Doctors Do What Their Patients Ask Of Them

Health Professional

USA TODAY is running an article concerning direct to consumer ads about medications. Patients see the ads, and then go to the doctor requesting that or a similar medication, and the doctor feels some pressure to prescribe something. The result is that even more money is spent on medications.

There are a few points to be made. The implication is that doctors would not have prescribed the drug-- or anything-- had the patient not seen the ad.

You might ask: was the doctor unaware that the patient had the condition? In which case the ad helped spark a dialogue.

Was the doctor aware of the condition, but didn't prescribe anything because he felt it was unnecessary? If the patient is asking, it may be time to revisit that feeling.

If the medication is, indeed, unnecessary, why is the doctor prescribing anything even if the patient asks? Why is he or she succumbing to the pressure?

There's often a large gap between what a patient thinks he needs and what a doctor thinks the patient needs. There are plenty of patients who don't think they need blood pressure medication, but do think they need a sleeping pill-- and the doctor thinks the opposite.

In the case of depression, there are plenty of DTC ads about antidepressants (and antipsychotics), as well as accessory medications (sleeping agents, etc.) It would be great if there was a rigorous, objective way to determine whether a person was depressed, or if they would benefit from an antidepressant, but in truth the decision is a combination of patient request and doctor instinct.

So when a person asks for "Zoloft" by name, they are really asking for a medication that does what Zoloft does, and they are generally unaware of the alternatives. For hypertension there's an easy way to tell if the person "needs" it; for depression the mere fact that a person thinks they need it is a fairly important piece of information.

The real question this article is asking is whether the prescription is worth the money. Could they have gotten better from eating better, or exercising? Or perhaps could a generic be substituted for the Zoloft? (Point of fact: there is a generic Zoloft available.) Unfortunately, there's little incentive for the doctor to consider cost, at all. If the insurance covers it, and it's indicated, why not give the medication, and even the branded medication? In order for cost to be a consideration, the doctor has to be forced to consider it. Artificially setting prices lower doesn't change this; the best way is to value medications according to their medical worth, and the only one who can do that is the doctor.

Here's one possible method: instead of setting prices for drugs, or having a formulary for each insurance, do the opposite. Remove all price controls, allow complete access to all medications, branded and generic, but give the doctor a "medication allowance" for each patient, for example, $30 per day. This way the doctor has to make a decision: brand this or two generics that? Do I add augment toe Wellbutrin with Lamictal, or do add Ambien? Do I use Seroquel ($6) as a sleeping pill (and a lot of doctors do it) or save some of the money and prescribe generic temazepam, allowing me the ability to use...

I'm against drug ads on TV, but I'm also against soda ads for the same reason: it makes people want them. However, the solution does not lie with banning drug ads (they should, anyway) but with changing the way doctors decide which medications to use.