Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Monday, February 11, 2013

On Medical Advertising

There was a time, somewhere around late September of 2012, when I suddenly noticed a void in my life. The presidential campaign, in all its inglorious malignancy, was ramping up, and political advertisements, in a novel form of Gresham's Law, were squeezing medical advertisements out of their usual time slots. There finally came a point when I realized that I hadn't seen a Cialis commercial in over two weeks.


No pictures of middle-aged couples sitting in paired bathtubs, holding hands! No languorous looks followed by the importation to pop a pill "when the moment's right." Instead, nothing but angry middle-aged men screaming at their opponents, who screamed back. How I longed for direct-to-consumer advertising, for the first and no doubt last (at least until the fall of 2016) time.


It got me thinking about medical advertising. Like most physicians, I despise direct-to-consumer advertising. The advertisements exist for the sole purpose of selling on-patent, expensive mass-market drugs. The drugs being advertised are frequently no better than an older, cheaper, off-patent compound. 


The  patients in these commercials, if one can call them that, are nothing like what I see in my office. In fact, despite a pressing need for whatever most expensive on-patent drug they can lay their hands on, they always seem healthier than me: fit, always smiling (once they have their pills and solve all their problems) and delighted to benefit from the wonders of modern medical science. One hardly even notices the voiceover describing the rare but lethal complications that may occur: contact your doctor immediately if your right arm falls off. But then, these charmed people never suffer side effects.


These advertisements waste an enormous amount of precious office time, as busy doctors patiently explain why the drug being advertised is not right for the patient's condition. Or, even worse, the doctor is so busy that he or she prescribes the more expensive, advertised, on-patent drug rather than take the time to explain its faults.


As a practicing oncologist, direct-to-consumer advertising has never wasted that much of my time. Cancer drugs are intrinsically niche, rather than mass-market, pharmaceuticals. I’m safe as long as cable TV lacks a triple negative breast cancer channel.


The one exception I recall happened a few years ago, when the makers of erythropoietin suddenly decided to perform direct-to-consumer advertising. My memory is of a grandfatherly individual unable to play with his grandchildren until, Lazarus-like, EPO resurrected him from the grave of his cancer-related fatigue. My subsequent lack of grief over that drug's fall from grace resulted directly from that advertisement.


Health care represents about one-seventh of the American economy, so the fact that drug makers would try and bypass gatekeeper physicians to improve their profit margin is no surprise. In 2011 drug companies spent $2.4 billion on direct-to-consumer advertising. This is actually lower than previous years. After peaking in 2007 at $3.1 billion, such advertising has declined every year, perhaps as a function of several blockbusters going off patent.


How successful is direct-to-consumer advertising? When Myriad Genetics took up direct-to-consumer marketing of BRCA mutation testing, the Centers for Disease Control examined its effects by comparing cities where the ads aired in comparison with “control” cities, polling doctors on test ordering.  Put simply, more patients asked for BRCA tests, and doctors ended up ordering more tests. Maybe that’s not a bad thing: BRCA testing is almost certainly underutilized by physicians.  But explaining breast and ovarian genetic testing is never a simple or quick conversation.


Dhaval Dave and Henry Saffer of the National Bureau of Economic Research published a paper in 2010 that modeled the effects of direct-to-consumer advertising. Looking at the period 1994-2005 (a period bracketing 1997 and 1999 FDA rulings that led to the expansion of direct-to-consumer advertising), the authors concluded that “the expansion in broadcast DTCA may be responsible for about 19 percent of the overall growth in prescription drug expenditures over the sample period, with over two-thirds of this impact being driven by an increase in demand as a result of the DTCA expansion and the remainder due to higher prices.”

Want to pay for Obamacare? Eliminate DTCA.

Doctors and Lawyers

Direct-to-consumer advertising is only one aspect of medical advertising.  The lawyers want in on the action, as always.  Medical-legal advertisements rarely talk about malpractice, at least not the TV adds I see. Medical-legal ads seem to come in two forms: mesothelioma ads, and commercials decrying the hazards of modern medicines. The mesothelioma ads are a consequence of lawsuits settled decades ago by the asbestos industry, with class action lawsuits providing a continuing revenue stream for certain law firms. They barely need to work to get paid: the existence of the disease, and evidence of asbestos exposure, are all the evidence one needs.


The ads, which tend to appear late nights and weekends on the more down-and-out second-string cable channels, are formulaic: “If you or a loved one was diagnosed with mesothelioma, call the number on your screen now…” Mesothelioma is a bad disease, call us and we’ll send you a book on mesothelioma written “by doctors who care for patients with the disease,” and you are entitled to a settlement.


The other medical-legal ads all tend to direct you to the same hotline: 1-800-BAD-DRUGS, which says it all. The Minerva IUD, transvaginal mesh, and Yaz and Yasmin oral contraceptives are among the targets of these advertisements. Yaz, for instance, causes blood clots.  Why pick on Yaz, when every oral contraceptive known to (wo)man causes blood clots? Partly because Yaz had a higher clot rate, and partly because its maker had made some unfortunate product claims. But mostly, one suspects, because Bayer has deep pockets: as of last year (according to Reuters) the company had settled some 3490 cases to the tune of $750 million.


Hospital Corporations Advertise

All right, so doctors hate direct-to-consumer advertising, and there is no love lost between physicians and lawyers, the dogs and cats of the professional world. But what about us medical types? Hospitals advertise, totally without shame. Most often these are local advertisements, part of the incessant low-level skirmishing carried on in cities across the country, though some (Cancer Treatment Centers of America) advertise nationally. Every hospital provides “world-class” medical care, delivered (always) by compassionate doctors who were tops in their medical school class and who use the fanciest new machines in the known universe. And they are holistic or wholistic or something like that.


Trust me, I’m a doctor, and I played one on TV, so I know about these things. My old hospital corporation, lacking any modicum of common sense, decided that it wanted me in a commercial devoted to cancer care.  It was the highlight of my acting career. In fact, it was my acting career.


I spent time in make-up: bird’s nest hair moussed, check! Pale, shiny skin made less pale and shiny, check! Then on to wardrobe. I haven’t worn a white coat in years, so they lent me one. Apparently I don’t look like a doctor unless I’m wearing a white coat. They also didn’t like my tie, replacing my cheerful baby blue one with a green-striped affair. Some hotshot branding expert had decided that green was the color for the cancer service line.


And then the filming. A veritable film company, with producer, directors, cameramen, gaffers, and grips. I don’t know what gaffers and grips do, but I always see them in film credits, so I assume they were present. I swear that they filmed me for what seemed like an hour. Somehow most of my oeuvre ended on the cutting room floor, for in the final product I occupy the screen for approximately 0.75 seconds, with me looking on reassuringly as I sit next to my bald, concerned-looking breast cancer patient.


My patients loved it, or at least found it amusing, though I admit the experience left me a tad nervous. I prefer my patients to come to my clinic for my medical expertise, not my Hollywood-handsome good looks (all right, I can fantasize). During last year’s Olympics, the local Indianapolis hospitals flooded the airwaves with these commercials. I saw myself three times in an hour, which totally ruined my appreciation of the women’s volleyball finals. I had to stop watching.


Probably the best part of my recent move to the West coast was that, as soon as my departure was announced, my advertisement was unceremoniously yanked from the air. Maybe it’s still circulating on YouTube, though a brief search failed to turn it up. Fame is fleeting in the medical advertising world. If only all the other advertisements would follow my example. The world would be a better place.