A recent medical article has demonstrated that doctors cave to their patients’ medication requests with regularity, even when controlled substances like Oxycodone are involved. It’s not that big a surprise really—the customer is always right, after all.
The study serves as a reminder, though, of a venerable truth: the relationship between the doctors who diagnose and the drugs they prescribe is every bit as complex as the well travelled crisscross between Gwyneth and Chris —maybe even more so. Long ago, it was all so simple: the doctor was part shaman, part priest, part pal with nothing to offer but a smile and a shrug.
Then came remedies: the powder, the salve, the wondrous elixir. The real charlatans (as opposed to flummoxed, inept, surely avaricious practitioners) all leaned in, hoping to find the next sucker born that minute. After all, no group is more ripe for the picking than the infirm, either those chronically afflicted or the once healthy who meet a sudden calamity. So much desperation means so many opportunities—how simple then, to squeeze out a fortune or two on the promise of a miraculous cure.
But with so much money changing hands, rules were created. That veteran killjoy, the FDA, stuck its sanctimonious nose into the entire orgy and separated the action into two basic teams: the doctors and the pharmacists. Each would get a healthy slice of the healthcare pie and live mostly peacefully and plumply, with the self-satisfied sense that they didn’t quite get all they deserved.
Rather than live happily ever after, however, this Eden too was invaded—by the customer. That’s you, the potential patient (and we are all potential patients, a market 7 billion strong and growing daily). First, as mentioned, was movement that came to regard patients as human beings, not animals or children that disinterested (though informed) outsiders made decisions about. In the first major self-reflective moment of modern medicine, doctors and patients alike suddenly remembered that illness, just like car repair, involved discussions between adults, not dictation and stenography.
Growing the exact opposite direction, though, towards the heart of wealth management, was the 1997 FDA “guidance” that trampled the barrier which previously had restrained direct to consumer (DTC) advertising. Prior to that, there was a gentleman’s agreement to behave, mostly; the TV and mag ads that ran were cautious and proper since the pharmaceutical guys knew the FDA might swoop in at any moment and make them play by the rules.
All of that ended with the 1997 “guidance” though. (Ah, the unzipped Clinton years.) With the action, the US joined New Zealand as the only industrialized nations to allow DTC advertising and the gold rush was on. Two of America’s most muscular and relentless groups—pharma and the advertising world—joined up to make certain that no man, woman, or child was left unaware of the remedy for heartburn. The premise was simple: sell a brand to the patient and trust that the patient will beg the doctor for the same brand. Ask your doctor about [your drug here].
It is incredible that the full-bore multi-billion dollar DTC movement is younger than Justin Bieber, but it’s true. Yes kids, not that long ago, people who might have were not riding horses on the beach; out-of-work middle-aged actors were not given long white coats and horn-rimmed glasses and taught to nod medically; and the have-to-watch-the-car-crash sensation of witnessing yet another ad describing the latest erectile dysfunction drug (will they kiss? smile longingly? how old is she? is he a young guy dying his hair gray just to get the part?) was unknown. No, drugs had to work and claims had to be honest.
But with winking acquiescence in place—the FDA, though nominally still watching over shoulders, more or less disappeared. According to a 2007 review of the DTC initiative published in the prestigious New England Journal of Medicine, the number of formal letters of inquiry regarding possible violations of advertising regulations from FDA to pharma dwindled from 142 in 1997 to 21 in 2006. There surely is no evidence that they have tightened any screws since—DTC ads now seem just a millimeter short of the swaggering promises of a drunk guy trying to pick up a girl in a bar. Even the World Health Organization, which has plenty to worry about in impoverished nations, knows there is big trouble afoot.
But DTC isn’t the worst of the problem. A more recent wrinkle is the doctor who prescribes from his own office, cutting out the middleman (read: pharmacist). On the premise that 20% of people don’t take their scripts to the drugstore, and 30% never get a refill, those Dudley Do-Rights of American society, the doctors, are happy to give you the pills on the prescription they just wrote you, collect the max from your insurance company, and split the profit with an invisible (and all-new) middle man. Many states forbid this three-card Monte, but the lobbying might of doctors and drug companies may be too much for any state to fend off.
Yet even the convoy rumbling through this latest loophole isn’t the worst of it. The worst is that both the DTC crowd and the doc as drug store movements have coopted important patient-centered goals for their own bottom line ends. The DTC people are riding the momentum of the “empowered” patient, the informed patient, the patient as equal; similarly, “Doctor Drugstore” claims to only want to improve patient convenience, another noble patient-centered goal.
This hijacking of humble democratic strivings is surely nothing new—one only need watch an Exxon/Mobile “green” ad about their concern for the environment to know this is everyday fare. But healthcare is different. We are talking about human health, something that never should be just another pawn in the game.
But as the new article showing how advertising can make a patient ask for a drug and a doctor give it over demonstrates, healthcare has encountered yet another checkmate.
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