Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, November 25, 2006

Evidence Based Everything Else

While watching yet another Direct to Consumer (DTC) drug commercial on TV, my son said something that provoked a forehead-thumping moment of "aha!" His was a general (hopefully rhetorical) question about why drugs should be advertised at all. Shouldn't doctors be the ones to tell people what medicines they need? (To which the answer is, "Duh.")

But I got to thinking, and interpreting the question as "Why is there such a thing as DTC advertising?" generated the obvious, if dismaying answer, "Because it works."

How do we know it works? Because if it didn't, you know damn well Big Pharma wouldn't be pouring billions of dollars into it annually. And that's when it hit me: every other business in the world works on the basis of evidence; especially advertising. If a commercial doesn't have the desired effect of increasing sales, it's pulled. If a certain mode of advertising is shown to pump up the bottom line -- whatever legal, moral or ethical issues there may be -- it runs. Any downsides (such as fines) are just "the costs of doing business."

So why should medicine be any different? Why is EBM such a hard sell? Maybe what we need is to commission a couple of New York advertising firms to do our EBM research for us. Hell, it's worked like a charm for Big Pharma.


At Sat Nov 25, 06:50:00 PM, Anonymous Anonymous said...

Big Pharma has no conscience. The honesty of EBM shouldn't need to be sold ... however ... we must admit that things have become somewhat inverted of late ...

Hope your Thanksgiving was happy!

At Sun Nov 26, 02:24:00 PM, Blogger MedStudentGod (MSG) said...

All I ever do is scoff at the ads Merck has been trying to sell recently - giving away free meds. "Nice PR campaign." is my fondest comment to which Wife always asks why I think that.

I think EBM hasn't caught on as much because a lot of people stick with what they know. If a few reports indicate that doing X instead of Y equates to better outcomes, there are a lot of docs who will just blow this off. I see it all the time - more so with the older guys since they appear to know everything.

I keeping with that idea, I did see a resident and attending fight over a NEJM article related to caring for heart failure. It got nasty and the attending ended it by saying that they held the resident's job in their hand, so they'd best just STFU. Of course the resident tucked tail and ran.

At Sun Nov 26, 05:07:00 PM, Blogger Mom MD said...

Side note: I LOVE your Laws of the Dinosaur...especially the First.

Perhaps companies based on EBM need to do a bit more advertising - The Medical Letter and such. Free pens, free pads, and free lollipops all with "NEMJ" or "UpToDate" enscribed on them. Or how about "UpToDateolol" or "UpToDatepril" or "UpToDateartis" all printed on pen lights. Giggle. Intern needs

At Mon Nov 27, 05:58:00 PM, Blogger Unknown said...

EBM is based on trials. Sometimes the results are unequivocal.

Unfortunately, as everybody who has designed and run a trial knows, sometimes the results are only valid with umpteen qualifiers and caveats that don't make it into the advertsing.

Earlier this year, Dr. Iheanacho (editor of the well-regarded Drugs and Therapeutics Bulletin) argued that the absence of benchmark measurements of effectiveness allow drug companies to collect and analyse several data, selecting only those outcomes that best showcase their products.
"Clinical trials vary greatly in the types of measures they use to assess the effects of asthma drugs, and this makes it difficult to compare different trials or to assess whether new treatments offer a genuine benefit for patients."

An up-coming paper in Thorax argues that the selection criteria for most RCTs in asthma limit the applicability of their results to the 'general' asthma population. So, even without getting into the sticky area of pharmacogenomics, a lot of that DTC advertising lies by omission.

Muddled thinking - but I'm trying to say that EBM is not as always as straightforward as its (limited) publicity implies. Although, it is understood that for many conditions, and most of the time, EBM is A Good Thing.

Muddle over for now.

Regards - Shinga

At Sat Mar 03, 10:23:00 PM, Anonymous Anonymous said...

Regarding your reason that there should be no DTC: because doctors should be the ones deciding? Doctors get much respect but doctors are humans too, and each doctor has their own biases, preferences, experiences, and exposure to information (the last is up to the doctor's investment in time and devotion to truly understanding the differences among drugs - highly variable, depending on the doctor). How much do doctors truly embrace the evidence based revolution? Not much! For example, doctors are also supposed to follow the evidence base in their operations (e.g. in hospitals) but the record of their consistency is terrible. The patient needs to also learn as much as possible. True DTC may be selective, but if it gets patients researching more then it's a great thing. Thanks for blogging! -JB


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