For many Americans, a doctor's decision to prescribe medication is something of a sacred transaction. A physician considers the patient and symptoms and chooses the best drug for the job, drawing upon years of training and clinical experience. It is an exchange conducted in a hushed sanctuary, far from the heat and noise of the marketplace -- a place where cool judgment reigns.
That sanctuary has been breached. Today, drug manufacturers do everything in their considerable power to ensure that their brand-name prescription medications are on the lips of patients and in the minds of physicians every time the two meet across an exam table. A growing chorus of critics says their efforts have begun to rewrite the dialogue between patient and doctor, influence physicians' judgments and open the act of prescribing to forces more profit-minded than sacred.
In 2006, drug-makers spent almost $5 billion to reach out to consumers with direct advertising. But the glossy magazine ads and buzz-generating TV spots are just the most visible parts of a campaign to build and nourish markets for brand-name prescription products. The world's pharmaceutical companies spend an estimated $19 billion annually to woo doctors. They sponsor teaching programs and research at universities across the country, gaining goodwill along the way. They give money to patient groups. They hire public relations firms to share patient stories of illness and triumph.
In a nation that consumed $279-billion worth of prescription medications in 2006 -- spending 80% of that on brand-name products -- their efforts appear to be paying off. Americans filling a prescription choose brand-name products 37% of the time, even though three-quarters of all prescription drugs in the U.S. are available in cheaper generics.
"The most effective marketing is the marketing you're not aware of," says Dr. Peter Rost, a one-time pharmaceutical company marketing executive who has become an Internet-based industry watchdog. "If you see an ad, you know it's marketing. But if a friend or your doctor talks to you about a drug, you don't."
Now the size, scope and apparent effectiveness of drug companies' marketing efforts has begun to prompt cries of foul even from within the medical establishment, which has long been silent about its growth. In a handful of state legislatures across the country, lawmakers already have acted to blunt drug-company marketing, and many more are considering similar measures. Lawmakers on Capitol Hill have suggested that federal legislation may come next.
At stake, critics say, are patients' health, the nation's healthcare budget and, ultimately, the trust and esteem in which Americans hold their physicians. Costs rise as more doctors prescribe brand-name drugs when cheaper, older or more effective drugs might be available.
Under-treated conditions that threaten the lives and wellness of large swaths of the population -- illnesses such as diabetes and high blood pressure -- may get less attention than conditions such as erectile dysfunction or insomnia, for which pharmaceutical firms have new and potentially more profitable offerings. And patients may be steered toward newer drugs with risks and side effects that are less well-known, in lieu of medications with a longer history of safe use.
"There is nothing fundamentally wrong with advertising products," Dr. Jerome P. Kassirer, a former editor of the New England Journal of Medicine, told a Senate committee recently. "But when financial incentives yield inappropriate or dangerous care, when they inordinately raise the cost of care, when they risk patients' lives in clinical trials, and when they damage the profession, they have gone too far."
The pharmaceutical industry counters by arguing that its marketing efforts are needed to recoup the cost of drug development and that they introduce Americans to medicines that can save lives and improve well-being. The industry's sponsorship of research and education pushes the process of drug discovery and development forward, drug-makers say. Companies' marketing to physicians keeps busy clinicians abreast of new therapies and scientific advances in a fast-changing landscape. And their advertising of drugs in mass-media outlets educates patients and improves their communication with doctors, they add.
And drug marketing improves the economic vitality of the nation, a representative of the drug industry's largest trade group, PhRMA, said at a recent Senate hearing. Prompted by drug industry marketing, more patients in recent years have sought out a doctor, and more doctors have looked for signs of under-treated conditions such as depression, diabetes and asthma among patients, Marjorie E. Powell, an attorney for PhRMA, said to the Senate Select Committee on Aging in late June. Citing a pair of studies published in 2003, Powell said that in the long run, increasing treatment of such chronic conditions should drive down the nation's healthcare bill. As the debate rages -- among doctors, within universities, in statehouses across the nation and in the halls of Congress -- here is a look at a wide range of marketing efforts that has touched it off.