Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?

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Original Research

Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?

J Fam Pract. 2005 December;54(12):1049-1057

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References

1. Alper PR. Direct-to-consumer advertising: Education or anathema [letter]. JAMA 1999;282:1226-1227.

2. Hoffman JR, Wilkes M. Direct to consumer advertising of prescription drugs: An idea whose time should not come [editorial]. BMJ 1999;318:1301-1302.

3. Hollon MF. Direct-to-consumer marketing of prescription drugs: Creating consumer demand [comment]. JAMA 1999;281:382-384.

4. Holmer AF. Direct-to-consumer prescription drug advertising builds bridges between patients and physicians [comment]. JAMA 1999;281:380-382.

5. Holmer AF. Direct-to-consumer advertising—Strengthening our health care system [editorial]. N Engl J Med 2002;346:526-528.

6. Kravitz RL. Direct to consumer advertising of prescription drugs: Implications for the physician-patient relationship [editorial]. JAMA 2000;284:2244.-

7. Kravitz RL. Direct-to-consumer advertising of prescription drugs: These ads present both perils and opportunities. West J Med 2000;73:221-222.

8. Rosner F, Kark P, Packer S, Bennett A, Berger J. Direct-to-consumer advertising: Education or anathema [letter]. JAMA 1999;282:1227-1228.

9. Spurgeon D. Doctors feel pressurised by direct to consumer advertising. BMJ 1999;319:1321.-

10. Tanne JH. Direct to consumer advertising is billion dollar business in US [news]. BMJ 1999;319:805.-

11. Wolfe SM. Direct-to-consumer advertising—education or emotion promotion? [editorial]. N Engl J Med 2002;346:524-526.

12. Consumer ads build awareness but not understanding of advertised medications, surveys reveal [news]. Am J Health-Systems Pharm. 1998;55:2344-2347.

13. Henry J. Kaiser Foundation. Understanding the effects of direct-to-consumer prescription drug advertising. Document No. 3197. Menlo Park, Calif;2001.

14. Physicians say direct-to-consumer advertising affects patient behavior [news] Am J Hosp Pharm. 1993;50:1329.-

15. Maine LL. Direct-to-consumer advertising: A pharmacy perspective. Clin Ther 1993;20(Suppl):C103-C110.

16. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising and the public. J Gen Intern Med 1999;14:651-657.

17. Bell RA, Wilkes MS, Kravitz RL. Advertisement-induced prescription drug requests: Patients anticipated reactions to a physician who refuses. J Fam Pract 1999;48:446-452.

18. Doucette WR, Schommer JC. Consumer p for drug information after direct-to-consumer advertising. Drug Inf J 1998;32:1081-1088.

19. Werner T. Drug companies tailoring ads to consumers. Philadelphia Business J 1997 May 26. Available at: www.amcity.com/philadelphia/stories/1997/05/26/story8.html. Accessed on July 21, 1999.

20. Consumers want details about prescription drugs; many use ‘alternative’ medicines [news] Am J Health-Systems Pharm. 1999;56:307.-

21. Hunt M. Direct-to-consumer advertising of prescription drugs [background paper]. Washington, DC: National Health Policy Forum, George Washington University; 1998.

22. Bradley LR, Zito JM. Direct-to-consumer prescription drug advertising. Med Care 1997;35:86-92.

23. Craig RP. The patient as a partner in prescribing: Direct-to-consumer advertising. J Manage Care Pharm 1998;4(1).:Available at: www.amcp.org/jmcp/vol14/num1/feature2.html. Accessed on June 26, 2002.

24. Lipsky MS, Taylor CA. The opinions and experiences of family physicians regarding direct-to-consumer advertising. J Fam Pract 1997;45:495-499.

25. Perri M, III, Shinde S, Banavali R. The past, present, and future of direct-to-consumer prescription drug advertising. Clin Ther 1999;21:1798-1811.

26. Feisullin S, Sause RB. Update on direct-to-consumer advertising of prescription drugs [review]. Am Pharm 1991;NS31:47-52.

27. Pines WL. Direct-to-consumer advertising [review]. Ann Pharmacother 2000;34:1341-1344.

28. APhA endorses manufacturers’ direct-to-consumer Rx drug ads Am Drug. 1988 May;26,28.:

29. Roth MS. Patterns in direct-to-consumer prescription drug print advertising and their public policy implications. J Public Policy Mark 1996;15:63-75.

30. Whyte J. Direct consumer advertising of prescription drugs [review]. JAMA 1993;26:146, 150.-

31. Schommer JC, Doucette WR, Mehta NH. Rote learning after exposure to a direct-to-consumer television advertisement for a prescription drug. Clin Ther 1998;20:617-632.

32. Madhaven S. Are we ready for direct to consumer advertising of prescription drugs? Pharm Bus. 1993 Win;4-28.

33. Lyles A. Direct marketing of pharmaceuticals to consumers. Annu Rev Public Health 2002;23:73-91.

34. Morris LA, Brinberg D, Klimberg R, Millstein LG, Rivera C. Consumer attitudes about advertisements for medicinal drugs. Soc Sci Med 1986;22:629-638.

35. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-2226.

36. Beisecker AE, Beisecker TD. Using metaphors to characterize doctor-patient relationships: Paternalism versus consumerism. Health Commun 1993;5:41-58.

37. Millar FE, Rogers LE. Relational dimensions of interpersonal dynamics. In: Roloff ME, Miller GR, eds, Interpersonal Processes: New Directions in Communication Research. Beverly Hills, Calif: Sage; 1987;117-139.

38. Ballard-Reisch DS. A model of participative decision making for physician-patient interaction. Health Commun 1990;2:91-104.

39. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising, 1989–1998: A content analysis of conditions, targets, inducements, and appeals. J Fam Pract 2000;49:329-335.

40. Young HN, Cline RJW. “Look George, there’s another One!” The volume and characteristics of direct-to-consumer advertising in popular magazines. J Pharm Mark Manage 2003;15:7-21.

41. Woloshin S, Schwartz LM, Tremmel J, Welch HG. Direct-to-consumer advertisements for prescription drugs: What are Americans being sold? Lancet. 2001;35:1141-1146.

42. Cline RJW, Young HN. Marketing drugs, marketing health care relationships: A content analysis of visual cues in direct-to-consumer prescription drug advertising. Health Commun 2004;16:131-157.

43. Bandura A. Social cognitive theory of mass communication. Media Psychol 2001;3:265-299.

44. Kravitz RL, Bell RA, Franz CE. A taxonomy of requests by patients (TORP): A new system for understanding the clinical negotiation in office practice. J Fam Pract 1999;48:872-878.

45. Cockburn J, Pit S. Prescribing behavior in clinical practice: Patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 1997;315:520-523.

46. Peyrot M, Alperstein NM, Van Doren D, Poli LG. Direct-to-consumer ads can influence behavior: Advertising increases consumer knowledge and prescription drug requests. Mark Health Serv 1998;18:26-32.

47. Cooper-Patrick L, Gallo JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-589.

48. Fleming DJ, Samuels KW. Direct-to-consumer advertising and the learned intermediary. Hosp Pract 1998;33:129-130.

49. Sullivan DL, Schommer JC, Birdwell SW. Consumer retention of risk information from direct-to-consumer advertising. Drug Inf J 1999;33:1-9.

TABLE 3
References indicating relational control by medical condition: Percentages by category

MEDICAL CONDITION	N*	CONSUMER	PHYSICIAN	SHARED
Allergies	61	11.5	52.5	36.1
Cancer	16	18.8	31.3	50.0
Cardiovascular	68	38.2	42.6	19.1
Dermatologic	24	0.0	75.0	25.0
Diabetes	79	8.9	69.6	21.5
Gastrointestinal/nutritional	29	0.0	65.5	34.5
HIV/AIDS	70	10.0	51.4	38.6
Infectious (non-HIV)	21	38.1	61.9	0.0
Musculoskeletal	30	26.7	56.7	16.7
Obstetric/gynecologic	46	2.2	17.4	80.4
Psychiatric/neurologic	47	23.4	53.2	23.4
Respiratory	12	16.7	75.0	8.3
Tobacco/addiction	33	21.2	57.6	21.2
Urological	37	5.4	73.0	21.6
Undisclosed	1	0.0	100.0	0.0
TOTAL	574	15.5	54.5	30.0
* N refers to number of references to communicating with a physician.

TABLE 4
Suggested topics for physician-patient communication by medical condition: percentages by category

MEDICAL CONDITION	N*	CLINICAL	GENERAL	SIDE EFFECTS	RISKS	UNKNOWN
Allergies	61	32.8	59.0	0.0	4.9	3.3
Cancer	16	50.0	12.5	12.5	6.3	18.8
Cardiovascular	68	54.4	20.6	19.1	2.9	2.9
Dermatologic	24	20.8	37.5	8.3	0.0	33.3
Diabetes	79	55.7	24.1	12.7	6.3	1.3
Gastrointestinal/nutritional	29	24.1	44.8	0.0	0.0	31.0
HIV/AIDS	70	32.9	41.4	10.0	0.0	15.7
Infectious (non-HIV)	21	28.6	38.1	19.0	0.0	14.3
Musculoskeletal	30	26.7	40.0	6.7	23.3	3.3
Obstetric/gynecologic	46	23.9	26.1	2.2	41.3	6.5
Psychiatric/neurologic	47	44.7	19.1	12.8	19.1	4.3
Respiratory	12	66.7	16.7	8.3	8.3	0.0
Tobacco/addiction	33	63.6	27.3	0.0	3.0	6.1
Urological	37	54.1	27.0	2.7	2.7	13.5
Undisclosed	1	0.0	100.0	0.0	0.0	0.0
TOTAL	574	41.8	32.1	8.5	8.5	9.1
* N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication.

Discussion

Typical DTCA contains multiple messages about physician-patient communication. The primary way that DTCA may endorse a participatory model is via messages that encourage consumers to initiate conversations with physicians about products. About 70% of communication references explicitly direct consumers to do so. Otherwise, ads do not encourage consumers’ control. In fact, nearly 55% of communication references cast the physician in control, while only 15% placed the consumer in control. Thus, DTCA reinforces physicians’ relational control while encouraging consumers to initiate communication.

DTCA steers conversation topics toward products’ benefits and away from their deficits. Ads most often suggest products’ medical utility and appropriateness as topics (ie, general information, clinical judgments), while avoiding negative topics (ie, side effects, risks).

DTCA’s communication lessons for practice

Present results have implications for physician-patient interaction. First, to the extent that DTCA influences patients’ communication behavior, physicians increasingly may encounter patients who initiate communication by asking questions, often about advertised drugs. Some physicians may see such questions as requests or even demands for those drugs. Physicians report feeling pressure to prescribe products about which patients inquire;⁹ thus, patients merely asking more questions may be perceived as “demanding.”⁴⁴

FAST TRACK

When inquiries are made about a drug, be sure to address side effects, which patients may ignore

However, physicians often perceive “patient demand” when patients have not specifically asked for a drug.⁴⁵ Physicians may want to check their perceptions before acting on them, recognizing that such questions may indicate patients’ preferences for a more participatory model, which, in turn, is associated with greater patient satisfaction.^46,47 Physicians desiring to avoid conflict when patients ask questions might encourage their participation rather than assuming “patient demand” or feeling pressure to alter prescribing behavior.

Second, despite some physicians’ concerns, DTCA’s communication messages do not encourage patients to take relational control, nor do they undermine physicians’ prescribing authority. Theoretically and ethically, physicians remain in control of decisions, including prescribing, by serving as learned intermediaries or “conduits of information between manufacturers and patients.”⁴⁸ Practically, physicians remain in control because their cooperation is necessary, even in cases where patients actively seek particular prescriptions.

Third, if DTCA influences patients’ choice of communication topics, patients may fail to inquire about drugs’ risks or side effects, a finding especially important in light of evidence indicating that consumers tend to not retain DTCA’s risk information.⁴⁹ Physicians need to be alerted to these trends so they ensure that conversations with patients include explicit discussion of drugs’ side effects and risks.

Limitations

This study has several limitations. First, we analyzed print DTCA only. Generalizing findings to television and Internet DTCA may not be possible.

Second, our sample, dated from 1998 to 1999, may differ systematically from current ads. However, our study does provide a theoretically-driven methodology for assessing, and understanding the implications of, changes in advertising strategies across time and media.

Third, we analyzed marketing efforts targeting consumers. Physicians are exposed to numerous pharmaceutical marketing efforts that may contain messages regarding physician-patient communication.

Fourth, we limited analysis of relational communication to relational control; communication theory and research considers additional relational dimensions (eg, affiliation, trust) that likely influence the physician-patient relationship. Finally, we identified DTCA messages that may influence consumers’ behavior; we did not investigate actual behavioral changes associated with exposure to DTCA.

ACKNOWLEDGMENTS

We wish to thank Katie M. Haynes, BS, for coding and technical assistance.