Marketing medicine
2/6/2006Dr. Richard Paat likes to help his patients, but there wasn't much he could do for one elderly lady asking for a medication she'd seen advertised on TV - for treating an enlarged prostate.
For those of you unfamiliar with the finer points of human anatomy, the prostate gland is found only in men. Dr. Paat, a Maumee family practice physician, still chuckles when he recalls the story.
"This elderly lady, God bless her, I thought I was doing a good job talking about her cholesterol and high blood pressure, and at the end I asked if she had any other questions," Dr. Paat said. "She said, 'well how about [the allergy medication] Allegra?' I asked, 'Do you have allergies?' And she said, 'No.' Then she said, "I saw it on TV.' Then, she said 'How about Proscar?' That's used to treat the prostate, and I said, 'uh, ma'am, you don't have to worry about that either.'"
Call it "Ask Your Doctor" syndrome. Dr. Paat, like most other physicians, has seen a lot of it.
If you watch TV, read magazines or newspapers, or surf the Internet, chances are you've been bombarded by advertisements pitching the latest drugs, all encouraging you to "ask your doctor" whether a certain drug is right for you.
So on the day after the biggest advertising day of the year - advertisers spent an estimated $2.5 million for a 30-second Super Bowl ad - it's worth noting that marketing works, and advertisements for drugs are no exception.
According to the nonprofit Kaiser Family Foundation, spending in the U.S. for prescription drugs was $179.2 billion in 2003, almost 4 1/2 times larger than the $40.3 billion spent in 1990.
Kaiser officials say part of that is due to the rapid increase in spending on what's known as "direct-to-consumer" or "DTC" advertising of prescription drugs. Drug companies spent $4 billion advertising their products to the general public in 2004, up from $790 million in 1996, according to the research firm, IMS Health.
Drug companies say DTC advertising helps inform the public about vital new treatments for diseases, as well as educate the public about things they might not otherwise think to discuss with their doctor. Others argue DTC advertising drives up drug costs and leads to unnecessary use of drugs.
"They say they're educating the consumer, but that's nonsense. There's nothing educational about watching Dorothy Hamill skate around and telling you Vioxx helped her skate," said Dr. Marcia Angell, author of The Truth About the Drug Companies: How They Deceive Us, and What to Do About It (Random House. 2004. $24.95).
"I think there is widespread overprescribing of medications, particularly medications for essentially normal people," said Dr. Angell, the former editor of the New England Journal of Medicine and now a professor at Harvard Medical School. "The companies try to convince Americans that they all have some sort of condition where they need a drug, things like heart burn or anxiety or erectile dysfunction. And it's usually a very new brand-name drug, never an old generic drug."
Dr. Bill Frist, the U.S. Senate Majority leader, is also concerned about direct-to-consumer advertising of drugs. Last summer, he called for drug companies to voluntarily restrict their DTC advertising efforts during a new drug's first two years on the market. In addition, Dr. Frist has asked the Government Accountability Office to update an old report on how drug companies market their drugs, and how the government regulates that.
Drug company officials dismiss the call for restricting their advertising, saying DTC ads help the public.
"We welcome the debate on this issue because we honestly believe DTC is a benefit to consumers. It's an amazing educational tool and it fosters dialogue between physicians and patients," said Andy Izquierdo, a spokesman for drug company AstraZeneca, which recently published "The Responsible Path: Responsible Direct-to-Consumer Advertising Serves the Interests of Patients, Doctors, and Society."
He said his company has established internal guidelines to make certain its ads are informative and "serious" in tone for its drugs, Crestor [a cholesterol lowering drug] and Nexium [used to treat heartburn]. In addition, his company is suggesting a mandatory requirement that all drug companies first submit their ads to the federal government for scientific review to ensure they're accurate.
Though they believe DTC is a valuable tool to reach the public, America's pharmaceutical industry has responded to the criticism of its marketing efforts. The Pharmaceutical Research and Manufacturers of America [PhRMA], the lobbying and trade group representing U.S. drug companies, points to a list of "Guiding Principles" it says the industry has adopted, starting last month.
The guidelines include a call to present information in clear and understandable language. It also calls for ads to avoid audiences and time slots that are not age-appropriate - such as the frequent ads for erectile dysfunction.
Whether DTC advertising is good or bad, both sides agree on one thing: It works.
Though many physicians say they're annoyed by patients asking about the latest drug they saw on TV, apparently many are equally willing to prescribe the drugs, according to researchers like Dr. Richard Kravitz of the University of California-Davis' Center for Health Services Research.
He and his colleagues published a study last year in the Journal of the American Medical Association that examined what happened when doctors were asked by "patients" about brand-name drugs. In a unique experiment, Dr. Kravitz recruited what are known as "standard patients" to visit 152 doctors in California and New York. Standard patients are those who are trained to mimic certain medical ailments. Normally, they're used to help train medical students and medical residents. The Medical University of Ohio has an active program.
Dr. Kravitz told his standard patients to visit the doctors and pretend to have a mental health disorder, such as depression. The patients were instructed to do one of three things: Don't make any specific medication requests, make a general medication request, or ask for a specific name-brand drug.
The result was eye-opening, Dr. Kravitz said. When patients didn't ask for any drugs they were only prescribed a drug 31 percent of the time. When they asked for a drug, they got one prescribed 76 percent of the time, and when they specifically asked for a brand-name drug, they got it 53 percent of the time.
"Of course physicians are influenced by what patients ask for. The twist here was we set up a situation where a medication wasn't necessarily needed," he said.
Dr. Matthew Hollon, an internal medicine physician at the University of Washington who wrote an opinion piece in the same JAMA issue, said the Kravitz study was useful because it showed how powerful drug ads can be.
"While drug ads probably stimulate discussion about important health issues, there's little or no evidence that they bring those at the highest risk for those conditions to seek care, and as Dr. Kravitz highlighted, the ads actually probably undermine optimal therapeutic decision making," he said.
He added that drug companies are well aware of how effective their advertising is.
"You're talking about an industry that's one of the most profitable industries in the world," he said. "The median profit margin in the U.S. in 2002 [for drug companies] was 17 percent, and that's compared with 3.1 percent for all other industries."
Of course, doctors aren't immune from drug company advertising, either. In fact, drug companies spend nearly twice as much directly marketing their products to doctors than they do on DTC advertisements, according to IMS.
Just take a look at all the free material - mugs, notebooks, pens, calendars - in the average doctor's office, much of it supplied by drug company sales representatives known as "detailers" in industry lingo, or "drug reps" by doctors. Drug companies have been under fire for their marketing to physicians, spending that includes things like paying for "training" seminars at a tropical resort - a practice drug companies say has dramatically decreased since voluntary guidelines went into effect in 2002.
Still present, however, are the free meals and other minor goodies supplied by drug reps to doctors' offices. The large amount of marketing to physicians prompted a group of physicians to write in JAMA this month that there should be stronger rules preventing such practices.
Paramount Healthcare, owned by Toledo-based ProMedica Health System, has its own examples of the power of DTC and direct-to-physician advertising. The company, which insures about 200,000 people in the region, "definitely saw less use" of certain drugs whenever advertising for those drugs stopped, said Dr. Neeraj Kanwal, medical director for Paramount.
"Our doctors tell us their patients demand products they see on television, and our doctors feel pressured by patients to prescribe the advertised product," Dr. Kanwal said. " ... the majority of physicians I meet with every day do not welcome these ads and say they do not create a helpful environment."
Dr. Paat said he's all for patient education - even if it causes confusion with some patients - but he says if drug companies are doing DTC advertising to help him, he'll pass.
"They're not helping me," he said. "The bottom line is they want to help their bottom line."
Contact Luke Shockman at: lshockman@theblade.com or 419-724-6084.