Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?
Among the many messages in DTC print ads is: communicate with, and listen to, your physicia.
Although medical information may help consumers establish credibility and arm them with medical content for discussion, DTCA’s statements about communication may imply guidelines for interacting appropriately with physicians. An ad that reads, “Ask your doctor about drug X,” explicitly provides a model opening line and contains implicit messages about who should initiate interaction (the consumer, encouraged to ask), who should have control (the doctor, upon whom the patient depends for an answer), and appropriate interaction topics (drug X). This interpretation of DTCA’s messages is rooted in relational communication theory and research; a consumer urged to “ask” a physician is cast as “one-down”37 or dependent on the physician for an answer. Alternatively, a consumer urged to “tell” a physician is portrayed as “in charge.” A message to “discuss” a matter with a physician indicates shared control.
The aim of our study. Our general question was: “What social norms regarding physician-patient communication does print DTCA suggest to consumers?” Specific research questions were:
How frequent are references to physicians in print DTCA?
How frequent are messages about physician-patient communication in print DTCA?
Within messages about physician-patient communication, what guidelines are implied, and with what frequencies, regarding: (a) who should initiate interaction, (b) who should have relational control, and (c) appropriate topics for interaction?
Methods
Sample
We examined all DTCA in 18 popular magazines (684 issues) from January 1998 to December 1999. We followed Bell, Kravitz, and Wilkes’s procedures to ensure a diverse sample of publications.39 Thirteen magazines were selected to represent the highest-ranked lay magazines (based on advertising pages sold) in specified categories; 5 additional magazines were selected to represent diverse populations. They were business (Business Week), fishing/hunting/guns (Field & Stream), food/wine (Gourmet), home (Better Homes and Gardens), men (GQ), music (Rolling Stone), news and opinion (Time), parenting (Parents), personal finance (Money Magazine), sports (Sports Illustrated), tabloid/general editorial (Reader’s Digest), women (Vogue), and medicine/health (Prevention); and ethnicity (Ebony and Hispanic), age (Modern Maturity and New Choices for the Best Years), and sexual orientation (The Advocate). We identified 994 product-specific and reminder ads for 83 drugs addressing 15 types of medical conditions.22 (Product-specific ads identify products by name and use and are subject to FDA monitoring guidelines.22 Reminder ads simply identify products by name, without identifying use or related claims, risks, etc.) After eliminating duplicates, the sample of 225 advertisements was analyzed.
Coding systems
The unit of analysis for this investigation was a statement focusing on physician-patient communication. For each advertisement, we first identified statements referencing physicians. (Although we included the terms “health provider” and “health professional” as references to physicians, all but 4 ads used the terms “physician” or “doctor.”)
Next, among references to physicians, we identified statements focusing on physician-patient communication (eg, “ask your physician;” “your doctor will tell you”). For these statements, we developed a coding system to reflect types of messages implied regarding physician-patient communication by systematically reviewing 25% of the sample, while considering relational control theory.37 Specific categories of messages, examples, and rules for coding were developed for 3 variables: (a) who should initiate communication, (b) who should take control, and (c) appropriate communication topic(s). Categories for each variable were mutually exclusive and exhaustive.
Upon completing development of the coding system, we applied it to the full sample of statements focusing on physician-patient communication. In addition, for each statement, the medical condition for which the drug was advertised was coded (14 disclosed conditions and a category for undisclosed conditions). Details of the coding system are available from the authors.
Initiating communication. Who should initiate communication was coded as (a) explicit directives to the consumer to initiate communication (eg, “ask your doctor,” “tell your doctor”), (b) implicit directives to the consumer to initiate communication (eg, “see your doctor about drug X,” “check with your doctor”), (c) references to doctor-initiated communication (eg, “your doctor will tell you,” “adhere to your doctor’s recommendations”), or (d) messages referencing both parties, implying either could initiate communication (eg, “my doctor and I agreed,” “you and your doctor must carefully discuss”).
Relational control. Consistent with relational control theory, 37 who should be in control was coded as (a) patient control (eg, “tell your doctor,” “let your professional know”), (b) physician control (eg, “ask your doctor,” “check with your doctor”), or (c) shared or unclear control (eg, “talk to your doctor,” “discuss with your doctor”).
Appropriate interaction topics. Suggested interaction topics were coded as (a) side effects, (b) risks of product use, (c) general product information, (d) clinical judgments (ie, determining appropriateness for the patient), or (e) topic unspecified or unclear (included multiple topics).
