Advertisement-Induced Prescription Drug Requests Patients' Anticipated Reactions to a Physician Who Refuses

Journal of Family Practice, June, 1999 by Robert A. Bell, Michael S. Wilkes, Richard L. Kravitz

BACKGROUND. Drug manufacturers increasingly encourage patient prescription drug demand through the use of direct-to-consumer (DTC) advertisements. We describe patients' forecasts of their reactions if their doctor were to deny an advertisement-motivated drug request and then identify significant predictors of these reactions.

METHODS. We conducted a random phone survey of 329 Sacramento adults (response rate = 69%). Key outcomes were respondents' perceived likelihood of reacting to the nonfulfillment of a prescription request by becoming disappointed, trying to persuade the physician to reconsider, seeking a prescription from a different physician, and changing physicians. We also assessed associations between the likelihood of these reactions and respondents' evaluations of their physician's communication skills; attitudes toward, assumptions about the regulation of, and past responses to DTC advertising; health status; and demographic characteristics.

RESULTS. Disappointment was the most likely reaction (46%). One fourth of the respondents anticipated resorting to persuasion and seeking the prescription elsewhere, while only 15% considered terminating their relationship with their physicians. Subjects who anticipated reacting in these 4 ways reported lower satisfaction with their physicians, evaluated DTC advertising more favorably, and possessed more confidence in the government's regulation of these advertisements.

CONCLUSIONS. A sizable fraction of patients believed they would react negatively if their physician refused to provide a prescription for a drug advertised in the general media. Avenues for dealing effectively with patients' advertising-induced requests for prescription drugs are needed.

KEY WORDS. Physician-patient relations; advertising; prescriptions, drug; patient education. (J Fam Pract 1999; 48:446-452)

The pharmaceutical industry is increasingly relying on direct-to-consumer (DTC) advertising to encourage demand for prescription drugs. Annual expenditures for DTC advertising totaled $1 billion in 1997, was estimated to be $1.8 billion for 1998, and could be as high as $7.5 billion by 2005.[1-3]

Consumers are paying attention to these promotions, talking to their doctors about them, and even requesting prescriptions on the basis of the information conveyed.[4,5] It is surprising, then, that the impact of DTC advertising on the physician-patient relationship has received virtually no empiric study. Such advertising could damage patients' relationships with their physicians. Patients may insist on inappropriate treatments[6,7] because they have seen promotional materials that they do not understand[8] and that come from an industry that has not always been honest about the medical value and safety of its products.[9-11] Such patient requests could also direct physician attention away from other medical needs and transform the physician-patient relationship into a physician-consumer relationship.[12]

Physicians appear ambivalent about the value of DTC advertising,[13,14] but consumers feel mildly positive toward it and reject the notion that these appeals threaten their relationships with their doctors.[15,16] In one study, the individuals most likely to be influenced by a DTC advertisement were also most interested in the physician's advice about the promoted drug, suggesting that requests stemming from DTC advertisements need not undermine the physician's role or influence.[17]

We build on past research by exploring for the first time factors that could influence how patients would react if a physician refused to provide a prescription for an advertised drug the patient thought would be beneficial. Patients have several options in such a situation that can be used alone, together, or sequentially. They can accept the physician's decision on the assumption that the physician knows best or because they trust the physician's explanation of why the drug is not right for them. Or these patients can feel disappointed with their physician's decision. They may attempt to persuade the physician to reconsider, seek to obtain the prescription through a different physician, or terminate their relationship with the physician.

We advanced several hypotheses. Stronger negative feelings toward having a prescription request rejected were expected among patients who evaluated their physician's communication skills as poor. A supportive physician-patient relationship should allow the physician to respond constructively to the patient's health concerns and should foster the patient's trust in the physician's clinical judgment. We anticipated that negative feelings would be greatest for patients who had more approving attitudes toward DTC advertisements. In terms of patients' beliefs about the value of DTC advertising, we hypothesized that those patients who held the incorrect belief[18] that these promotions have been subjected to government scrutiny and endorsement would hold more positive attitudes about the trustworthiness of DTC advertising. We expected that individuals who have previously requested more information or a prescription from their physician as a result of a DTC advertisement would be more upset about their physician's refusal to fill a prescription drug request. We also predicted that the intensity of reactions to request nonfulfillment would be greatest among those patients most likely to feel a need for drug treatments--in particular those who evaluate their health as poor and are already making regular use of prescription drugs.