ince 1997, when the Food and Drug Administration clarified its rules on advertising prescription drugs, pharmaceutical advertisements on television and in print have increased significantly. Gale Scott spoke to two doctors about how the advertising affects patients. Following are edited excerpts from those interviews.

Are Direct-to-Consumer Pharmaceutical Advertisements Confusing to Patients?

YES, they are. The United States is the only industrialized nation that allows drugs to be advertised to the public. Other nations find the practice unethical. The sole purpose of these ads is to brand and sell products, not patient education.

I have had patients come into my office who have seen these ads, and they are confused over whether they need a specific brand-name drug. It could be one advertised for hormone replacement therapy, allergy, pain — just about anything.

They see the ads and they become convinced that they need that particular drug, which is often the most expensive one for their particular condition. These branding ads paint a rosy picture that may create unrealistic expectations for patients. Many of the ads are just sound bites with the product name.

Not only do we have to take time to explain to these patients the nature of the medical problem they have, and whether it needs to be treated with drugs, but we also have to discuss whether the drug they have seen promoted is their best option. Patients need better quality information than they are getting from many of these ads.

The Food and Drug Administration should impose limits on the pharmaceutical industry by evaluating these ads before they are made public. The current F.D.A. regulatory process is much too lenient. It allows drug companies to advertise their messages to the public before the F.D.A. has had a chance to check the appropriateness of the information.

This advertising is also extremely expensive, a cost passed on by raising drug prices.

Some defenders of the ads say they bring new patients into care, just to ask about a drug they've seen advertised. I have not seen that happen. I've seen the opposite. Last year's new flu drug is a great example. We got reports that patients called their physicians saying they had the flu and wanted the doctor to phone in a prescription for this advertised antiviral drug. But some of these patients actually had bacterial pneumonia, not the flu virus. The antiviral flu drug didn't work for those patients and their pneumonia got worse. That's a dangerous situation.

It is not too late for the F.D.A. to reel this practice of direct-to-consumer advertising back in. It would take some tweaking of federal regulations, but our position at the American College of Physicians-American Society of Internal Medicine is that the F.D.A. should screen these ads before they are released. It is great to get drug information to consumers, but the information has to be balanced.

Another area of concern is that these ads may be feeding into another dangerous practice — people buying drugs over the Internet without seeing a doctor. Ads create a demand, and patients may turn to the Internet, getting a prescription from a faceless name at the other end of a cable.

We want patients to receive the best products for them, not just the most heavily advertised products.

DR. SANDRA ADAMSON FRYHOFER
Associate professor, Emory University

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NO. These ads are helpful because they inform consumers. An educated patient is an easier patient to treat. In the world of health care, ignorance is not bliss. Other than the time and place of your own death, what things are we better off not knowing?

In my private practice, I treat mostly patients with diabetes, a chronic disease. It is easier to help these patients when they realize that they become acutely ill when they do not take care of their underlying problems. These ads stress to my patients that they need to bring their blood sugar and blood pressure under control, and that drugs play a role. When patients realize this, I am two steps ahead in caring for them.

But I think the ads are also helpful in dealing with acute, short-term illness. Ads can get people to come in for flu shots, for instance. The main benefit I see in my patients is that when they come into the office, they are ready to start talking about the latest diabetes pill or treatment.

Physicians' time with patients is so limited now. In the late 1980's the average endocrinologist was seeing 18 patients a day. Now we are seeing 25 to 30 patients, sometimes even more. These are complex patients.

It is not just in my specialty. One emergency physician I work with tells me his attitude has become: "Just keep the meat moving." It is too easy to feel like we are becoming part of some kind of an assembly line. Meanwhile, the reimbursement we receive is down. We are running harder and harder, and the little time we have with our patients is eaten into with more and more paperwork.

These pressures are changing the doctor/ patient relationship. Patients now seen as "clients" or "customers" are being forced to change health plans more often. You are strangers to each other at the time of treatment. So if an ad educates a patient, that at least gives you both more time to use in getting acquainted in the office visit and more time for providing care.

Another advantage to these direct-to-consumer ads is that they can make patients aware of drugs that could be of great benefit to them but that their health plans might not cover. A few years ago a diabetes drug called Glucophage came on the market. I was at a medical meeting in San Diego and gave a lecture on its benefits. The drug allows patients to go off insulin. Afterward the doctors in my audience said: "Good lecture, good drug, but we can't use it. Our H.M.O. won't pay for it."

They explained that their H.M.O. had already made up its formulary, that is, the list of drugs it would cover, for that year. Then the H.M.O. told its doctors that if they wanted to prescribe it they could, but the H.M.O. would deduct the cost from their paychecks. How many doctors would prescribe it then?

If advertising sometimes results in patients' asking for a drug that is inappropriate, I will say so. That's not a problem. If it means patients ask for an expensive drug that might not work, it is still better that they know there is such a drug. If they cannot pay for the drug, pharmaceutical companies have programs to provide free drugs for the indigent.

I think more patients are coming in for treatment just to see if a drug they have seen advertised might help them with a problem. That's good.

DR. RICHARD DOLINAR
Endocrinology Associates, Phoenix