“ask your doctor if ____________ is right for you”

a discussion of media medicine

Douglas C Beatty M.D.

beatty.douglas@bellsouth.net

Abstract: The media audience is currently under a competitive blitz from pharmaceutical companies promoting new drugs. The assumption is that a patient can make a diagnostic and therapeutic choices based on very limited information. The ethics and desirability of this practice is the focus of considerable discussion.

Introduction: The average family does not own a PDR and all its supplements, a DSM IV-R, or any other scientific treatises on the practice of medicine. What it does have is a TV set, often droning away in the background. Just as daytime TV advertising belongs to the ambulance chasers and chiropractors, the evening belongs to the medical marketers. One of a cynical bent might wonder if this push toward the market is in the patient’s best interest, or if it is a clever way to recruit subjects for Phase IV drug trials. On the other hand, it may provide the impetus for physicians to become maximally familiar with a new drug to be prepared for the forthcoming wave of patient questions. Finally, however, the patient can always trump the matter with a, “If you won’t give it to me, then I’ll find a doctor who will.”

“Depression: where does it hurt?” “Everywhere.” “Depression: who does it hurt?” “Everyone.” And so goes the advertisement for Duloxetine. It takes eight and one-half pages of small print in the PDR (2009) to summarize its risks and benefits, or a one minute television spot directed at people with all variants of dysphoria. One of the dilemmas of psychiatry is to determine if a given dysphoria is an innate phenomenon or a reactive disorder. A pill cannot cure the normal reaction to job loss, marital dissolution or other forms of grief-involved loss unless it results in a particular physiologic state specifically described in DSM – IV, (the five out of nine criteria.) The world today is filled with the situations of ensuing dysphoria, and though no specific lab tests for major depression are in use, we must learn to differentiate the physiologic state of depression from a reactive disorder before we can know the extent to which Duloxetine and other antidepressants are effective. The TV ad does not do this. It simply implies that if one is unhappy, he is depressed. The further implication is, “Take this pill and you will be happy.” It is of note that the Hippocratic Oath never speaks of making people happy, but rather its impetus is “to relieve suffering.” The subtle cues of happiness given in this ad, (staring adoringly at one’s wife or dog, etc.) appeal to the emotions rather than to the rational side of thought.

Nasal Allergy: The media is abuzz with the over-sized bee, his heavy Mediterranean accent, and his professorial enumerations of the wonders of topical nasal steroids on nasal allergy. The bee and pollen analogy are fairly straightforward, though the accent is not. Perhaps it is meant to make the bee sound kindly and professorial. Once again the kindly old bee doesn’t mention nasal perforations, oral candidiasis, increased intraocular pressure, pharyngitis, and decreased growth velocity in children, or congenital malformations such as cleft palate and other bone deformities in laboratory animals treated with this class of drugs.

PDE5 Inhibitors: Cialis has a six and one-half page dissertation in the PDR including mechanism of action, pharmacology, complications and specific contraindications. The same applies to the other PDE 5 Inhibitors. On TV, it shows a couple holding hands in separate bathtubs, a hotel door closing with a “Do Not Disturb” sign on the knob, or the Viagra-sponsored NASCAR vehicle zooming by. The suggestion of benignity lends itself to a “buddy-buddy” congeniality with this class of drugs. Although mentioned, the occurrence of angina, m.i., acute hypotension, or acute priapism are presented as if they could only happen to someone else. Some patients, desiring this drug at all costs, might memorize the given contraindications and deny every one of them to a physician with disastrous consequences to himself and the public perception of the drug.

Biphosphates for the treatment of osteoporosis appear regularly over the TV medium. These are illustrated by swimming skeletons, elderly ladies dancing with long unfurling scarves, or Sally Field sitting cross-legged on a bed talking girl-to-girl. As a group, these seem the most beneficial and the least risky of all the marketed drugs. There are a few simple rules as to how to take the medicines which are relatively uncomplicated, and side effects which may occur are well spelled out. The ads don’t mention correcting low serum levels of calcium or Vitamin D before starting the medicines, but presumably a physician would address this

Hormonally Based Contraceptives: These products are often represented in the TV medium by a lot of hopping, skipping, and smiling. Evidently it is a kind of menstrual dance in which a female is reassured that she is not pregnant. No one is hopping around on a thrombophlebitic leg, though this is mentioned in highly scientific terms, and certain contraindications are given.

Antibiotics: These are conspicuously absent from the medium with the exception of oral medicines to prevent the spread of Herpes type II. These ads often present a couple in close and intimate circumstances, smiling and unconcerned about the future (or the past).

Statins: These are usually represented by a relatively young guy who unfortunately had a heart attack. He does the right things: he is not obese, rides his bike, and doesn’t smoke, then, whammy, he has a heart attack. Another well-traveled ad is the famous cardiologist who does all the right things and takes his statin medication. Finally there is the dancing guy who splits in half to demonstrate his combined statin and calcium channel blocker BP medicine all in one tablet.

Donepezil (Aricept) is well-represented by the old guy on television with the kindly but vacant look in his eyes. On the medication, he is able to recognize his grandchildren a little better, also his friends, and is less prone to wander off. His ADL’s are bit improved when he picks up a cue stick to shoot some pool, but hope is not raised that the ravages of his illness will suddenly disappear. There is emphasis of his family consulting professionals prior to embarking on this treatment.

Conclusion: The three blind men who examined the elephant could argue endlessly over the advertisement of prescription drugs in the TV medium. On the one hand it increases patient awareness of new treatments and drugs therapies. On the other hand it asks them to make medical decisions for which they are ill-prepared. That is not to say that they may not have “Googled” the topic half to death. It puts the physician under duress if in his clinical judgment the new treatment is ill-advised or not superior to traditional therapies. Sometimes it creates an almost adversarial circumstance when the patient demands a new therapy.

The TV has gone from an odd curiosity in the early 1950’s to the source of most household knowledge. It is hard for some people to distinguish between the news and a marketing spot. Until such time that these delineations are clearer, it behooves every physician, physician assistant, and pharmacist to stay absolutely current with contemporary biopharmacology to be of maximal service to his patients.