Published 3/1/2008
Stephen P. Makk, MD, MBA

DTCA on trial: Addressing the issues

Two recent articles in AAOS NOW—“DTCA: Improving patient education or simply increasing pharmaceutical profits?” (December 2007) and “Give them what they need, not what they ask for” (January 2008)—piqued my interest and begged for additional discussion and clarification. Together, they put direct-to-consumer advertising (DTCA) on trial while leaving room for additional, valuable discussion points.

Advertising is the use of media—including print, mail, radio, television, and the Internet—to promote products and services. Marketing, on the other hand, involves proactively determining your customers’ needs and then devising solutions that meet or exceed their expectations. Branding is an intangible asset that reflects consumers’ mindshare and determines selection behaviors. Although these terms are often confused, understanding the distinctions will ultimately help to provide better care for our patients.

Traditionally, health recommendations were paternalistically communicated from physicians to patients. Advertising and marketing activities were directed from medical device, pharmaceutical, and service companies to physicians. With the advent of the Internet and more effective search engines, medical information has become widely available and more transparent. Arguably, not all of it is accurate.

The introduction of DTCA in health products and services has proven to be an effective marketing technique, increasing sales, and allowing patients with a variety of medical conditions to become both educated and treated. Advertisements are subject to truth-in-advertising laws under the Federal Trade Commission Act (www.ftc.gov), which requires that they be fair, truthful, and nondeceptive and that claims be backed up by evidence. The Act defines “deceptive” as likely to mislead consumers acting reasonably under the circumstances and applies it to “material” claims—those important to a consumer’s decision to buy or use the product.

Another side of DTCA
According to the Washington Health Policy Fellows, “the Food and Drug Administration (FDA) has only 40 employees to review more than 30,000 advertisements per year” and “it appears that regulatory agencies such as the FDA will be hampered in their ability to control and monitor the content of such advertising.” Doing the math, if the 40 employees each work 222 days per year, reviewing 30,000 ads would require that each of these tax-supported government workers evaluate 3.38 ads per day. This is hardly an oppressive workload in my estimation.

Is DTCA circumspect and deceptive? Does it undermine the physician-patient relationship, waste encounter time, and misallocate precious healthcare resources? Consider whether ads that encourage screening colonoscopies or monthly breast self-examinations cause overuse. Arguably, if everyone who could benefit from them actually did them, the costs to the system would be immense in the short-term. But wouldn’t they be worth it?

Although healthcare companies are “profit-driven enterprises,” I would be remiss, as the chair of the Practice Management Committee, if I did not point out that so are we! Physicians must remain financially viable or the “best and brightest” will not seek medical careers and patients may not receive the best care.

Pharmaceutical and medical device manufacturers drive worldwide health innovations and bring them to market. Ultimately, it is OUR responsibility to educate patients, not theirs. Consumers make economically based decisions when it is in their best interests with the information that they have. They decide whether or not it is “worth it” in their opinion.

Although DTCA television advertisements present benefits at a sixth-grade level and the risks at a ninth-grade level, can an orthopaedic surgeon with a “twenty-fifth”-grade education present them any better? Are all physicians always effective communicators selflessly acting in their patients’ best interests? Perhaps some of us need more than ever to attend the AAOS Communications Skills Mentoring Program.

It’s true that the European Union (EU) restricts DTCA and that the United States and New Zealand are the only countries that allow it. But most countries in the EU have socialized medicine, while the United States and, to some extent, New Zealand have a mix of private and public healthcare. Companies in socialized environments market to the government that makes the purchasing decisions. Are these always in the best interests of each patient, or simply good enough for most?

One study shows that 3 out of 4 orthopaedic surgeons believe that DTCA negatively affected their patient interactions and their overall practices, that patients came to office visits with inaccurate information, and that patients were confused about procedures and implants for their particular orthopaedic ailments. That same study also points out that “direct-to-consumer advertising seems to play a substantial role in surgeon- and patient-decision making in orthopaedics. Future efforts should be aimed at improving the quality and accuracy of information contained in consumer-directed advertisements related to orthopaedic implants and procedures.”

Dealing with the cyberchondriac
Although Thomas K. Fehring, MD, (“Give them what they need, not what they ask for, AAOS Now, January 2008) credits “direct-to-consumer marketing” as creating “a new type of patient,” he may actually have meant DTCA. Marketing” would mean that patients’ needs were proactively determined and solutions were crafted to meet or exceed their expectations. However, his “We should see it as an opportunity to present concisely our fund of knowledge on the subject” hits the nail on the head and rises to the “marketing” challenge beautifully.

A patient with an inch-thick pile of Internet downloads should not be perceived as a threat. Instead, embrace this as an opportunity to show the patient what you know. If you have problems communicating with patients on their own level, then seek out the excellent patient education materials that the AAOS offers. You’ll reduce wasted time and win the patient’s confidence.

Cyberchondriacs are patients with great, unaddressed needs that they care deeply about. They provide a perfect opportunity for you to score as both an effective communicator and a skilled physician and surgeon. Focus on the underlying concern, address it, temper it with your medical training and judgment to arrive at the right treatment, and you should win the patient over.

As Dr Fehring correctly points out, you must know when to say “no” even if doing so risks losing the patient to someone else. Effective communications will help ensure this is a rare occurrence; if you find it happening often, examine your communication techniques and take advantage of AAOS resources.

Physician-based ads
Another subject that merits attention is physician-based advertisements. All fellows, particularly those who advertise, should familiarize themselves with the Standards of Professionalism (SOPs) on Advertising, which is available on the AAOS Web site.

Physician infomercials and newspaper ads generally fly beneath the regulatory radar. If you advertise, be sure your ads do not make unrealistic claims or promote unrealistic expectations. How many innovators, designers, and “firsts” do we truly have among us? Do your marketing and advertising ethically. The SOPs is a helpful guide, and the AAOS has marketing resources available.

The bottom line is that DTCA will not go away and we cannot stick our heads in the sand. We must own it by being effective communicators and shepherds of our patients’ best interests. To not do this is not in our own or our patients’ interests. We need to hold deceptive advertisers accountable both individually and collectively so that responsible ads prevail and marketing works well.

Stephen P. Makk, MD, MBA, is chair of the AAOS Practice Management Committee and a member of the AAOS Now Editorial Board. He holds an MBA from the Kellogg Graduate School of Management at Northwestern University.