In This Issue: Doctor-Patient and Drug Company-Patient Communication
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* Kurt C. Stange

This issue of the *Annals* presents research on communication with starkly different intent, process, and potential outcomes. We also convey 2 new clinical practice guidelines, a cost-effectiveness analysis of a common medical problem, and research with implications for how health care is organized and delivered.

## DRUG-TO-CONSUMER ADVERTISING

A content analysis study by Frosch and colleagues1 scrutinizes pharmaceutical television advertisements. While ads present facts and rational arguments, almost all make emotional appeals for their product. The majority of ads portray medication use as socially approved and as a way to regain control over some component of life. Few mention lifestyle approaches as a positive alternative or convey a balance of treatment options.

Editorialists David Kessler, former head of the US Food and Drug Administration, and Douglas Levy note that these ads promote pharmaceutical company profits but do not promote the public health. They emphasize drugs that have little to do with the predominant causes of morbidity and mortality and are not living up to standards of health education that focus on the public good.2

Unsaid in the study or editorial is the tremendous intrusion of such advertisements into the clinician-patient relationship. These ads suck precious time, motivation, and energy from the patient visit, forcing clinicians to educate patients about why a slickly promoted drug is not as important as a less sexy lifestyle change or even a cheaper but equally effective alternative medication. The advertisements represent yet another competing demand in an outpatient visit that averages 10 minutes of face-to-face time3 and already involves attempting to prioritize, personalize, and integrate care for an average of 3 to 4 problems.4,5 In effect, these ads steal from the poor to give to the rich—a kind of reverse Robin Hood for public health.

## CLINICIAN-PATIENT COMMUNICATION

Other studies in this issue examine different, but potentially related aspects of clinician-patient communication.

Using a rigorous standardized patient method, Epstein and colleagues examine the effect of physicians’ exploration and validation of patient concerns on their rate of antidepressant prescribing for major depression.6 In visits with low levels of physician exploration and validation of patient concerns, prescribing was driven by patient requests, not clinical indications. In visits with high levels of exploration and validation of patient concerns, prescribing was driven equally by clinical indications and patient requests.

If patient requests for care are driven by direct-to-consumer advertising in which new drugs are sold like soap,2 the Epstein study would seem to be yet another indictment of the potential for direct-to-consumer advertising to intrude into the process of health care. Yet, the issue is at least slightly more complex. A recent systematic review concluded that there is good evidence that direct-to-consumer marketing increases demand, but no evidence of benefit.7 Other analyses of the data in the Epstein study,8,9 however, show a complex relationship between patient demand and quality of care for a single disease. Patient requests for antidepressant medication are associated with more depression-specific history taking, as well as both averting underuse and fostering overuse of antidepressant medication, without apparently distracting from history taking for a second musculoskeletal condition presented during the visit.

What these studies don’t show is the huge and potentially negative spillover effect, as broad media appeals reach not just the narrow group of those undertreated for an important disease which a new drug can treat, but the large masses of people who inappropriately are made to feel they need the new medication, thus fostering worry and taking time and energy from more important concerns. Until its effect on competing demands across care of the whole patient are known, direct-to-consumer marketing must be considered an unproved public health intervention that raises serious cause for concern.

An essay in this issue enriches our understanding of the art of health care communication. Brody shows the effects of factors both outside and inside the visit on creating the space that allows the patient’s true issue (not always an easily classified diagnosis) to emerge.10 This essay documents the fascinating complexity and joy of unfettered family practice—and the opportunity to have formative effects that improve people’s lives. The higher-order quality of care documented in this essay is not measurable by our current quality measures. This sort of excellent human care may actually be impeded by current pay-for-performance schemes and is unlikely to be helped by advertisements that push patients to request the latest drug. Adapting a well-known visit typology,11 this illness visit starts out looking like a routine visit, moves quickly to a drama, and ends with a ceremony. This visit appears to have a seminal effect not only on a child’s illness, but on the powerful labeling effects and family relationships that are formative on a child’s development and life trajectory.

## GUIDELINES AND SCIENTIFIC EVIDENCE FOR THE DIAGNOSIS AND TREATMENT OF THROMBOEMBOLISM

Showing the result of collaboration between internal medicine and family medicine professional organizations and journals, this issue features clinical practice guidelines for the diagnosis12 and treatment13 of thromboembolism. An evidence review in the *Annals*14 and a companion review in the *Annals of Internal Medicine*15 provide access to the detailed science behind these clinically useful guidelines. We feature the diagnosis guideline and evidence review in this issue’s *Annals* Journal Club.16

## OTHER CLINICAL AND HEALTH SERVICES DELIVERY RESEARCH

A carefully done cost-effectiveness analysis compares several observational and antibiotic treatment regimes for otitis media.17 This analysis provides an empirical way to bring together concerns about antibiotic overuse and patient quality of life and cost, and to apply these to the care of patients.

In one of only a handful of studies that examine the effect of the widely touted Chronic Care Model in small independent practices, Nutting and colleagues show an association with higher levels of process measures and intermediate outcomes for diabetes care.18

In a Swedish cohort study, Albertsson and colleagues find that 4-item measure predicts 2-year hip fracture risk and mortality, and a single item predicts vertebral fracture risk among elderly women.19

A study involving 20 US primary care practice-based research networks (PBRNs) documents important differences between patient visits to PBRNs and national data on outpatient visits.20 This study also shows the potential utility of a new PBRN visit characterization measure.

We encourage readers to share experiences and ideas by joining the *Annals* online discussion at [http://www.annfammed.org](http://www.annfammed.org).

*   © 2007 Annals of Family Medicine, Inc.

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10. Brody H. A headache at the end of the day. Ann Fam Med. 2007; 5(1):81–83.
    
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13. Snow V, Qaseem A, Barry P, et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Fam Med. 2007;5(1):74–80.
    
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14. Segal JB, Eng J, Tamariz LJ, Bass EB. Review of the evidence on diagnosis of deep venous thrombosis and pulmonary embolism. Ann Fam Med. 2007;5(1):63–73.
    
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17. Coco AS. Cost-effectiveness analysis of treatment options for acute otitis media. Ann Fam Med. 2007;5(1):29–38.
    
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18. Nutting PA, Dickinson WP, Dickinson LM, et al. Use of chronic care model elements is associated with higher quality care for diabetes. Ann Fam Med. 2007;5(1):14–20.
    
    [Abstract/FREE Full Text](http://www.annfammed.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NjoiNS8xLzE0IjtzOjQ6ImF0b20iO3M6MjA6Ii9hbm5hbHNmbS81LzEvMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

19. Albertsson DM, Mellström D, Petersson C, Eggertsen R. Validation of a 4-item score predicting hip fracture and mortality risk among elderly women. Ann Fam Med. 2007;5(1):48–56.
    
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20. Binns HJ, Lanier D, Pace WD, et al. Describing primary care encounters: the Primary Care Network Survey and the National Ambulatory Medical Care Survey. Ann Fam Med. 2007;5(1):39–47.
    
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