USA Today, Thursday, July 5, 2001

Doctors step out; drug salespeople step in


By Ivan Oransky 
Reprinted with permission of the author

Imagine it's late at night. You've been feeling blue for a 
while. You turn on 
the TV, and someone depressed appears on the screen. Soothing 
music 
is accompanied by the name of a popular antidepressant. 
"Speak to 
your doctor," intones a voice-over, as the formerly depressed 
patient 
appears again, this time smiling and playing with his 
daughter.

The ad seems to be made for you. So you make an appointment 
to see 
your doctor, who, seeing that you're depressed, prescribes 
the drug you saw 
on TV ­ after you suggest it during your 5-minute visit.

Sounds great. A patient was educated and empowered to get the 
drug 
he needed. The only problem: You actually suffer from bipolar 
disorder ­ 
formerly known as manic depression ­ and the antidepressants 
you 
thought would help you will only throw you into a mania, 
placing you at real risk 
of committing reckless behavior.

Your doctor didn't ask the right questions. He didn't ask 
about a past history of 
mania or members of your family who had the disease. 
Depression ­ which 
you're undoubtedly suffering from ­ is actually just half of 
your illness.

The scenario sounds scary. And it is. But who's to blame? The 
ad that sent you 
to the doctor or the doctor for not making the right 
diagnosis?

Direct-to-consumer drug advertising, on which drug companies 
spent 
$1.8 billion in 1999, is growing, with substantial results. A 
1997 survey found 
that more than a third of patients had asked their doctors 
about drugs they saw 
in ads, and nearly a quarter of patients had asked for a 
prescription for the 
drugs the ads promoted.

Proponents of the ads say that they help educate patients 
about diseases 
they may not know they have, or about better ways to treat 
their known 
illnesses. Citing actions by the Food and Drug Administration 
(FDA) to curb 
certain ads, critics say many ads understate risks and side 
effects or oversell 
what drugs are meant for.

More troubling, however, is the segment of doctors who won't 
"just say no" 
when patients ask them for drugs. In the 1997 survey, three-
quarters of patients 
who asked for a specific drug left their doctors' offices 
with a prescription for 
that drug. Some doctors think that if they make a clinical 
decision that a patient 
doesn't need a drug they ask for, they'll lose credibility in 
the eyes of patients.

"We have a lot of data that suggest that physicians having 
those 
office experiences do roll over and prescribe the drug that's 
requested," says 
Steven Findlay, director of research at the National 
Institute for Health 
Care Management.

Direct-to-consumer advertising has become part of our pill 
culture. That makes it 
difficult for doctors to control their relationship with 
patients, particularly 
demanding ones.

Some groups are understandably concerned about these trends. 
At its 
June annual meeting, the American Medical Association (AMA) 
considered 
but failed to approve a resolution that would urge the 
government to 
ban direct-to-consumer drug ads from television, newspapers 
and magazines.

Banning the ads, which already are regulated by the FDA, 
isn't a great solution, 
even forgetting that it cuts close to a violation of the 
First Amendment. The 
proposal made at the AMA meeting would have only sidestepped 
the real 
issue, which is that too many doctors can't or won't spend 
the time necessary to 
make a correct diagnosis.

Pressured by a ticking managed-care clock, doctors take the 
quick way out. If it 
looks like a duck and walks like a duck, it must be a duck. 
Who wants to argue 
with patients? If you're sneezing and it's May, you must need 
the antihistamine 
you saw on TV. If you have a fever and a cough, you must need 
antibiotics, 
even if that sort of practice gives rise to superbacteria 
that can't be killed by any 
antibiotics in our arsenal, as we're learning.

Many times, that logic will hold and is perfectly safe. But 
if you look like 
a patient with depression, and you're actually a patient with 
bipolar 
disorder, you'd best hope that your doctor doesn't prescribe 
an antidepressant 
without asking the right questions first.

Doctors need to stand firm and do what's right in the long 
term clinically 
for their patients, not what's right in the immediate term to 
avoid angering 
the demanding ones. The buck stops here, where the pen hits 
the 
prescription pad.

Ivan Oransky, M.D., is editor of Praxis Post, an online 
medical magazine.