One of the advantages of teaching medical students is that I can keep abreast of changes in medical education. It’s far too easy for a doctor (even just a few years out of training) to become complacent and oblivious to changes in the modern medical curriculum. So I was pleasantly surprised earlier this week when a fourth-year medical student told me that his recent licensing examination included a vignette which tested his ability to interpret data from a pharmaceutical company advertisement. Given that most patients (and, indeed, most doctors) now get their information from such sources, it was nice to see that this is now part of a medical student’s education.
For those of you unfamiliar with the process, the US Medical Licensing Examination (USMLE) is a three-step examination that all medical students must take in order to obtain a medical license in the United States. Most students take steps 1 and 2 during medical school, while step 3 is taken during residency.
Effective this month, the drug-ad questions will appear in the Step 2 examination. Obviously, I don’t have access to the particular ad that my med student saw, but here’s a sample item taken from the USMLE website (click to enlarge):
It’s attractive and seems concise. It’s certainly easier to read—some might even say more “fun”—than a dry, boring journal article or data table. But is it informative? What would a doctor need to know to confidently prescribe this new drug? That’s the emphasis of this new type of test question. Specifically, the two questions pertaining to this item ask the student (1) to identify which statement is most strongly supported by information in the ad, and (2) which type of research design would give the best data in support of using this drug.
It’s good to know that students are being encouraged to ask such questions of themselves (and, more importantly, one would hope, of the people presenting them with such information). For comparison, here are two “real-world” examples of promotional advertising I have received for two recently launched psychiatric drugs:
Again, nice to look at. But essentially devoid of information. Okay, maybe that’s unfair: Latuda was found to be effective in “two studies for each dose,” and the Oleptro ad claims that “an eight-week study showed that depression symptoms improved for many people taking Oleptro.” But what does “effective” mean? What does “improved” mean? Where’s the data? How do these drugs compare to medications we’ve been using for years? Those are the questions that we need to ask, not only to save costs (new drugs are expensive) but also to prevent exposing our patients to adverse effects that only emerge after a period of time on a drug.
(To be fair, it is quite easy to obtain this information on the drug company’s web sites, or by asking the respective drug reps. But first impressions count for a lot, and how many providers actually ask for the info? Or can understand it once they do get it??)
The issue of drug advertising and its influence on doctors has received a good degree of attention lately. An article in PLoS Medicine last year found that exposure to pharmaceutical company information was frequently (although not always) associated with more prescriptions, higher health care costs, or lower prescribing quality. Similarly, a report last May in the Archives of Otolaryngology evaluated 50 drug ads in otolaryngology (ENT) journals and found that only 14 (28%) of those claims were based on “strong evidence.” And the journal Emergency Medicine Australasia went one step further last February and banned all drug company advertising, claiming that “marketing of drugs by the pharmaceutical industry, whose prime aim is to bias readers towards prescribing a particular product, is fundamentally at odds with the mission of medical journals.”
The authors of the PLoS article even wrote the editors of the Lancet, one of the world’s top medical journals, to ask if they’d be willing to ban drug ads, too. Unfortunately, banning drug advertising may not solve the problem either. As discussed in an excellent article by Harriet Washington in this summer’s American Scholar, drug companies have great influence over the research that gets funded, carried out, and published, regardless of advertising. Washington writes: “there exist many ways to subvert the clinical-trial process for marketing purposes, and the pharmaceutical industry seems to have found them all.”
As I’ve written before, I have no philosophical—or practical—opposition to pharmaceutical companies, commercial R&D, or drug advertising. But I am opposed to the blind acceptance of messages that are the direct product of corporate marketing departments, Madison Avenue hucksters, and drug-company shills. It’s nice to know that the doctors of tomorrow are being taught to ask the right questions, to become aware of bias, and to develop stronger critical thinking skills. Hopefully this will help them to make better decisions for their patients, rather than serve as unwitting conduits for big pharma’s more wasteful wares.