing representatives ...... 92 

Table 17: Correlation analysis: E-learning behaviour ....................................... 93 

Table 18: Correlation analysis: Source of information ...................................... 93 

Table 19: Multiple regression analysis: Education ........................................... 94 



ix 

Table 20: Multiple regression coefficient analysis ............................................ 94 

Table 21: Correlation analysis for source of information .................................. 96 

Table 22: Attitude towards doctor detailing representatives ............................. 97 

Table 23: Multiple regressions coefficient analysis .......................................... 99 

 

  



x 

LIST OF FIGURES 

Figure 1: Triangle and pyramid models of services marketing 18 

Figure 2: HHK’s multi-faceted paths 32 

Figure 3: Prescribing behaviour change before and after academic detailing 41 

Figure 4: Study periods and academic detailing 43 

Figure 5: Effect of academic detailing on antibiotics prescriptions 45 

Figure 6: Selected e-detailing approaches 48 

Figure 7: Benefits and challenges of e-detailing in Europe 49 

Figure 8: Spectrum of communication options 50 

Figure 9: Key messages in the product life cycle 51 

Figure 10: Motivations for physicians searching on internet 55 

Figure 11: Factors important to physicians in accessing online CMEs 56 

Figure 12: Conceptual model of analysis 62 

Figure 13: Gender distribution 78 

Figure 14: Home language 79 

Figure 15: Practice sector 81 

 



1 

CHAPTER 1: INTRODUCTION  

1.1 Purpose of the study 

The purpose of this research was to establish whether e-learning could be an 

innovative continued medical education platform for medical doctors in South 

Africa. The e-learning platform was examined to establish its effect on doctors’ 

medical education. In view of the COVID-19 pandemic in 2020, this research also 

investigated its impact thus far on doctors’ e-learning. 

1.2 Theoretical background to the study 

This study has theoretical roots in two primary domains (Singh, 2014). 

1.2.1 Diffusion of innovations model 

This model by Rogers (2003) explains how an innovation spreads via 

communication channels to members in a social system, which resonates with 

the medical profession. The origins of this model are attributed to the behavioural 

sciences. The diffusion of innovations model looks at four elements, which are 

innovation, communication channels, time, and social systems. Rogers (2003) 

defined an innovation as an idea, practice, or project that an individual is exposed 

to for the first time. The innovation could have existed for a long time, but the first 

time experience for the user makes it an innovation for that person.  

Diffusion is how the adoption of the innovation takes place. Communication 

channels are segmented into localite and cosmopolite channels that 

communicate between an individual of a social system and outside resources. 

Time is a critical factor in the innovation – diffusion process, as it puts the 

innovation in a category and shows its rate of adoption. Rogers (2003) defined 

the social system as set of interrelated units trying to solve a common problem 

and accomplish a goal. This is what doctors in the medical professional do daily, 



2 

working cross-functionally with different faculties to solve a common medical 

problem.  

1.2.2 Technology readiness index  

The conceptual framework for classifying innovations comprises (a) continuous 

innovations, (b) dynamically continuous innovations, and (c) discontinuous 

innovations (Robertson, 1967). A continuous innovation has the least interruption 

to a pattern. This can be an alteration to a product and not the establishment of 

new product. A dynamically continuous innovation has more disruption than a 

continuous innovation, although generally not altering established patterns. It 

may involve the creation of a new product or the alteration of an existing product. 

A discontinuous innovation involves an establishment of a new product and the 

establishment of new behaviour patterns. The e-learning platform to educate 

doctors will be a discontinuous innovation as this will be a new educational 

platform to change behaviour patterns of doctors to embrace and be educated 

online. The technology readiness index was adopted in this research to look at 

the readiness of doctors to adopt the new e-learning platform (Parasuraman & 

Colby, 2015). This platform caters for the gaps in their medical education and 

affords doctors an opportunity to be educated at a convenient time and in a 

comfortable situation. 

1.3 Context of the study 

The formal educational requirement for doctors to qualify takes an average of six 

to eight years after completing their school education. To keep up-to-date on the 

latest clinical findings and education thereafter, they attend conferences, 

advisory boards, and focus group meetings. The invitations to these meetings 

are done through targeting and selection by pharmaceutical companies. Doctors 

are identified by the potential of their prescription habits and influence on the 

market share. Medical representatives are then trained and educated to call on 

these doctors and detail to them the latest clinical advancements in medicine and 



3 

product benefits. The aim of the representative is to get doctors to script the 

company’s product more frequently (Soumerai & Avorn, 1990). 

Doctors that are not visited by representatives must access other means of 

educational sources. Some doctors do not have the time to see medical 

representatives due to their busy schedules, however still need to fill the gap in 

their education and attain continued professional development points. The 

manner in which pharmaceutical companies establish relationships and call on 

doctors is called to question by many doctors who see this as an unethical 

practice and refuse to see representatives (Gonul, Carter, Petrova, & Srinivasan, 

2001). Doctors need to be at forefront of the latest discoveries in medicine to 

prescribe their patients with the safest and most effective drugs thus ensuring an 

efficient treatment plan. 

In the 1920s, many studies looked at the education of healthcare professionals 

and including modern science into medical faculties in universities. These 

teaching schools looked at equipping health professionals with knowledge that 

would double the life span of the 20th century (Frenk et al., 2010). This created a 

wave of medical teaching universities to be opened in United States (US) and 

Canada, which filtered into Europe with the vision of sharing advancements in 

medical science and discoveries equitably. In the twenty-first century, this has 

still not been achieved and there are major gaps in sharing of information and 

knowledge.  

Medical science is advancing with clinical breakthroughs, and new diseases and 

health conditions emerging. The migration of people from one geographical 

location to the next brings with it complexities in healthcare treatment throughout 

the world. Worldwide healthcare systems are being overburdened with the 

shortage of staff. The professional education of healthcare workers has not kept 

pace with the changing environment. The divide in wealth among countries, and 

the migration of doctors from one region to another has increased the divide of 

transferring education, knowledge, skills, and new reforms in medicine evenly 

(Frenk et al., 2010).  



4 

Health is all about people and it involves one set of professionals providing a 

community and societal service to another set of unhealthy individuals. The 

relationship between doctor and patient is based on ethical standards, trust, and 

the educational competence of the medical professional. There is a multifaceted 

channel of events with the aim of delivering high quality care; the medical doctor 

needs ongoing education on the latest trends in medicine, so that the patient gets 

the best treatment. Uniform education for all medical doctors should deliver 

effective clinical practice to patients. This is not happening in the healthcare 

industry. Pharmaceutical companies are targeting doctors according to their 

scripting habits and using script data from data mining companies like IMS Health 

(Fugh-Berman & Ahari, 2007) to target doctors and drive the company’s market 

share. Doctors are being targeted by pharmaceutical representatives according 

to the script share data, from which marketing and sales strategies are put into 

place with the aim of driving profit from sales. On average, a representative will 

see between six and eight doctors per day, spending between five and eight 

minutes detailing doctors. The line-up of the detail call is usually two products, 

with a third product as a leave behind reminder (Soumerai & Avorn, 1990).  

The medical doctors at the top of the healthcare pyramid become the key opinion 

leaders on a specific therapeutic area and are given preferential treatment to 

attend conferences and invited to be keynote speakers. Medical advancements 

remain within the elite targeted doctors and key opinion leaders. Many doctors, 

who are not the highest prescribers in a category, are not included in the 

invitations to CME meetings (Fugh-Berman & Ahari, 2007). Many medical 

doctors are migrating to the cities to generate a higher income and thus become 

high script generators. Pharmaceutical companies use the Pareto principle and 

target doctors accordingly, thus decreasing their resources for reaching doctors 

in rural and country settings. Some representatives make a country visit once a 

month to target these doctors, and are fortunate doctors is in their practice on 

that day. This segmented targeting of doctors is creating a further gap in 

continued professional development of doctors not targeted by pharmaceutical 

companies.  



5 

As time proceeds, the lack of CME increases and the new and latest 

advancements in medical science does not reach doctors. This has been a major 

issue from as early as 1910, as mentioned in the Flexner report to the Carnegie 

Institute on medical education (Flexner, 2002). In the spirit of Abraham Flexner, 

the 2010 report had a similar idea of reform in medical education, that the report 

would generate some excitement on the reform of innovation in education for 

graduate and undergraduate medical professionals.  

Three US reports have had powerful effects on the professional health education 

in North US and this has spread to the rest of the world: the Flexner report of 

1910, the Welch-Rose report of 1915, and the Goldmark report of 1923 (Frenk et 

al., 2010). All these reports called for major instructional reforms to allow modern 

medical sciences into the core curriculum, to link education to research, and to 

base professional education in universities. 

To cater for the gap in doctors’ continued medical education (CME) and to gain 

their continued professional development points, the e-learning platform could 

bring about a reform in their medical education. This innovation would give 

access to education irrespective of them being seen by medical representatives 

or attending CME activities. This would remove the discrepancy by 

pharmaceutical companies of only educating detailed doctors, and allow doctors 

the opportunity to manage their time effectively and avoid unethical business 

practices, thus focussing on the science of medicine and the best treatment 

options for patients. In view of the COVID-19 pandemic in 2020, this research 

considered its effect on detailing representative visits, and made a 

recommendation on curbing the impact of COVID-19 on doctors’ e-learning.  

Before the 2010 Flexner report, there were numerous developments on the future 

of education of medical doctors and health professionals on a local and 

international level. This gave rise to four sets of reports stressing the importance 

of medical reforms in education driven by the Millennium Development Goals 

(MDGs). The main objectives of these reports called for more competency-based 

programs, the sharing of best practices, and finally IT led, empowered learning. 

These reports recommended an increased investment in education and training, 



6 

sharing of resources, and a global interdependent world of health professionals 

(Frenk et al., 2010). 

In the education of doctors, the following constructs were critical in this research: 

 E-learning; 

 Innovation; 

 Detailing; 

 Technology readiness; 

 Continued professional development; 

 CME; and 

 Key opinion leaders. 

1.4 Problem statement 

There is a need for CME of all doctors on clinical and product knowledge in the 

pharmaceutical industry (Soumerai & Avorn, 1990).  

The main problem is to determine and develop a more effective way to reach and 

provide accurate, credible education for all doctors using an e-learning platform 

as an alternative to representative detailing visits.  

1.4.1 Sub-problem 1 

To determine whether there is a preference by medical doctors to utilise visiting 

doctor detailing representatives for their education or an e-learning platform.  

1.4.2 Sub-problem 2 

To determine if there is a positive correlation between the impact of e-learning 

behaviour on doctors education and clinical decision-making.  



7 

1.5 Significance of the study 

The objectives of the study included the following: 

 The main objective of the study was to emphasise the critical role that an 

innovation in e-learning contributes to the CME of medical doctors (Frenk 

et al., 2010). Medical institutions face the challenge of educating doctors 

for tomorrow due to less teaching time available at medical schools. It is 

also evident that there is a gradual movement from classroom face-to-

face teaching to a more self-directed learning approach (Ruiz, Mintzer, & 

Leipzig, 2006). In view of this, e-learning provides an innovative solution 

to their CME. 

 The second objective of this study was to propose an innovative e-

learning platform that doctors throughout the world can log into in the 

comfort of their home and at their chosen time to continue their ongoing 

education. 

This study looked at the evidence of the effectiveness of e-learning in getting a 

key clinical message across to doctors, and contributing to their education on 

scripting the safest and most effective drug for their patients. 

The way learning is delivered to doctors is the major advantage of e-learning, 

with content being available in real time, as new clinical findings are discovered, 

content is standardised and approved by medical associations, content is easily 

distributed, and accountability for learning rests with doctors (Ruiz et al., 2006). 

E-learning frees up time for doctors to concentrate on their patients and steer 

them clear of any unethical behaviour with pharmaceutical companies (Fugh-

Berman, & Ahari, 2007). 

The aims of the study were evaluated and researched through extensive 

literature review comparing the CME among medical doctors and concluded with 

the proposal of an innovative CME e-learning platform for doctors. 



8 

1.6 Definition of terms 

An understanding of the following terms is essential in understanding the 

research: 

 Detailing: Forms part of strategic medical marketing and involves 

educating medical doctors using trained medical representatives as part 

of the broader marketing mix used by pharmaceutical companies. The 

representatives do personal selling to doctors using detailing aids that are 

paper based, drop off samples, literature, and patient information (Lilien, 

Rao, & Kalish, 1981). 

 E-detailing: Uses an electronic device such as a personal digital assistant, 

tablets, laptops, and podcasts (Bernewitz, 2001). 

 Detailed doctors: Doctors visited by representatives to provide education 

on the efficacy of a product (Zipkin, & Steinman, 2005). 

 Non-detailed doctors: Doctors not visited by a representative (Zipkin, & 

Steinman, 2005). 

 E-learning: - As defined by the American Society of Training and 

Development, learning that takes place through a wide set of applications 

and processes such as web-based platform learning, computer-based 

learning, virtual classrooms, and digital collaboration (Derouin, Fritzsche, 

& Salas, 2005). 

 Key opinion leader:– An academic, highly esteemed by colleagues in their 

profession, at the forefront of clinical research, and a thought leader in 

their profession who is called upon by pharmaceutical companies to 

deliver therapeutic area education and is a key influencer in getting a 

clinical message across (Soumerai & Avorn, 1990). 

 Innovation: An idea, practice or project that is seen as new by the 

individual (Rogers, Medina, Rivera, & Wiley, 2005). 



9 

 Diffusion: A process in which an innovation spreads through certain 

communication channels over time (Rogers et al., 2005). 

 Communication channel: An avenue or platform through which information 

is shared to gain a common understanding of an idea or concept, or 

education of the target group (Rogers et al., 2005). 

 Continued professional development: An ongoing educational process by 

which medical doctors keep up-to-date on latest research, clinical findings, 

therapeutic area knowledge, and trends to deliver the best practice to their 

patients (Graham et al., 2006). 

 CME: An ongoing set of planned activities that medical doctors engage in 

to keep their knowledge up-to-date on the latest medical science. This can 

take the form of journals, conferences, and round table discussions 

(Graham et al., 2006). 

1.7 Contribution of the study 

This study contributes to the efficacy of detailing and educating doctors on an 

innovative e-learning platform which enables pharmaceutical companies 

reaching all doctors in real time with the latest clinical findings and development 

of drugs so that patients’ basic right to the best medical practice is realised. 

Thought processes will be challenged, and policy changes will look at new 

innovative ways to allow doctors to gain their continued professional 

development points and have an interdependent world of exchanging best in 

class medical practices. This will allow for medical knowledge to be standardised, 

accredited, and acknowledged so there is consistency in the medical profession 

across markets. This research proposes an e-learning platform that will allow for 

the dissemination of medical knowledge to all doctors without any prejudices. 

Medical doctors will have access to CMEs in the comfort of their practices and 

homes without being side-lined by not being detailed to and not being invited by 

pharmaceutical companies to CME meetings. 



10 

CHAPTER 2: LITERATURE REVIEW 

2.1 Introduction 

Chapter 2 consists of the literature review that supports the depth, understanding, 

and building blocks of this study. Literature sources were reviewed, compared, 

and critically analysed to form a firm base to the study of e-learning as an 

innovative educational platform for medical doctors.  

The subsections consist of the diffusion of innovations model, the technology 

readiness index, detailing to doctors, barriers that influence the adoption of 

innovations, e-learning, and finally a conceptual model is presented. 

2.2 Diffusion of innovations model 

The origins of the diffusion model can be traced back to the field of agriculture in 

the 1950s. The model later lent itself to other sectors such as public health. 

Diffusion is a process by which an innovation, an idea, or project seen as new, 

or for the first time, begins to spread through communication channels in a social 

system (Rogers, 2004). Recently, approximately 5 000 studies on innovation 

range from seed corn and modern maths, to antibiotic drugs and AIDS 

prevention, have been made. The pioneers of the diffusion model were first seen 

in the study of two farming communities in the hybrid seed corn study in the state 

of Iowa (Ryan & Gross, 1943). This was the establishment of the shift for diffusion 

research. Ryan came over from Harvard and joined Iowa State University’s 

sociology department. He was very interested in the economics of agriculture, 

but then his vast reading of anthropological studies aroused his interest in 

understanding the non-economic factors that influenced the decisions that 

farmers made. He chose to study the diffusion and adoption of hybrid seed corn 

with the farmers there. He had a suspicion that sociological factors like the 

influence of the farmer’s neighbour played an important role in decision-making 

for the farmer. This decision either made the farmer adopt the seed corn or refuse 

to adopt (Ryan & Gross, 1943).   



11 

For Iowa State, the hybrid seed corn produced was a revolution in the corn 

production category. The corn produced gave rise to a genetically stronger crop 

that could withstand harsh environmental conditions and thus contributed to a 

higher increased yield of 20 per cent. At the time, mechanical combine harvesters 

were being introduced and the sturdy crop with strong stalks was better suited 

for harvesting by these machines, another advantage to be adopted. The 

droughts of 1934 and 1936 were not a challenge for the hybrid crop as it 

withstood these conditions as well.  

Such a revolutionary new hybrid crop would seem like good news among the 

farmers there and it was expected to diffuse at a fast rate among the farmers; 

instead, it was found that this diffusion process took 13 years (Ryan & Gross, 

1943), with the first planting taking seven years. Of interest was the influence of 

neighbouring farmers in adopting the innovation. At the heart of the diffusion was 

the exchange of information on experiences and best practice sharing of the new 

idea. This gave rise to the term innovation.  

The diffusion model lent itself to other disciplines of study, such as medicine, 

nursing, and marketing, and Rogers was teaching it at University; therefore, the 

model itself started the diffusion process.  

The diffusion model has existed for over 60 years and the studies of diffusion 

have continued. The basic diffusion model of 1962 had some important additions 

to the model as outlined below: 

 Critical mass: Defined as reaching the higher volume of individuals that 

become the advocates of the innovation such that further diffusion takes 

place and becomes self-sustaining; 

 Focus on networks: As a means of further understanding of how a new 

idea spreads through interpersonal channels; and 

 Re-invention: A process by which an invention changes by its adopters as 

it evolves during the diffusion process. 



12 

The model has been reassessed with new emerging empirical data (Fitzgerald, 

Ferlie, Wood & Hawkins, 2002). Their findings were a result of two studies 

conducted in the United Kingdom healthcare system, which showed that there 

was no single, linear, one-fit route of the diffusion process. They looked at newly 

found evidence-based medical scientific discoveries, passive adopters of the 

diffusion process and the influence that different scenarios or contexts have on 

the diffusion process. The discovery of new clinical findings in medicine is 

classified as privileged information, which most of the time helps to break long-

standing habits and behaviours among doctors. This context is knowledge-

based, and the education is either new or problem solving information; these key 

drivers allowed the diffusion process to start (Williamson, 1992).  

Roger’s (1995) work focusses on whether need precedes the newfound 

knowledge or the other way around. However, these models provide limited 

interpretation of the knowledge in situations of ambiguity (Fitzgerald et al., 2002). 

In the medical profession, there is a hierarchy of how knowledge is cascaded. 

Knowledge transfer takes place by means of a pyramid structure or top-down 

approach. Among medical professionals, the science is argued, reasoned with 

the fraternity and networks, and clinical best practices are shared, thus allowing 

a slow rate of diffusion of the new knowledge. From this study, three key themes 

emerged. First was to validate the credibility of the evidence; discovery of new 

knowledge in the medical profession first needs to be accepted before it will be 

used in practice. The second, for an innovation to be adopted it requires the 

decision of active adopters, not passive. In this theme, there is interaction 

between actors and innovations, and between groups. The third theme looks at 

the interlocking characteristics of communities. These three themes all affect the 

diffusion process.  

The process of diffusion is not straightforward but very complex and full of 

uncertainty. Diffusion requires a network of interwoven relationships. In medical 

evidence, no direct or distinct connection with the discovery of the new science 

and the rate of diffusion existed. The high quality of evidence did not have an 

impact on the diffusion.  



13 

Diffusion in the healthcare system is not only affected by budget constraints but 

also political hierarchy in the system. As mentioned previously (Rogers, 1995), 

diffusion is not only complex and uncertain, it involves many interactions, which 

go beyond re-invention or translation, as in the actor-network theory (Latour, 

1987). Users have their own interpretations and negotiate on what they thought 

to be credible evidence. This modification to suit their needs also assisted the 

diffusion process. In the healthcare sector, there is a very complex system of 

interactions between professors, physicians, doctors, nurses, and pharmacists. 

The knowledge transfer from one professional to the next can be very sticky and 

this affects the overall diffusion process. In this profession and the race for 

science and credibility, academics and politics go hand in hand, and this causes 

the complexity in knowledge transfer (Van de Ven, 1999) 

The healthcare sector has many interlocking relationships that affect the rate of 

diffusion as the study by Fitzgerald et al. (2002) found. The history, culture, and 

quality of relationships affect the rate of diffusion and this too evolves over time. 

The learning and change capacity also vary as per local settings, adaptations, 

and negotiations, which mean that diffusions cannot roll out readily. The study 

alludes to the point that there is no uniform pattern in the diffusion of an 

innovation, the diffusion process in multifaceted and depends on a myriad of 

characteristics.  

In the healthcare sector, the use of key opinion leaders is another critical pathway 

that affects the rate of diffusion of an innovation (Valente, 1999). Several criteria 

exist, by which key opinion leaders are chosen and selected, each with their own 

pro and cons. A key opinion leader is selected in five ways: 

(1) Key opinion leaders will select themselves; 

(2) Project teams and staff will select key opinion leaders; 

(3) Members in a community will recruit participants that are not leaders, 

these participants in turn will recruit new participants (Broadhead, 

Heckathorn, Grund, Stern, & Anthony, 1995); this was seen much in the 

AIDS project, where participants were comfortable in this approach; 



14 

(4) Individuals within a community selected other key people to be opinion 

leaders (Kelly et al., 1991); or 

(5) All community members are invited to nominate key opinion leaders 

(Lomas et al., 1991). 

Each of these methods has its own drawbacks. When selecting a key opinion 

leader, the trustworthiness and credibility of that person has a direct impact on 

the rate of adoption and diffusion. These leaders come to meetings to push their 

own agendas and very rarely have the community’s interests as their focal point. 

Being resolute on their agenda, they lack the expertise of knowing the needs of 

the adopters. The third approach is temporary in nature, and key ideas and 

behaviours are not communicated effectively; however, allowing community 

members to nominate leaders takes care of the main disadvantage. The fourth 

approach provides a pool of community leaders, the drawback being the method 

of selection and possible bias in the process.  

The fifth approach is similar to a democratic presidential election. The 

trustworthiness and credibility of the opinion leader is ensured through this 

method, as the people nominate the leader. This allows for a mix of leaders each 

with different skill sets and knowledge that permits a better intervention and 

dissemination of the knowledge as and when required in the diffusion process. 

The selected opinion leader can then be educated and trained in the intervention 

or knowledge, and paired up with a community leader. This is vital as it affects 

the rate of diffusion and adoption of the innovation within the community (Valente, 

1999).  

2.3 Technology readiness index 

The technology readiness index is a 36-item scale that was first published in 

2000. Technology readiness as defined by Parasuraman and Colby (2015) is 

peoples’ ability to accept and use new technologies for accomplishing goals both 

at work and in their personal lives. As the years have passed, technology has 

found its place in every service category. The rise of the internet has seen an 



15 

exponential growth over the years, and the growth of mobile technology has been 

prolific, and is on the increase year-on-year (Brahima, 2013). Social media is 

another channel that has accelerated at a staggering rate – Facebook had 1 

million subscribers worldwide in 2004, 350 million in 2009, and over 1 billion in 

2012. While the areas of speed, capacity, connectivity, functionality, and the ease 

of use of current technologies is a focus, innovations are near discovery. 

Technology-triggered transformation is likely to continue accelerating 

(Parasuraman & Colby, 2015).  

With the rise of technology set to revolutionise services, managers need to be 

mindful of the complexity that arises from delivering innovative customer 

experiences and customers being receptive to those experiences. The customer 

needs to know how to interact and use the new technologies, and manage its 

content. If this is not done, it leads to frustration and poor user experience, which 

in turn affects the rate of adoption and the diffusion process negatively. 

Employees need to be minimally affected, which requires constant 

communication, education, and training in the areas of new technology, which in 

turn makes employees comfortable and confident about the new technology. If 

this is not addressed, then productivity and staff morale can decline. 

Understanding consumers’ readiness for technology adoption is critical in 

understanding their reactions (Parasuraman & Colby, 2015). 

The original technology readiness index had its roots in literature on adoption of 

new technologies and interactions between people and technology. 

Parasuraman (2000) mentions the work of Mick and Fournier (1998) who 

conducted research on people’s use, response, and reactions and identified eight 

different opposite states, for example freedom/enslavement, 

assimilation/isolation, and efficiency/inefficiency. Their findings meant that 

technology had both positive and negative feelings (Mick & Fournier, 1998). 

Many previous studies in the areas of interactive media, tele-shopping, and self-

service technologies (SST), strengthened Parasuraman and Colby’s (2015) 

argument that relative dominance of positive and negative feelings about 

technology would be different across people and cause corresponding variations 

in people’s ability to embrace and employ new technologies. Similarly, other 



16 

studies (Davis, Baggozzi, & Warshaw, 1989) found specific consumer beliefs and 

motivations that might fast track or stop new technology adoption.  

Technology readiness was developing, and at the same time the internet boom 

was increasing, leading researchers to put strategies in place to increase 

consumer trust in the e-commerce environment. This research looked at the 

advantages and disadvantages of new technology-based systems and the 

meaning for the consumer in accepting these technologies. Since the first 

publication of technology readiness, much advancement has taken place in this 

technology space. More internet users, the speed of the internet, the switching 

form normal cell phones to smartphones, the social media boom, mobile 

commerce, and cloud computing. With this history behind technology readiness 

and the experience gained over 12 years until Parasuraman’s (2000) research, 

the authors of the technology readiness index agreed that there was a need to 

streamline and update the index.  

A clear differentiation between the new technology readiness index and the old 

one needs to be made. The former was named TRI 2.0 and the latter TRI 1.0. 

TRI 1.0 consists of 36 belief statements, each fully anchored on the five-point 

Likert scale (1 = strongly disagree to 5 = strongly agree). Of the 36 statements, 

10 measure optimism, seven measure innovativeness, 10 measure discomfort, 

and nine measure insecurity. TRI 1.0 provides dimension-specific as well as 

overall measures of technology readiness (Parasuraman & Colby, 2015). 

With the years, technology has increased and improved exponentially. The 

internet has progressed in terms of speed, connectivity, and access, which has 

had a direct effect on the attitudes and behaviours of consumers towards 

technology. With these changes, the language has also changed. TRI 1.0 has 

words like ‘machine’, ‘computer’, and ‘computer programme’, which are fast 

becoming outdated. In 1999, when TRI 1.0 was developed, many of today’s 

devices were in their infancy and some not even ideated. These were 

smartphones, wireless internet, social media, and home video conferencing. In 

addition, the 36-item index was too long. All these advancements and 

improvements motivated the need to relook TRI 1.0 and thus develop TRI 2.0.  



17 

TRI 2.0 is made up of 16 belief statements, of the 16 items, 11 are from TRI 1.0, 

while five have been newly added. The technology readiness statements use the 

same five-point scale used in TRI 1.0. One third of the items in TRI 2.0 have been 

reworded in keeping with the times and new technology (Parasuraman & Colby, 

2015).  

Many companies have increased the use and adoption of technologies in the 

selling and marketing of their products and services to customers. Similarly, the 

use of technology among customers is also rapidly increasing (Parasuraman, 

2000). Parasuraman (2000) noted little scholarly research on people’s readiness 

to use such systems. Traditionally in business there was a clear difference 

between goods companies and service companies, but this argument was 

challenged and contested by Rust (1998, as cited in Parasuraman, 2000), who 

stated that all companies provide a service. Research to establish the readiness 

of people to adopt the use of technology as a service offering was sparse. 

Parasuraman (2000) proposed a conceptual framework that looks at the 

traditional domain of marketing and what needs changing. In Parasuraman’s 

(2000) research, a ‘pyramid model’ of services marketing was put forward. This 

model is an extension of the triangle marketing model by Kotler (1994). These 

models are depicted in Figure 1. 



18 

 

Figure 1: Triangle and pyramid models of services marketing 

(Parasuraman, 2000, p. 308) 

The traditional 4-Ps of marketing, namely product, placement, price, and 

promotion or distribution forms the basis of the triangle model. The effective 

marketing of services looks to include two more forms of marketing: internal and 

interactive. Internal marketing has been used in many research papers and 

literary works and is accredited to the work of Berry (1981), which states that the 

employee of an organisation is the first customer, who needs the knowledge, 

education, and training internally to allow them to deliver superior service 

experience to customers. The impression created by the first interaction of the 

customer with an employee of a company through the delivery of a service is 

interactive marketing. 

According to Parasuraman (2000), internal and interactive marketing was 

consistent with other research by Booms and Bitner (1981) who recommended 

having three additional Ps: people, process, and physical environment, added to 

the traditional 4-Ps. However, these two types of marketing still do not cater for 

technology. With technology on the increase on both the goods and services 



19 

sides of business, as well as consumers’ use of technology, the triangle model 

does not capture all the complexities of services marketing. To cater for these 

complexities, the pyramid model adds the dimension of technology and shows 

three distinct relationships that need to be managed to ensure effective marketing 

services. These three relationships are company-technology, technology-

employee, and technology-customer. Parasuraman’s (2000) first objective in this 

study was to set out the development of the technology readiness model and the 

multi-item scale to assess users’ acceptance and readiness of this model. The 

second objective was to investigate the scale’s psychometric properties, future 

applications, and use of this model.  

Looking at the comparison of the automobile, which took 55 years to reach 25 

per cent ownership, with the cell phone that took 13 years to achieve the same 

ownership (Berry, 1999); although there was an increase in technology, the users 

of this technology were frustrated and left disillusioned with the technology 

(Alsop, 1999). Some of the reasons for this were first the early adopters were 

much more technology wise than the laggards. Second, the use and experience 

of technology, and third the complexity of use of the product.  

These reasons were the motivation to understand what factors will predict 

whether a user will embrace technology or not; are people ready to use 

technology and do demographics affect the use of technology (Parasuraman, 

2000). This gave rise to the development of the technology readiness index with 

the main aim of assessing people’s technology readiness.  

Many studies have been conducted on the technology readiness, which 

differentiates users as either being positive towards new technology or negative. 

Users with positive attributes adopt and embrace new technologies more easily, 

while users with negative attributes shy away from using new technology. There 

were different technology contradictions that looked at a more general overview 

of technology readiness of people as outlined in work by Mick and Fournier 

(1998) and Davis et al. (1989), which looked at specific consumer motivation and 

beliefs behind the adoption and readiness to embrace technology. The above-

mentioned studies, together with some qualitative work formed the foundation of 



20 

this research to understand the development of technology readiness and its 

future applications. 

Parasuraman’s (2000) development of the technology readiness index was a 

collaborative effort with an organisation that tasked him with the objective of 

trying to understand the attitudes and behaviours of technology readiness for a 

client they were commissioned to work with. This study took many years and 

adopted both qualitative and quantitative evidence. The qualitative research took 

the form of focus groups, which had well set out themes around being positive 

and negative. Flexibility, convenience, enjoyment, and efficiency were the 

positive factors and security concerns, users lacking of control, technology being 

impersonal, and the risk of the technology becoming obsolete made up the 

negative factors (Parasuraman, 2000).  

Another study, the Salae Mae study (Parasuraman, 2000), researched 

customer’s openness to various technology-based services using 44-item survey 

and a five-point Likert scale. The sample size was 3 000 people, and results 

rendered 1 200 useable responses. The ratings received underwent a series of 

statistical analysis leading to a shortened scale of 28 items differentiated into four 

categories: 

(1) Optimism: A positive view of technology and the belief that it adds value 

by offering people increased control, efficiency, and flexibility in their lives; 

(2) Innovativeness: The tendency to be the first adopter and mover on 

technology, as well as a thought leader in this area;  

(3) Discomfort: Lack of control over the technology and having a sense of 

being overwhelmed by the technology; and 

(4) Insecurity: When trust in technology is lost and respondents display 

scepticism about the use and belief of what the technology can do.  

Optimism and innovativeness are the positive factors in technology readiness, 

whereas discomfort and insecurity are negative factors, stalling and sometimes 

stopping the use of technology. These subscales of the technology readiness 



21 

scale appeared to be good predictors of technology-based behaviour. The 

technology readiness index is a sound psychometric multi-item scale that 

companies can use to gain a thorough understanding of their customers 

readiness to interact with new technology, especially computer or internet-based 

technology (Parasuraman, 2000). In addition, it can be used by companies to 

assess the readiness of its employees to either embrace or reject new 

technology.  

In the framework of researching technology readiness, another study looked at 

the readiness of physicians using smartphones in clinical practice. Historically 

physicians walked around with pagers, which had a direct impact on the hospital 

budget; they were expensive. The introduction of the smartphone revolutionised 

this and replaced the pager, bringing with it a decrease in diagnosing errors and 

prescriptions. As the internet and hospital information technology increased the 

advantage was an overall cost reduction (Putzer & Park, 2012).  

The study examined the innovation characteristics of compatibility, job relevance, 

internal environment, observability, personal experience and the external 

environment. All these characteristics have an impact on physicians’ attitude 

towards the use of smartphones. On compatibility, if physicians found that 

smartphones are connected to the hospitals’ other information technology related 

offerings then their attitude is positive toward the adoption of smartphones. 

Hence, hospital infrastructure needs to consider the support structure in terms of 

bandwidth, network monitoring, and synchronizing capabilities with desktops in 

the hospital. The legal implications entail the capturing of doctors’ personal 

information. Practicality and job relevance in the use of a smartphone was 

another important factor, if physicians found that the device brought about better 

patient care, a positive attitude towards the use of the device was evident (Putzer 

& Park, 2012).  

Physicians’ personal experience and interactions with the innovative 

characteristic was important in this study although previous findings by Putzer 

and Park (2012) found mixed results between physicians and nurses. The 

explanation was that in their study’s sample more than 50 per cent of physicians 



22 

were older, much more experienced in clinical practice, and needed more 

exposure to become accustomed to the devices.  

The internal environment proved a significant predictor of adoption and use of 

the smartphone; it involved the support physicians received from the hospital 

structure with regard to networks, budgets set aside for smartphones, and 

technology support, which proved to be critical in physicians’ attitudes to adoption 

of the technology. The relevance of the use of smartphones in making better 

clinical decisions for the patient has now been widely supported by hospital 

policies and procedures, and technical support is now in place. Smartphones 

have since increased in functionality and capabilities, which has given rise to the 

increase of technology and is here to stay (Putzer & Park, 2012). 

2.4 Detailing to healthcare professionals  

With all the glitz and glamour that technology brings, the main objective of every 

healthcare system is the delivery of services by one set of professionals to those 

in need of services to maintain and improve overall health. This transactional 

exchange of services is founded on a set of skills, knowledge, values, expertise, 

relationships, and trust that patients invest in doctors to get the best and most 

effective treatment. Through time and interactions, this trust is earned through a 

special set of skills, ethical duties, commitment, and social accountability, which 

forms the core of professional work (Frenk et al., 2010). Obtaining and 

developing this mix of characteristics requires lengthy periods of study, 

education, and investment from the medical student and society. The 

professional medical education that a doctor undertakes is one of the key 

attributes in delivering high quality, safe, and effective services to communities.  

With the advancement and the pace of technology, education in the medical 

profession has not kept pace. Into the twenty-first century and more recently 

there still exist major holes in the professional education of doctors and 

pharmacists. The discovery of new science, best clinical practices, fresh 

challenges, and demographic transitions has not kept pace with the professional 

education of healthcare professionals (Frenk et al., 2010). 



23 

In reports calling for reformation in medical education, it is noted that before the 

celebrations of 100 years of the Flexner report, there was a heightened 

awareness of and focussed attention on, nationally and internationally, the future 

of education of health professionals. The four sets of major reports, as mentioned 

in section 1.2 of this research report, calls for the focus on education of the global 

workforce, nursing education, public health education, and medical education. In 

fact, these reports call for a reform in education that emphasise patient and 

population centeredness, competency-based curriculum, inter-professional, and 

team-based education. These areas will form a strong base for formulation of 

reform initiatives for the twenty-first century. All reports proposed an investment 

in education and training, sharing of resources and partnerships within and 

across countries (Frenk et al., 2010).  

A lot of research has been done by Manchanda and Honka (2005) in the area of 

the effects of the role of direct physician marketing in the pharmaceutical industry. 

Face-to-face doctor detailing does have its positive and negative attributes as it 

drives education driven, changes scripting behaviour patterns, and builds 

relationships. The proposal put forward is that the experience of face-to-face 

detailing needs to be effective and used in the best possible way, practice ethical 

marketing, and allow for a mixed model of incorporating e-learning to reach 

doctors not reached by pharmaceutical representatives in face-to-face detailing 

(Manchanda & Honka, 2005). 

Education of doctors driven by detailing can take the form of face-to-face detailing 

or in a group, like lunch and breakfast appointments. Research looked at the 

benefits of these two types of detailing, the motivation was that it was noticed that 

there was an increase in prescriptions of anticholinergics to the elderly, which led 

to higher side effects and contributed to a decreased life span. The aim of this 

detail exercise was to drive CME to both pharmacists and doctors, and to bring 

about a reduction in the prescriptions of these drugs and thus the knock on effect 

of reducing the dispensing of these drugs (Van Eijk, Avorn, Porsius, & de Boer, 

2001). The findings of this study were conclusive in that both individual and group 

detailing brought about a change in behaviour and drove fewer prescriptions of 

anticholinergic drugs among the elderly.  



24 

The differences highlighted in group detailing is that there was more conformity, 

which was attributed to peer pressure; with individual, face-to-face detailing it 

was noted that healthcare professionals were much freer to talk about their 

prescribing habits. In this study, both individual, face-to-face detailing and group 

detailing changed prescribing behaviour. This prescribing behaviour can be 

attributed by the frequency of the visiting detailing representatives; more visits 

meant the delivery of the same key messages, which drove top-of-mind 

behaviour and prescribing habits.  

For physicians, choosing an individual drug is one of the most important clinical 

decisions in a medical practice. The prescribing decision is influenced by many 

factors such as patients providing information to doctors on what they are 

experiencing, commercial drive by pharmaceutical companies, colleague 

influence, medical journal articles, and government regulations (Soumerai, 

McLaughlin, & Avorn, 1989). In this research, it was found that the older 

population, above 65 years of age, were taking more prescription drugs. 

Prescribing behaviour in such age group is critical due to the adverse events of 

drugs in this population and prescribing behaviour can influence their quality of 

life and life span. Strangely enough there is an over prescription of drugs in this 

age group. This study looked at non-regulatory methods and its effect on 

changing prescribing behaviour patterns to reduce over-prescription of drugs.  

One of these methods looked at face-to-face educational detailing to change 

behaviour patterns. Several health education studies that show evidence of one-

on-one education can effectively change behaviour patterns; such an example is 

changing behaviours in smokers (Leventhal & Cleary, 1980). Soumerai et al. 

(1989) also made mention of this method being effective in his previous studies. 

As mentioned, pharmaceutical companies train their medical representatives to 

detail doctors with the purpose of changing prescribing behaviours. One of the 

key reasons for prescribing errors in a clinical setting is over zealous medical 

representatives and relationship-based selling. The results from this study 

(Soumerai et al., 1989) showed that one-on-one education of physicians by a 

visiting pharmacist or counsellor brought about a change in prescribing 



25 

behaviour. The pharmacist or counsellor in this study was the medical 

representative. 

There are several studies showing that detailing supports behaviour change, 

brings about better clinical outcomes for the patient, and reduces prescribing 

errors. Another study showed a different benefit of detailing: culture. In the US, 

many medical doctors failed to understand the minority cultures when treating 

patients. This lack of knowledge in understanding the different cultures created 

huge differences in healthcare treatment when it came to the minority versus their 

white counterparts (Horner et al., 2004). The literature review showed many 

studies examining reasons for, and consequences of, observed racial, ethnic, 

gender, and socioeconomic differences in the management of many conditions 

across different therapeutic areas of cardiovascular disease, central nervous 

system disorders, cancer, and pain management.  

Upon these findings, the medical fraternity put together a task force to address 

these differences and generate a plan to rectify this situation. This task force was 

a representation of different healthcare professional bodies and medical 

academic institutions. The healthcare professionals did not understand the health 

system and came with their own mindsets on racial, ethnic, and social class. Their 

lack of awareness on these attributes meant they did not understand their 

patients, which led to incorrect diagnoses and treatment plans. These 

professionals lacked cultural competence.  

The working group was to establish a set of recommendations that would be 

effective in driving behaviour change in these health professionals. One of those 

recommendations was educational outreach, which took the form of detailing on 

cultural competence, and was found to be effective in changing behaviour. 

Another study (Horner et al., 2004) made mention that this type of detailing 

should be part of the classroom setting for healthcare professionals. Training of 

cultural competence and supporting a diverse workforce is an area that needs 

attention and can take several forms: 

 Providing healthcare professionals and staff with continued education on 

cultural competence; 



26 

 Availing practical resources to doctors to be cross-culturally sensitive; 

 Putting incentives in place for staff by means of textbooks, journals, and 

access to internet; and 

 Providing transportation and interpreters where needed.  

Cultural competence training at medical schools in the US and the United 

Kingdom vary, but overall the numbers focussing on this is low. Research has 

shown that detailing is effective in changing behaviour, and this behaviour can 

be changed to reduce disparities in the healthcare system of diagnosing and 

treating patients from different cultural backgrounds.  

By comparison, detailing in South Africa is limited, and further research is needed 

to look at how product e-detailing is transforming traditional pharmaceutical 

marketing. Prior to 1997, direct marketing to consumers was very limited, 

Pharmaceutical companies, as mentioned earlier, continued driving education 

with doctors via detailing (Trucco & Amirkhanova, 2006). Research in US 

pharmaceutical companies showed that the cost of detailing took a huge share 

of the marketing budget, between 45 and 70 per cent. In Europe this figure is 

even more significant as the direct consumer advertising spend is low (Bates, 

Bailey & Rajyaguru, 2002). The main objective of detailing is to gain market share 

of the products they detail and thus drive up company profits, and in the interim 

build strong relationships. Over the years, a major shift has occurred to challenge 

detailing efforts due to trends and radical changes in the industry to drive ethical 

marketing. These changes are as follows: 

 Introduction of new policies and procedures locally and globally;  

 Generic products and clone products as original drugs lose their patency;  

 Increased demand of doctors time as more detailing representatives flood 

the market; and 

 Rising costs of research and development. 



27 

Traditionally if there were inefficiencies in the sales force, this was addressed by 

increasing the number of medical representative, thus increasing the reach to 

new doctors and increasing the frequency of calls to A-listed doctors. The sales 

representative force globally increased by an average of 21 per cent from 1999 

to 2001. This increase has been strongest in the US, with 42 per cent, and the 

least in Japan, with 1.2 per cent. However, this cannot be a long-term solution, 

as the return on investment (ROI) of the representatives will start to outweigh the 

profits generated. In addition, having numerous representatives in an area means 

that they compete for the doctors’ time, a 15 minute call could reduce to five 

minutes as doctors need to make time to see other representatives. Some 

doctors go to the extent of refusing to see any representatives because of the 

influx of so many of them in the field.  

It has been noted that in countries like the US, the number of medical graduates 

annually has been a steady flat number, but the medical representative force has 

been doubling. The marketing exercise of targeting and segmenting has seen the 

detailing efforts focused on the high potential, high prescribing doctors. It means 

these doctors are being flooded by representatives demanding their time; all 

competitor pharmaceutical companies are doing the same, all competing for the 

doctors’ time. The detailing cycle planning includes two priority detailing products, 

some companies will have a third as a reminder product. With the pressure and 

line up of these products on the representatives detailing cycle, the effectiveness 

of detailing is not beneficial on message delivery and recall. The combination of 

all these factors have led to an ever-decreasing ROI for the pharmaceutical 

companies, that leaves a major gap in educating doctors if pharmaceutical 

companies want to see profits from sales increasing (Trucco & Amirkhanova, 

2006). 

2.5 Barriers to innovations 

The medical profession is one sector that thrives on research and clinical trials, 

it boasts a sector rich in medical science discoveries. Having stated this, major 

gaps in knowledge remain when it comes to putting this knowledge into clinical 



28 

daily practice (Berwick, 2003). This gap is described in the Institute of Medicine 

Report; there is a divide between what science has delivered and the healthcare 

provided. 

In the US, this is a huge problem, as alluded to earlier in this research, due to the 

lack of knowledge, dispensing errors and treatment regimens have been 

affected. It is one thing discovering an innovation; however, the actual rate of 

dissemination of this innovation can take much longer, as seen in Rogers’ (2010) 

work in Iowa State, with the seed corn innovation. 

The rate of diffusion and dissemination of innovations is often a long process; 

Berwick (2003) researched the barriers to innovation and what makes 

dissemination successful. As in Rogers’ (2010) study on diffusion of innovations, 

it took the farming community 13 years to adopt the seed innovation.  

In the diffusion of innovations studies by Rogers (2010) and Van der Ven’s (1999) 

work on innovation research, and many others, they focussed on three basic 

clusters of influence that enables a diffusion to disseminate. They looked at (1) 

perceptions of innovation; (2) characteristics of the people who adopt the 

innovation, or fail to do so; and (3) contextual factors, especially involving 

communication channels, incentives, leadership, and management.  

For an innovation to have a successful adoption in a system, Rogers (2003) and 

Berwick (2003) highlighted five characteristic perceptions of innovations: 

(1) Relative advantage of the innovation; 

(2) Compatibility; 

(3) Complexity; 

(4) Trial ability; and  

(5) Observability. 



29 

2.5.1 Relative advantage 

Any innovation needs to give the user an advantage of being more effective and 

efficient; in addition, the cost of the innovation as well as what it would take to 

maintain. Social motivation is another factor of relative advantage. While the early 

innovators, early adopters, and early majority are status motivated, the late 

adopter and laggards do not perceive status as important. To increase the rate 

of adoption and make the innovation relative, direct and indirect payment 

incentives can be in place to motivate the adoption of the innovation (Rogers, 

2003). 

Education plays a critical role in the adoption of an innovation, the more 

knowledge shared on the innovation the more likely it is to be adopted, Rogers 

(1995) calls this ‘reduction in uncertainty’.  

2.5.2 Compatibility 

Everyone has a system of beliefs, attitudes, and values. Rogers (2003) stated 

that compatibility occurs when the innovation is consistent with existing values, 

past experiences, and the needs of potential adopters. If individuals do not have 

experience in technology or the use of it, this will affect their ability to adopt an 

innovation in this sector and thus few will use the innovation (McKenzie, 2001). 

In a literature review by Hoerup (2001), innovations influence teachers’ opinions, 

beliefs, values, and views about teaching. Another key factor is the naming of the 

innovation, as users associate themselves with brands and names.  

Values, beliefs, history, and current needs of the individual affect the rate of 

diffusion of an innovation. At times in the medical profession, it is noted that only 

a minority of doctors will use scientific guidelines and algorithms in treating their 

patients (Casillino et al., 2003). This is largely due to the surgeon or physician’s 

stubbornness towards the use of the innovation, or a mismatch of the innovation 

serving the current needs of the practice and thus the healthcare professional 

does not see the need to adopt the innovation (Berwick, 2003).  



30 

2.5.3 Complexity 

According to Rogers (2010), complexity is the degree to which the user perceives 

the adoption as being difficult to understand and use. Simplicity and ease of use 

is paramount in an innovation. With so many technological advancements, 

grappling with understanding how to use innovations should be minimal. If the 

innovation does not meet such criteria, then the rate of adoptions is much slower. 

Successful adoption depends on the ease of use of both the software and 

hardware of the innovation. 

Most of the time the developer of the innovation is not a good salesman and is 

more interested in its elegance, seeing the innovation as being something that 

can be replicated once it is adopted and adapted to meet the local needs 

(Berwick, 2003).  

2.5.4 Trial-ability 

Trial-ability, according to Rogers (2003), is the testing of or experimenting with 

the innovation for a limited period; a trial run. Some companies use what is 

referred to a test market, and during this period troubleshooting takes place and 

adjustments made so that the rate of adoption can be quick and ease of use 

ensured. Feedback is given on what is working, what is not, and how the 

innovation can be improved. This is also is an example of best practices sharing, 

and if other individuals and markets see the value the innovation brings, then 

they are more likely to adopt the innovation.  

2.5.6 Observability 

When the innovation becomes visible to others and they see it in use, this is 

observability, as defined by Rogers (2003). Users and observers need to see the 

benefit of the innovation as a solution to a problem; this is vital to the rate of 

diffusion.  

The adoption of a new idea or innovation is not an easy process, for an adoption 

to be successful; these barriers to innovation (section 2.5) need to be taken into 



31 

account to ensure the rate of adoption is impactful and the diffusion process 

speedy (Rogers, 2003). The change in attitudes, behaviour, and adoption 

diffuses faster when these factors are applied to the innovation (Berwick, 2003).  

The Canadian health heart kit (HHK) research is a study that applied these 

factors to an innovation that was built on the constructs of Roger’s (2010) theory 

of diffusion and the theory of planned behaviour. According to the theory of 

planned behaviour, an individual’s aim to perform the set behaviour is vital to 

performing the behaviour, as is the motivation as a key driver behind the 

behaviour (Ajzen, 1991). In Berwick’s (2003) study, he makes mention that 

Eccles et al. (2006) suggested that there is a predictable connection between 

healthcare professional’s objective to engage in behaviour and their succeeding 

behaviour.  

The two main aims of the Canadian HHK research were to find out (1) if there 

were specific factors of the HHK as well as circumstances and situational factors 

that contributed to the aim and actual use of the kit; and (2) if any situational or 

other circumstantial factors are associated with individual or environmental 

barriers that prevent the uptake and adoption of the kit among physicians who do 

not intend to use it (Scott, Plotnikoff, Karunamuni, Bize, & Rodgers, 2008).  

The decision to adopt an innovation is not a linear path, but highly multifaceted, 

a dynamic and active process that involves interactions between individuals, 

situational factors, different circumstances, and considerations of the attributes 

of the innovation itself.  

 



32 

Figure 2: HHK’s multi-faceted paths 

(Scott et al., 2008, p. 6) 

As mentioned in section 2.5, the two key attributes of the study (Scott et al., 2008) 

was relative advantage and observability. An innovation that has a clear 

advantage over another will be adopted should the need arise. The advantage 

can be conceptualised in terms of economic profit, social prestige, or ease of use. 

Observability of the benefits of using the HHK was another attribute that ranked 

high in this study on the intentions to use the kit. The outcomes show that the 

adoption process is not linear and straightforward but that contextual factors, 

attributes of the innovation, and situational factors play a critical role in the 

adoption process and the innovation diffusion, as depicted in Figure 2.  

2.6 Detailing representatives adding value to CME of doctors 

Pharmaceutical companies invest a lot of time, money, and resources in 

equipping representatives to get a clinical message out to doctors. This detailing 

process involves the promotion of drugs and is effective in the early life cycle 

stage of drug marketing, with incremental returns on investment. Research and 

development of a next originator or ethical drug takes years to discover and 

manufacture. The representative thus continues detailing a product over a very 

long period after the early life cycle of the drug, the efficacy of the detailing 

process is questioned as to whether the process continues to add value or new 

education to doctors (Manchanda & Honka, 2005).  

This process of face-to-face detailing increasing becomes a relationship-based 

selling tactic used by pharmaceutical companies with the main aim of driving 

repeated messaging and re-enforcement (Fugh-Berman & Ahari, 2007). 

Pharmaceutical companies segment, target, and profile doctors according to the 

amount of scripts they write and the potential of their scripts (Soumerai & Avorn, 

1990).  

The Flexner report, discussed in sections 1.2 and 2.4, is a report on medical 

education, 100 years from 1910, a series of requests and proposals have gained 



33 

local and international attention on the reform of medical education (Flexner, 

2002). This heightened awareness has been included as part of the MDGs. The 

MDG report, in addition to three others detailed in section 1.2, all stress the 

importance of education and training in the medical fraternity. The joint request 

of these reports calls for an incremental increase in investment in medical 

education, best practices sharing, along with sharing of resources and 

partnerships within and across borders (Frenk et al., 2010).  

Health is all about people, the professional development of doctors encompasses 

life-long learning either formally or informally. Effective healthcare requires 

continuous learning (Bennett et al., 2000). As noted in section 2.4, not all doctors 

are visited by pharmaceutical representatives. The face-to-face detailing process 

provides an avenue for doctors to be susceptible to the influence of 

pharmaceutical companies; the gift bearing involved, the relationships built, and 

the tactfully and carefully selected messages (Fugh-Berman & Ahari, 2007). 

Pharmaceutical companies target doctors that add to the net revenue and profits; 

therefore, the education gap between detailed doctors and non-detailed doctors 

is widening, and is not in line with the MDGs and other reports. 

Research has shown that detailing by representatives adds to the CME of doctors 

and is a key factor that changes behaviour. All in the name of science, the 

medical profession has been plagued for many years with misdiagnoses and 

incorrect prescriptions adding to and increasing the death rates (Choudhry, 

Fletcher & Soumerai, 2005). One way to address this critical gap in education 

that exists is by doctor detailing.  

This was proved in a hospital setting where vasodilators were incorrectly 

prescribed (Soumerai & Avorn, 1990). Pharmacists were trained in selling skills 

and pharmacotherapy to visit physicians to educate them in bringing about 

change in their behaviour pattern and prescribing habits of vasodilators. The 

pharmacists in this case where the detailing representatives. On the first detailing 

visit, there was no difference in behaviour, when key educational messages were 

repeated on the second visit; behaviour change was noted (Soumerai & Avorn, 

1990). Other studies have concluded positive changes in prescribing behaviour 



34 

thus decreasing prescribing errors when face-to-face doctor detailing was 

employed (Soumerai & Avorn, 1984). Educating doctors and changing their 

prescribing behaviours meant huge cost savings due to prevention of prescribing 

errors and misdiagnosis of medical conditions. 

In view of the fact that representatives change the behaviour patterns of 

prescribing doctors there is very little quantitative evidence on the impact they 

have, the evidence (Hemminki, 1977) that does exist is broad sales presentations 

on survey results. Soumerai and Avorn (1990) set out to research and 

understand if the representatives could change prescribing behaviour of 

physicians by detailing and educating them, which adds to their continued 

professional development. The medical detailing can be likened to a non-

government organisation, as the pyramid of influence is similar and detailing 

looks at spreading of education. The objective of the research was to find out if 

the representatives were adding value to doctors’ prescribing behaviour. The 

prescription of antibiotics has always been a contentious issue due to the over-

prescription of these drugs. Previous research looked at the over-prescription of 

antibiotics and a behavioural change strategy to stop this problematic activity, 

and instead lead patients to self-care and over the counter medications like 

aspirin (Soumerai & Avorn, 1986).  

The analysis of the impact of detailing was based on different techniques and 

principles used to bring about behaviour change. Adult-based education, 

diffusion of innovation, and communication were the techniques used. The 

motivation behind doctors’ prescribing of a product is important to understand the 

impact that face-to-face detailing would have. It is misleading to believe that the 

delivery on CME to doctors alone will bring about a shift in prescribing behaviour 

and effective treatment for the patient. The discovery of new clinical science has, 

in some cases, brought about a change in prescribing behaviour; research has 

also shown that the personality, attitudes, behaviour styles, competitive 

landscape, competitor activities, peer influence, and CME strategies form part of 

the detailing mix (Soumerai, McLaughlin, & Avorn, 1990). The representative is 

extensively trained and educated to use this information in their detailing calls to 

doctors.  



35 

In detailing to medical professionals, the source of information is critical, as this 

is associated with the credibility of the message. The research centre of the trial, 

the journal in which the trial was published, the key researcher in the trial, all 

these factors are what makes the message credible. Pharmaceutical 

representatives are trained to deliver these messages, so they come across as 

being credible. Symposiums are also sponsored by pharmaceutical companies 

and the attending doctors are met with representatives delivering the key 

messages when they interact with doctors at the exhibition booths at medical 

symposiums (Bowman, 1986).  

Detailing representatives are also highly incentivised to achieve sales targets; 

however, this leads to overzealous representatives delivering messages to 

achieve a sales target. In the delivery of this type of message, the credibility of 

the message is brought into question. During Soumerai and Avorn’s (1990) 

research, doctors have not fully confessed that they have been swayed by 

representatives and the relationships they have. Ethical medical practice should 

be based on the science and thus lead to effective clinical decisions for best 

outcomes for both patient and treating doctor (Soumerai & Avorn, 1990).  

The time to see a representative can be easily substituted and channelled to 

spend more time on seeing a patient. Doctors dedicate time in their busy 

schedules to seeing representatives and when asked why they do this, most did 

not even have an answer to this question. It felt to them like it was part of their 

job. Some found representatives to waste their time, but still found time to see 

them. A study that looked into the reasons that physicians refuse to see 

representatives stated that these appointments were taking too much time in a 

day, and that the trinkets and gifts they brought creates bias and this sways the 

doctors’ prescription habits (Brody, 2005).  

However, having stated this, this practice of seeing representatives has not 

changed since 1961, and every year pharmaceutical companies continue to 

employ representatives to call on high potential, high prescribing doctors. Brody’s 

(2005) study showed that doctors felt compelled to see representatives due to 

the gifts received and that prescribing became personal. A more robust way to 



36 

verify the educational content delivered by the representative would have been 

to receive the information and then spend time reviewing the clinical evidence to 

verify the content given by the representative. The decision then lies with the 

doctor to prescribe the correct medication and dedicate their time to the patient 

and treatment diagnosis and regimen. If doctors spend time with representatives, 

and are swayed with gifts and trinkets, then the ethics and integrity of the 

profession is questioned. Representatives are business people that are being 

loyal to their employers in delivering key clinical messages, the integrity of 

doctors is solely in the power of the doctors’ hands and the representative is not 

responsible for the integrity of doctors. 

Detailing to doctors involves a multifaceted approach and, in another study, 

Soumerai et al. (1990) researched the quality assurance of prescriptions and 

investigated seven pillars that assisted the representative in the detailing 

process. These pillars are: (1) the use of printed educational materials in the form 

of leave behinds; (2) the list of medications that patients were prescribed; (3) 

group gatherings in the form of breakfast, lunch, and round tables; (4) qualitative 

feedback of prescribing habits of physicians; (5) reminders by the representatives 

at times of prescribing; (6) detailing that involved face-to-face interaction; and (7) 

continued ongoing pharmacy services. 

The use of printed educational materials alone matches the findings in previous 

literature that education in the form of pamphlets, fact sheets, unbranded 

advertorials, and leave behind materials does change the attitudes of doctors; 

however, it does not change prescribing behaviour (Soumerai et al., 1990).  

Sending a list of the patients’ drugs without any proper instructions, reports, and 

findings did not change the prescribing behaviour of doctors in any way (Hershey, 

Porter, Breslau & Cohen, 1986). There is little research on group learning 

changing prescribing habits. Group education is a common practice in the 

medical profession; universally many doctors work in corporate groups. It was 

found that when senior physicians led the discussions, and were seen as key 

opinion leaders (Inui, Yourtee, & Williamson, 1976), they were able to influence 



37 

and bring about a change in prescription behaviour in terms of antibiotics and 

hypertension (Klein, Charache, & Johannes, 1981).  

In terms of feedback on prescribing patterns, the past habits of doctors were 

compared to their present habits and with that of their peers. It was found that 

this did influence behaviour and change prescribing habits; however, not many 

findings are conclusive in this category. One study was well controlled and 

showed a generic prescribing of 46 per cent over the controls (Gehlbach et al., 

1984), which proved that with adequate feedback prescribing behaviours can be 

changed.  

Many interventions looked at reminders to doctors at the time of prescribing, even 

though education was taking place, this did not pose a problem, but it was 

something that doctors overlooked. The most recent study failed to show the 

effectiveness of either reminder or feedback on physicians’ compliance with other 

drug protocols (Tierney, Hui & McDonald, 1986).  

As mentioned in section 2.4, the one-on-one detailing by representatives to 

doctors does contribute to their education and changes prescribing behaviours. 

This has been seen in antibiotic prescriptions, scripting of vasodilators, 

cardiovascular drugs, and even smoking cessation (Soumerai & Avorn, 1990). 

Detailing does contribute to the medical education of doctors and their 

professional development.  

In the detailing to doctors and adding to their continued professional 

development, one specific area that doctors were questioned on was conflict of 

interest and their handling of this issue (Chimonas, Brennan, & Rothman, 2007). 

Many surveys were carried out and many inconsistencies remain; some doctors 

believe that seeing representatives and receiving gifts is part of their educational 

development (Keim, Sanders, Witzke, Dyne, & Fulginiti, 1993), while others 

believe that this shows bias towards the representatives and company behind 

the products. Several surveys carried out showed that doctors were not aware of 

the negative effectives of the detailing and their relationships with 

representatives. They justified their relationships as part of their job and 

necessary to their professional development. 



38 

The methodology followed focus groups among physicians, which was an 

excellent format to understand how physicians managed the inner conflict of 

manufacturers trying to sell a product, while they were trying to maintain their 

integrity and have patient care at the forefront (Chimonas et al., 2007). Since, the 

pharmaceutical industry, medical bodies, and governments have put in place 

legislation to make sure that unethical practices do not take place between 

pharmaceutical companies and doctors.  

The trend in the 1970s and 1980s saw a huge investment from pharmaceutical 

companies sponsoring CME of doctors and thus adding to their continued 

professional development, be this in the form of detailing by representatives, 

round table dinners, or national and international symposiums. Over the years, 

the pharmaceutical industry has come under heavy legal and regulatory scrutiny 

and seen policies and regulations put in place. This was instituted by the 

Accreditation Council for Continuing Medical Education (ACCME), which 

accredits all CME providers, and put in place policies and procedures to identify, 

disclose, and resolve conflicts of interest (Steinman, Landefeld & Baron, 2012).  

With the decline of industry support of CMEs, physicians are concerned about 

their CME and thus their continued professional development. The shift has 

already been seen with medical schools moving CMEs to their facilities and 

lecture rooms. This means that there is no cost for conference venues, 

accommodation, and transport. This money can be channelled into other 

avenues that can help medical teaching hospitals. This shift is also taking place 

from traditional physical attendance to online interactions; however, physicians 

feel they will miss the opportunity of listening to key opinion leaders on various 

subjects and thus the knowledge deficit will widen.  

Reducing funding for accredited CMEs also poses a problem for pharmaceutical 

companies having their own CMEs in restaurants and other venues, which mean 

that education is not accredited and standardised, adding to confusion and lack 

of clarity on education. Industry support for accredited CME is unlikely to 

disappear totally from the profession, time will tell as tighter restrictions from a 

regulatory and economic perspectives is seen more frequently. This shift calls for 



39 

the medical profession to make a cross-functional collaborative effort with 

physicians, accredited CME providers, and pharmaceutical companies to work 

together for the main purpose of better education and patient outcomes 

(Steinman et al., 2012). 

2.7 Academic detailing to improve clinical decision-making 

Healthcare is not affordable for many, and with the cost of drugs increasing, it is 

important that these drugs be prescribed as rationally as possible; this is not 

happening. The drugs doctors’ choose to prescribe for the patient, and the cost 

of the drug often falls short of the desired clinical outcome due to adverse 

reactions to the drug. Several theories and principles of communication and 

behaviour change can be found that underlie the success of pharmaceutical 

companies in influencing prescribing practices (Soumerai & Avorn, 1990).  

Pharmaceutical representatives have been operating for more than 100 years. In 

the US, Soumerai and Avorn’s (1990) research on representatives showed 

numbers of approximately 28 000. Pharmaceutical companies have a high 

annual investment in detailing representatives. Several studies indicate that 

representatives are the first point of contact for information dissemination to 

doctors. Detailers do shape much of the prescribing behaviour, but there is a lack 

of scientific literature on how they might adapt their detailing to reduce prescribing 

behaviour.  

Medical representatives often employ incentive strategies to all personnel in the 

medical profession, nurses, receptionists, theatre sisters, and doctors. The 

objective behind this tactic is to gain entry and time with selected, targeted 

doctors to deliver a clinical, medical marketing message. One of the key 

credentials to recruit a medical representative is for them to have a scientific, 

health sciences, educational background so that they can converse with doctors 

and be successful at undergoing a rigorous training programme on clinical 

science, sales, and marketing. The motivation behind their task is further 

enhanced by huge incentives, like overseas trips, if they exceed their sales 

targets through doctors they detail. This is a hazard as you get over-zealous 



40 

representatives trying to push a message through with the sole purpose of 

generating additional income, instead of having doctors and patients in mind for 

the best, cost effective treatment (Soumerai & Avorn, 1990). From this angle, 

many physicians have questioned the credibility of the messages from the 

representatives on product efficacy. In some instances, these incentives have led 

representatives to deliver the wrong messages on the drugs being detailed.  

The way educational information is diffused by pharmaceutical companies is at 

times misleading to doctors. In 2012, giants such as GSK (Thomas & Schmidt, 

2012) and Eli Lilly we