Social Relations and Innovation

in the Medical Profession: The

Epidemiology of a New Drug*
By HERBERT MENZEL and ELIHU KATZ
A study of drug adoptions by physicians allowed the introduction of sodo-
metric techniques into a field survey of decision-making. Pharmacists' files
made available a precise record of the decisions made.
This pilot study confirms the role played by face-to-face contacts in mediat-
ing influences from the outride world in a case of decision-making among
professional experts. Several amendments to the hypothesis of the two-step
flow of communications became necessary.
Herbert Menzd is a research associate at the Bureau of Applied Social
Research, Columbia University. Elihu Katz, formerly of the Bureau, is an
Assistant Professor of Sociology at the University of Chicago.

J. N THE last few years, research on communications and opinion forma-

tion has taken more and more account of the various ways in which
interpersonal relations may "intervene" in the communication process.
Thus, for example, the role played by personal influence in affecting
individual decisions has received increasing attention. Events in the world
outside, be they political acts, technological innovations, or fashion re-
leases, seem to impinge upon the individual not so much through the
direct channels of the mass media, as through the mediation of face-to-face
contacts with other individuals—some of whom, in turn, are affected by
the mass media.1 This realization of the role of so-called "opinion leaders"
has been accompanied by another awareness: sources of influence which
are not inherently relevant to the subject matter at hand must be con-
sidered even where expert opinions and specialized sources of information
•This paper may be identified as Publication No. A 190 of the Bureau of Applied
Social Research, Columbia University. The study was supported by a grant from Chat.
PfizerfcCo., Inc. manufacturers of chemicals and pharmacenticals. The authors acknowl-
edge the contribution of Dr. Joseph A. Precker, then Director of Market Research,
Chas. Pfizer 8c Co., Inc., in initiating the study and in participating in its design. Con-
tributions to various phases of the planning of the study were made by James Coleman,
Philip Ennis, Marjorie Fiske, and Rolf Meyenohn, all then of the Bureau of Applied
Social Research. An earlier version of this article was presented at the 1955 meetings of
the American Association for Public Opinion Research.
•See, eg., Lazarsfeld, Berelson and Gaudet, The People's Choice, (New York: Columbia
University Press, 1948), Chap. XVI; R. K. Merton, "Patterns of Influence," in Lazarsfdd
and Stanton, eds.. Communication Research 1948-49, (New York: Harper, 1949); and
Katz and Lazarsfeld, Personal Influence, (Glencoe: Free Press, 1955).

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 338 PUBLIC OPINION QUARTERLY, WINTER 1955-56

are available. Among the sources which influence a very wide arc of the
individual's behavior with very little respect for the boundaries of subject
matter are enduring networks of social contacts. Thus, for example, in
politics, neither the newspaper editor nor even the ward heeler appear to
affect the individual's vote as powerfully as his parents, his spouse, or his
ethnic and religious loyalties.1 .'
But personal inmience is not the only aspect of interpersonal relations
which is relevant to an understanding of the flow of mass communications
and their effects on individual decisions. The extent of an individual's
integration in a group may be an important variable, for example. Thus,
one study has shown that children who are relatively well integrated in
groups of peers tend to make quite, different use of adventure stories on
the radio than children who are relatively isolated from such contacts.8
Or, an earlier study has shown that Allied propaganda to German troops
did not take effect until the soldier was cut off from his intimate, inter-
personal ties—when his own small unit of peers and non-commissioned
officers broke up. 4
If "belonging or not belonging" is a key variable, so is belonging to one
group rather than another. An individual is.ordinarily reluctant to depart
from the norms of his particular group, unless the departure itaelf receives
some form of group support, and a communication aimed at influencing
his thoughts or actions may therefore fail. When changes occur, it is
usually only when the individual perceives that his group approves, or
that support comes from a dissident sub-group, or from an outside group
toward which the individual sees himself moving or whose presumed
standards he accepts.8

COMMUNICATION IN THE MEDICAL PROFESSION

A current study on the flow of scientific information in the medical

•See Berelson, Bernard, Piul F. Lazarsfeld and William McPhee, Voting, (Chicago:
University of Chicago Press, 1954).
'Rilcy, M. W. and J. W. Riley, "A Sociological Approach to Communications Re-
search," Public Opinion Quarterly, Vol. 15, pp. 445-60.
*Shil», E. A. and M. Janowiu, "Cohesion and Disintegration in the Wehrmacht,"
Public Opinion Quarterly, Vol. 12, pp. 280-315.
"This is the thinking implicit, for example, in Kurt Lewin's approach to "Group
Decision and Social Change," in Swanson, Newcomb and Hartley, eds., Reading? in
Social Psychology, (New York: Henry Holt, 1952) and in subsequent studies in this
tradition. An important illustration is H. H. Kelley and E. H. Volkart, "The Resistance
to Change of Group-Anchored Attitudes," American Sociological Review, Vol 17, pp.
453-465. Of obvious relevance, too, is the tradition of research and theory concerning
"reference groups" synthesized in R. K. Morten and A. KiH, "Contributions to the
Theory of Reference Group Behavior," in Merton and Lazarsfeld, eds., Continuities in
Social Research: Studies in the Scope and Method of the American Soldier, (Glencoe:
Free Prew, 1950).

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 EPIDEMIOLOGY OF A NEW DRUG 339

profession has provided an opportunity to apply these ideas to a new and

substantively different sociological field. By contrast to earlier studies of
opinion formation and decision-making, we are dealing here with a rela-
tively closed community of specialists. We are not concerned with topics
where everybody is supposed to be entitled to his own opinion, but with
matters based on scientific findings, where the relevant expert sources are
generally recognized, easily identified, and universally available. The
hypothesis of the roles of less expert sources and of interpersonal channels
as mediators of influences is therefore put to a more crucial test.6
The general concern of this project is physicians' reactions to innova-
tions in therapy, particularly with regard to new drugs. Drugs, unlike
other matters of medical practice, have standardized names and easily
ascertainable release dates, and it is possible to pinpoint the time of
first use of a drug by each physician. In this sense, then, the process of
diffusion of a new drug can be traced through the social structure of the
medical community.
The data we shall draw upon are from a pilot study conducted in May,
1954, in a New England city of approximately 30,000; S3 of the 40 doctors
practicing in the community were interviewed. Since the behavior in
which we are interested (prescribing of new drugs) can take place only
among physicians, we have thus interviewed 83 per cent of the relevant
members of the community. But because of the small number of cases,
the findings must be treated as highly tentative. We preseat these early
results primarily for the purpose of calling attention to the dues implicit
here for research in the flow of influence and innovation. The analysis of
later interviews with over 200 doctors in the Midwest is now in progress
at the Bureau of Applied Social Research.
In this paper, we will consider the ways in which the doctor's position
in the social structure of his local medical fraternity affects his acceptance
of new pharmaceutical products. Our procedure differs from that of most
previous studies which have sought to trace the role of •personal influences
in individual decisions. Typically, in these other studies, individuals who
have recently made some decision are first identified and whenever then-
account shows that another person has figured in the decision, they are
asked to identify this "opinion leader." The nature of the social relation-
ship between the influential person and the person influenced, as well as
the characteristics differentiating t&e two, are then determined.
This is not, of course, to say that snch communication is "unscientific"; direct com-
munication among colleagues is vital to all sciences. This paper attempts to show how
influential such communication is, even on the local level, and in spite of the existence
of multitudes of professional journals which—potentially—bring relevant articles by the
top authorities in each field directly to the dak of each practicing physician.

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 540 PUBLIC OPINION QUARTERLY. WINTER 1955-56

In our study, however, we first interviewed all the local doctors we could
and, by means of three sociometric questions, determined the network
of social relations among them without reference to any one particular
decision. The channels of information and influence which entered into
a recent drug decision were also ascertained in all interviews, and com-
pared with the doctor's position in the social network. Only then did we
superimpose on the social network the flow of adoptions of a new prac-
tice, as indicated by the precise sequence of dates on which each respond-
ent introduced a certain new medication. This latter information was ob-
tained through an examination of the prescription files of local pharmacies.

SOCIOMETRIC QUESTIONS, STARS, AND ISOLATES

T o locate each of the 33 physician-respondents in the structure of his

local medical community, three sociometric questions were asked. The
first question was, "Could you name the three or four physicians you meet
most frequently on social occasions?" The resulting picture is shown in
Soaogram I.T Three major networks of choices appear, designated A, B,
and C. (B and C may also be regarded as sub-groups of the same network,
since their segregation from one another is not as definite as that of either
from A.) There are also two isolated individuals and five "neutrals," who
choose into Cliques A and B equally.
A second sociometric question was aimed at a more specialized kind
of social contact: "Who are the three or four physicians in your con-
versations with whom the subject of drug therapy most often comes up?"
A comparison of the resulting map (not shown here) with Sociogram I
shows that the basic pattern holds for both, with two differences: fewer
drug-talk companions than friends are named, and there is increased
concentration of attention around two top leaders.
A third map of informal social relations was obtained by still another
question: "When you need added information or advice about questions
of drug therapy, where do you usually turn?" This question was designed
to elicit the names of individuals to whom a position of authority is
accorded. As might have been anticipated, the responses in this case were
even more heavily concentrated on a small number of stars.
As we have indicated in the introduction, the role of interpersonal
relations in individual decisions is not confined to the conveying of in-
formation and to the channeling of influence. For example, a doctor who
T h e Sotiogram was constructed by a trial-and-error method. Clusters of mutually
choosing stars were first identified, and others then grouped around them, so that
individuals were nearest that duster to which they seemed most closely tied, and so
that crass-overs were minimi™-^ For the larger study which is still in progress, it was
to develop more standardized techniques.

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 EPIDEMIOLOGY OF A NEW DRUG 341

shares an office with another may feel less hesitant about the risk of trying
out new drugs in general, and not merely because of anything the other
doctor may have said about any particular drug; or, a doctor whose
friendship is not reciprocated by other doctors may develop quite a dif-
ferent relationship to other rhgnnpU of information—he may become
more friendly with the pharmaceutical reipuman, for example—than the
doctor who is well integrated in the medical community. Thus, a doctor's
association with other doctors may serve (1) as an important source of
information and influence on a particular innovation, and (2) as an
important determinant of his response to innovations in general, and to
information and influence wnanaring from other sources.
For this reason, the socdometric data will be related to doctors' behavior
in two basically distinct ways. The first of these is the examination of
certain characteristics which differentiate individuals who have received
many and few sotiometric choices. What, for instance, is the use made of

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joo me*1 most frcojutntly on
(octal occmioat?*

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 542 PUBLIC OPINION QUARTERLY, WINTER 1955-56

the diverse rhannpU of communication by the sociometric stars—by those

receiving many choices? How does it differ from the use made of these
channels by their less popular colleagues? A second use of the sociometric
data will be to ask what difference it makes with which doctors a given
doctor is associated, rather than how many name him, say, as a friend.
For example, is a doctor more ready to adopt a new drug if he has friends
who have already adopted it?

THE CHANNELS OF INFLUENCE

Each respondent was asked how he had learned about two of the drugs
he had recently adopted. Table 1 cross-tabulates the replies with the
popularity of the doctor among his colleagues. An interesting pattern

TABLE 1 *
DRUG-TALK CHOICES AND CHANNELS EMPLOYED IN DECISIONS ON TWO RECENT
DRUG ADOPTIONS
Numbtr of Drug-Talk Choitts Rtcavtd
Mont One, Two ThxttorMort
Mail and periodical! from drug houses 30% 18% 21%
Articles in journals 10 39 32
Detail men (salesmen) 40 25 21
Colleagues 15 15 16
Meetings 0 0 11
Other rninnflii 5 3 0
100% 100% 100%
(Number of fhannMn) (20) (34) (19)
T h e percentages are based on the total number of channels mentioned, which exceeds
the number of doctors in each category, since many doctors reported on two decisions, and
the average number of channels per decision was 1.88.

emerges. Journal reading plays a much larger role in the drug adoptions
of doctors who receive one or more designations than among the isolates.
This conforms to the hypothesis of the "two-step flow of communications,"
which states, in essence, that messages originating outside of the individ-
ual's face-to-face group do not impinge on him directly, but are mediated
by a few members of his group, who expose themselves to messages from
the outside world more than their confreres.
The source of this hypothesis is in mass media research, where it has
been found that opinion leaders are in closer contact with the mass media
than their followers. But doctors can keep in touch with the outside
world in other ways than through the printed media—e.g., by attendance
at medical meetings in other cities. The two-step flow hypothesis therefore
leads one to expect that out-of-town meetings as well as journals would
be more important in the decisions of the most popular drug discussion
partners than in those of their less popular colleagues. Table 1 bears out

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 EPIDEMIOLOGY OF A NEW DRUG MS

this expectation: only those who receive three choices or more report that
what they learned at meetings entered into their decisions. It would seem
that the star does indeed serve as a relay: he incorporates what he has
learned at the meetings into his own decisions and, it may be assumed,
into his conversations with others.
The drug decisions of the sociometric isolate, by contrast, are marked
by heavier reliance on commercial sources—direct mail advertising from
the pharmaceutical companies and the "detail man" as the drug house
representative is called. These sources, to be sure, also come from out of
town. What differentiates them from journals and meetings is that, being
commercial sources, they carry less prestige, and that it requires less effort
to keep up with them. Evidently the two-step flow hypothesis does not
apply to all channels from the outside world. Some of the channels do
impinge on most members of their intended audiences directly, and are
not disproportionately utilized by the opinion leaders.
Incidentally, the differential importance which the detail man has for
the social isolate is not limited to his role as a purveyor of information
about new medicines. Two of the four doctors who received no friendship
choices volunteered the information that they very often Calked with the
detail man on subjects other than drugs: "Well get off the track sometimes
on economics, politics, family affairs," said one. Another relatively isolated
doctor corhmented on the detail men as follows:
They are helpful—they know mil the doctor* in the communities around here and
give you all Che dirt and gossip and incidental news about what is going on amongst
the doctors in this community.
This pharmaceutical salesman evidently serves as a near-professional
companion for men who are relatively cut off from informal contacts with
other physicians.
A final observation from Table 1 yields a surprise. The classic model of
the two-^tep flow of communication provides that it is the rank-and-file
members who are influenced by the opinion leaders, while the latter
are influenced by the mass media. But in Table 1 "colleagues" are
mentioned exactly as frequently by opinion leaders as by the rest. The
most likely explanation is that the opinion leaders may themselves
turn to colleagues of even higher status, and that it may take three
or four steps, perhaps rather than two, before a level of leadership is
reached where dependence on personal contacts is markedly decreased.8
Revision of the model to allow for multistep flow of communications
would thus seem in order. A second revision has already been pointed out:
•Regarding the relatively low overall frequency of mentions of "colleagues" in Table
1, see note 12 below.

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 544 PUBLIC OPINION QUARTERLY, WINTER 1955-56

that messages from the outside world need not come through the printed
word or other mass media. In the case of physicians, we have seen that
attendance at society meetings may take over this function. As the multi-
step flow hypothesis is applied to still other publics, it may be found that
the opinion leader can keep in touch with relevant parts of the outside
world in still other ways. Finally, the model may not apply to channels
of low prestige and unusually easy accessibility.
One more finding, still tentative, regarding the channels of information
used in recent drug decisions is especially worthy of attention. Medical
problems differ widely in the degree to which their answers are well-
structured and generally established. Table 1 includes the reports of
doctors concerning their adoptions of a variety of different drugs. We can,
however, divide these into two broad classes: one class of drugs is appli-
cable to certain acute conditions which call for immediate action and
present a very small number of alternate methods of treatment; success
or failure is visible in a day or two. The other class of drugs is applicable
to chronic conditions where many dozens of treatments compete, and the
effectiveness of therapy is very difficult to gauge. We find that colleagues
constitute only seven per cent of the channels reported as leading up to
the adoption of a drug for the acute conditions but represent 22 per cent
of the channels concerned with the chronic diseases. In other words, the
role of colleagues increases substantially in the relatively more ambiguous
situation. In a sense, this recalls the studies of suggestion and influence by
Sherif and others: the role of personal influence is more important in the
relatively more unstructured situation.

THE SOCIAL NETWORK AND THE DIFFUSION OF DRUG ADOPTIONS

T o explore further the workings of person-to-person relations in this

realm, we shall now turn from correlates of the number of sociometric
designations received to the question, "What difference does it make to
which clique you belong?" Age, ethnicity, religion, father's occupation,
and pursuing a specialty practice were all found to be correlated with
clique membership. The existence of these background correlations lends
some feel of reality to the division into cliques which the sociometric data
indicated.9 In order to relate the social network to the adoption of a new
item of behavior, the local pharmacists were asked to search their files for
the first prescription written by each of the interviewed doctors for a cer-
tain drug which had come on the market a few months before. Table 8 is
•Our findings fit very well with Oswild Hall'f much more extensive study of inter-
personal relations in a New England medical community considerably larger than the
one under discussion here. See T h e Informal Organization of the Medical Profession,"
Canadian Journal of Economic! and Political Science, Vol. 12, No. 1.

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 EPIDEMIOLOGY OF A NEW DRUG 545

TABLE 2
UtE OF CHANNELS OP COMMUNICATION IN DECISIONS REGARDING ACOTE AND
CHRONIC CONDITIONS*

Ptr ted ef total chamtdt mtmtioiti

AtuU Conditions Chomt Com&tiaMS
Mail and periodicals from drug bouses 23% 17%
Article* in journals 26 27
Detail men 33 27
Colleague. 7 22
Meetings 0 5
Other channels 10 2
100% 100%
(Number of channels) (30) (41)
*Tbe percentages are based on the total number of rtmnnfh mentioned, which exceeds
the number of doctors in each category, since many doctors reported on two decision*, and
the average number of channels per decision was 1.88.

a presentation of the chronological order in which doctors in the sample

adopted the drug. (Surgeons and other specialists not normally prescribing
drugs through pharmacies are excluded from this table.) Intervals on the
table correspond roughly to the time intervals involved.

TABLE 3
DATE or FIRST PRESCRIPTION OF A SPECIFIED NEW DKUO BY EACH DOCTOR*

No praeriptions btfort Jidy 1:

Drs. 7, 9, 70,20,22,28
Drs.
2
5
6
8 Drs.
19 25
Dr. Dr. Dr. 33 Dr. Dr. Dr. Dr. 26
31 12 1 34 17 30 18 23 27
H 1 1 1 1 1 1 1 H 1 1 1 1
December | January | February I March | April I May | June
1953 1954
•Each doctor is represented by his identifying number. Doctors following specialties
not usually prescribing drugs through commercial pharmacies are omitted.

Our original intention was simply to correlate early or late use of the
new drug with characteristics of individual doctors. But after Table 3 was
drawn up, we were intrigued by the strange alternation of slow periods
and spurts which it shows: first, three pioneers adopt the new drug at
three-week intervals. Then, suddenly, during a period of only eleven days
in February seven doctors start writing prescriptions for the new drug.
During the next three months, only four doctors start prescribing the

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 546 PUBLIC OPINION QUARTERLY, WINTER 1955-56

drug, at widely spaced intervals. Then, again, three doctors initiate use
of the drug within a period of only five days in mid-May. No further
doctors appear on the table after this, although our data are complete for
an additional month and a half. There thus remain six doctors who either
do not prescribe the drug at all, or do so only at an unknown time very
much later than any of their colleagues.10
How is this alternation of slow and fast periods to be accounted for?
One possibility is, of course, that the fast periods are those when there
is more need for this particular drug in the community—times of epi-
demics, for instance. However, the slow and fast periods do not coincide
with the known seasonal variations in the incidence of diseases for
which this drug is indicated. A second possible explanation for the alter-
nation of slow and fast periods is that the two fast periods correspond to
two sales campaigns that may have been carried on by the pharmaceutical
companies involved. This may be the case but fails to explain why certain
doctors responded to the first campaign, while others did not.
The third possibility is that the alternations can be accounted for by
social relations. During the initial slow period a few hardy individuals
try out the new product—perhaps watched with interest by their more
conservative colleagues. Each spurt then represents the almost simul-
taneous adoption of the drug by a well-integrated group of physicians.
This hypothesis, unlike the other two, would not only explain why spurts
occur at all, but also why it is the particular doctors who participate in
each spurt that act in unison—e.g., why Drs. A, B, C and D act simul-
taneously, but not Drs. D, E, and F.
We therefore decided to bring together the data on first prescription
dates with the data on social groupings. The result is Sociogram II which
is identical with Sociogram I, but adds information on the date of each
doctor's first prescription for the new drug. Different shadings denote the
time periods during which each doctor first prescribed it. Triangles indi-
cate doctors following specialties not normally prescribing drugs through
pharmacies. Solid circles indicate other doctors who did not prescribe
the drug at all during the period covered by the survey. Let us now trace
the flow of the innovation through this map of friendships among the
physicians. Two questions will occupy us as we do so: (a) are doctors who
adopt the drug on successive dates in contact with one another? (b) is each
spurt of adoptions located within one of the cliques?
"Data collected elsewhere mbsoquent to the termination of thii surrey make it likely
that most of these "diehards" did at least try out the new drug some time during 1954.

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 EPIDEMIOLOGY OF A NEW DRUG 547

SOCIOGRAM II: The

Epid«n>iotoflT of Doctors'
Drug Prescription*.

LEGEND
Flraf ftpttfOt* Ik* * . « :

O tafon I/IS/M Cr
tint » * • parted*)

© S/M-3/M ("Waal tawl")

M m ipfcMrr rarel, ».•-
A
M « ta * * • • v«tailte«, M
• W3O

(1) Initial slow period. The first three doctors are symbolized by blank
circles. Their initial prescriptions took place on December 1, December
22, and January 10.
(2) First spurt. Seven physicians represented by single hatched circles
adopted the drug between February 1 and 11. Four of them are in direct
contact with a pioneer (Le., a blank circle), and the remaining three have
second-order contact with a pioneer.
At the end of this February spurt, three out of four doctors in Clique C
have used the drug; so have six out of eight doctors in Clique A; but not
a single member of Clique B. (Surgeons and other non-prescribing special-
ists are excluded.) Even more striking than this contrast between the
proportions of each clique who have used the drug by February 11 is

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 548 PUBLIC OPINION QUARTERLY. WINTER 1955-56

another fact. One might think that the remainder of Cliques A and C
would follow suit after some lag—perhaps two or three weeks later. But
in fact only one of them ever filed a prescription for the new drug with
the pharmacies reporting to us throughout the period covered—i.e.,
through the end of June. In other words, after the first pioneering period
and the February spurt, only real diehards still hold out in Cliques A and
C.
(3) Second Slow Period. Several more doctors (recorded as cross-hatched
circles) adopt the drug during the next few weeks; their dates are widely
dispersed over a long period of time (March 4, March 29, April 9, and
April 16).
(4) Second Spurt. Then suddenly, between May 14 and 18, three doctors
in Clique B, represented by dotted circles prescribe the drug leaving only
two doctors as non-prescribers in Clique B. Again, these two are not merely
a little behind their colleagues, but they are "diehards," having no pre-
scriptions for the new drug on record throughout the period covered by
our survey.
We have now traced the sequence of prescriptions of a new drug
through our map of friendships among the doctors in this city, much as
doctors themselves do when they trace the "epidemiology" of an infectious
disease on the map of a city. What we have seen can be summarized in
three propositions:
(1) That half or more of the members of each clique who are ever to
adopt the drug do so within a few days of one another.
(2) That for each of the three cliques, it is possible to state a cut-off date
such that those members who have not adopted the drug by that date do
not adopt it at all during the survey period. Only one respondent deviates
from this generalization.
(3) That no one (except the three pioneers) adopts the drug unless he
has a direct sociometric contact with a doctor who adopted it before him.
Three respondents deviate from this generalization, and it is therefore
restated as follows: that drug adoptions on any particular date are more
frequent among doctors who are in direct sociometric contact with others
who have already adopted the drug, than among doctors who lack such
contact.
Tables 4 and 5 constitute quantitative expressions of the empirical
deviations from these three propositions. Table 4 shows no deviations
from the first proposition. It also shows that the one doctor who actually
deviated from the second proposition and prescribed the drug after the
cut-off date for his clique constitutes but 14 per cent of the deviations that
could have occurred. Table 5 tabulates the deviations from the third

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 EPIDEMIOLOGY OF A NEW DRUG $49

proposition. It was necessary to compute separately for each date on which

an adoption occurred the number of eligible doctors who had not already
adopted the new drug but were in contact with others who had, and the
number of similar doctors lacking such contact. Summing for all the dates,
we find 49 contact situations and 34 non-contact situations. Each of these
could have led to an adoption on the date involved. Actually, 22 per cent
of the contact situations and only 9 per cent of the non-contact situations
eventuated in a drug adoption. The corresponding percentages for the
case of complete dependence of contacts and adoptions would be 29 per
cent and zero per cent; for complete independence, 17 per cent and 17
per cent 1 1
We therefore feel justified in proposing that the spread of this inno-
vation in the medical community flows through social channels, and
that each of the spurts of adoptions in middle February and middle May
does indeed represent the simultaneous adoption of the drug by a socially
close-knit group of physicians. There are a variety of ways in which such
simultaneous decisions may be reached: (1) perhaps a decision, once
reached by one member of a clique, is easily accepted by his associates
who trust his judgment; (2) perhaps members of the same clique share
norms of reliability and criteria of judgment to such an extent that what-
ever is convincing to one member is likely to be equally appealing to the
rest; (3) perhaps each group shares exposure to channels, so that they are
homogeneous as to stimuli received; (4) perhaps they even look at a case
in the hospital together and are apprised on such an occasion of the
success of a new treatment. (The occurrence of two sales campaigns for the
new drug, which was mentioned as a possibility, would be compatible
with items (2) or (3).) Whatever the process by which a group of doctors
reaches such a near-simultaneous decision, it would be followed by a slow
period of sporadic adoptions by doctors in other groups until some
event—perhaps endorsement by a respected leader—triggers off a new
spurt of adoptions in one of these other groups. In each group certain
n
In the case of Propositions 1 and 2 (Table 4), we have not, to far, been able to de-
termine the chance-expected values for the case of "complete independence.'' Reflection
on what would constitute a "chance" model from which empirical deviations in the
direction of satisfying our hypotheses could be measured suggests that these hypotheses
imply deviation from "independence" in some or all of at least three different ways:
(1) That the community-wide distribution of adoptions over time deflates from the
change-expected distribution over time. (It is an open question what the proper model
for the chance-expected distribution should be.) (2) That the clique-specific distribution
curves of adoptions over time have their peaks and other characteristic features at differ-
ent points along the time-continuum. (3) That all the clique-specific cnnes of adoptions
over time have a similar shape, which approximates some one hypothesized character-
istic shape (e.g., that corresponding to a "spurt").

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 350 PUBLIC OPINION QUARTERLY, WINTER 1955-56

TABLE 4
CLIQUES AND SPURTS* OF DRUG ADOPTIONS

Adoptions Adoptions after Cut-off Date

Cut, Total Adop- during Spurt (Demotions) Non-
Clique off Adop- tions Adop-
Date tions prior to No. Per Cent Per Cent of Per Cent of tions
Spurt No. total adopt- possible
turns deviations

A 2/10 6 2 4 67% 3
B 5/18 4 1 3 75 2
C 2/11 4 1 2 50 V 25% 50%
All Cliques 14 4 9 64% 1 7% 14% 5

Neutrals 3 1
Total 17 6

•"Spurt" is defined as the seven days ending with the cut-off date. Doctors following
specialties not normally prescribing drugs through pharmacies are excluded from Table 4.

TABLE 5
ADOPTIONS OF THE N E W DRUO AMONO DOCTORS W H O , ON THE D A Y THE
ADOPTION OCCURRED, WERE AND WERE NOT IN DIRECT SOCIOHETRIC CONTACT
WITH ANOTHER DOCTOR W H O HAD ALREADY ADOPTED I T *

Number of Doctors whs, on the date indicated, had not yet adopted the new drug and:

Date Wcreii l contact and— Were not in contactand—

Adopted Did not Total Adopted Did not Total total

adopt tdopt

Feb. 1 0 6 6 1 7 8 14
Feb. 5 2 5 7 0 6 6 13
Feb. 6 1 6 7 0 4 4 11
Feb. 10 1 5 6 1 3 4 10
Feb. 11 1 4 5 0 3 3 8
Mar. 4 0 4 4 1 2 3 7
Mar. 29 1 3 4 0 2 2 6
Apr. 9 1 2 3 0 2 2 5
Apr. 16 1 2 3 0 1 1 4
May 14 1 1 2 0 1 1 3
May 18 2 0 2 0 0 0 2
After 0 0 0
Total num-
bers 11 38 49 3 31 34
Total per
cent 22% 9%
•Doctors who never adopted the drug during the period covered by the survey, as well
as doctors following specialties not normally prescribing drugs through pharmacies, are
excluded from Table 5, as are the three earliest adopters. The results are not substanti-
ally altered when the length of the intervals between the dates in Table 5 is taken into
account and the three earliest adopters are added.

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 EPIDEMIOLOGY OF A NEW DRUG 351

"diehards" would be left over, who cannot be convinced of the usefulness

of the new drug.1*
What sort of doctors are the three pioneers who prescribed the new drug
as early as December and January? Contrary to our expectations, they are
neither outstanding specialists, nor outstanding leaders by any available
criterion, nor in possession of an unusual degree of access to outside in-
formation. By contrast, the outstanding sociometric stars in our sample are
predominantly late-comers in the adoption of the drug.
This inverse correlation between early prescription for the new drug
and leadership is surprising, and one is tempted to conjecture as to the
process that might be at work if the finding is a reliable one. It would
almost seem as if each clique had its early experimenters or "advance
scouts," who were willing to try out an innovation before any of their
local colleagues. In each clique, the sociometric stars are among the last
to adopt the drug; but when they finally do, all the other members except
the real diehards fall in line immediately. This would account for the
sudden final spurts of adoptions which we have observed. We must
caution, however, that the reliability of this finding is in doubt. Our later
Illinois data show a direct correlation of leadership and innovation. We
do not know whether this is due to a true regional difference, or to error
in one of the sets of data. It is noteworthy that the study of the diffusion
and acceptance of new farm practices has given rise to equally contradic-
tory findings concerning the extent of overlap between innovators and
inftuentials. Eugene Wilkening's North Carolina study finds little overlap;
Herbert Lionberger's Missouri study finds considerable overlap. A recent
study by Marsh and Coleman implies a possible basis for reconciliation:
in a "low adoption" neighborhood—that is, where the neighborhood
norm is conservative with respect to farm innovations—the leaders or
"Only the tint of these four mechanisms by which groups may reach simultaneous
decisions requires "personal influence" in the strict sense of the term. In the doctors' own
accounts of the channels of information and influence which went into the making of a
drug decision, it may be recalled (Table 1), colleagues constitute only 16% of the chan-
nels mentioned. (They are mentioned in 30% of the accounts, but most accounts contain
more than one channel.) This is much less often than personal influence is usually
mentioned in interviews on marketing or similar decisions, and also much less than
would seem to correspond to the indications just reported, that the spread of this in-
novation Sows through social channels. Two explanations of the low frequency of
mentions of colleagues in the doctors' own accounts are possible: (1) that the doctors'
reports understate the extent to which their colleagues actually have a part in their
decisions; (2) that personal influence actually is lower in these drug decisions than in
ordinary consumer products decisions, and that the congruence of social relations and
drug adoptions reported in this section is not achieved by direct personal influence, but
through one of the other three mechanisms suggested above.

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 352 PUBLIC OPINION QUARTERLY, WINTER 1955-56

influential did not have significantly higher adoption rates than non-
leaders; in "high adoption" areas, however, the leaders were far ahead-18
In summary, we have found that the bringing together of independently
established information on social relationships, on innovating behavior,
and on the use of channels of information in decision-making supports the
hypotheses of the role played by face-to-face contacts in mediating inno-
vations from the world outside.
We have seen that the notions of the importance of interpersonal
relations are applicable to a case of decision-making among specialists
concerning matters based on scientific findings where well-recognized
expert sources of knowledge exist. This, we noted, is particularly the
case when decisions are required for relatively ambiguous situations.
Finally, we have found it necessary to propose amendments for the
model of the two-step flow of communications: by considering the possi-
bility of multi-step rather than two-step flow; by noting that sources other
than printed publications may be the channels to the outside world main-
tained by the opinion leaders; by noting that the model may not apply
to channels of low prestige and unusually easy accessibility; and by
differentiating various kinds of leadership, especially by emphasizing the
differential roles of the innovator or pioneer on the one hand and the
opinion leader or arbiter on the other.
"See E. A. Wilkening, "Informal Leaden and Innovators in Farm Practices," Rural
Sociology, Vol. 17, pp. 272-275; H. F. Lionberger, "Some Characteristics of Farm
Operators Sought as Sources of Farm Information in a Missouri Community," Rural
Sociology, Vol. 18, pp. 327-338; C. P. Marsh and A. L. Coleman, "Farmers" Practice
Adoption Rates in Relation to Adoption Rates of Leaders," Rural Sociology, Vol. 19,
pp. 180-181. These three studies are excellent representatives of a research tradition of
the greatest importance for undents of communication.

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