Oh Henry
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Direct-to-consumer drug ads dominate the airways. Though it pains me to say it, this is one time where caveat emptor doesn’t apply. 


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I present to you, dear readers, a true conundrum, an intellectual Gordian knot of an unusual nature to challenge your thought processes. It will not, at first, seem as profound as the meaning of life or even what sandwich to order at Katz’s Delicatessen (“I’ll have what she’s having”). But it involves the roles of government, the basics of the First Amendment, religion and, heaven forbid, common sense.

Before I begin, I want to remind you all of the continuous debate that takes place between autonomy and beneficence. Do we do for the patient that which they want or that which is best for them? And do we have a right to impose our will upon them? This conflict between doing the right thing and doing what is desired by the patient is always paramount. The great physician gets the patient to want for himself or herself what the physician wants for that patient.

I admit that I watch too much television. Being a true Northern European mutt (a quarter English, a quarter Scottish, a quarter Swedish and a quarter Danish), I am genetically drawn to PBS’s European products. Downtown Abbey, Call the Midwife and Foyle’s War have captivated me. But it’s not just the programming that causes me to recoil from non-PBS shows (is a country that produces Real Housewives of Atlanta and The Bachelorette really ready for self-government?). It’s the advertising as well. To be specific, health products now dominate the airwaves. It is estimated that, in some American markets, health-related products take up to 50 percent of the advertising dollars. It’s a one-two punch: not only is the population getting older and more anxious about health problems, but they have more time to sit in front of the tube. It feeds directly into modern Western society’s belief that happiness comes out of a bottle.

Most targeted advertising is aimed somewhere between the navel and the knees. Genitourinary products are very popular; fear of peeing ourselves seems to be an overwhelming preoccupation in the country at this moment in time. Vaginal dryness comes in a poor second to failed erections in the genital regions.

And, of course, there’s this now iconic ad. The scene opens. A very handsome but clearly mature couple is doing almost anything when their hands touch. Cue announcer: “Will you be ready when the time is right?” Your eyes are trained on this couple as the side effects and contraindications are listed. There’s movement and romance in the air. This is planned. There is no way you are listening to whatever they are saying until they purposely challenge your manhood with a line like: “If you are healthy enough to have sex.” What do you mean: “Healthy enough to have sex”? Now they’ve got your interest. They make certain that this slap down to your virility is heard loud and clear. But by far the best line in all Cialis commercials is: “If an erection lasts more than four hours, call your doctor.” Four hours! If my erection lasts more than four hours, I’m calling everybody —— including a few old girlfriends. By the way, if you don’t believe me, just watch the commercials. They’ve got this strategy down to a science. How this couple ends up in adjoining clawfoot bathtubs is never really explained – oh well.

To what degree in a free society should the government get involved in these discussions? This is America! If you are gullible enough to believe the tube monster, that’s your problem. Right? Well, not so fast. After all, the government already weighs in on which sins you are allowed to watch at home. The gambling industry can advertise on television while tobacco products cannot. Is gambling that much better for you than a good cigar (with a tip of the cutter to Kipling)? And if tobacco is banned, why not alcohol? This week the World Health Organization announced that worldwide more deaths are caused by the effects of alcohol than AIDS, tuberculosis, malaria and non-war violence combined.

Let’s admit that the cultural insanity of today’s advertising simply represents the fashion of the time and the scientific falsehoods of the age. There is probably nothing we need to do with most advertising. Ads for Ensure, Depends, diet schemes, workout equipment, vitamins and the rest are pretty much all under the domain of caveat emptor. But there is an area that crosses into our bailiwick and that’s any product where a physician’s signature is required. And it’s not just medications I’m talking about. Medicare will pay for a scooter if your doctor will only “sign the form.”

I love this phrase: “You deserve X, Y or Z.” Basically these commercials tell people that —— if only your doctor agrees —– you can be relieved of pain, suffering and enjoy hours of coital bliss. And it’s only getting more dangerous as new drugs get pushed straight to consumers. These are expensive drugs with the potential for real harm. This is not a theoretical discussion.

In his first inaugural address, President Reagan announced: “Government is not the solution to our problems; government is the problem.” Rousseau told us we are born free, held down only by those chains that are put upon us by the state.

So what’s the answer? Are we idiots who, according to the New Left, need to be saved from ourselves? Or do we say: “Damn the torpedoes!” and let social Darwinism take its course? Do we follow Hobbes or Hayek?

So enters our savior in the form of the FDA (“I’m from the federal government and I’m here to help”). You will note that all proprietary drugs must be government-ruled and they must list the principal side effects in all advertising. It is interesting to note that the efficacy and efficiency of prescription drugs does not have to be listed. Sound fair and balanced? Not so fast.

One of the principal reasons I have a deep, and in this particular case justified, suspicion of government is that it does not know how to play with the “big boys.” They (the FDA) are just no good at determining outcomes versus intentions. The advertising agencies that work for the drug companies, on the other hand, are experts at it.

Long-time readers of this column know I am not a fan of rules and protocols. I am the antithesis of John Rawls, who believes that the state exists in order to reallocate the social product. To his liberal eye, all goods are unowned until distributed. I am diametrically opposed. The role of the government is to cut the grass on the playing field where the give-and-take of the free market will take place, where buyers and sellers can come together for the best outcome.

So, without further ado, here’s my plan. At the end of the pitch for the product in each one of these television ads, the viewer should be distracted by nothing. The commercial goes to a flat blue screen where the contraindications and side effects would be bullet-pointed. They would be pointed out clearly and simply. This alone would stop much of the unwanted and unnecessary sales of products. Either that or we could insist that in half the ads they show patients who’d had bad outcomes. For example, in the Enbrel ads we could show a patient in the ICU in septic shock from the use of the drug. It really makes no difference which strategy we take. The point is simple: I don’t want to suppress anyone’s right to advertise, but let’s make the playing field fair. The inordinate increase in all the prescription drug usage in the country is based on our inability as physicians to talk to these patients, understand their problems and occasionally say the word “no.”

The question is not whether the government can be big; it already is. The real question: Can it be useful and savvy in serving the needs of its people? The state felt it needed to give reasonable protection to citizens when they seek healthcare and when they use healthcare products. In theory, it is a noble pursuit. The counter to pharmaceutical advertising was always intended to be the licensed, qualified healthcare provider who used judgment and compassion in the management of human problems. Sometimes honesty is not popular. It’s unfortunate that a physician’s “satisfaction scores” may be besmirched by doing the right thing. In the Anglo-phonetic realm where most of our readers practice, it seems that the common law justice, which should remind each citizen that he is accountable to others for the freedom he or she enjoys, is slowly but decisively fading away.

These are dark times indeed. The real tragedy is we have come to the point where patients feel they cannot ask us about their problems without causing some offense. It’s sad. It’s genuinely sad. Lest you become frustrated by this endless tug of war defining the role of government in our lives, I recommend to you “The Rules Of Nobody: Saving America From Dead Laws And Broken Government” by Philip K. Howard. In it he refers to our regulations as a progressive disease. The system wears people down. We make laws and never ask whether the results matched the intent. It’s sort of like our research on hypothermic resuscitation. A good idea but nobody really asks: Are the outcomes any better?

In this book, as an example of the death of common sense, Howard points to a soup kitchen in New Jersey closed after 26 years of service to the poor. The Catholic Church-sponsored kitchen used local parishioners who made food in their homes and distributed to the poor so that the elderly could be properly taken care of. It was not only a free lunch but it was compassion. It was contact. It was people coming to homes of the isolated, the forgotten and the lonely. Even though they had never had one complaint in 26 years, the Health Department decided they had no control over these individual kitchens and closed them down. In that same city in New Jersey, there are now 66 steps in disciplining a child at school. Our system passed the point of absurdity long ago. Why do we continue to wander into the abyss?

So on we go with our passage into modernity. Rules subdivide and proliferate in order to cover all circumstances. Government handles this variety not by giving officials the freedom to adapt but by creating more rules, more protocols, and more forms to fill out. My last question: Has the association of individuals that so impressed de Tocqueville disappeared now from the land that invented it?

Veritas simplex oratio est.

The language of truth is simple

Greg Henry, MD, is a past president of ACEP and the founder and CEO of Medical Practice Risk Assessment, Inc.

 

Comments   

# A Sucker Is Born Every MinuteVal Nicholson 2014-07-16 13:59
Greg,
I read with interest your column in this month's EP Monthly. The other concern I have is the marketing pitches that are made directly to us as physicians.

On a personal note, I had made an appointment with a specialty physician last week for a problem. He did not bother to take a full history which in my case has become a complicated one in the last five years of my health....nor examine me. He glanced by the more important issues of diet change and physiotherapy to an implanted medical device. He did not give me any of the contraindicatio ns nor did he have any idea if the device could be used in an immunosuppresse d individual. He said he would do a lit search.

I went home got on line and went to the manufacturers site. There is NO WAY that I would ever be a candidate for this technology.

So, we as physicians, are also very much part of this problem. And part of the enemy is indeed us. We can prostitute ourselves to manufacturers if we do not
hold our ground. Dare I suggest that a history and physical are not outdated!
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# RE: A Sucker is Born Every Minute: Pharmaceutical Ads, Government, and the Physician-Patie nt RelationshipBill Graffeo M.D. 2014-07-16 15:58
Once again Greg Henry hit the mark, certainly more eloquently than I ever could! Not only are they advertising medications; but now I see "self diagnosis ads". Example; if you have a red rash, that is painful or itching you may have shingles. THe next day a dozen patients with poison ivy or whatever sign in (ahh- medicaid) for evaluation of Shingles! More and more patients are coming in telling us what they have and what meds will work for it. I don't know the answer but it's getting out of control! Greg, thanks for elucidating a growing problem! Bill G.
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# MDpam bensen 2014-07-23 23:23
Greg, Never once in our decades of friendship have your words failed to resonate with my most logical axons and dendrites. I offer mine as a sacrifice, so yours can lead the world to sanity!
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