Anyone who switches on a television or reads a newspaper cannot help but notice the dramatic upsurge in the number of prescription drug advertisements. The benefits and costs of this practice have been intensely debated.1-2 A major concern is the effect of DTC advertising on the patient-physician relationship.
One factor contributing to the rise of DTC advertising is the erosion of physicians' authority to prescribe specific drugs. Recent years have seen the proliferation of drug formularies, utilization review systems, and pharmaceutical risk-sharing agreements. As a result, it is more difficult for pharmaceutical companies to transform the goodwill generated from company-sponsored "educational" dinners into actual prescriptions.
Critics of DTC advertising argue that pharmaceutical companies have simply found a new way to push physicians—in the face of resistance from group medical directors and chairs of formulary committees to prescribe the brand name drug over the generic, the new drug over the old, and the profitable drug over the unprofitable. And who better to provide the pushing than the patient, now an enlightened "health care consumer" armed with information from DTC ads?2
Studies suggest that while patients are in favor of these ads, their physicians are not. A survey conducted in the early 1990s, for example, found that consumers were open to the idea of using DTC ads as a source of information about drugs to supplement advice from physicians.3 A 1997 study of US family physicians, however, found that four fifths believed that DTC advertising was "not a good idea" because they increase costs and promote "misleading, biased views" of drugs.4
Recent studies have shown beyond a doubt that DTC advertising motivates discussions between patients and their physicians about pharmaceutical products.5 What could be wrong with that? Nothing, if the discussions focus on the patient's presenting complaints, their diagnostic implications, the meaning of the diagnosis in the context of the patient's life, and the full range of treatment options available. However, if discussions focus on specific brand-name drugs, trivial complaints, or procurement issues, they could detract from more meaningful discussions about health.
One concern is that DTC advertising rarely mentions lifestyle changes or other nonpharmacological interventions, which are often as important as drug therapy in improving outcomes. Patients may become angry when their physician insists on discussing a low-fat diet, stress management, or allergen avoidance rather than writing a prescription. Indeed, 1 study found that as many as half of patients would register disappointment, and 15% would consider switching physicians, if their physician refused a request for an advertised prescription medication.6
The complicated issues raised by DTC advertising can be illustrated by 2 examples.7 Imagine a patient who sees a magazine advertisement for an antidepressant and decides that her symptoms are suggestive of major depression. She reveals her symptoms to a physician, who performs a careful history and physical exam and decides that hypothyroidism could be responsible. After testing confirms the diagnosis, the patient is successfully treated with thyroid hormone replacement therapy. In a different scenario, the patient waves the same ad in front of another physician and demands the drug. After taking a cursory history that suggests depressive symptoms, the second physician writes the prescription. Six months later the patient is hospitalized for severe hypothyroidism.
In the first example, the DTC advertisement serves as a springboard for a thorough investigation of the patient's symptoms, development of a reasonable differential diagnosis, and prescription of appropriate therapy. The first physician remembers her professional responsibility to evaluate not just the patient's request but also the patient's problem. In the second scenario, however, the physician carries the ethos of customer satisfaction to an unsafe extreme.
What should physicians do with patients who make ad-induced requests? A responsible strategy is to direct the conversation back to symptoms and concerns, from which a differential diagnosis can emerge and appropriate therapy follow. Requests are often best met by more questions, asked in a neutral way: "Where did you hear about the drug? What did the ad say? How were you hoping it would help? What do you know of the drug's benefits and side effects? Tell me more about your symptoms. Would you like to hear more about this drug and its alternatives?"
By asking sincere and open questions, the physician begins to understand the context of the patient's request and makes his or her concern for the patient more palpable. This opens the way to a more productive clinical dialogue that is uninhibited by patient anxiety and physician defensiveness.
