Canadian Medical Association Journal 1996; 154: 755-764
We have long been struck that those who educate, supervise and pay for the ultimate quantum of medicine (the physician-patient encounter), who should be interested in its efficiency, validity and appropriateness, have not been tempted to follow the lead of the pharmaceutical industry.
Our capitalist (not a pejorative term, by the way) partners in health care have long sent representatives door to door to "promote" new developments in drug therapy. The fact that the practice has persisted over the decades suggests that there is profit in it. Would it be too outrageous to imagine a roving group of paid "health care" representatives going door to door, and, in 15 minutes, with the aid of handy hand-outs, explaining scientifically the health benefits of whichever clinical practice guidelines were chosen as the product of the month?
Gordon I. Brock, MD
Vydas Gurekas, MD
Centre de santé Témiscaming
Témiscaming, Que.
Received via email
Pharmaceutical companies spend about 20% of their revenues on marketing. In Canada this translates to more than $2 billion annually spent on marketing drugs to physicians, pharmacists and the public. By contrast, total Canadian expenditures on all forms of medical research -- including pharmaceutical research -- are about $1.4 billion. Ideally, we would market all good evidence-based research to the appropriate audiences. Of course, it is better to drain the swamp (i.e., to promote practice based on the best available research), but the immediate challenge is to fight off the alligators unleashed by the relentless drug-industry marketing juggernaut.
Given the stakes -- the battle is for the concept and practice of medicine -- it may be rational and even wise to spend huge sums counter- detailing, but this would be costly levelling. Drug companies spend more than $2 billion digging the hole, and public agencies spend another enormous sum to fill it in. The losers in this heroicly unconstructive battle are the citizens who ultimately pay for both.
There are, then, two objectives: developing a culture in which practitioners and at least some consumers seek out and assimilate valid knowledge, and equipping the targets of advertising with the tools to filter out the junk. Several medical groups and academic health science centres have taken prophylactic steps: they do not see the detailers, do not read their propaganda, control their access to students and instil critical appraisal skills in future practitioners. This still leaves thousands of physicians and the public vulnerable to sales pitches of varying quality and honesty.
The policy solution, which is heavy handed but effective, is to ban pharmaceutical and related advertising, just as we ban cigarette advertising from television. That will not happen; from a public-interest perspective, let us say that it should not. What is to be done?
One option is to set up an organization of high-quality, disinterested scientists and public representatives to vet drug advertising. The organization would certify that the advertisements meet standards of accuracy and balance and otherwise contribute to understanding without distortion. In time, providers and the public would learn to recognize the stamp of approval (say, a prominent logo), creating an incentive for the industry to clean up its act. Who knows -- in time the good information may become recommended reading.
Alternatively, the industry could self-regulate and cease digging the figurative hole. Then, whatever funds we have to spend on marketing good evidence could achieve the admirable purposes Brock and Gurekas no doubt have in mind.
Steven Lewis, MA
Chief executive officer
Health Services Utilization
and Research Commission
Saskatoon, Sask.