John La Puma, M.D.

John La Puma, M.D.

At a time in which top-selling meds are referred to as "blockbusters" and videotaped pharmaceutical messages fill physicians' mailboxes, it is still sex, drugs and rock and roll that sell. Especially drugs.

According to the New York Times, Americans spent more money on "anti-ulcerants" last year--$6.2 billion — than on any other type of medication. Antidepressants were second--$4.6 billion.

Marshal McLuhan said, "The medium is the message." Nowhere is this more true than in direct-to-consumer ad campaigns. Last year, pharmaceutical companies spent $1 billion on direct-to-consumer advertising. This year, they'll spend 50 percent more.

The money is well spent. The same New York Times report indicates sales of Claritin, the massively publicized antihistamine, increased 40 percent in the United States, to $908 million, in 1997. All that without discount coupons or shelf space at Wal-Mart.

Pharmaceutical advertising used to be prohibited to protect consumers from exploitation and unscrupulous merchants. But this paternalistic view of medical ethics has given way to the caveat emptor of business ethics. Patients have become desirous consumers, and the media fuel those desires by providing just enough information to bring customers to the door, or at least the phone.

The ads are here to stay. The issue is, do they help patients or do they harm them?

Ads provide information. Doctors have less time than ever to provide information to their patients, much less build relationships. Consumers want information at least as much as they want to be able to make decisions. Just knowing that pills for depression can work well is news worth repeating.

The positive side

Ads can provide better choices. More information implies more choice, and if there is an American core value, it is choice. Many medical conditions can be attended to without a physician's touch. Mild seasonal allergic rhinitis is such a problem, and over-the-counter chlorpheniramine maleate and pseudoephedrine may not work for everyone. So, Claritin might be reasonable to try next.

Ads equalize power between clinician and patient. New pharmaceutical advances include more effective medications with less frequent dosing and fewer side effects. Patients who get their medical information from ad campaigns can be one step ahead when the doctor walks into the office.

Ads usually market tested goods. Pharmaceuticals are evaluated and approved by the FDA, differently from dietary supplements, herbal essences and vitamins. Direct ads recommend that a patient discuss questions with her doctor (not with her chiropractor, for example, or his massage therapist). Ads that promote medical products or services about which little scientific data are available do a disservice to patients.

Ads allow patient and physician to know up front what is expected. A study published in the British Medical Journal last December showed that 67 percent of 526 patients waiting to see their primary care physician hoped for a prescription. One quarter of patients who wanted one left without it, presumably because they did not need it or could have been harmed. But patients' expectations are clear: Doctors prescribe powerful medications to treat disease, and patients want something to make them feel better.

Potential harm

Ads aim to sell, not inform. "Infomercials" and "edutainment" flourish, and they are part of the same trend as direct ads. The information in drug ads may be nonfiction, but it also may mislead and create unrealistic expectations. Doctors know their patients are only getting part of the story from public ad campaigns. And that's why patients call, wondering if their statin is good enough to prevent their first heart attack.

Ad sequelae take a lot of physician time. It is probably a bad idea for a 45-year-old with hypertension to take loratadine complexed with 240 milligrams of pseudoephedrine: The combination may clear his nasal passages just long enough for him to breathe deeply and have a stroke. Explaining this often involves phone calls, time away from other patients, reviewing drug interactions, suggesting a satisfactory different approach, arranging appropriate follow-up and trying to picture the patient. All because of dust mites.

Time is at a premium in medicine. But doesn't investing time with a patient build rapport, promote good communication and improve satisfaction? Sure. Yet, too many physicians have become cynical in and with managed care. Why waste the effort building rapport when the patient's employer will probably change health plans — and physician panels — next year?

Ads advertise new drugs that are often nonformulary and more costly than well-accepted, equally effective, less costly drugs. Drug costs are huge, and formularies can bring them down. But calls from the pharmacist about a patient unwilling to pay $70 for a month's supply of Paxil when Zoloft is available — or the other way around — also take time. So does the order for the replacement on-formulary prescription.

Sales of duplicative drugs now account for up to 75 percent of the revenues of large pharmaceutical companies. These drugs are among the most heavily promoted, detailed and sampled. They are the drugs that probably fill one third of your sample cabinet, closet or spare room.

Why spend so much money advertising shiny, new, duplicative drugs? To start, they represent surer pharmacologic mechanisms and shareholder profits. Most older — also effective — drugs do not enjoy advertising budgets or sampling or detailing. They are aging towards generic geriatric status, unable to turn the profits they once could.

Ads appeal to the possibility of fixing medical problems over the phone: preventing heart attacks, alleviating pain, stopping smoking. The subliminal message: Take a pill, feel better.

Direct-to-consumer ads will proliferate. Drug company credit cards are probably not far off. Yet the real problem with ads is not their incomplete information or the commodification of health care. The real problem is that physicians do not have enough time to talk with their patients about what medications are best for them and why.

It is not strength of character that physicians require to evaluate requests for medications patients may not need. It is time.

John La Puma practices internal medicine at Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based educator. He is the author of Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics, recently published by Hatherleigh Press (1-800-367-2550) in New York and based on his columns for Managed Care.

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