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Direct-to-consumer print ads for drugs: Do they undermine the physician-patient relationship?
- Messages about physician-patient communication found in prescription direct-to-consumer advertising (DTCA) uphold rather than undermine the physician’s control.
- Keep in mind that patients encouraged by DTCA to ask you about prescription drugs are not necessarily demanding prescriptions.
- Be sure to discuss with patients who inquire about advertised products their risks and side effects—topics largely ignored by print DTCA messages.
Background Critics of DTCA contend it alters physician-patient communication by promoting greater patient participation and control. We assessed the nature of messages in print DTCA to identify potential guidelines they may provide to consumers for communicating with physicians.
Methods We analyzed all unique advertisements (ie, excluded ads repeated across issues or magazines) in 18 popular magazines (684 issues) from January 1998 to December 1999 (n=225). We identified every statement that referred to physicians, and within that set, statements that focused on physician-patient communication. Each communication-related statement was coded as a message to consumers about communication in terms of cues suggesting who should initiate communication, who should be in relational control, and appropriate interaction topic(s).
Results More than three-quarters (83.8%) of the advertisements’ statements referring to physicians focused on physician-patient communication (M=2.6 per ad; SD=1.8). Most (76.1%) of these messages explicitly or implicitly promoted consumers initiating communication, but cast the physician in relational control (54.5%). The most frequently suggested interaction topics were clinical judgments of the product’s appropriateness (41.8%) and information about the product (32.1%).
Conclusions Typical direct-to-consumer print ads contain multiple messages about communicating with physicians. The patterned nature of these messages appears to promote social norms for consumers’ communication behavior by repeatedly implying the appropriateness of consumers initiating interaction, physicians maintaining relational control, and avoiding negative consequences of advertised drugs as conversational topics.
Arecent medical journal debate focuses on effects of direct-to-consumer advertising of prescription drugs (DTCA) on the physician-patient relationship.1-11 Both sides contend that DTCA alters consumers’ communication behavior, and, ultimately, relationships with physicians, by encouraging greater patient participation and control. Increasingly, patients are asking physicians about advertised products and doctors do feel pressured to prescribe.12-20 Thus, research to date has indicated that social norms for physician-patient communication are changing, but has not accounted for DTCA’s features that focus directly on physician-patient communication. This study examines DTCA’s references to physician-patient communication that may imply guidelines for consumers’ interaction behavior.
Pro and con opinions. Opinions vary regarding DTCA’s effects on health care and public health.21 Critics disagree about DTCA’s effects on cost (including time),1-3,8,10,22-27 consumers’ knowledge,2,24-25 and health care quality.1,3,4,24-25 Advocates view DTCA as empowering patients to partner with physicians,4,24 initiate discussion,25 show interest, and ask questions.27,28 Opponents say DTCA undermines the relationship,2,24,29,30 by overloading physicians with time-consuming questions they are unprepared to answer,25,31 creating pressure to prescribe, and increasing patient demand that yields inappropriate prescribing.32
The issue centers on who should be “in charge.” Proponents tend to value patients’ empowerment;4,33 opponents generally advocate physicians’ authority.34 However, both sides agree that DTCA influences patients to communicate more actively and take greater control.
Ultimate goal of DTCA.Because obtaining prescription drugs requires physicians’ cooperation, DTCA’s aims differ from traditional advertising. Successful ads must both attract consumers to products and facilitate consumers gaining physicians’ cooperation. Even “sold” consumers may not have the communication skills to interact appropriately and persuasively with physicians. Thus, to succeed commercially, DTCA must encourage particular consumer communication behaviors.
Establishing who is in control. Physician-patient relationships are developed and maintained largely via communication patterns. Communication patterns associated with physician-patient relationship models differ, largely, in terms of relational control.35,36 Relational control, accomplished through communication, “refers to the process of establishing [who has] the right to direct, delimit, and define the actions of the dyad,” in this case, the physician-patient relationship.37
Paternalism36 casts the physician in control of information and decisions, and the patient as expected to cooperate.38
Participatory models35 reflect a partnership with relatively equal power evident in mutual information sharing and exploration of alternatives.38
Consumerism places control in patients’ hands; consumers may bargain and engage actively in communication, but theoretically they control final decisions and may demand particular treatment regimens.36
Are DTCAs “training” consumers? Previous content analyses of DTCA focus on marketing factors (eg, ad frequency, product type)39,40 and on appeals, motivators, or inducements for consumers,39-41 but do not address DTCA’s statements about physician-patient communication.42 When social cognitive theory is applied to DTCA, it suggests that DTCA may “train” consumers by providing models or examples from which to learn vicariously, while associating those models with positive outcomes or rewards, and the advertised drug, thus motivating consumers to seek the product.43 Thus, DTCA may encourage specific communication behaviors as the means to acquire advertised products. If so, its influence may lie less in its educational function than in its social training function.
Although medical information may help consumers establish credibility and arm them with medical content for discussion, DTCA’s statements about communication may imply guidelines for interacting appropriately with physicians. An ad that reads, “Ask your doctor about drug X,” explicitly provides a model opening line and contains implicit messages about who should initiate interaction (the consumer, encouraged to ask), who should have control (the doctor, upon whom the patient depends for an answer), and appropriate interaction topics (drug X). This interpretation of DTCA’s messages is rooted in relational communication theory and research; a consumer urged to “ask” a physician is cast as “one-down”37 or dependent on the physician for an answer. Alternatively, a consumer urged to “tell” a physician is portrayed as “in charge.” A message to “discuss” a matter with a physician indicates shared control.
The aim of our study. Our general question was: “What social norms regarding physician-patient communication does print DTCA suggest to consumers?” Specific research questions were:
How frequent are references to physicians in print DTCA?
How frequent are messages about physician-patient communication in print DTCA?
Within messages about physician-patient communication, what guidelines are implied, and with what frequencies, regarding: (a) who should initiate interaction, (b) who should have relational control, and (c) appropriate topics for interaction?
Methods
Sample
We examined all DTCA in 18 popular magazines (684 issues) from January 1998 to December 1999. We followed Bell, Kravitz, and Wilkes’s procedures to ensure a diverse sample of publications.39 Thirteen magazines were selected to represent the highest-ranked lay magazines (based on advertising pages sold) in specified categories; 5 additional magazines were selected to represent diverse populations. They were business (Business Week), fishing/hunting/guns (Field & Stream), food/wine (Gourmet), home (Better Homes and Gardens), men (GQ), music (Rolling Stone), news and opinion (Time), parenting (Parents), personal finance (Money Magazine), sports (Sports Illustrated), tabloid/general editorial (Reader’s Digest), women (Vogue), and medicine/health (Prevention); and ethnicity (Ebony and Hispanic), age (Modern Maturity and New Choices for the Best Years), and sexual orientation (The Advocate). We identified 994 product-specific and reminder ads for 83 drugs addressing 15 types of medical conditions.22 (Product-specific ads identify products by name and use and are subject to FDA monitoring guidelines.22 Reminder ads simply identify products by name, without identifying use or related claims, risks, etc.) After eliminating duplicates, the sample of 225 advertisements was analyzed.
Coding systems
The unit of analysis for this investigation was a statement focusing on physician-patient communication. For each advertisement, we first identified statements referencing physicians. (Although we included the terms “health provider” and “health professional” as references to physicians, all but 4 ads used the terms “physician” or “doctor.”)
Next, among references to physicians, we identified statements focusing on physician-patient communication (eg, “ask your physician;” “your doctor will tell you”). For these statements, we developed a coding system to reflect types of messages implied regarding physician-patient communication by systematically reviewing 25% of the sample, while considering relational control theory.37 Specific categories of messages, examples, and rules for coding were developed for 3 variables: (a) who should initiate communication, (b) who should take control, and (c) appropriate communication topic(s). Categories for each variable were mutually exclusive and exhaustive.
Upon completing development of the coding system, we applied it to the full sample of statements focusing on physician-patient communication. In addition, for each statement, the medical condition for which the drug was advertised was coded (14 disclosed conditions and a category for undisclosed conditions). Details of the coding system are available from the authors.
Initiating communication. Who should initiate communication was coded as (a) explicit directives to the consumer to initiate communication (eg, “ask your doctor,” “tell your doctor”), (b) implicit directives to the consumer to initiate communication (eg, “see your doctor about drug X,” “check with your doctor”), (c) references to doctor-initiated communication (eg, “your doctor will tell you,” “adhere to your doctor’s recommendations”), or (d) messages referencing both parties, implying either could initiate communication (eg, “my doctor and I agreed,” “you and your doctor must carefully discuss”).
Relational control. Consistent with relational control theory, 37 who should be in control was coded as (a) patient control (eg, “tell your doctor,” “let your professional know”), (b) physician control (eg, “ask your doctor,” “check with your doctor”), or (c) shared or unclear control (eg, “talk to your doctor,” “discuss with your doctor”).
Appropriate interaction topics. Suggested interaction topics were coded as (a) side effects, (b) risks of product use, (c) general product information, (d) clinical judgments (ie, determining appropriateness for the patient), or (e) topic unspecified or unclear (included multiple topics).
TABLE 1
References to physician(s) and to communication with physician(s) by medical condition
| PHYSICIAN REFERENCES | COMMUNICATION REFERENCES | ||||
|---|---|---|---|---|---|
| MEDICAL CONDITION | N* | M | SD | M | SD |
| Allergies | 35 | 1.83 | 95 | 1.74 | .89 |
| Cancer | 5 | 4.00 | .71 | 3.20 | .45 |
| Cardiovascular | 14 | 6.29 | 1.44 | 4.86 | 1.03 |
| Dermatologic | 12 | 3.58 | 2.81 | 2.00 | 1.04 |
| Diabetes | 15 | 5.93 | 4.28 | 5.27 | .77 |
| Gastrointestinal/nutritional | 14 | 2.43 | 1.09 | 2.07 | .83 |
| HIV/AIDS | 39 | 1.92 | 1.48 | 1.79 | 1.28 |
| Infectious (non-HIV) | 8 | 2.63 | 1.85 | 2.63 | 1.85 |
| Musculoskeltal | 14 | 2.64 | .63 | 2.14 | .66 |
| Obstetric/gynecologic | 22 | 2.36 | 1.65 | 2.09 | 1.41 |
| Psychiatric/neurologic | 16 | 4.06 | 1.69 | 2.94 | 1.06 |
| Respiratory | 4 | 4.00 | 1.63 | 3.00 | 1.63 |
| Tobacco/addiction | 8 | 4.38 | .74 | 4.13 | .64 |
| Urological | 13 | 3.69 | 2.06 | 2.85 | 1.07 |
| Undisclosed | 6 | .17 | .41 | .17 | .41 |
| TOTAL | 225 | 3.06 | 2.30 | 2.55 | 1.82 |
| *N refer to number of advertisements. | |||||
Coding procedures
A coder was trained, and initially acceptable inter- and intra-rater reliability levels were established. To eliminate effects due to particular magazines, products, etc, the 225 ads were placed in random order. The coder independently coded the randomlyordered sample of 225 advertisements. In addition, to assess reliability, the coder recoded (and the second author coded) a randomly selected subset of 25 ads. Final intra-rater reliabilities (percentage of agreement) and inter-rater reliabilities (Cohen’s kappa) were: initiator of interaction: 93.8%, κ=.93; relational control: 90.6%, κ=.89; and interaction topic: 92.2%, κ=.92.
TABLE 2
References regarding who initiates communication: Percentages by category
| MEDICAL CONDITION | N* | EXPLICIT | IMPLICIT | PHYSICIAN | EITHER |
|---|---|---|---|---|---|
| Allergies | 61 | 80.3 | 8.2 | 3.3 | 8.2 |
| Cancer | 16 | 37.5 | 12.5 | 37.5 | 12.5 |
| Cardiovascular | 68 | 89.7 | 1.5 | 4.4 | 4.4 |
| Dermatologic | 24 | 54.2 | 20.8 | 20.8 | 4.2 |
| Diabetes | 79 | 53.2 | 8.9 | 29.1 | 8.9 |
| Gastrointestinal/nutritional | 29 | 72.4 | 3.4 | 6.9 | 17.2 |
| HIV/AIDS | 70 | 81.4 | 2.9 | 4.3 | 11.4 |
| Infectious (non-HIV) | 21 | 100.0 | 0.0 | 0.0 | 0.0 |
| Musculoskeletal | 30 | 60.0 | 3.3 | 23.3 | 13.3 |
| Obstetric/gynecologic | 46 | 63.0 | 0.0 | 2.2 | 34.8 |
| Psychiatric/neurologic | 47 | 61.7 | 8.5 | 27.7 | 2.1 |
| Respiratory | 12 | 58.3 | 25.0 | 16.7 | 0.0 |
| Tobacco/addiction | 33 | 54.5 | 12.1 | 30.3 | 3.0 |
| Urological | 37 | 75.7 | 5.4 | 10.8 | 8.1 |
| Undisclosed | 1 | 100.0 | 0.0 | 0.0 | 0.0 |
| TOTAL | 574 | 69.7 | 6.4 | 14.1 | 9.8 |
| * N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication. | |||||
Results
References to physicians
The number of references to physicians per ad ranged from 0 to 12; the average exceeded 3 (TABLE 1). All but 4.4% of ads made reference to physicians. The major exception, mostly reminder ads for undisclosed conditions, contained little text. Numbers of references to physicians varied by disclosed medical condition, from lows of less than 2 (allergies, HIV/AIDS), to a high exceeding 6 (cardiovascular).
Physician-patient communication messages
The number of statements that focused on physician-patient communication ranged from 0 to 10 per ad. Most references to physicians (83.8%) focused on communication; typically ads contained more than 2 communication messages. Average numbers of communication messages varied by disclosed medical condition, from less than 2 (allergies, HIV/AIDS), to a high exceeding 5 (diabetes).
Cues regarding how to communicate with physicians
Who should initiate interaction. More than three quarters (76.1%) of communication references indicated that consumers should initiate communication; most did so explicitly (69.7%) (TABLE 2). The percent age of explicit directives to consumers to initiate communication varied widely by condition, from 37.5% (cancer) to 100% (non-HIV infection, undisclosed conditions). More than 50% of communication references, in all conditions except cancer, explicitly indicated the consumer as initiator. Implicit directives to consumers to initiate communication ranged from 0% (non-HIV infection) to 25% (respiratory).
Relatively few messages indicated the physician as initiator (14.1%), varying by medical condition from 0% (non-HIV infection, undisclosed) to 37.5% (cancer).
Messages indicating either party could initiate communication appeared in less than 10% of the statements (9.8%) and varied by medical condition from 0% (non-HIV infection, respiratory, undisclosed) to 34.8% (obstetric/gynecologic); this type of message appeared in less than 10% of communication messages in ads for 10 conditions.
Who should have relational control. The majority (54.5%) of communication messages placed physicians in control (TABLE 3). Nearly one third (30%) indicated shared (or unknown) control, while only about 15.5% cast consumers in control. However, relational control cues varied widely by medical condition. Physicians were cast in exclusive control in ads for undisclosed conditions (100%), although these numbers were small. For disclosed medical conditions, physician control ranged from 17.4% (obstetric/gynecologic) to 75% (dermatologic, respiratory). Consumer control ranged from 0% (gastrointestinal/nutritional, dermatologic, and undisclosed) to 38.2% (cardiovascular). One of the most striking differences due to medical condition occurred for obstetric/gynecologic ads, in which shared/unknown control dominated (80.4%).
Appropriate interaction topics. The most frequently suggested interaction topic was clinical appropriateness (41.8%), followed by general product information (32.1%) (TABLE 4). Fewer than 1-in-5 suggested topics focused on products’ negative aspects (8.5% each for side effects and risks). For 9.1% of the statements, no topic was suggested, or the suggested topic was unclear. Suggested topics varied by disclosed medical condition. Clinical judgment accounted for 30% or more of suggested topics in most disclosed medical conditions, ranging from 20% (dermatologic) to 67% (respiratory). General information accounted for 25% or more of suggested topics in most of the disclosed conditions, ranging from 12.5% (cancer) to 59% (allergies). The topic of side effects ranged from 0% (allergies, gastrointestinal/nutritional, tobacco/addiction, undisclosed conditions) to 19.1% (cardiovascular). Similarly, the topic of risks ranged from 0% (5 conditions) to 41.3% (obstetric/gynecologic). Follow-up analyses revealed that when the suggested topic was negative (risks or side effects), in only 10 of 98 cases (10.2%) was the physician indicated as initiating communication.
TABLE 3
References indicating relational control by medical condition: Percentages by category
| MEDICAL CONDITION | N* | CONSUMER | PHYSICIAN | SHARED | |
|---|---|---|---|---|---|
| Allergies | 61 | 11.5 | 52.5 | 36.1 | |
| Cancer | 16 | 18.8 | 31.3 | 50.0 | |
| Cardiovascular | 68 | 38.2 | 42.6 | 19.1 | |
| Dermatologic | 24 | 0.0 | 75.0 | 25.0 | |
| Diabetes | 79 | 8.9 | 69.6 | 21.5 | |
| Gastrointestinal/nutritional | 29 | 0.0 | 65.5 | 34.5 | |
| HIV/AIDS | 70 | 10.0 | 51.4 | 38.6 | |
| Infectious (non-HIV) | 21 | 38.1 | 61.9 | 0.0 | |
| Musculoskeletal | 30 | 26.7 | 56.7 | 16.7 | |
| Obstetric/gynecologic | 46 | 2.2 | 17.4 | 80.4 | |
| Psychiatric/neurologic | 47 | 23.4 | 53.2 | 23.4 | |
| Respiratory | 12 | 16.7 | 75.0 | 8.3 | |
| Tobacco/addiction | 33 | 21.2 | 57.6 | 21.2 | |
| Urological | 37 | 5.4 | 73.0 | 21.6 | |
| Undisclosed | 1 | 0.0 | 100.0 | 0.0 | |
| TOTAL | 574 | 15.5 | 54.5 | 30.0 | |
| * N refers to number of references to communicating with a physician. | |||||
TABLE 4
Suggested topics for physician-patient communication by medical condition: percentages by category
| MEDICAL CONDITION | N* | CLINICAL | GENERAL | SIDE EFFECTS | RISKS | UNKNOWN |
|---|---|---|---|---|---|---|
| Allergies | 61 | 32.8 | 59.0 | 0.0 | 4.9 | 3.3 |
| Cancer | 16 | 50.0 | 12.5 | 12.5 | 6.3 | 18.8 |
| Cardiovascular | 68 | 54.4 | 20.6 | 19.1 | 2.9 | 2.9 |
| Dermatologic | 24 | 20.8 | 37.5 | 8.3 | 0.0 | 33.3 |
| Diabetes | 79 | 55.7 | 24.1 | 12.7 | 6.3 | 1.3 |
| Gastrointestinal/nutritional | 29 | 24.1 | 44.8 | 0.0 | 0.0 | 31.0 |
| HIV/AIDS | 70 | 32.9 | 41.4 | 10.0 | 0.0 | 15.7 |
| Infectious (non-HIV) | 21 | 28.6 | 38.1 | 19.0 | 0.0 | 14.3 |
| Musculoskeletal | 30 | 26.7 | 40.0 | 6.7 | 23.3 | 3.3 |
| Obstetric/gynecologic | 46 | 23.9 | 26.1 | 2.2 | 41.3 | 6.5 |
| Psychiatric/neurologic | 47 | 44.7 | 19.1 | 12.8 | 19.1 | 4.3 |
| Respiratory | 12 | 66.7 | 16.7 | 8.3 | 8.3 | 0.0 |
| Tobacco/addiction | 33 | 63.6 | 27.3 | 0.0 | 3.0 | 6.1 |
| Urological | 37 | 54.1 | 27.0 | 2.7 | 2.7 | 13.5 |
| Undisclosed | 1 | 0.0 | 100.0 | 0.0 | 0.0 | 0.0 |
| TOTAL | 574 | 41.8 | 32.1 | 8.5 | 8.5 | 9.1 |
| * N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication. | ||||||
Discussion
Typical DTCA contains multiple messages about physician-patient communication. The primary way that DTCA may endorse a participatory model is via messages that encourage consumers to initiate conversations with physicians about products. About 70% of communication references explicitly direct consumers to do so. Otherwise, ads do not encourage consumers’ control. In fact, nearly 55% of communication references cast the physician in control, while only 15% placed the consumer in control. Thus, DTCA reinforces physicians’ relational control while encouraging consumers to initiate communication.
DTCA steers conversation topics toward products’ benefits and away from their deficits. Ads most often suggest products’ medical utility and appropriateness as topics (ie, general information, clinical judgments), while avoiding negative topics (ie, side effects, risks).
DTCA’s communication lessons for practice
Present results have implications for physician-patient interaction. First, to the extent that DTCA influences patients’ communication behavior, physicians increasingly may encounter patients who initiate communication by asking questions, often about advertised drugs. Some physicians may see such questions as requests or even demands for those drugs. Physicians report feeling pressure to prescribe products about which patients inquire;9 thus, patients merely asking more questions may be perceived as “demanding.”44
However, physicians often perceive “patient demand” when patients have not specifically asked for a drug.45 Physicians may want to check their perceptions before acting on them, recognizing that such questions may indicate patients’ preferences for a more participatory model, which, in turn, is associated with greater patient satisfaction.46,47 Physicians desiring to avoid conflict when patients ask questions might encourage their participation rather than assuming “patient demand” or feeling pressure to alter prescribing behavior.
Second, despite some physicians’ concerns, DTCA’s communication messages do not encourage patients to take relational control, nor do they undermine physicians’ prescribing authority. Theoretically and ethically, physicians remain in control of decisions, including prescribing, by serving as learned intermediaries or “conduits of information between manufacturers and patients.”48 Practically, physicians remain in control because their cooperation is necessary, even in cases where patients actively seek particular prescriptions.
Third, if DTCA influences patients’ choice of communication topics, patients may fail to inquire about drugs’ risks or side effects, a finding especially important in light of evidence indicating that consumers tend to not retain DTCA’s risk information.49 Physicians need to be alerted to these trends so they ensure that conversations with patients include explicit discussion of drugs’ side effects and risks.
Limitations
This study has several limitations. First, we analyzed print DTCA only. Generalizing findings to television and Internet DTCA may not be possible.
Second, our sample, dated from 1998 to 1999, may differ systematically from current ads. However, our study does provide a theoretically-driven methodology for assessing, and understanding the implications of, changes in advertising strategies across time and media.
Third, we analyzed marketing efforts targeting consumers. Physicians are exposed to numerous pharmaceutical marketing efforts that may contain messages regarding physician-patient communication.
Fourth, we limited analysis of relational communication to relational control; communication theory and research considers additional relational dimensions (eg, affiliation, trust) that likely influence the physician-patient relationship. Finally, we identified DTCA messages that may influence consumers’ behavior; we did not investigate actual behavioral changes associated with exposure to DTCA.
ACKNOWLEDGMENTS
We wish to thank Katie M. Haynes, BS, for coding and technical assistance.
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- Messages about physician-patient communication found in prescription direct-to-consumer advertising (DTCA) uphold rather than undermine the physician’s control.
- Keep in mind that patients encouraged by DTCA to ask you about prescription drugs are not necessarily demanding prescriptions.
- Be sure to discuss with patients who inquire about advertised products their risks and side effects—topics largely ignored by print DTCA messages.
Background Critics of DTCA contend it alters physician-patient communication by promoting greater patient participation and control. We assessed the nature of messages in print DTCA to identify potential guidelines they may provide to consumers for communicating with physicians.
Methods We analyzed all unique advertisements (ie, excluded ads repeated across issues or magazines) in 18 popular magazines (684 issues) from January 1998 to December 1999 (n=225). We identified every statement that referred to physicians, and within that set, statements that focused on physician-patient communication. Each communication-related statement was coded as a message to consumers about communication in terms of cues suggesting who should initiate communication, who should be in relational control, and appropriate interaction topic(s).
Results More than three-quarters (83.8%) of the advertisements’ statements referring to physicians focused on physician-patient communication (M=2.6 per ad; SD=1.8). Most (76.1%) of these messages explicitly or implicitly promoted consumers initiating communication, but cast the physician in relational control (54.5%). The most frequently suggested interaction topics were clinical judgments of the product’s appropriateness (41.8%) and information about the product (32.1%).
Conclusions Typical direct-to-consumer print ads contain multiple messages about communicating with physicians. The patterned nature of these messages appears to promote social norms for consumers’ communication behavior by repeatedly implying the appropriateness of consumers initiating interaction, physicians maintaining relational control, and avoiding negative consequences of advertised drugs as conversational topics.
Arecent medical journal debate focuses on effects of direct-to-consumer advertising of prescription drugs (DTCA) on the physician-patient relationship.1-11 Both sides contend that DTCA alters consumers’ communication behavior, and, ultimately, relationships with physicians, by encouraging greater patient participation and control. Increasingly, patients are asking physicians about advertised products and doctors do feel pressured to prescribe.12-20 Thus, research to date has indicated that social norms for physician-patient communication are changing, but has not accounted for DTCA’s features that focus directly on physician-patient communication. This study examines DTCA’s references to physician-patient communication that may imply guidelines for consumers’ interaction behavior.
Pro and con opinions. Opinions vary regarding DTCA’s effects on health care and public health.21 Critics disagree about DTCA’s effects on cost (including time),1-3,8,10,22-27 consumers’ knowledge,2,24-25 and health care quality.1,3,4,24-25 Advocates view DTCA as empowering patients to partner with physicians,4,24 initiate discussion,25 show interest, and ask questions.27,28 Opponents say DTCA undermines the relationship,2,24,29,30 by overloading physicians with time-consuming questions they are unprepared to answer,25,31 creating pressure to prescribe, and increasing patient demand that yields inappropriate prescribing.32
The issue centers on who should be “in charge.” Proponents tend to value patients’ empowerment;4,33 opponents generally advocate physicians’ authority.34 However, both sides agree that DTCA influences patients to communicate more actively and take greater control.
Ultimate goal of DTCA.Because obtaining prescription drugs requires physicians’ cooperation, DTCA’s aims differ from traditional advertising. Successful ads must both attract consumers to products and facilitate consumers gaining physicians’ cooperation. Even “sold” consumers may not have the communication skills to interact appropriately and persuasively with physicians. Thus, to succeed commercially, DTCA must encourage particular consumer communication behaviors.
Establishing who is in control. Physician-patient relationships are developed and maintained largely via communication patterns. Communication patterns associated with physician-patient relationship models differ, largely, in terms of relational control.35,36 Relational control, accomplished through communication, “refers to the process of establishing [who has] the right to direct, delimit, and define the actions of the dyad,” in this case, the physician-patient relationship.37
Paternalism36 casts the physician in control of information and decisions, and the patient as expected to cooperate.38
Participatory models35 reflect a partnership with relatively equal power evident in mutual information sharing and exploration of alternatives.38
Consumerism places control in patients’ hands; consumers may bargain and engage actively in communication, but theoretically they control final decisions and may demand particular treatment regimens.36
Are DTCAs “training” consumers? Previous content analyses of DTCA focus on marketing factors (eg, ad frequency, product type)39,40 and on appeals, motivators, or inducements for consumers,39-41 but do not address DTCA’s statements about physician-patient communication.42 When social cognitive theory is applied to DTCA, it suggests that DTCA may “train” consumers by providing models or examples from which to learn vicariously, while associating those models with positive outcomes or rewards, and the advertised drug, thus motivating consumers to seek the product.43 Thus, DTCA may encourage specific communication behaviors as the means to acquire advertised products. If so, its influence may lie less in its educational function than in its social training function.
Although medical information may help consumers establish credibility and arm them with medical content for discussion, DTCA’s statements about communication may imply guidelines for interacting appropriately with physicians. An ad that reads, “Ask your doctor about drug X,” explicitly provides a model opening line and contains implicit messages about who should initiate interaction (the consumer, encouraged to ask), who should have control (the doctor, upon whom the patient depends for an answer), and appropriate interaction topics (drug X). This interpretation of DTCA’s messages is rooted in relational communication theory and research; a consumer urged to “ask” a physician is cast as “one-down”37 or dependent on the physician for an answer. Alternatively, a consumer urged to “tell” a physician is portrayed as “in charge.” A message to “discuss” a matter with a physician indicates shared control.
The aim of our study. Our general question was: “What social norms regarding physician-patient communication does print DTCA suggest to consumers?” Specific research questions were:
How frequent are references to physicians in print DTCA?
How frequent are messages about physician-patient communication in print DTCA?
Within messages about physician-patient communication, what guidelines are implied, and with what frequencies, regarding: (a) who should initiate interaction, (b) who should have relational control, and (c) appropriate topics for interaction?
Methods
Sample
We examined all DTCA in 18 popular magazines (684 issues) from January 1998 to December 1999. We followed Bell, Kravitz, and Wilkes’s procedures to ensure a diverse sample of publications.39 Thirteen magazines were selected to represent the highest-ranked lay magazines (based on advertising pages sold) in specified categories; 5 additional magazines were selected to represent diverse populations. They were business (Business Week), fishing/hunting/guns (Field & Stream), food/wine (Gourmet), home (Better Homes and Gardens), men (GQ), music (Rolling Stone), news and opinion (Time), parenting (Parents), personal finance (Money Magazine), sports (Sports Illustrated), tabloid/general editorial (Reader’s Digest), women (Vogue), and medicine/health (Prevention); and ethnicity (Ebony and Hispanic), age (Modern Maturity and New Choices for the Best Years), and sexual orientation (The Advocate). We identified 994 product-specific and reminder ads for 83 drugs addressing 15 types of medical conditions.22 (Product-specific ads identify products by name and use and are subject to FDA monitoring guidelines.22 Reminder ads simply identify products by name, without identifying use or related claims, risks, etc.) After eliminating duplicates, the sample of 225 advertisements was analyzed.
Coding systems
The unit of analysis for this investigation was a statement focusing on physician-patient communication. For each advertisement, we first identified statements referencing physicians. (Although we included the terms “health provider” and “health professional” as references to physicians, all but 4 ads used the terms “physician” or “doctor.”)
Next, among references to physicians, we identified statements focusing on physician-patient communication (eg, “ask your physician;” “your doctor will tell you”). For these statements, we developed a coding system to reflect types of messages implied regarding physician-patient communication by systematically reviewing 25% of the sample, while considering relational control theory.37 Specific categories of messages, examples, and rules for coding were developed for 3 variables: (a) who should initiate communication, (b) who should take control, and (c) appropriate communication topic(s). Categories for each variable were mutually exclusive and exhaustive.
Upon completing development of the coding system, we applied it to the full sample of statements focusing on physician-patient communication. In addition, for each statement, the medical condition for which the drug was advertised was coded (14 disclosed conditions and a category for undisclosed conditions). Details of the coding system are available from the authors.
Initiating communication. Who should initiate communication was coded as (a) explicit directives to the consumer to initiate communication (eg, “ask your doctor,” “tell your doctor”), (b) implicit directives to the consumer to initiate communication (eg, “see your doctor about drug X,” “check with your doctor”), (c) references to doctor-initiated communication (eg, “your doctor will tell you,” “adhere to your doctor’s recommendations”), or (d) messages referencing both parties, implying either could initiate communication (eg, “my doctor and I agreed,” “you and your doctor must carefully discuss”).
Relational control. Consistent with relational control theory, 37 who should be in control was coded as (a) patient control (eg, “tell your doctor,” “let your professional know”), (b) physician control (eg, “ask your doctor,” “check with your doctor”), or (c) shared or unclear control (eg, “talk to your doctor,” “discuss with your doctor”).
Appropriate interaction topics. Suggested interaction topics were coded as (a) side effects, (b) risks of product use, (c) general product information, (d) clinical judgments (ie, determining appropriateness for the patient), or (e) topic unspecified or unclear (included multiple topics).
TABLE 1
References to physician(s) and to communication with physician(s) by medical condition
| PHYSICIAN REFERENCES | COMMUNICATION REFERENCES | ||||
|---|---|---|---|---|---|
| MEDICAL CONDITION | N* | M | SD | M | SD |
| Allergies | 35 | 1.83 | 95 | 1.74 | .89 |
| Cancer | 5 | 4.00 | .71 | 3.20 | .45 |
| Cardiovascular | 14 | 6.29 | 1.44 | 4.86 | 1.03 |
| Dermatologic | 12 | 3.58 | 2.81 | 2.00 | 1.04 |
| Diabetes | 15 | 5.93 | 4.28 | 5.27 | .77 |
| Gastrointestinal/nutritional | 14 | 2.43 | 1.09 | 2.07 | .83 |
| HIV/AIDS | 39 | 1.92 | 1.48 | 1.79 | 1.28 |
| Infectious (non-HIV) | 8 | 2.63 | 1.85 | 2.63 | 1.85 |
| Musculoskeltal | 14 | 2.64 | .63 | 2.14 | .66 |
| Obstetric/gynecologic | 22 | 2.36 | 1.65 | 2.09 | 1.41 |
| Psychiatric/neurologic | 16 | 4.06 | 1.69 | 2.94 | 1.06 |
| Respiratory | 4 | 4.00 | 1.63 | 3.00 | 1.63 |
| Tobacco/addiction | 8 | 4.38 | .74 | 4.13 | .64 |
| Urological | 13 | 3.69 | 2.06 | 2.85 | 1.07 |
| Undisclosed | 6 | .17 | .41 | .17 | .41 |
| TOTAL | 225 | 3.06 | 2.30 | 2.55 | 1.82 |
| *N refer to number of advertisements. | |||||
Coding procedures
A coder was trained, and initially acceptable inter- and intra-rater reliability levels were established. To eliminate effects due to particular magazines, products, etc, the 225 ads were placed in random order. The coder independently coded the randomlyordered sample of 225 advertisements. In addition, to assess reliability, the coder recoded (and the second author coded) a randomly selected subset of 25 ads. Final intra-rater reliabilities (percentage of agreement) and inter-rater reliabilities (Cohen’s kappa) were: initiator of interaction: 93.8%, κ=.93; relational control: 90.6%, κ=.89; and interaction topic: 92.2%, κ=.92.
TABLE 2
References regarding who initiates communication: Percentages by category
| MEDICAL CONDITION | N* | EXPLICIT | IMPLICIT | PHYSICIAN | EITHER |
|---|---|---|---|---|---|
| Allergies | 61 | 80.3 | 8.2 | 3.3 | 8.2 |
| Cancer | 16 | 37.5 | 12.5 | 37.5 | 12.5 |
| Cardiovascular | 68 | 89.7 | 1.5 | 4.4 | 4.4 |
| Dermatologic | 24 | 54.2 | 20.8 | 20.8 | 4.2 |
| Diabetes | 79 | 53.2 | 8.9 | 29.1 | 8.9 |
| Gastrointestinal/nutritional | 29 | 72.4 | 3.4 | 6.9 | 17.2 |
| HIV/AIDS | 70 | 81.4 | 2.9 | 4.3 | 11.4 |
| Infectious (non-HIV) | 21 | 100.0 | 0.0 | 0.0 | 0.0 |
| Musculoskeletal | 30 | 60.0 | 3.3 | 23.3 | 13.3 |
| Obstetric/gynecologic | 46 | 63.0 | 0.0 | 2.2 | 34.8 |
| Psychiatric/neurologic | 47 | 61.7 | 8.5 | 27.7 | 2.1 |
| Respiratory | 12 | 58.3 | 25.0 | 16.7 | 0.0 |
| Tobacco/addiction | 33 | 54.5 | 12.1 | 30.3 | 3.0 |
| Urological | 37 | 75.7 | 5.4 | 10.8 | 8.1 |
| Undisclosed | 1 | 100.0 | 0.0 | 0.0 | 0.0 |
| TOTAL | 574 | 69.7 | 6.4 | 14.1 | 9.8 |
| * N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication. | |||||
Results
References to physicians
The number of references to physicians per ad ranged from 0 to 12; the average exceeded 3 (TABLE 1). All but 4.4% of ads made reference to physicians. The major exception, mostly reminder ads for undisclosed conditions, contained little text. Numbers of references to physicians varied by disclosed medical condition, from lows of less than 2 (allergies, HIV/AIDS), to a high exceeding 6 (cardiovascular).
Physician-patient communication messages
The number of statements that focused on physician-patient communication ranged from 0 to 10 per ad. Most references to physicians (83.8%) focused on communication; typically ads contained more than 2 communication messages. Average numbers of communication messages varied by disclosed medical condition, from less than 2 (allergies, HIV/AIDS), to a high exceeding 5 (diabetes).
Cues regarding how to communicate with physicians
Who should initiate interaction. More than three quarters (76.1%) of communication references indicated that consumers should initiate communication; most did so explicitly (69.7%) (TABLE 2). The percent age of explicit directives to consumers to initiate communication varied widely by condition, from 37.5% (cancer) to 100% (non-HIV infection, undisclosed conditions). More than 50% of communication references, in all conditions except cancer, explicitly indicated the consumer as initiator. Implicit directives to consumers to initiate communication ranged from 0% (non-HIV infection) to 25% (respiratory).
Relatively few messages indicated the physician as initiator (14.1%), varying by medical condition from 0% (non-HIV infection, undisclosed) to 37.5% (cancer).
Messages indicating either party could initiate communication appeared in less than 10% of the statements (9.8%) and varied by medical condition from 0% (non-HIV infection, respiratory, undisclosed) to 34.8% (obstetric/gynecologic); this type of message appeared in less than 10% of communication messages in ads for 10 conditions.
Who should have relational control. The majority (54.5%) of communication messages placed physicians in control (TABLE 3). Nearly one third (30%) indicated shared (or unknown) control, while only about 15.5% cast consumers in control. However, relational control cues varied widely by medical condition. Physicians were cast in exclusive control in ads for undisclosed conditions (100%), although these numbers were small. For disclosed medical conditions, physician control ranged from 17.4% (obstetric/gynecologic) to 75% (dermatologic, respiratory). Consumer control ranged from 0% (gastrointestinal/nutritional, dermatologic, and undisclosed) to 38.2% (cardiovascular). One of the most striking differences due to medical condition occurred for obstetric/gynecologic ads, in which shared/unknown control dominated (80.4%).
Appropriate interaction topics. The most frequently suggested interaction topic was clinical appropriateness (41.8%), followed by general product information (32.1%) (TABLE 4). Fewer than 1-in-5 suggested topics focused on products’ negative aspects (8.5% each for side effects and risks). For 9.1% of the statements, no topic was suggested, or the suggested topic was unclear. Suggested topics varied by disclosed medical condition. Clinical judgment accounted for 30% or more of suggested topics in most disclosed medical conditions, ranging from 20% (dermatologic) to 67% (respiratory). General information accounted for 25% or more of suggested topics in most of the disclosed conditions, ranging from 12.5% (cancer) to 59% (allergies). The topic of side effects ranged from 0% (allergies, gastrointestinal/nutritional, tobacco/addiction, undisclosed conditions) to 19.1% (cardiovascular). Similarly, the topic of risks ranged from 0% (5 conditions) to 41.3% (obstetric/gynecologic). Follow-up analyses revealed that when the suggested topic was negative (risks or side effects), in only 10 of 98 cases (10.2%) was the physician indicated as initiating communication.
TABLE 3
References indicating relational control by medical condition: Percentages by category
| MEDICAL CONDITION | N* | CONSUMER | PHYSICIAN | SHARED | |
|---|---|---|---|---|---|
| Allergies | 61 | 11.5 | 52.5 | 36.1 | |
| Cancer | 16 | 18.8 | 31.3 | 50.0 | |
| Cardiovascular | 68 | 38.2 | 42.6 | 19.1 | |
| Dermatologic | 24 | 0.0 | 75.0 | 25.0 | |
| Diabetes | 79 | 8.9 | 69.6 | 21.5 | |
| Gastrointestinal/nutritional | 29 | 0.0 | 65.5 | 34.5 | |
| HIV/AIDS | 70 | 10.0 | 51.4 | 38.6 | |
| Infectious (non-HIV) | 21 | 38.1 | 61.9 | 0.0 | |
| Musculoskeletal | 30 | 26.7 | 56.7 | 16.7 | |
| Obstetric/gynecologic | 46 | 2.2 | 17.4 | 80.4 | |
| Psychiatric/neurologic | 47 | 23.4 | 53.2 | 23.4 | |
| Respiratory | 12 | 16.7 | 75.0 | 8.3 | |
| Tobacco/addiction | 33 | 21.2 | 57.6 | 21.2 | |
| Urological | 37 | 5.4 | 73.0 | 21.6 | |
| Undisclosed | 1 | 0.0 | 100.0 | 0.0 | |
| TOTAL | 574 | 15.5 | 54.5 | 30.0 | |
| * N refers to number of references to communicating with a physician. | |||||
TABLE 4
Suggested topics for physician-patient communication by medical condition: percentages by category
| MEDICAL CONDITION | N* | CLINICAL | GENERAL | SIDE EFFECTS | RISKS | UNKNOWN |
|---|---|---|---|---|---|---|
| Allergies | 61 | 32.8 | 59.0 | 0.0 | 4.9 | 3.3 |
| Cancer | 16 | 50.0 | 12.5 | 12.5 | 6.3 | 18.8 |
| Cardiovascular | 68 | 54.4 | 20.6 | 19.1 | 2.9 | 2.9 |
| Dermatologic | 24 | 20.8 | 37.5 | 8.3 | 0.0 | 33.3 |
| Diabetes | 79 | 55.7 | 24.1 | 12.7 | 6.3 | 1.3 |
| Gastrointestinal/nutritional | 29 | 24.1 | 44.8 | 0.0 | 0.0 | 31.0 |
| HIV/AIDS | 70 | 32.9 | 41.4 | 10.0 | 0.0 | 15.7 |
| Infectious (non-HIV) | 21 | 28.6 | 38.1 | 19.0 | 0.0 | 14.3 |
| Musculoskeletal | 30 | 26.7 | 40.0 | 6.7 | 23.3 | 3.3 |
| Obstetric/gynecologic | 46 | 23.9 | 26.1 | 2.2 | 41.3 | 6.5 |
| Psychiatric/neurologic | 47 | 44.7 | 19.1 | 12.8 | 19.1 | 4.3 |
| Respiratory | 12 | 66.7 | 16.7 | 8.3 | 8.3 | 0.0 |
| Tobacco/addiction | 33 | 63.6 | 27.3 | 0.0 | 3.0 | 6.1 |
| Urological | 37 | 54.1 | 27.0 | 2.7 | 2.7 | 13.5 |
| Undisclosed | 1 | 0.0 | 100.0 | 0.0 | 0.0 | 0.0 |
| TOTAL | 574 | 41.8 | 32.1 | 8.5 | 8.5 | 9.1 |
| * N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication. | ||||||
Discussion
Typical DTCA contains multiple messages about physician-patient communication. The primary way that DTCA may endorse a participatory model is via messages that encourage consumers to initiate conversations with physicians about products. About 70% of communication references explicitly direct consumers to do so. Otherwise, ads do not encourage consumers’ control. In fact, nearly 55% of communication references cast the physician in control, while only 15% placed the consumer in control. Thus, DTCA reinforces physicians’ relational control while encouraging consumers to initiate communication.
DTCA steers conversation topics toward products’ benefits and away from their deficits. Ads most often suggest products’ medical utility and appropriateness as topics (ie, general information, clinical judgments), while avoiding negative topics (ie, side effects, risks).
DTCA’s communication lessons for practice
Present results have implications for physician-patient interaction. First, to the extent that DTCA influences patients’ communication behavior, physicians increasingly may encounter patients who initiate communication by asking questions, often about advertised drugs. Some physicians may see such questions as requests or even demands for those drugs. Physicians report feeling pressure to prescribe products about which patients inquire;9 thus, patients merely asking more questions may be perceived as “demanding.”44
However, physicians often perceive “patient demand” when patients have not specifically asked for a drug.45 Physicians may want to check their perceptions before acting on them, recognizing that such questions may indicate patients’ preferences for a more participatory model, which, in turn, is associated with greater patient satisfaction.46,47 Physicians desiring to avoid conflict when patients ask questions might encourage their participation rather than assuming “patient demand” or feeling pressure to alter prescribing behavior.
Second, despite some physicians’ concerns, DTCA’s communication messages do not encourage patients to take relational control, nor do they undermine physicians’ prescribing authority. Theoretically and ethically, physicians remain in control of decisions, including prescribing, by serving as learned intermediaries or “conduits of information between manufacturers and patients.”48 Practically, physicians remain in control because their cooperation is necessary, even in cases where patients actively seek particular prescriptions.
Third, if DTCA influences patients’ choice of communication topics, patients may fail to inquire about drugs’ risks or side effects, a finding especially important in light of evidence indicating that consumers tend to not retain DTCA’s risk information.49 Physicians need to be alerted to these trends so they ensure that conversations with patients include explicit discussion of drugs’ side effects and risks.
Limitations
This study has several limitations. First, we analyzed print DTCA only. Generalizing findings to television and Internet DTCA may not be possible.
Second, our sample, dated from 1998 to 1999, may differ systematically from current ads. However, our study does provide a theoretically-driven methodology for assessing, and understanding the implications of, changes in advertising strategies across time and media.
Third, we analyzed marketing efforts targeting consumers. Physicians are exposed to numerous pharmaceutical marketing efforts that may contain messages regarding physician-patient communication.
Fourth, we limited analysis of relational communication to relational control; communication theory and research considers additional relational dimensions (eg, affiliation, trust) that likely influence the physician-patient relationship. Finally, we identified DTCA messages that may influence consumers’ behavior; we did not investigate actual behavioral changes associated with exposure to DTCA.
ACKNOWLEDGMENTS
We wish to thank Katie M. Haynes, BS, for coding and technical assistance.
- Messages about physician-patient communication found in prescription direct-to-consumer advertising (DTCA) uphold rather than undermine the physician’s control.
- Keep in mind that patients encouraged by DTCA to ask you about prescription drugs are not necessarily demanding prescriptions.
- Be sure to discuss with patients who inquire about advertised products their risks and side effects—topics largely ignored by print DTCA messages.
Background Critics of DTCA contend it alters physician-patient communication by promoting greater patient participation and control. We assessed the nature of messages in print DTCA to identify potential guidelines they may provide to consumers for communicating with physicians.
Methods We analyzed all unique advertisements (ie, excluded ads repeated across issues or magazines) in 18 popular magazines (684 issues) from January 1998 to December 1999 (n=225). We identified every statement that referred to physicians, and within that set, statements that focused on physician-patient communication. Each communication-related statement was coded as a message to consumers about communication in terms of cues suggesting who should initiate communication, who should be in relational control, and appropriate interaction topic(s).
Results More than three-quarters (83.8%) of the advertisements’ statements referring to physicians focused on physician-patient communication (M=2.6 per ad; SD=1.8). Most (76.1%) of these messages explicitly or implicitly promoted consumers initiating communication, but cast the physician in relational control (54.5%). The most frequently suggested interaction topics were clinical judgments of the product’s appropriateness (41.8%) and information about the product (32.1%).
Conclusions Typical direct-to-consumer print ads contain multiple messages about communicating with physicians. The patterned nature of these messages appears to promote social norms for consumers’ communication behavior by repeatedly implying the appropriateness of consumers initiating interaction, physicians maintaining relational control, and avoiding negative consequences of advertised drugs as conversational topics.
Arecent medical journal debate focuses on effects of direct-to-consumer advertising of prescription drugs (DTCA) on the physician-patient relationship.1-11 Both sides contend that DTCA alters consumers’ communication behavior, and, ultimately, relationships with physicians, by encouraging greater patient participation and control. Increasingly, patients are asking physicians about advertised products and doctors do feel pressured to prescribe.12-20 Thus, research to date has indicated that social norms for physician-patient communication are changing, but has not accounted for DTCA’s features that focus directly on physician-patient communication. This study examines DTCA’s references to physician-patient communication that may imply guidelines for consumers’ interaction behavior.
Pro and con opinions. Opinions vary regarding DTCA’s effects on health care and public health.21 Critics disagree about DTCA’s effects on cost (including time),1-3,8,10,22-27 consumers’ knowledge,2,24-25 and health care quality.1,3,4,24-25 Advocates view DTCA as empowering patients to partner with physicians,4,24 initiate discussion,25 show interest, and ask questions.27,28 Opponents say DTCA undermines the relationship,2,24,29,30 by overloading physicians with time-consuming questions they are unprepared to answer,25,31 creating pressure to prescribe, and increasing patient demand that yields inappropriate prescribing.32
The issue centers on who should be “in charge.” Proponents tend to value patients’ empowerment;4,33 opponents generally advocate physicians’ authority.34 However, both sides agree that DTCA influences patients to communicate more actively and take greater control.
Ultimate goal of DTCA.Because obtaining prescription drugs requires physicians’ cooperation, DTCA’s aims differ from traditional advertising. Successful ads must both attract consumers to products and facilitate consumers gaining physicians’ cooperation. Even “sold” consumers may not have the communication skills to interact appropriately and persuasively with physicians. Thus, to succeed commercially, DTCA must encourage particular consumer communication behaviors.
Establishing who is in control. Physician-patient relationships are developed and maintained largely via communication patterns. Communication patterns associated with physician-patient relationship models differ, largely, in terms of relational control.35,36 Relational control, accomplished through communication, “refers to the process of establishing [who has] the right to direct, delimit, and define the actions of the dyad,” in this case, the physician-patient relationship.37
Paternalism36 casts the physician in control of information and decisions, and the patient as expected to cooperate.38
Participatory models35 reflect a partnership with relatively equal power evident in mutual information sharing and exploration of alternatives.38
Consumerism places control in patients’ hands; consumers may bargain and engage actively in communication, but theoretically they control final decisions and may demand particular treatment regimens.36
Are DTCAs “training” consumers? Previous content analyses of DTCA focus on marketing factors (eg, ad frequency, product type)39,40 and on appeals, motivators, or inducements for consumers,39-41 but do not address DTCA’s statements about physician-patient communication.42 When social cognitive theory is applied to DTCA, it suggests that DTCA may “train” consumers by providing models or examples from which to learn vicariously, while associating those models with positive outcomes or rewards, and the advertised drug, thus motivating consumers to seek the product.43 Thus, DTCA may encourage specific communication behaviors as the means to acquire advertised products. If so, its influence may lie less in its educational function than in its social training function.
Although medical information may help consumers establish credibility and arm them with medical content for discussion, DTCA’s statements about communication may imply guidelines for interacting appropriately with physicians. An ad that reads, “Ask your doctor about drug X,” explicitly provides a model opening line and contains implicit messages about who should initiate interaction (the consumer, encouraged to ask), who should have control (the doctor, upon whom the patient depends for an answer), and appropriate interaction topics (drug X). This interpretation of DTCA’s messages is rooted in relational communication theory and research; a consumer urged to “ask” a physician is cast as “one-down”37 or dependent on the physician for an answer. Alternatively, a consumer urged to “tell” a physician is portrayed as “in charge.” A message to “discuss” a matter with a physician indicates shared control.
The aim of our study. Our general question was: “What social norms regarding physician-patient communication does print DTCA suggest to consumers?” Specific research questions were:
How frequent are references to physicians in print DTCA?
How frequent are messages about physician-patient communication in print DTCA?
Within messages about physician-patient communication, what guidelines are implied, and with what frequencies, regarding: (a) who should initiate interaction, (b) who should have relational control, and (c) appropriate topics for interaction?
Methods
Sample
We examined all DTCA in 18 popular magazines (684 issues) from January 1998 to December 1999. We followed Bell, Kravitz, and Wilkes’s procedures to ensure a diverse sample of publications.39 Thirteen magazines were selected to represent the highest-ranked lay magazines (based on advertising pages sold) in specified categories; 5 additional magazines were selected to represent diverse populations. They were business (Business Week), fishing/hunting/guns (Field & Stream), food/wine (Gourmet), home (Better Homes and Gardens), men (GQ), music (Rolling Stone), news and opinion (Time), parenting (Parents), personal finance (Money Magazine), sports (Sports Illustrated), tabloid/general editorial (Reader’s Digest), women (Vogue), and medicine/health (Prevention); and ethnicity (Ebony and Hispanic), age (Modern Maturity and New Choices for the Best Years), and sexual orientation (The Advocate). We identified 994 product-specific and reminder ads for 83 drugs addressing 15 types of medical conditions.22 (Product-specific ads identify products by name and use and are subject to FDA monitoring guidelines.22 Reminder ads simply identify products by name, without identifying use or related claims, risks, etc.) After eliminating duplicates, the sample of 225 advertisements was analyzed.
Coding systems
The unit of analysis for this investigation was a statement focusing on physician-patient communication. For each advertisement, we first identified statements referencing physicians. (Although we included the terms “health provider” and “health professional” as references to physicians, all but 4 ads used the terms “physician” or “doctor.”)
Next, among references to physicians, we identified statements focusing on physician-patient communication (eg, “ask your physician;” “your doctor will tell you”). For these statements, we developed a coding system to reflect types of messages implied regarding physician-patient communication by systematically reviewing 25% of the sample, while considering relational control theory.37 Specific categories of messages, examples, and rules for coding were developed for 3 variables: (a) who should initiate communication, (b) who should take control, and (c) appropriate communication topic(s). Categories for each variable were mutually exclusive and exhaustive.
Upon completing development of the coding system, we applied it to the full sample of statements focusing on physician-patient communication. In addition, for each statement, the medical condition for which the drug was advertised was coded (14 disclosed conditions and a category for undisclosed conditions). Details of the coding system are available from the authors.
Initiating communication. Who should initiate communication was coded as (a) explicit directives to the consumer to initiate communication (eg, “ask your doctor,” “tell your doctor”), (b) implicit directives to the consumer to initiate communication (eg, “see your doctor about drug X,” “check with your doctor”), (c) references to doctor-initiated communication (eg, “your doctor will tell you,” “adhere to your doctor’s recommendations”), or (d) messages referencing both parties, implying either could initiate communication (eg, “my doctor and I agreed,” “you and your doctor must carefully discuss”).
Relational control. Consistent with relational control theory, 37 who should be in control was coded as (a) patient control (eg, “tell your doctor,” “let your professional know”), (b) physician control (eg, “ask your doctor,” “check with your doctor”), or (c) shared or unclear control (eg, “talk to your doctor,” “discuss with your doctor”).
Appropriate interaction topics. Suggested interaction topics were coded as (a) side effects, (b) risks of product use, (c) general product information, (d) clinical judgments (ie, determining appropriateness for the patient), or (e) topic unspecified or unclear (included multiple topics).
TABLE 1
References to physician(s) and to communication with physician(s) by medical condition
| PHYSICIAN REFERENCES | COMMUNICATION REFERENCES | ||||
|---|---|---|---|---|---|
| MEDICAL CONDITION | N* | M | SD | M | SD |
| Allergies | 35 | 1.83 | 95 | 1.74 | .89 |
| Cancer | 5 | 4.00 | .71 | 3.20 | .45 |
| Cardiovascular | 14 | 6.29 | 1.44 | 4.86 | 1.03 |
| Dermatologic | 12 | 3.58 | 2.81 | 2.00 | 1.04 |
| Diabetes | 15 | 5.93 | 4.28 | 5.27 | .77 |
| Gastrointestinal/nutritional | 14 | 2.43 | 1.09 | 2.07 | .83 |
| HIV/AIDS | 39 | 1.92 | 1.48 | 1.79 | 1.28 |
| Infectious (non-HIV) | 8 | 2.63 | 1.85 | 2.63 | 1.85 |
| Musculoskeltal | 14 | 2.64 | .63 | 2.14 | .66 |
| Obstetric/gynecologic | 22 | 2.36 | 1.65 | 2.09 | 1.41 |
| Psychiatric/neurologic | 16 | 4.06 | 1.69 | 2.94 | 1.06 |
| Respiratory | 4 | 4.00 | 1.63 | 3.00 | 1.63 |
| Tobacco/addiction | 8 | 4.38 | .74 | 4.13 | .64 |
| Urological | 13 | 3.69 | 2.06 | 2.85 | 1.07 |
| Undisclosed | 6 | .17 | .41 | .17 | .41 |
| TOTAL | 225 | 3.06 | 2.30 | 2.55 | 1.82 |
| *N refer to number of advertisements. | |||||
Coding procedures
A coder was trained, and initially acceptable inter- and intra-rater reliability levels were established. To eliminate effects due to particular magazines, products, etc, the 225 ads were placed in random order. The coder independently coded the randomlyordered sample of 225 advertisements. In addition, to assess reliability, the coder recoded (and the second author coded) a randomly selected subset of 25 ads. Final intra-rater reliabilities (percentage of agreement) and inter-rater reliabilities (Cohen’s kappa) were: initiator of interaction: 93.8%, κ=.93; relational control: 90.6%, κ=.89; and interaction topic: 92.2%, κ=.92.
TABLE 2
References regarding who initiates communication: Percentages by category
| MEDICAL CONDITION | N* | EXPLICIT | IMPLICIT | PHYSICIAN | EITHER |
|---|---|---|---|---|---|
| Allergies | 61 | 80.3 | 8.2 | 3.3 | 8.2 |
| Cancer | 16 | 37.5 | 12.5 | 37.5 | 12.5 |
| Cardiovascular | 68 | 89.7 | 1.5 | 4.4 | 4.4 |
| Dermatologic | 24 | 54.2 | 20.8 | 20.8 | 4.2 |
| Diabetes | 79 | 53.2 | 8.9 | 29.1 | 8.9 |
| Gastrointestinal/nutritional | 29 | 72.4 | 3.4 | 6.9 | 17.2 |
| HIV/AIDS | 70 | 81.4 | 2.9 | 4.3 | 11.4 |
| Infectious (non-HIV) | 21 | 100.0 | 0.0 | 0.0 | 0.0 |
| Musculoskeletal | 30 | 60.0 | 3.3 | 23.3 | 13.3 |
| Obstetric/gynecologic | 46 | 63.0 | 0.0 | 2.2 | 34.8 |
| Psychiatric/neurologic | 47 | 61.7 | 8.5 | 27.7 | 2.1 |
| Respiratory | 12 | 58.3 | 25.0 | 16.7 | 0.0 |
| Tobacco/addiction | 33 | 54.5 | 12.1 | 30.3 | 3.0 |
| Urological | 37 | 75.7 | 5.4 | 10.8 | 8.1 |
| Undisclosed | 1 | 100.0 | 0.0 | 0.0 | 0.0 |
| TOTAL | 574 | 69.7 | 6.4 | 14.1 | 9.8 |
| * N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication. | |||||
Results
References to physicians
The number of references to physicians per ad ranged from 0 to 12; the average exceeded 3 (TABLE 1). All but 4.4% of ads made reference to physicians. The major exception, mostly reminder ads for undisclosed conditions, contained little text. Numbers of references to physicians varied by disclosed medical condition, from lows of less than 2 (allergies, HIV/AIDS), to a high exceeding 6 (cardiovascular).
Physician-patient communication messages
The number of statements that focused on physician-patient communication ranged from 0 to 10 per ad. Most references to physicians (83.8%) focused on communication; typically ads contained more than 2 communication messages. Average numbers of communication messages varied by disclosed medical condition, from less than 2 (allergies, HIV/AIDS), to a high exceeding 5 (diabetes).
Cues regarding how to communicate with physicians
Who should initiate interaction. More than three quarters (76.1%) of communication references indicated that consumers should initiate communication; most did so explicitly (69.7%) (TABLE 2). The percent age of explicit directives to consumers to initiate communication varied widely by condition, from 37.5% (cancer) to 100% (non-HIV infection, undisclosed conditions). More than 50% of communication references, in all conditions except cancer, explicitly indicated the consumer as initiator. Implicit directives to consumers to initiate communication ranged from 0% (non-HIV infection) to 25% (respiratory).
Relatively few messages indicated the physician as initiator (14.1%), varying by medical condition from 0% (non-HIV infection, undisclosed) to 37.5% (cancer).
Messages indicating either party could initiate communication appeared in less than 10% of the statements (9.8%) and varied by medical condition from 0% (non-HIV infection, respiratory, undisclosed) to 34.8% (obstetric/gynecologic); this type of message appeared in less than 10% of communication messages in ads for 10 conditions.
Who should have relational control. The majority (54.5%) of communication messages placed physicians in control (TABLE 3). Nearly one third (30%) indicated shared (or unknown) control, while only about 15.5% cast consumers in control. However, relational control cues varied widely by medical condition. Physicians were cast in exclusive control in ads for undisclosed conditions (100%), although these numbers were small. For disclosed medical conditions, physician control ranged from 17.4% (obstetric/gynecologic) to 75% (dermatologic, respiratory). Consumer control ranged from 0% (gastrointestinal/nutritional, dermatologic, and undisclosed) to 38.2% (cardiovascular). One of the most striking differences due to medical condition occurred for obstetric/gynecologic ads, in which shared/unknown control dominated (80.4%).
Appropriate interaction topics. The most frequently suggested interaction topic was clinical appropriateness (41.8%), followed by general product information (32.1%) (TABLE 4). Fewer than 1-in-5 suggested topics focused on products’ negative aspects (8.5% each for side effects and risks). For 9.1% of the statements, no topic was suggested, or the suggested topic was unclear. Suggested topics varied by disclosed medical condition. Clinical judgment accounted for 30% or more of suggested topics in most disclosed medical conditions, ranging from 20% (dermatologic) to 67% (respiratory). General information accounted for 25% or more of suggested topics in most of the disclosed conditions, ranging from 12.5% (cancer) to 59% (allergies). The topic of side effects ranged from 0% (allergies, gastrointestinal/nutritional, tobacco/addiction, undisclosed conditions) to 19.1% (cardiovascular). Similarly, the topic of risks ranged from 0% (5 conditions) to 41.3% (obstetric/gynecologic). Follow-up analyses revealed that when the suggested topic was negative (risks or side effects), in only 10 of 98 cases (10.2%) was the physician indicated as initiating communication.
TABLE 3
References indicating relational control by medical condition: Percentages by category
| MEDICAL CONDITION | N* | CONSUMER | PHYSICIAN | SHARED | |
|---|---|---|---|---|---|
| Allergies | 61 | 11.5 | 52.5 | 36.1 | |
| Cancer | 16 | 18.8 | 31.3 | 50.0 | |
| Cardiovascular | 68 | 38.2 | 42.6 | 19.1 | |
| Dermatologic | 24 | 0.0 | 75.0 | 25.0 | |
| Diabetes | 79 | 8.9 | 69.6 | 21.5 | |
| Gastrointestinal/nutritional | 29 | 0.0 | 65.5 | 34.5 | |
| HIV/AIDS | 70 | 10.0 | 51.4 | 38.6 | |
| Infectious (non-HIV) | 21 | 38.1 | 61.9 | 0.0 | |
| Musculoskeletal | 30 | 26.7 | 56.7 | 16.7 | |
| Obstetric/gynecologic | 46 | 2.2 | 17.4 | 80.4 | |
| Psychiatric/neurologic | 47 | 23.4 | 53.2 | 23.4 | |
| Respiratory | 12 | 16.7 | 75.0 | 8.3 | |
| Tobacco/addiction | 33 | 21.2 | 57.6 | 21.2 | |
| Urological | 37 | 5.4 | 73.0 | 21.6 | |
| Undisclosed | 1 | 0.0 | 100.0 | 0.0 | |
| TOTAL | 574 | 15.5 | 54.5 | 30.0 | |
| * N refers to number of references to communicating with a physician. | |||||
TABLE 4
Suggested topics for physician-patient communication by medical condition: percentages by category
| MEDICAL CONDITION | N* | CLINICAL | GENERAL | SIDE EFFECTS | RISKS | UNKNOWN |
|---|---|---|---|---|---|---|
| Allergies | 61 | 32.8 | 59.0 | 0.0 | 4.9 | 3.3 |
| Cancer | 16 | 50.0 | 12.5 | 12.5 | 6.3 | 18.8 |
| Cardiovascular | 68 | 54.4 | 20.6 | 19.1 | 2.9 | 2.9 |
| Dermatologic | 24 | 20.8 | 37.5 | 8.3 | 0.0 | 33.3 |
| Diabetes | 79 | 55.7 | 24.1 | 12.7 | 6.3 | 1.3 |
| Gastrointestinal/nutritional | 29 | 24.1 | 44.8 | 0.0 | 0.0 | 31.0 |
| HIV/AIDS | 70 | 32.9 | 41.4 | 10.0 | 0.0 | 15.7 |
| Infectious (non-HIV) | 21 | 28.6 | 38.1 | 19.0 | 0.0 | 14.3 |
| Musculoskeletal | 30 | 26.7 | 40.0 | 6.7 | 23.3 | 3.3 |
| Obstetric/gynecologic | 46 | 23.9 | 26.1 | 2.2 | 41.3 | 6.5 |
| Psychiatric/neurologic | 47 | 44.7 | 19.1 | 12.8 | 19.1 | 4.3 |
| Respiratory | 12 | 66.7 | 16.7 | 8.3 | 8.3 | 0.0 |
| Tobacco/addiction | 33 | 63.6 | 27.3 | 0.0 | 3.0 | 6.1 |
| Urological | 37 | 54.1 | 27.0 | 2.7 | 2.7 | 13.5 |
| Undisclosed | 1 | 0.0 | 100.0 | 0.0 | 0.0 | 0.0 |
| TOTAL | 574 | 41.8 | 32.1 | 8.5 | 8.5 | 9.1 |
| * N refers to number of references to physician-patient communication. Codes: Explicit=explicit directives to patients to initiate communication; Implicit=implicit directives to patients to initiate communication; Physicians=references to physician initiated communication; Either=either party can initiate communication. | ||||||
Discussion
Typical DTCA contains multiple messages about physician-patient communication. The primary way that DTCA may endorse a participatory model is via messages that encourage consumers to initiate conversations with physicians about products. About 70% of communication references explicitly direct consumers to do so. Otherwise, ads do not encourage consumers’ control. In fact, nearly 55% of communication references cast the physician in control, while only 15% placed the consumer in control. Thus, DTCA reinforces physicians’ relational control while encouraging consumers to initiate communication.
DTCA steers conversation topics toward products’ benefits and away from their deficits. Ads most often suggest products’ medical utility and appropriateness as topics (ie, general information, clinical judgments), while avoiding negative topics (ie, side effects, risks).
DTCA’s communication lessons for practice
Present results have implications for physician-patient interaction. First, to the extent that DTCA influences patients’ communication behavior, physicians increasingly may encounter patients who initiate communication by asking questions, often about advertised drugs. Some physicians may see such questions as requests or even demands for those drugs. Physicians report feeling pressure to prescribe products about which patients inquire;9 thus, patients merely asking more questions may be perceived as “demanding.”44
However, physicians often perceive “patient demand” when patients have not specifically asked for a drug.45 Physicians may want to check their perceptions before acting on them, recognizing that such questions may indicate patients’ preferences for a more participatory model, which, in turn, is associated with greater patient satisfaction.46,47 Physicians desiring to avoid conflict when patients ask questions might encourage their participation rather than assuming “patient demand” or feeling pressure to alter prescribing behavior.
Second, despite some physicians’ concerns, DTCA’s communication messages do not encourage patients to take relational control, nor do they undermine physicians’ prescribing authority. Theoretically and ethically, physicians remain in control of decisions, including prescribing, by serving as learned intermediaries or “conduits of information between manufacturers and patients.”48 Practically, physicians remain in control because their cooperation is necessary, even in cases where patients actively seek particular prescriptions.
Third, if DTCA influences patients’ choice of communication topics, patients may fail to inquire about drugs’ risks or side effects, a finding especially important in light of evidence indicating that consumers tend to not retain DTCA’s risk information.49 Physicians need to be alerted to these trends so they ensure that conversations with patients include explicit discussion of drugs’ side effects and risks.
Limitations
This study has several limitations. First, we analyzed print DTCA only. Generalizing findings to television and Internet DTCA may not be possible.
Second, our sample, dated from 1998 to 1999, may differ systematically from current ads. However, our study does provide a theoretically-driven methodology for assessing, and understanding the implications of, changes in advertising strategies across time and media.
Third, we analyzed marketing efforts targeting consumers. Physicians are exposed to numerous pharmaceutical marketing efforts that may contain messages regarding physician-patient communication.
Fourth, we limited analysis of relational communication to relational control; communication theory and research considers additional relational dimensions (eg, affiliation, trust) that likely influence the physician-patient relationship. Finally, we identified DTCA messages that may influence consumers’ behavior; we did not investigate actual behavioral changes associated with exposure to DTCA.
ACKNOWLEDGMENTS
We wish to thank Katie M. Haynes, BS, for coding and technical assistance.
1. Alper PR. Direct-to-consumer advertising: Education or anathema [letter]. JAMA 1999;282:1226-1227.
2. Hoffman JR, Wilkes M. Direct to consumer advertising of prescription drugs: An idea whose time should not come [editorial]. BMJ 1999;318:1301-1302.
3. Hollon MF. Direct-to-consumer marketing of prescription drugs: Creating consumer demand [comment]. JAMA 1999;281:382-384.
4. Holmer AF. Direct-to-consumer prescription drug advertising builds bridges between patients and physicians [comment]. JAMA 1999;281:380-382.
5. Holmer AF. Direct-to-consumer advertising—Strengthening our health care system [editorial]. N Engl J Med 2002;346:526-528.
6. Kravitz RL. Direct to consumer advertising of prescription drugs: Implications for the physician-patient relationship [editorial]. JAMA 2000;284:2244.-
7. Kravitz RL. Direct-to-consumer advertising of prescription drugs: These ads present both perils and opportunities. West J Med 2000;73:221-222.
8. Rosner F, Kark P, Packer S, Bennett A, Berger J. Direct-to-consumer advertising: Education or anathema [letter]. JAMA 1999;282:1227-1228.
9. Spurgeon D. Doctors feel pressurised by direct to consumer advertising. BMJ 1999;319:1321.-
10. Tanne JH. Direct to consumer advertising is billion dollar business in US [news]. BMJ 1999;319:805.-
11. Wolfe SM. Direct-to-consumer advertising—education or emotion promotion? [editorial]. N Engl J Med 2002;346:524-526.
12. Consumer ads build awareness but not understanding of advertised medications, surveys reveal [news]. Am J Health-Systems Pharm. 1998;55:2344-2347.
13. Henry J. Kaiser Foundation. Understanding the effects of direct-to-consumer prescription drug advertising. Document No. 3197. Menlo Park, Calif;2001.
14. Physicians say direct-to-consumer advertising affects patient behavior [news] Am J Hosp Pharm. 1993;50:1329.-
15. Maine LL. Direct-to-consumer advertising: A pharmacy perspective. Clin Ther 1993;20(Suppl):C103-C110.
16. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising and the public. J Gen Intern Med 1999;14:651-657.
17. Bell RA, Wilkes MS, Kravitz RL. Advertisement-induced prescription drug requests: Patients anticipated reactions to a physician who refuses. J Fam Pract 1999;48:446-452.
18. Doucette WR, Schommer JC. Consumer p for drug information after direct-to-consumer advertising. Drug Inf J 1998;32:1081-1088.
19. Werner T. Drug companies tailoring ads to consumers. Philadelphia Business J 1997 May 26. Available at: www.amcity.com/philadelphia/stories/1997/05/26/story8.html. Accessed on July 21, 1999.
20. Consumers want details about prescription drugs; many use ‘alternative’ medicines [news] Am J Health-Systems Pharm. 1999;56:307.-
21. Hunt M. Direct-to-consumer advertising of prescription drugs [background paper]. Washington, DC: National Health Policy Forum, George Washington University; 1998.
22. Bradley LR, Zito JM. Direct-to-consumer prescription drug advertising. Med Care 1997;35:86-92.
23. Craig RP. The patient as a partner in prescribing: Direct-to-consumer advertising. J Manage Care Pharm 1998;4(1).:Available at: www.amcp.org/jmcp/vol14/num1/feature2.html. Accessed on June 26, 2002.
24. Lipsky MS, Taylor CA. The opinions and experiences of family physicians regarding direct-to-consumer advertising. J Fam Pract 1997;45:495-499.
25. Perri M, III, Shinde S, Banavali R. The past, present, and future of direct-to-consumer prescription drug advertising. Clin Ther 1999;21:1798-1811.
26. Feisullin S, Sause RB. Update on direct-to-consumer advertising of prescription drugs [review]. Am Pharm 1991;NS31:47-52.
27. Pines WL. Direct-to-consumer advertising [review]. Ann Pharmacother 2000;34:1341-1344.
28. APhA endorses manufacturers’ direct-to-consumer Rx drug ads Am Drug. 1988 May;26,28.:
29. Roth MS. Patterns in direct-to-consumer prescription drug print advertising and their public policy implications. J Public Policy Mark 1996;15:63-75.
30. Whyte J. Direct consumer advertising of prescription drugs [review]. JAMA 1993;26:146, 150.-
31. Schommer JC, Doucette WR, Mehta NH. Rote learning after exposure to a direct-to-consumer television advertisement for a prescription drug. Clin Ther 1998;20:617-632.
32. Madhaven S. Are we ready for direct to consumer advertising of prescription drugs? Pharm Bus. 1993 Win;4-28.
33. Lyles A. Direct marketing of pharmaceuticals to consumers. Annu Rev Public Health 2002;23:73-91.
34. Morris LA, Brinberg D, Klimberg R, Millstein LG, Rivera C. Consumer attitudes about advertisements for medicinal drugs. Soc Sci Med 1986;22:629-638.
35. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-2226.
36. Beisecker AE, Beisecker TD. Using metaphors to characterize doctor-patient relationships: Paternalism versus consumerism. Health Commun 1993;5:41-58.
37. Millar FE, Rogers LE. Relational dimensions of interpersonal dynamics. In: Roloff ME, Miller GR, eds, Interpersonal Processes: New Directions in Communication Research. Beverly Hills, Calif: Sage; 1987;117-139.
38. Ballard-Reisch DS. A model of participative decision making for physician-patient interaction. Health Commun 1990;2:91-104.
39. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising, 1989–1998: A content analysis of conditions, targets, inducements, and appeals. J Fam Pract 2000;49:329-335.
40. Young HN, Cline RJW. “Look George, there’s another One!” The volume and characteristics of direct-to-consumer advertising in popular magazines. J Pharm Mark Manage 2003;15:7-21.
41. Woloshin S, Schwartz LM, Tremmel J, Welch HG. Direct-to-consumer advertisements for prescription drugs: What are Americans being sold? Lancet. 2001;35:1141-1146.
42. Cline RJW, Young HN. Marketing drugs, marketing health care relationships: A content analysis of visual cues in direct-to-consumer prescription drug advertising. Health Commun 2004;16:131-157.
43. Bandura A. Social cognitive theory of mass communication. Media Psychol 2001;3:265-299.
44. Kravitz RL, Bell RA, Franz CE. A taxonomy of requests by patients (TORP): A new system for understanding the clinical negotiation in office practice. J Fam Pract 1999;48:872-878.
45. Cockburn J, Pit S. Prescribing behavior in clinical practice: Patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 1997;315:520-523.
46. Peyrot M, Alperstein NM, Van Doren D, Poli LG. Direct-to-consumer ads can influence behavior: Advertising increases consumer knowledge and prescription drug requests. Mark Health Serv 1998;18:26-32.
47. Cooper-Patrick L, Gallo JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-589.
48. Fleming DJ, Samuels KW. Direct-to-consumer advertising and the learned intermediary. Hosp Pract 1998;33:129-130.
49. Sullivan DL, Schommer JC, Birdwell SW. Consumer retention of risk information from direct-to-consumer advertising. Drug Inf J 1999;33:1-9.
1. Alper PR. Direct-to-consumer advertising: Education or anathema [letter]. JAMA 1999;282:1226-1227.
2. Hoffman JR, Wilkes M. Direct to consumer advertising of prescription drugs: An idea whose time should not come [editorial]. BMJ 1999;318:1301-1302.
3. Hollon MF. Direct-to-consumer marketing of prescription drugs: Creating consumer demand [comment]. JAMA 1999;281:382-384.
4. Holmer AF. Direct-to-consumer prescription drug advertising builds bridges between patients and physicians [comment]. JAMA 1999;281:380-382.
5. Holmer AF. Direct-to-consumer advertising—Strengthening our health care system [editorial]. N Engl J Med 2002;346:526-528.
6. Kravitz RL. Direct to consumer advertising of prescription drugs: Implications for the physician-patient relationship [editorial]. JAMA 2000;284:2244.-
7. Kravitz RL. Direct-to-consumer advertising of prescription drugs: These ads present both perils and opportunities. West J Med 2000;73:221-222.
8. Rosner F, Kark P, Packer S, Bennett A, Berger J. Direct-to-consumer advertising: Education or anathema [letter]. JAMA 1999;282:1227-1228.
9. Spurgeon D. Doctors feel pressurised by direct to consumer advertising. BMJ 1999;319:1321.-
10. Tanne JH. Direct to consumer advertising is billion dollar business in US [news]. BMJ 1999;319:805.-
11. Wolfe SM. Direct-to-consumer advertising—education or emotion promotion? [editorial]. N Engl J Med 2002;346:524-526.
12. Consumer ads build awareness but not understanding of advertised medications, surveys reveal [news]. Am J Health-Systems Pharm. 1998;55:2344-2347.
13. Henry J. Kaiser Foundation. Understanding the effects of direct-to-consumer prescription drug advertising. Document No. 3197. Menlo Park, Calif;2001.
14. Physicians say direct-to-consumer advertising affects patient behavior [news] Am J Hosp Pharm. 1993;50:1329.-
15. Maine LL. Direct-to-consumer advertising: A pharmacy perspective. Clin Ther 1993;20(Suppl):C103-C110.
16. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising and the public. J Gen Intern Med 1999;14:651-657.
17. Bell RA, Wilkes MS, Kravitz RL. Advertisement-induced prescription drug requests: Patients anticipated reactions to a physician who refuses. J Fam Pract 1999;48:446-452.
18. Doucette WR, Schommer JC. Consumer p for drug information after direct-to-consumer advertising. Drug Inf J 1998;32:1081-1088.
19. Werner T. Drug companies tailoring ads to consumers. Philadelphia Business J 1997 May 26. Available at: www.amcity.com/philadelphia/stories/1997/05/26/story8.html. Accessed on July 21, 1999.
20. Consumers want details about prescription drugs; many use ‘alternative’ medicines [news] Am J Health-Systems Pharm. 1999;56:307.-
21. Hunt M. Direct-to-consumer advertising of prescription drugs [background paper]. Washington, DC: National Health Policy Forum, George Washington University; 1998.
22. Bradley LR, Zito JM. Direct-to-consumer prescription drug advertising. Med Care 1997;35:86-92.
23. Craig RP. The patient as a partner in prescribing: Direct-to-consumer advertising. J Manage Care Pharm 1998;4(1).:Available at: www.amcp.org/jmcp/vol14/num1/feature2.html. Accessed on June 26, 2002.
24. Lipsky MS, Taylor CA. The opinions and experiences of family physicians regarding direct-to-consumer advertising. J Fam Pract 1997;45:495-499.
25. Perri M, III, Shinde S, Banavali R. The past, present, and future of direct-to-consumer prescription drug advertising. Clin Ther 1999;21:1798-1811.
26. Feisullin S, Sause RB. Update on direct-to-consumer advertising of prescription drugs [review]. Am Pharm 1991;NS31:47-52.
27. Pines WL. Direct-to-consumer advertising [review]. Ann Pharmacother 2000;34:1341-1344.
28. APhA endorses manufacturers’ direct-to-consumer Rx drug ads Am Drug. 1988 May;26,28.:
29. Roth MS. Patterns in direct-to-consumer prescription drug print advertising and their public policy implications. J Public Policy Mark 1996;15:63-75.
30. Whyte J. Direct consumer advertising of prescription drugs [review]. JAMA 1993;26:146, 150.-
31. Schommer JC, Doucette WR, Mehta NH. Rote learning after exposure to a direct-to-consumer television advertisement for a prescription drug. Clin Ther 1998;20:617-632.
32. Madhaven S. Are we ready for direct to consumer advertising of prescription drugs? Pharm Bus. 1993 Win;4-28.
33. Lyles A. Direct marketing of pharmaceuticals to consumers. Annu Rev Public Health 2002;23:73-91.
34. Morris LA, Brinberg D, Klimberg R, Millstein LG, Rivera C. Consumer attitudes about advertisements for medicinal drugs. Soc Sci Med 1986;22:629-638.
35. Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-2226.
36. Beisecker AE, Beisecker TD. Using metaphors to characterize doctor-patient relationships: Paternalism versus consumerism. Health Commun 1993;5:41-58.
37. Millar FE, Rogers LE. Relational dimensions of interpersonal dynamics. In: Roloff ME, Miller GR, eds, Interpersonal Processes: New Directions in Communication Research. Beverly Hills, Calif: Sage; 1987;117-139.
38. Ballard-Reisch DS. A model of participative decision making for physician-patient interaction. Health Commun 1990;2:91-104.
39. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising, 1989–1998: A content analysis of conditions, targets, inducements, and appeals. J Fam Pract 2000;49:329-335.
40. Young HN, Cline RJW. “Look George, there’s another One!” The volume and characteristics of direct-to-consumer advertising in popular magazines. J Pharm Mark Manage 2003;15:7-21.
41. Woloshin S, Schwartz LM, Tremmel J, Welch HG. Direct-to-consumer advertisements for prescription drugs: What are Americans being sold? Lancet. 2001;35:1141-1146.
42. Cline RJW, Young HN. Marketing drugs, marketing health care relationships: A content analysis of visual cues in direct-to-consumer prescription drug advertising. Health Commun 2004;16:131-157.
43. Bandura A. Social cognitive theory of mass communication. Media Psychol 2001;3:265-299.
44. Kravitz RL, Bell RA, Franz CE. A taxonomy of requests by patients (TORP): A new system for understanding the clinical negotiation in office practice. J Fam Pract 1999;48:872-878.
45. Cockburn J, Pit S. Prescribing behavior in clinical practice: Patients’ expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 1997;315:520-523.
46. Peyrot M, Alperstein NM, Van Doren D, Poli LG. Direct-to-consumer ads can influence behavior: Advertising increases consumer knowledge and prescription drug requests. Mark Health Serv 1998;18:26-32.
47. Cooper-Patrick L, Gallo JJ, Vu HT, Powe NR, Nelson C, Ford DE. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583-589.
48. Fleming DJ, Samuels KW. Direct-to-consumer advertising and the learned intermediary. Hosp Pract 1998;33:129-130.
49. Sullivan DL, Schommer JC, Birdwell SW. Consumer retention of risk information from direct-to-consumer advertising. Drug Inf J 1999;33:1-9.