To the Editor:

In the December 2005 issue you chose to publish Cline and Young’s research on printed direct-to-consumer advertising (DTCA) (“Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?,” J Fam Pract 2005; 54(12):1049–1057). JFP has been derelict in its mission and has forgotten its promise of evidence that matters—specifically, this research presents evidence that does not matter.

The research addresses the influence of print advertisement wording on the social norms for the physician-patient relationship. Conclusions are based upon and drawn from the analysis of the frequency of occurrence of words in the advertisements. The analysis is thorough and impeccable, but the extrapolation of these findings to the physician-patient interaction is a stretch that is neither justified nor appropriate. In fact, their conclusion—that DTCA has no negative effect on that interaction—is preposterous, as a practicing physician (as opposed to a PhD) already knows.

A. F. Holmer, referenced in this article, proposes that “increased use of pharmaceuticals will improve public health.”¹ He also quotes a 1998 national study estimating that DTCA produced 53 million requests to physicians for drugs and 12.1 million patients (23%) received a requested drug. These numbers increase yearly. According to the Kaiser Family Foundation, spending for DTCA—typically to advertise newer, higher-priced drugs—was 15 times greater in 2004 than in 1994!² My interpretation: DTCA sells drugs and that is what matters. The pharmaceutical industry sees the physicianpatient relationship as a necessary evil, since their drugs have been regulated by the FDA and require a physician prescription prior to a sale.

The effect of DTCA on the physicianpatient relationship has not actually been measured by the Cline and Young research, and more importantly its effect on patient well-being has also not been measured. Does DTCA affect patient well-being? How about a POEM to address that outcome? Short of that, JFP (subtitled Timely, Practical, Evidence-Based, Peer-Reviewed, Indexed) should avoid the appearance of servitude to the pharmaceutical industry and choose not to publish this type of research article.

Jack Cahn, MD
Alleghany Family Practice, Sparta, NC

The authors respond:

Thank you for the opportunity to respond. We believe that both the premises of our research and the conclusions we drew apparently were misunderstood by Dr Cahn, and we wish to clarify both in response to his interpretation.

First, we agree with Dr Cahn that DTCA has had a tremendous influence on prescribing behavior and on consumers’ requests to physicians for drugs. Because of constraints in article length, and the fact that DTCA’s impact has been so well documented in the literature, we did not revisit evidence regarding its magnitude and impact in this article. This article is part of a larger program of research has looked at marketing characteristics and visual and textual cues in the ads^4-6 that might serve to influence consumers. In our previous publications (including one cited in the JFP article⁴), we documented the growth and magnitude of DTCA and cited evidence regarding influence on patients’ behavior. ^4-6 Our research questions in the JFP article as well as in other studies focused not on whether influence on the physicianpatient relationship was occurring (a phenomenon we assumed), but on how that influence occurred, that is, on features of the ads that might cause changes in patients’ behavior. Specifically, we sought to understand advertising characteristics that might encourage patients to behave differently in encounters with physicians. Thus, like Dr Cahn, we assumed the powerful influence of DTCA; our inquiry has focused on trying to deconstruct advertising to gain insights into potential sources of that influence.

Second, Dr Cahn identified our conclusion as the following: “that DTCA has no negative effect on that interaction.” In fact, we did not make such a claim. We did not investigate physician-patient interactions nor study the effects of DTCA on that interaction. We did conclude that the ads contain multiple messages about physician-patient communication that suggest to patients the appropriateness of (1) patients initiating interactions with physicians about prescription drugs, (2) physicians maintaining relational control in those interactions, and (3) interactions focusing on the benefits of advertised drugs and avoiding topics that focus on the negative consequences of advertised drugs.

Finally, we would like to address the question implied by Dr Cahn’s response: “Why is such research valuable?” According to previous research, physicians frequently find themselves in the position of responding to patients who initiate discussions about advertised drugs, bring advertising to clinic visits, or request specific advertised drugs. Understanding factors the advertising that may have influenced patients to engage in these behaviors may help physicians to respond effectively and appropriately to those behaviors. We addressed these issues in the article. In addition, this research may provide the basis for stronger health education, health literacy, and media literacy programs for patients to better enable them to interpret DTCA, understand its purposes and limitations as an information source, and act on it appropriately.

Rebecca J. Welch Cline, PhD
Barbara Ann Karmanos Cancer Institute/
Wayne State University, Detroit, Mich

Henry J. Young, PhD
University of Wisconsin, Madison

Direct-to-consumer ads and their effect on prescribing behavior