Bioethics Discussion Blog: Ask Your Doctor and You May Receive

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Tuesday, March 13, 2007

Ask Your Doctor and You May Receive

The study published in the March 12 2007 issue of Archives of Internal Medicine may help explain how direct to consumer advertising may affect physician prescription writing, the topic as discussed in the last thread. But more than that it could explain, if confirmed by further study, the mechanism by which the costs of medical care may be rising through the physicians’ response to the public’s medical consumerism.

As summarized by the physician’s medical news publication “First Watch”,

“ Researchers interviewed patients in waiting rooms just before their visits; those expressing a wish for a new drug, test, or referral were invited to participate by having their visit audiotaped. In 200 such clinical encounters, some 250 expectations were communicated and 67% were met. Expectations for drugs and tests were met more frequently (both about three-quarters of the time) than were referral requests (just over a third of the time).

Physicians, when asked on a post-visit questionnaire to report requests their patients had made, said that, had the patients not asked, they would not have fulfilled almost half of the 138 requests so reported. They said they felt ‘uncomfortable’ about fulfilling 8 of the requests.

The authors comment that the unmet expectations did not seem to negatively affect patients' satisfaction or trust.”

I would ask my visitors if they have had any experience asking their physicians for specific drugs, specific tests or specific referrals and whether their requests were met. ..Maurice.

12 Comments:

At Thursday, March 15, 2007 11:00:00 AM, Blogger Lisa said...

My experience is with bowel-cleansing preps for colonoscopy. As a 28-year-old 21-year Crohn’s patient, I have to be screened for colon cancer every year. I used to use liquid Fleet’s Phospho Soda preps, which caused horrible nausea every time I used them. So, I’d drink some, I’d throw it all up, I’d call the doctor and ask them what to do. The reply was always “drink some more.” So I’d drink some more, I’d throw it up, and the cycle would continue (antiemetics, which didn’t occur to anyone until I actually asked for them, didn’t help). It was a struggle every time to keep enough down to be adequately prepped. I went to every appointment in fear that they would decide the prep wasn’t good enough and send me home to do it again. This went on until I got an issue of an IBD advocacy group’s magazine, and the back had an ad for a product called Visicol. It’s a colonoscopy prep, but in pill form. I tore it out and took it to my GI specialist. He wasn’t familiar with it, but agreed to give it a try. The stuff is nothing short of a miracle. I don’t suffer from terrible nausea and vomiting anymore, and I always get good preps. When I’ve had to move to other doctors, I always tell them I use Visicol. The last 2-3 times this has happened, the physicians I’ve consulted with have never heard of it. Why should they have? As far as most physicians are concerned, old-fashioned preps work just fine. The fact that these preps might make some people too sick to tolerate them doesn’t seem to be on doctors’ radar enough to make them aware of alternatives to liquid preps. It seems to me that stuff like this just doesn’t register with physicians who have always prescribed the same thing to all their patients. There’s really no reason for them to learn about any alternatives if their patients never ask, and their patients never ask because they’re not aware there are any alternatives, and so on. If the only way to make people aware were some kind of “public health message” along the lines of “talk to your doctor about alternative colonoscopy preps” chances are the response you would get would be “Hmm.. I’m not really aware of any.” My doctors have always been open to using Visicol once I explain what it is (and yes, I am aware of the risks associated with using it). Is there something wrong with this scenario that would be fixed if the drugmaker weren’t allowed to advertise?

 
At Thursday, March 15, 2007 8:11:00 PM, Blogger Maurice Bernstein, M.D. said...

Patient education through advertisements would be acceptable if two conditions are met.
1) The drug is one that is well established with regard to efficacy and safety by pre-marketing research studies and has outlived a several year or more period of general use without problems occuring.
2) The advertisement is limited to those patients who have the disorder which the drug is known to treat. In the case of Lisa, publishing the ad in a magazine of an inflammatory bowel disease advocacy group would appropriately direct the education to the very patients for whom the medication is most needed and not others who do not have the diagnosed disease.

I have never held the view that patients who find, through whatever media, information regarding their disease which was not mentioned by their physician, shouldn't ask their doctor about what they learned. As I have said previously, both doctor and patient must work together and share information which could aid in the goal of treating the illness more effectively. ..Maurice.

 
At Friday, March 16, 2007 1:12:00 PM, Blogger Lisa said...

I'm curious about your condition #1. The only way to know if a drug has side effects is for people to use it. It's not as though once a drug is approved by the FDA it's put into the water supply and everyone is exposed to it whether they like it or not. Everyone takes a drug by choice. Even if you want to extend the approval process, someone still has to try the drug in premarket clinical trials. To say that "not enough is known about a drug" sounds almost as if there's a certain population of people who are sacrificial lambs, upon whom it's ok to test new drugs, but the rest of the population deserves better than to have to take drugs about which not enough is known. To take the attitude of "I'll wait" does not make drugs safer, it simply shifts the burden of risk to people other than you. How much is "enough" knowledge about a drug, and who should have to shoulder the burden of risk of trying a new drug in order to get that knowledge?

 
At Friday, March 16, 2007 9:51:00 PM, Blogger Maurice Bernstein, M.D. said...

Lisa, I am writing about advertising a drug to the public. I don't think it is appropriate to advertise a drug when it is still new and complications, not noted in pre-market research, haven't yet or just begins to appear. The information regarding a drug as advertised by the pharmaceutical company to the public should be part of the full informed consent if the drug is finally to be prescribed by a physician. It would be non-beneficent to the public to make a drug sound rosey like Vioxx when there is a hidden danger yet to be revealed. Waiting for time to prove efficacy and safety is usually of no harm to the patient. There are cheaper and older drugs that are often as effective as the new ones which a physician can prescribe and which have survived the test of time. ..Maurice.

 
At Saturday, March 17, 2007 4:39:00 PM, Anonymous Diora said...

A couple of times I asked for specific drugs - none based on the ads:
1. Renova - don't know if it even counts - I bet lots of women ask about it by name. Curious that the company doesn't even bother advertising.

2. Specific form of HRT: Prometrium instead of norethindrone acetate as part of HRT. I found out that micronized progesterone doesn't have a negative effect on cholesterol while norethindrone acetate does, and it was a bit of a problem that one year. I also asked for Vivelle Dot patches instead of Climara: same beta 17 estradiol, but much smaller size. Found out on early menopause support board from other ladies about Vivelle Dot; did some research on progesterone on my own.

Don't particularly like drug ads. Usually fast forward through most of them anyway. Some are more annoying than others, especially when the person in the ad doesn't look at all like the typical one to need the drug - e.g. those showing slim active women in statin ads. Ads for psychiatric drugs for kids are annoying as well.

 
At Saturday, March 17, 2007 7:55:00 PM, Blogger Lisa said...

"Waiting for time to prove efficacy and safety is usually of no harm to the patient."
So, again, who is supposed to be trying this drug to get this information? Is there a specific population of patients who should be doing this so that everyone else can use the old drugs and wait to see what happens to those who try the new ones?

 
At Sunday, March 18, 2007 9:56:00 PM, Blogger Maurice Bernstein, M.D. said...

Lisa, I wrote about advertising a drug to the public,. Of course, physicians should be made aware of the new drug and if the physician finds that the early found benefit, early found risks and costs of the drug is appropriate, it is the physician who should add this drug to the list of appropriate drugs which should be then discussed with the patient.
The new drug will then be part of the therapy of a larger and broader group of patients than the initial studies. If after experience of the general use of the drug finds the drug truely useful and safe, I would consider advertising to the public more appropriate. Yes, I do believe that physicians are generally much more medically educated than their patients and are the ones to first receive and contemplate the value and safety for their individual patient. ..Maurice.

 
At Monday, March 19, 2007 2:02:00 PM, Blogger Lisa said...

I understand that you are talking about advertising. Perhaps I was not clear enough. Imagine that the universe of patients consists of two people: you and me. We have the same disease, but different doctors, and we live in a world with no drug advertising at all. A company comes out with drug X, which is targeted toward our disease. My doctor, who is always on the lookout for new therapies, decides to discuss the risks and benefits of drug X with me, and I decide to give it a try. Your doctor, on the other hand, believes that it’s too risky to try drugs until they’ve “been on the market a few years”, and chooses not to mention drug X to you at all. Trusting that he presents you with all available therapeutic options, you go on as before. Essentially, it seems to me that you doctor, based on his personal tolerance for risk, has decided that people like me, whose doctors have a slightly different view of new drugs, should be the guinea pigs who make sure that drugs are “safe enough” for his patient (you). Because you are unaware that there are new therapeutic advances, you don’t get a chance to try drug X until your doctor decides it’s been sufficiently tested on me. You don't even get a chance to discuss it with your doctor or find a doctor who is willing to discuss it intelligently with you. In essence, you are “the public” who deserves only safe and well-tested drugs, and I am the patient whom it’s somehow OK to experiment on. I think that scenario has a lot of problems. What do you think?

 
At Monday, March 19, 2007 6:04:00 PM, Blogger Maurice Bernstein, M.D. said...

Lisa you are correct. It is the patients whose physician prescribed the new medicine that will become the pool of monitored or unmonitored "guinea pigs" who will allow the post-marketing efficacy and safety to be demonstrated. Every physician, whether agreeing to prescribe or disagreeing to prescribe should inform the patient about the new drug. Those patients whose physician concludes that the new drug would be appropriate for the patient must also relate to that patient the uncertainties of all new drugs as they enter the world-wide market. The patient must then decide on their own if they want to become that "guinea pig". But let this conversation about new drugs occur between doctor and his or her specific patient with a worked up disease and not between the pharmaceutical company and any person out there in TV land with "who knows what" symptoms and "who knows what" disease, if even present. ..Maurice.

 
At Thursday, April 05, 2007 1:13:00 AM, Anonymous Chris and Vic said...

With respect to Lisa's questions:

In order for your proposed plan to work, Dr. B., the patient and doctor would have to dialog frequently. The patient would have more frequent visits, or at least phone conversations (or email access) with their doctors. That isn't how healthcare works.

On the horizon is disease management by a nurse who is specially trained to keep in close touch with patients who have chronic conditions, to monitor them daily, weekly, bi-weekly, etc., and to present their blood sugars (in diabetes), blood pressures (in hypertension), or whatever s/s that are significant in their chronic condition, to their physcians---with a view towards keeping them out of the hospital.

Lisa's interest in new drugs or treatments on the market, or her willingness to participate in a clinical trial of a new drug or treatment, could be on-record, and she could receive notice and have the chance to ask questions via this "disease management" option. OR her doctor could agree to be in close touch with her about these issues.
Chris and Vic

 
At Thursday, April 05, 2007 8:51:00 PM, Blogger Maurice Bernstein, M.D. said...

I agree with the posting of Chris and Vic. There are currently programs in some clinic situations where such nurse monitoring of chronic illnesses such as diabetes or congestive heart failure does involve literally daily communication with the patient. Problems or questions can easily be communicated to the supervising physicians regarding changes in management including changing medications. ..Maurice.

 
At Friday, December 12, 2008 7:12:00 PM, Blogger Maurice Bernstein, M.D. said...

I received the following e-mail from a visitor today that I thought would be appropriate for this thread...Maurice.


I have a great example of the over-use of these advertisements. While I was putting my four year old son to bed one night, he went to the window and said “I want the green butterfly”. At first I was really confused, then he said it again and I knew what he wanted. Lunesta! That is how powerful these adds are to the public. Even a child understood that “the butterfly” could help him sleep. Drug use in this country is epic. I am a firm believer in trying to cure the disease, rather than masking the symptoms. Medications have far too many underlining effects on the body. It should not be up to a patient to inform the doctor that they would like to be on abc medication.

 

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