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Unformatted text preview: Essay Focus patients. Both parties have thereby occupied new roles and new subject positions, especially when their conversations revolve around prescription drugs. Also overlooked by most US publications are the ways in which DTC advertising has changed physicians’ own understandings of the treatments they prescribe. Of course, countless studies—almost as prevalent as the advertisements themselves—examine the eﬀect of the advertisements on prescribing practices, and an equal amount of market analysis assesses changing patient attitudes and behaviour.6 But fairly little has been written about the ways in which doctors’ own beliefs about and expectations of prescription drugs are shaped by the fact that they too are members of US culture, and are as such subject to the same advertisements as are their patients. To suggest that medical knowledge somehow protects physicians from cultural trends seems irrational; yet whether DTC advertisements aﬀect doctors and patients similarly remains a matter of speculation. DTC advertisements have also ampliﬁed, and in some cases changed, cultural expectations about illness and health. For instance, television in the USA is replete with images of Levitra-invigorated men throwing footballs through tyres, or women who are proﬁcient at motherhood duties because of antidepressants.7 Even the outﬁeld walls in many professional baseball stadiums now carry colourful billboards touting the latest erectiledysfunction treatments to players, coaches, and fans. Such representations undoubtedly represent savvy marketing, yet they also show how advertising of drugs calls on and reﬂects existing cultural assumptions about matters such as gender, sexuality, race, and class to create expectations for prescription drugs. The advertisements connect prescription medications with assumptions about what it means to be a normal man, woman, black person, white person, lover, worker, or a host of other abstract, protean roles in US society. By doing so, the advertisements promote information not only about drugs, but also about the social contexts in which medications accrue symbolic meanings that, one might well surmise, play out in clinical contexts. For better and for worse, DTC advertising thereby demonstrates how medicalisation intersects with values that drug advertisers are surely adept in recognising, but that are already present in the ways doctors and patients conceptualise categories of illness, health, and gender—otherwise the advertisements would be ineﬀective. Yet, evidence suggests that US clinicians have struggled with these new relationships, expectations, and roles. Even though DTC advertisements overtly encourage conversations between doctors and patients, many physicians suspect covert attempts to usurp their authority or dictate clinical decisions a priori. The result is tension, not only between doctors and drug companies, but between doctors and patients. For instance, a US Food and Drug
www.thelancet.com Vol 369 February 24, 2007 Administration survey of US physicians showed that 47% felt pressure from patients to prescribe advertised drugs, 62% said DTC advertising had caused tension between themselves and their patients, and 92% said they could think of at least one patient who instigated discussion about an advertised drug.8 Such ﬁndings have led to calls to more tightly regulate or abolish DTC advertising.9 More nuanced clinical conversations about prescription drugs are needed between doctors and patients. Instead of feeling pressure or viewing prescription interactions solely as yes or no decisions, physicians should become more aware of, and constructively address, the intended and unintended expectations and misperceptions raised by DTC advertisements. Such an approach would require physicians to be trained to identify the social narratives around prescription drugs at the same time as they are trained to identify the drugs’ chemical eﬀects. Understanding the nuances of pharmacodynamics, drug interactions, and clinical diagnoses remain vital. Yet, nowadays, such skills might be enhanced by the mastery of clinical strategies to allow patients and doctors to identify and discuss their preconceived expectations about prescription drugs—what might, in an earlier era, have been called the transference and countertransference of pharmacology. Do patients think that medications might help them become better parents, students, or athletes? Why, or why not? What is the source of these beliefs? How do the answers to these questions intersect with a particular clinician’s own expectations with respect to the potential beneﬁts of treatment? Clinicians might also learn to become more attentive to expressions of illness that are diﬀerent from the stereotypes promoted by drug advertisements. They might be asked to consider, for instance, the clinical relevance of an economy in which, during the second half of the 20th century, antidepressant advertisements promoted stereotypes of white women whereas at the same time largely excluding representations of patients from ethnic minorities, men in the role of fathers, people in same-sex relationships, and other groups.10 The 9-year US experiment with DTC advertising ultimately imparts an important lesson about clinical interactions, whether or not these advertisements are exported, regulated, or banned. DTC advertisements expose ways that doctors and patients might understand, and explicitly discuss, how market forces, cultural ideologies, and often unspoken expectations aﬀect beliefs about prescription drugs. By recognising these forces, doctors and patients can begin to take control of issues that seem to be imposed by the drug industry, but in fact are dependent on values, judgments, and assumptions made by both participants in the examination room.
Conﬂict of interest statement I declare that I have no conﬂict of interest. 705 ...
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