Monday, February 22, 2010

False Advertising

We don’t usually watch TV at our house, so are a bit out of touch with TV advertising. However, with the Olympics, we dug up an antenna and suddenly the TV is back on. And what we’ve been watching is pretty amazing.

It’s not just that there seems to be more time spent on advertisements than on the Olympics itself. It’s the number of medically related advertisements as well as the misleading information they contain that made my jaw drop.

“High technology is best,” and “the more technology the better,” are clear messages in the advertisements for hospitals and medical devices. Hospitals are luring patients with the promise that they have the newest facilities and the most technology. The reality is, though, that when patients do need hospitalization, it is the amount of experience that the physicians have with the technology that makes the difference. New technology in inexperienced hands is a recipe for waste and bad outcomes. None of the hospital advertisements mentioned the actual complication rates for their facilities nor the number of doctors, if any, who had significant enough experience with the promised technology to actually be competent using it. There is no data out there that proves that a new building leads to better patient outcomes. Sure, patients like a nice, clean, facility. But don’t let the new gloss make you think that you will get higher quality care. You will, however, be getting higher cost care. The new hospitals imply that those pesky poor and uninsured patients won’t be showing up at their new facilities located in the wealthiest suburbs. They don’t mention that even if you have insurance, their higher charges will be reflected in your higher premiums. They make a profit. Your insurance company makes a profit. In the long term, though, everyone suffers.

A device manufacturer is advertising its hand held portable ultrasound machine to the public. They show a series of people who supposedly have abdominal pain; different health care providers, from ancient times to the present, come up to these patients and say, “let’s take a look.” No one actually examines the patients or even seems to talk with them. They go immediately to the “lets take a look” behavior. Finally, the current, modern doctor pulls up the patient’s shirt and does an ultrasound.

The message that technology brings us out of the dark ages and is far superior to “just taking a look” is very clear. What is not apparent, though, is the fact that the vast majority of diagnoses (up to 85%, as I was taught in medical school) are made on the basis of the medical history alone. In other words, if you want to know what is wrong with your patient, you talk to them. You ask them about their symptoms, when they started, what makes them better and worse, whether they are constant or come and go, that kind of thing. With a thorough history, a characteristic pattern emerges. For instance, the patient with pain in the upper right abdomen that comes on suddenly after a fatty meal, doubles them over, is so painful they can’t find a comfortable position, gets more and less severe in waves, lasts a couple of hours and goes away, is associated with dark urine and light colored stools, and may have shoulder pain associated with it, is most certainly gall bladder disease. A totally different pattern of symptoms characterizes a stomach ulcer or appendicitis or ulcerative colitis. When the history is classic, the diagnosis is certain.

Another 7% of diagnoses are made on the basis of the physical exam. In case the history may have been a bit ambiguous, the physical exam may not be. The patient with pain in the upper middle abdomen who jumps when you press on their lower right abdomen probably has early appendicitis. The patient with middle abdomen symptoms who has exquisite pain when you press under the right ribs probably has gallbladder disease.

After the history and the physical, laboratory and radiology tests simply confirm what the physician already knows. Once you’ve made the diagnosis of gallstones, it is just a matter of form to find them on an ultrasound. Funny thing, though. A normal test does not mean you don’t have the disorder suspected. An ultrasound isn’t going to show appendicitis. It may be normal if you’ve already passed the gallstone or kidney stone. It is rare, indeed, that a test shows something that you had no idea would be there. How convenient that the advertisers don’t bother to mention just how limited the usefulness of their tests really are. How frustrating for us that we are led to believe that we should pay several hundred dollars to have an ultrasound when our diagnosis can be made without it.

And then there are the pharmaceutical advertisements. These are illegal in most countries, and until a few years ago were illegal here. Just like the hospital and device advertisements, they are also misleading. They imply that your life will be better if you use their medication. For instance, a new lipid lowering agent implies that you need to take it to live longer and avoid heart disease. They do not mention that you actually will have results just as good if you take the generic version of medications already out there. And that you won’t have any adverse side effects if you lose weight and exercise. And that their medication costs 10 or 20 times what a generic costs.

There are ads for antipsychotic agents that imply that you need to take them with your antidepressant if you are depressed. They fail to mention that the best treatment for depression is therapy coupled with traditional antidepressants, and that there is no antidepressant out there superior in effectiveness to any other antidepressant. Further, there is no evidence that in those few patients who do not do well on an antidepressant alone that the antipsychotic they are advertising, which costs in the range of $800 a month, would be any more effective than any other available augmentation strategy, like a second antidepressant from a different class or low dose thyroid, both of which can cost under $10 a month and do not have the serious side effects that antipsychotics can have.

It would be wonderful if all medical advertising is eliminated. It leads patients to demand newer technology, meds, and facilities, which raise the cost of medical care in this country without resulting in ANY improved outcomes. Instead of medical advertising, we should have public service announcements that discuss the actual risks and benefits of treatments, the times that tests might be helpful, and presentation of evidence based recommendations for screening or treatments.

In the meantime, TV watchers sit there slack jawed, soaking in all that false information, wanting, even demanding, to have what they are told they want. In our house, though, we are taking down the antenna and turning off the TV. We will get to bed earlier, avoid brainwashing from all that advertising, and if we really need to watch the Olympics, instead of just reading about the results, we can watch it on the internet for free the next day. After all, the results don’t depend on whether or not we are on the other side of the TV watching. And they will be just as exciting, and probably more so, when not interrupted by the interminable ads. Now if I can just figure out how to avoid those pesky internet advertisements, too.