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Over the past several months, I’ve been interviewing endocrinologists who manage a specific rare metabolic disorder -- one that most community-based specialists encounter only a handful of times each year. One ENDO I spoke with currently has roughly 20 active patients with this condition in her panel. That’s meaningful volume for a rare disease. But it still pales in comparison to what dominates her week.
Type 2 diabetes.
As we discussed how she selects therapy in this rare condition, more specifically how she thinks about initiation, sequencing, and patient fit, something important emerged. Her approach wasn’t built primarily from repetition within the rare disease itself. It was anchored in how she manages diabetes every single day.
In a typical week, she sees dozens of patients with type 2 diabetes. She initiates GLP-1s and SGLT2s without hesitation. Her staff educates patients on injectables. They manage prior authorizations routinely. She adjusts therapy based on A1c trends almost reflexively. That’s where her muscle memory lives.
So when a patient with this rare disorder presents, she doesn’t start from zero. She starts from familiarity.
Her comfort with certain routes of administration. Her assumptions about adherence. Her sequencing logic: when to escalate, when to wait. Even her tolerance for side effects. These patterns were built through thousands of diabetes encounters.
Her decisions in the rare disease weren’t irrational.
They were patterned.
Habitual.
That conversation reinforced a lesson I’ve seen repeatedly: success in rare disease isn’t just about compelling clinical data. It’s about understanding the prevailing habits physicians have established in higher-volume conditions -- and how those habits quietly shape and impact decisions when repetition in the rare disease is limited.
Rare and orphan drugs now account for more than half of new FDA approvals in many recent years and represent a growing share of biopharma pipelines and long-term growth strategies.
Board decks reflect it. Investor calls reflect it. R&D portfolios certainly reflect it.
But exam rooms don’t.
Most physicians still see relatively few patients with any given rare condition. An endocrinologist may manage 20 rare patients -- but hundreds with diabetes, thyroid disease, or osteoporosis. A pulmonologist may see a small handful of rare ILD patients in a year while managing COPD and asthma daily. A neurologist treats MS all week and may encounter a DMD patient only occasionally.
That imbalance matters.
Repetition builds fluency. Fluency builds confidence. Confidence builds habit.
Rare disease does not offer many repetitions.
Yet commercial strategy often treats rare disease as if it’s a rational equation: identify the right patient, communicate differentiated data, secure access -- and prescribing will follow.
On paper, that logic holds.
In practice, it overlooks something more powerful: prevailing habits forged in high-frequency conditions.
When a rare patient presents, the physician is not a blank slate. They bring ingrained mental models: about sequencing, about risk tolerance, about routes of administration, about when to escalate and when to wait. Those models were not built in the rare disease. They were built elsewhere.
If we don’t account for that, we misread behavior. Resistance may not be skepticism. Delay may not be doubt. It may simply be habit operating exactly as designed.
Here’s where it becomes operational.
When behavior is repeated daily, it evolves. Physicians refine it. They adapt. They learn from feedback.
When behavior is infrequent, it tends to calcify.
We call this a “Thanksgiving Day” habit. Most of us cook a turkey once a year. We follow the same recipe -- not because it’s perfect, but because we don’t get enough reps to meaningfully improve it. The infrequency locks in the behavior.
Rare disease treatment often works the same way.
If a physician sees only a few cases a year, each encounter reinforces the prior approach. There isn’t enough volume to experiment. The first workable pathway becomes the default pathway. Over time, that pathway hardens -- not through rigorous optimization, but through scarcity of experience.
So when launching a new orphan medication -- or when an existing rare disease brand is underperforming -- the core issue may not be awareness or access.
It may be a low-frequency behavioral loop that has never been intentionally examined.
That is not a messaging challenge.
It is a habit architecture / habit mechanics challenge.
There’s another layer.
Infrequent behavior doesn’t just harden -- it borrows.
Rare disease decision-making is shaped by dominant habits from high-volume conditions. The endocrinologist treating T2DM daily will draw from those mental frameworks when treating a rare metabolic disorder. Comfort with injectables. Sensitivity to adherence. Escalation logic. Risk thresholds.
Those patterns don’t switch off.
The same dynamic plays out across specialties. Pulmonologists import COPD escalation norms. Neurologists import MS sequencing logic. Rheumatologists import RA instincts.
The result is what we call the mirror effect: prevailing habits from common diseases become the lens through which rare disease decisions are made.
Which means in rare disease, you are rarely competing against another brand alone.
You are competing against muscle memory built elsewhere.
We recently partnered with a company preparing to launch a therapy for a rare lung disease. Early physician research revealed a striking pattern: clinicians instinctively framed the new therapy as a last-resort option, reserved only for the sickest patients.
Why?
Because in common respiratory diseases, escalation typically occurs only after familiar therapies fail. The dominant cue was severity. The action was late-stage escalation, reinforced over countless reps in COPD and other high-volume conditions.
But the clinical profile of this therapy supported earlier use -- before severe progression -- to maximize long-term outcomes.
Using Habit Lens, our team was able to deconstruct the habit loop:
Their data alone wasn’t going to break that loop.
So we recommended reframing the cue.
Instead of severity, we identified "trajectory awareness," defined as the recognition of early progression patterns that physicians already monitor closely. That cue aligned with an experience they valued: intervening before irreversible decline.
Once the cue shifted, the action changed. More notably, the reward changed. Early use became associated not with risk, but with control -- something most physicians find deeply rewarding/reinforcing.
The result? Positioning and launch strategy shifted. Sales training emphasized different patient signals. Early trial support focused on reinforcing positive experiences.
The strategy wasn’t about louder messaging.
It was about designing for a different habit loop.
Rare and orphan therapies are no longer niche. They represent a substantial and growing portion of approvals and long-term market value. But in rare disease commercialization, market access is only half the battle.
Even the most differentiated therapy can underperform if prevailing habits stymie adoption.
This is precisely why Habit Lens should be deployed early: during market understanding and commercial development, not after a launch falters.
When launching a new orphan medication, habit analysis prevents costly misreads of the competitive dynamic.
When a rare disease brand underperforms, habit analysis often reveals that the barrier isn’t belief -- it’s behavioral inertia.
Habit Lens forces the questions that matter:
These insights directly shape positioning, segmentation, messaging, and sales execution. They reduce strategic guesswork. They prevent misdiagnosing hesitation as skepticism. And they help brands avoid fighting muscle memory with data alone.
In rare disease, you don’t have many chances to reshape behavior. HCPs may see only a handful of patients each year. Each prescribing experience carries disproportionate weight.
The real scarcity isn’t patients.
It’s opportunities to change habit.
And that’s where commercial success is won -- or lost.
