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ORIGINAL INVESTIGATION
Clinicians’ Responses to Direct-to-Consumer
Advertising of Prescription Medications
Woodie M. Zachry III, PhD; James E. Dalen, MD; Terrence R. Jackson, PharmD, MS
Background: The direct-to-consumer advertising (DTCA)
of prescription medications is proliferating in the United
States. The relationship between patient exposure to DTCA
and the response of clinicians is not well understood.
Methods: A randomized postal survey of Arizona primary care provider physicians (n = 1080) and physician
assistants (n=704) was conducted. A questionnaire was
created using a hypothetical patient scenario that varied
according to the diagnosis of the patient (ie, hypertension, hypercholesterolemia, seasonal allergies, or obesity) and the type of informational exposure generating
the patient’s questions (ie, DTCA vs drug references such
as Physicians’ Desk Reference). Clinicians were randomly assigned 1 of 8 forms of the scenario and were asked
standardized questions related to their responses when
faced with the patient scenario.
Results: The response rate was 44% (40.5% of physicians and 49.3% of physician assistants). No statisti-
cally significant differences were found between the early
and late responders or between responders and nonresponders. Relative to clinicians who received the “drug
reference book” patient scenario, clinicians who received the DTCA patient scenario were more likely to become annoyed with a patient for asking for more information about medications (P=.003); less likely to answer
the patient’s questions (P=.03) or provide additional written information (P=.007); more likely to become frustrated (P =.003) and annoyed (P⬍.001) with the patient
for asking to try a specific medication; and less likely to
provide samples (P=.001) or a prescription (P⬍.001) for
a specific medication.
Conclusion: Clinicians are amenable to patients asking
for drug information and medications, but they are less
receptive to questions arising from DTCA.
Arch Intern Med. 2003;163:1808-1812
S
From the Colleges of Pharmacy
(Dr Zachry) and Medicine
(Dr Dalen), University of
Arizona, Tucson; the College of
Pharmacy, University of Illinois
at Chicago, Chicago
(Dr Jackson). The authors have
no relevant financial interest in
this article.
PENDING ON direct-to-consumer advertising (DTCA)
for prescription drugs in the
United States has increased
dramatically over the last decade. It was estimated that $2.47 billion
was spent in 2000 by pharmaceutical companies advertising directly to patients.1,2
This compares with estimated spending of
$1.07, $1.32, and $1.85 billion in 1997,
1998, and 1999, respectively.1,2 The ubiquity of DTCA has occurred much to the
dismay of many in the medical community. A 1997 survey of physicians by Intercontinental Marketing Services found
that 39% believed that DTCA caused consumers to come to the wrong conclusions about medications, and 35% were in
favor of eliminating DTCA completely.3
While only 16% of those physicians reported that DTCA was an effective educational vehicle, 41% believed that the advertisements (ads) confused and educated
patients in equal amounts.
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The potential for DTCA to influence
patient perceptions concerning pharmaceuticals has been well established in the
literature. From 1984 to 1986, Morris and
colleagues4-6 produced the earliest and
strongest evidence of DTCA’s influence on
patients. Results from these studies demonstrated that the amount, type, and presentation of information in a drug ad could
influence a viewer’s perceptions of the drug
and/or disease advertised. They also
showed that up to 6% of those viewing
drug ads drew incorrect conclusions about
the product that were not explicitly stated
in the ad and that up to 14% indicated a
mistaken impression as the main point of
the ad.4,5 The authors noted that higher
misconception rates seemed to be tied to
strong visual signals within the ad, misunderstandings about the treatment of the
disease, and commonly held beliefs about
the type of medicine in the ad.5 Overall,
benefits were recalled at a higher rate than
the risks presented in the ads.4 The au-
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thors also noted that the amount of risk information communicated by the ad influenced the perceived seriousness and limitations of the disease.6
Once patients have formed impressions based on an
ad, the possibility exists for these impressions to influence behavior. This includes the possibility that a patient will seek information, a specific medication, and even
different care if his or her requests are denied. A survey
by Prevention Magazine7 revealed that 32% of those viewing a DTCA talked with their physician about an advertised medicine, and 26% of those talking with their physicians actually asked for the medication. A study by Bell
and colleagues8 found that 15% of respondents were somewhat to very likely to switch physicians based on the original physician’s negative response to a prescription drug
request, and 24% were somewhat to very likely to visit
other physicians to get the prescription they were originally denied.8
The ability of patient expectations to influence the
prescribing process has received considerable attention
in the literature. Research has shown that the likelihood
that a practitioner would provide a prescription was significantly associated with the patient’s expectations of receiving a prescription.9,10 Cockburn and Pit11 found that
patients who expected to receive a prescription on seeing a physician were 3 times more likely to receive one
than those who did not. Studies have also reported that
physicians admit that patient demand influences their prescribing behavior, and that they were 10 times more likely
to write a prescription when they believed that the patient expected one.11,12 However, this literature has not
addressed the source of patient inquiries and expectations and its relationship to clinician behaviors. Specifically, the likelihood of clinician behavior to change when
faced with patients exposed to a drug ad has not been
explored. Therefore, the purpose of this study was to examine the responses (behavioral intentions and emotional reactions) of clinicians when faced with patients
who sought information and medications in response to
a DTCA.
METHODS
This study was a mail survey of physicians and physician assistants. All primary care physicians (family practice, internal
medicine, and general practice) and physician assistants licensed and practicing in Arizona, as defined by the Arizona Board
of Medical Examiners, were included in the sample frame. A
total of 2953 physicians and 706 physician assistants met these
criteria. A random sample of 1080 licensed physicians and 704
licensed physician assistants in Arizona were mailed a questionnaire. The subjects were provided with a case scenario in
which a patient, recently diagnosed with a moderate form of a
certain disease, mentioned a medication they had questions
about. Eight versions of the case scenario were created differing on the disease/treatment pairs mentioned and whether the
medication came to the attention of the patient through a drug
reference work (eg, Physicians’ Desk Reference) or a prescription drug ad (ie, DTCA). The scenarios were based on the following 4 disease/treatment pairs: (1) hypertension/angiotensinconverting enzyme (ACE) inhibitor, (2) hypercholesterolemia/
hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase
inhibitor (statin), (3) seasonal allergies/antihistamine, and (4)
obesity/weight-loss aid. The case scenarios followed the fol-
lowing standard format with the words in parentheses indicating a source of variance among forms:
Imagine you are examining one of your patients diagnosed with
moderate (hypertension, hypercholesterolemia, seasonal allergies, obesity) whose overall health is good. After examining the
patient, the patient mentions a prescription (ACE inhibitor,
HMG-CoA inhibitor, antihistamine, weight-loss aid) he/she
(viewed in a drug advertisement, read about in a drug reference).
Please answer the following questions based on the information provided. Since no specific agents are named and no further information about the patient is given, answer the questions based upon your general beliefs associated with the
treatments for (hypertension, hypercholesterolemia, seasonal
allergies, obesity).
Clinicians were then asked to report on a 6-point scale the likelihood (6, very likely; 5, likely; 4, somewhat likely; 3, somewhat unlikely; 2, unlikely; 1, very unlikely) of 14 different behaviors and/or reactions related to the patient’s requests for
information and the medication: (1) frustration with the patient for asking for more information; (2) annoyance with the
patient for asking for more information; (3) answering the patient’s questions; (4) providing more information beyond the
initial inquiry; (5) providing additional written information;
(6) changing the subject rather than discussing the medication; (7) explaining that the drug information is probably beyond the patient’s comprehension; (8) frustration with the patient for asking for a specific medication; (9) annoyance with
the patient for asking for a specific medication; (10) discomfort with a request for a specific medication; (11) communicating discomfort with a specific medication request to the patient; (12) prescribing a medication other than what the patient
asked for to discourage the patient from asking for specific medications in the future; (13) providing samples of the medication; and (14) providing a prescription for the specific medication. Each response was considered to be on an interval scale,
having a midpoint of 3.5. In the final section of the questionnaire, respondents were asked questions about their demographic characteristics (ie, age, sex, race and/or ethnicity) and
practice setting (ie, number of patients seen on an average day).
Eight versions of the questionnaire were randomly distributed to the sample population. The 8 versions varied only
with regard to the disease and the patient’s source of information communicated in the case study. Clinicians were randomly sent 1 version of the questionnaire and were blinded to
other forms of the instrument. The total design method developed by Dillman13 was used to conduct the survey. A postcard
notification was sent out 1 week prior to the initial questionnaire mailing. A reminder letter was mailed 1 week after the
first instrument mailing. A follow-up mailing of the questionnaire took place 3 weeks from when the initial instrument was
mailed. The survey was conducted under the auspices of the
University of Arizona Human Subjects Protection Program. Information about the subject’s voluntary participation was provided in a cover letter sent with the survey. An entry into a raffle
for 1 of 3 copies of a medical reference was offered as an incentive to enhance the response rate.
Analyses were conducted to assess if any differences existed among responders and nonresponders based on practice
site (metropolitan vs nonmetropolitan). Metropolitan practice sites were defined as being in cities with 50000 or more
residents, according to projected census figures.14 Nonmetropolitan cities were defined as having fewer than 50 000 residents.15 Further analyses were conducted to research the probability differences in early (first 3 weeks) and late responders
based on practice site, age, sex, and ethnicity of the respondent. ␹2 Analyses were used for data not meeting parametric as-
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sumptions and 1-way analysis of variance was used for data meeting parametric assumptions.
General linear models were used to examine relationships between the dependent variables (responses for each of
the 14 items) and 1 independent variable (DTCA exposure)
while controlling for the remaining 2 independent variables (professional title and disease/treatment pair advertised) and covariates (patients seen on an average day and respondent age).
Post hoc pairwise comparisons were also performed. An a priori
␣ level of .05 was used for all analyses.
RESULTS
For the physician and physician assistant subgroups, 423
and 340 usable surveys were returned, respectively. The
overall response rate for useable surveys was 44% (40.5%
physicians and 49.3% physician assistants). Respondents
were predominantly male (63%) and white (white, 80.6%;
Asian, 6.6%; Hispanic, 5.6%; African American,1.7%; Native American, 1.4%; and other, 2.6%). Most respondents
(17.8%) were aged 45 to 49 years; 15.1%, 40 to 44 years;
14.7%, 50 to 54 years; and 14.1%, 35 to 39 years.
There were demographic differences between physicians and physician assistants based on age (␹2 =59.908;
P⬍.001) and sex (␹2 = 44.127; P⬍.001) categories. A
greater percentage of physicians (73.8%) than physician assistants (50.4%) were male. Physician respondents were also older. A greater percentage of physicians (29.1%) than physician assistants (10.6%) were 50
years or older, while a higher percentage of physician assistants (43.4%) than physicians (21.5%) were aged between 19 and 34 years. However, the highest percentage of both groups (physicians, 49.4%; physician
assistants, 46.0%) were aged 35 to 49 years.
No overall statistically significant differences were
found between the early responders (those responding
in the first 3 weeks after initial mailing of the instrument) and late responders (those responding after the
second mailing of the instrument) based on age (P=.96),
sex (P=.77), ethnicity (P=.11), or the metropolitan designation of their practice setting (P = .40). Similarly, no
statistically significant differences were found between
responders and nonresponders based on the metropolitan designations of their practice setting (P = .21). Variables representing DTCA exposure (P⬍.001), professional title (P⬍.001), the disease mentioned in the case
study (P⬍.001), and age (P = .04) all achieved significance at the multivariate level (Wilk ␭). Finally, no interactions between the independent variables were found
to be statistically significant.
OVERALL DESCRIPTIVE FINDINGS
When clinicians were asked to indicate their responses
to the patient scenario, most reported that they were somewhat likely to very likely to answer a patient’s questions
about a medication (96.6%) and provide information beyond the original inquiry (86.2%). Nearly all clinicians
reported that they were somewhat unlikely to very unlikely to attempt to change the subject rather than discuss a medication (97.4%) or explain that drug information is beyond the patient’s comprehension (96.8%). Also,
most clinicians indicated that they were somewhat un-
likely to very unlikely to become frustrated (93%) or annoyed (92.9%) with requests for drug information.
Similar results (ie, somewhat unlikely to very unlikely) were obtained when respondents were asked about
a patient inquiry for a medication (frustrated, 90.6%; annoyed, 92.1%). Furthermore, most clinicians reported that
they were somewhat unlikely to very unlikely to be uncomfortable with a patient request for a medication
(74.4%) or to communicate being uncomfortable with a
medication request (64.2%). Also, most clinicians (92.5%)
reported that they were somewhat unlikely to very unlikely to prescribe a medication other than what was asked
for to prevent patients from asking for medications in the
future. Finally, clinicians appeared receptive to providing samples (77.5% somewhat likely to very likely) or a
prescription (75.5% somewhat likely to very likely) when
requested by the patient.
SOURCE OF DRUG INFORMATION
The Table summarizes the analyses examining the differences related to the type of informational exposure of
the patient, controlling for the type of clinician, clinician
age, average number of patients seen daily, and the disease/
drug pair mentioned in the survey case study. The type of
information exposure reported by the patient was related
to the likelihood of clinicians providing information to the
patient. Clinicians reported that they were more likely to
become annoyed with a patient for asking for more information about a medication they saw in an ad (P=.003) than
one they saw in a drug reference. Clinicians also reported
that, relative to a drug reference, they were less likely to
answer the patient’s questions about an advertised medication (P=.03) and were less likely to provide additional
written information about an advertised medication
(P=.007). Furthermore, clinicians reported that they were
more likely to attempt to change the subject rather than
discuss a medication a patient saw in an ad vs a medication read about in a drug reference (P=.02).
Similar significant associations were found between the type of patient informational exposure and the
likelihood of the clinician’s response to a patient’s request to try a particular medication. Clinicians reported
that they were more likely to become frustrated (P=.003)
and annoyed (P⬍.001) with the patient for asking to try
a medication that they had seen in an ad as opposed to
one they had read about in a drug reference. For patients reporting DTCA exposure, clinicians were more
likely to prescribe a medication other than the one for
which the patient asked than for patients reporting a drug
reference exposure (P = .002). Moreover, clinicians reported that they were less likely to provide samples
(P=.001) or a prescription (P⬍.001) for the medication
a patient saw in drug ad when compared with patients
using a drug reference.
COMMENT
This study examined the possible responses of clinicians when faced with inquisitive patients. The results
suggest that clinicians respond favorably to patient in-
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Estimated Marginal Means for the Questionnaire Items by Medication Information Source
Estimated Marginal Means*
Dependent Variable
If a patient asked for information about a medication, what is the likelihood you
would:
Become frustrated with patient for asking for more information
Become annoyed with patient for asking for more information
Answer patient’s questions about the medication
Provide more information to patient beyond original inquiry
Provide additional written information to patient
Attempt to change subject rather than discuss the medication
Explain that the information is probably beyond patient’s comprehension
If a patient asked if he/she could try the medication, what is the likelihood you would:
Become frustrated with patient for asking to try the medication
Become annoyed with patient for asking to try the medication
Feel uncomfortable with the medication request
Communicate to the patient your discomfort with the medication request
Attempt to prescribe different medication to keep from
promoting patient to ask for medications in the future
Provide samples of the medication, if available
Provide prescription of the medication if no samples available
DTCA (x)
Drug Reference (z)
Difference (x−z)
P Value
1.966
1.945
5.397
4.657
3.194
1.658
1.496
1.839
1.744
5.541
4.729
3.455
1.513
1.476
0.127
0.201
−0.144
−0.072
−0.261
0.145
0.020
.06
.003†
.03†
.40
.007†
.02†
.74
2.132
2.104
2.707
2.964
2.072
1.921
1.845
2.544
2.943
1.844
0.211
0.259
0.163
0.021
0.228
.003†
⬍.001†
.08
.85
.002†
4.135
3.865
4.476
4.229
−0.341
−0.364
.001†
⬍.001†
Abbreviation: DTCA, direct-to-consumer advertising.
*Rated from 1 (very unlikely) to 6 (very likely) and controlling for age, average number of patients seen daily, disease, and respondent title (physician or
physician assistant).
†Statistically significant at P ⬍.05.
quiries, regardless of the source of drug information. Furthermore, it does not seem likely that clinicians will take
part in behaviors designed to circumvent patient involvement in their care. These overall findings remained consistent with regard to the influence of DTCA on clinician behavioral intentions. However, statistically
significant findings did suggest differences related to the
DTCA exposure of the patient. Clinicians were less likely
to provide drug information and medication samples or
prescriptions to the patient if the basis of their questions was a DTCA rather than a drug reference. Furthermore, clinicians reported that they were more likely to
become annoyed and/or frustrated with DTCAprompted questions than they were with those sparked
by a drug reference.
These results are unique in that they address the issue of DTCA-influenced patients without directly soliciting physician opinions about the subject matter. Rather
than ask clinicians’ views about DTCA policy, this study
asked the clinicians to report their likelihood of certain
behaviors when faced with patients exposed to a drug reference or a DTCA. Therefore, these results provide evidence of how DTCA may be affecting actual practice.
Though important, clinician perceptions of the stresses
and dangers imposed by pharmaceutical advertising do
not describe how the clinicians react to patients exposed to DTCA. To that end, the results of this study are
important in that they provide the first practical view of
how DTCA may shape clinician behavioral intentions and,
ultimately, their behaviors.
Several studies and editorials have expressed clinicians’ concerns about the quality and content of information portrayed in DTCA.3,16-21 Health care professionals are
generally concerned with the potential of these ads to convince patients that they need a medication that they ac-
tually do not. A content analysis performed by Bell and
colleagues22 reported that a substantial proportion (40%)
of ads made claims of innovativeness without communicating the benefits and risks compared with traditional
therapies. These messages may increase patient expectations for drug treatment, placing pressure on the clinician to meet those expectations. In the present study, clinicians did not seem to have a problem with patients
approaching them with questions or even asking for specific medications. While clinicians seemed less receptive
to the idea of patients asking questions about a prescription drug ad, the presence of that exposure was not associated with clinicians being wholly unlikely to address patient questions. This suggests that physicians are somewhat
receptive to DTCA as a source of patient awareness of drug
therapies. However, they are more accepting of the awareness generated by a drug reference. It is unclear from the
results of the present study what this relative acceptance
of DTCA may communicate. Although the literature suggests that clinicians may have reservations about the content and quality of DTCA messages, physicians may feel
resigned to the presence of DTCA in some form. As stated
by Dr Joseph Cranston, of the American Medical Association drug policy department, “With the thrust on patient
empowerment and the customers’ zeal for as much information as possible . . . DTCAs are here to stay.”23
Based on these findings, it is useful to reflect on clinician education with respect to the care of the patient.
Traditionally, medicine has been practiced under 1 of 3
models of care: (1) activity passivity, where the patient
unquestioningly follows the direction of the physician;
(2) guidance cooperation, where the patient is capable of
interpersonal communication yet defers to the clinician’s expertise; and (3) mutual participation, where the
patient depends on practitioner expertise while the prac-
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titioner depends on the patient’s knowledge of living with
the condition.24 These models of care center around the
treatment of disease and its manifestations. However, with
the rise of consumerism, patients have arguably become
less deferential. Many clinicians fear that care may shift
to more of a commodity-driven model, where patients
are buyers of services, and physicians are sellers obligated to provide consumer-perceived value.19,25,26 At its
worst, the incentives for evidence-based care would be
supplanted by the need to satisfy the consumer.
To discourage the development of this consumerism model, clinicians must begin to practice a patientfocused care. Clinician training must be refocused to enable them to address patient needs, values, feelings, and
expectations associated with their conditions and treatments without sacrificing evidence-based care. Clinicians should be trained to become better communicators
so that they may focus care on the treatment of the whole
patient rather than simply the disease.27,28 Thus, media cues
such as drug references or ads may be used as an opportunity to engage patients, promote positive health behaviors, and encourage patients to invest in better outcomes.
In this manner, physicians become managers of patient expectations rather than being managed by them.
The findings of this study must be considered in the
context of the population that was surveyed. The relatively high response rate and the lack of significant differences between early, late, and nonresponders provide confidence that the sample was representative of the
target population. However, the characteristics of the target population may differ significantly from providers in
other parts of the United States. Arizona is predominantly served by managed care organizations. Therefore, the results of this survey may not extend to a population of clinicians operating under different market
constraints. Also, it is important to emphasize that these
findings represent behavioral intentions rather than actual activities. Several factors can prevent a behavioral
intention from being carried out. These intentions, however, are important in communicating the potential actions of clinicians. Furthermore, they provide us with evidence of the relative importance of factors related to the
actual practice of prescribing professionals.
In conclusion, the results of these analyses suggest
that clinicians are receptive to patient participation in the
prescribing process, although the relative likelihood that
they will behave in certain manners (exhibit frustration
and/or annoyance, provide information, prescribe medications) is related to the informational exposure of their
patients. The results suggest that, while clinicians are amenable to patients asking questions about a DTCA, they are
more receptive if those questions arise from exposure to
a drug reference. Past research suggests that this difference may be due to clinician concerns over the quality and
content of the DTCA message. Hopefully, these results will
encourage further research aimed at understanding how
to improve DTCA and/or clinician perceptions of DTCA
relative to nonpromotional sources of information.
Accepted for publication September 23, 2002.
This study/initiative was supported by an unrestricted educational grant from The Merck Company Foun-
dation, the philanthropic arm of Merck & Co Inc, Whitehouse Station, NJ.
Corresponding author and reprints: Woodie M. Zachry
III, PhD, College of Pharmacy, PO Box 210207, University
of Arizona, Tucson, AZ 85721-0207 (e-mail:
[email protected]).
REFERENCES
1. Findlay S. Prescription Drugs and Mass Media Advertising. Washington, DC: The
National Institute for Health Care Management Research and Educational Foundation; 2001. Available at: www.nihcm.org/dtcbrief2001.pdf. Accessed February 24, 2003.
2. Rosenthal MB, Berndt ER, Donohue JM, Frank RG, Epstein AM. Promotion of
prescription drugs to consumers. N Engl J Med. 2002;346:498-505.
3. Sherr MK, Hoffman DC. Physicians: gatekeepers to DTC success. Pharm Executive. 1997;17:56-66.
4. Morris LA, Millstein LG. Drug advertising to consumers: effects of formats for
magazine and television advertisements. Food Drug Cosmetic Law J. 1984;39:
497-503.
5. Morris LA, Klimberg R, Rivera C, Millstein LG. Miscomprehension rates for prescription drug advertisements. Curr Issues Res Advertising. 1986;9:93-118.
6. Morris LA, Brinberg D, Plimpton L. Prescription drug information for consumers: an experiment of source and format. Curr Issues Res Advertising. 1984;7:
65-78.
7. Prevention’s International Survey on Wellness and Consumer Reaction to DTC
Advertising of Rx Drugs. Emmaus, Pa: Rodale Press; 2001.
8. Bell RA, Wilkes MS, Kravitz RL. Advertisement-induced prescription drug requests: patients’ anticipated reactions to a physician who refuses. J Fam Pract.
1999;48:446-452.
9. Webb S, Lloyd M. Prescribing and referral in general practice: a study of patients’ expectations and doctors’ actions. Br J Gen Pract. 1994;44:165-169.
10. Britten N, Ukoumunne O. The influence of patients’ hopes of receiving a prescription on doctors’ perceptions and the decision to prescribe: a questionnaire
survey. BMJ. 1997;315:1506-1510.
11. Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations
and doctors’ perceptions of patients’ expectations. BMJ. 1997;315:520-523.
12. Schwartz RK, Soumerai SB, Avorn J. Physician motivations for nonscientific drug
prescribing. Social Sci Med. 1989;28:577-582.
13. Dillman DA. Mail and Telephone Surveys: The Total Design Method. New York,
NY: John Wiley & Sons; 1978.
14. Arizona Department of Economic Security. Estimates and projections established by the US Census Bureau. Available at: http://www.de.state.az.us/links
/economic/webpage/popweb/subco97.html. Accessed February 14, 2003.
15. Metropolitan and nonmetropolitan counties: definitions from the US Office of Management and Budget. Available at: http://www.rupri.org/policyres/context/omb
.html. Accessed February 14, 2003.
16. Wilkes MS, Bell RA, Kravitz RL. Direct-to-consumer prescription drug advertising: trends, impact, and implications. Health Aff (Millwood). 2000;19:110-128.
17. Hoen E. Direct-to-consumer advertising: for better profits or for better health?
Am J Health Syst Pharm. 1998;55:594-597.
18. Hollon MF. Direct-to-consumer marketing of prescription drugs: creating consumer demand. JAMA. 1999;281:382-384.
19. Kravitz RL. Direct-to-consumer advertising of prescription drugs: implications
for the patient-physician relationship. JAMA. 2000;284:2244.
20. Lipsky MS, Taylor CA. The opinions and experiences of family physicians regarding direct-to-consumer advertising. J Fam Pract. 1997;45:495-499.
21. Petroshius S, Titus P, Hatch K. Physician attitudes toward pharmaceutical drug
advertising. J Advertising Res. 1995;35:41-51.
22. Bell RA, Kravitz RL, Wilkes MS. Direct-to-consumer prescription drug advertising, 1989-1998: a content analysis of conditions, targets, inducements, and appeals. J Fam Pract. 2000;49:329-335.
23. Conlan M. In-your-face pharmacy. Drug Topics. 1996;140:92-98.
24. Szasz T, Hollander M. A contribution tothe philosophy of medicine: the basic model
of the doctor-patient relationship. Arch Intern Med. 1956;97:585-592.
25. Reeder LG. The patient-client as a consumer: some observations on the changing professional-client relationship. J Health Social Behavior. 1972;13:406-412.
26. Moros DA. Consumerism rampant: a critique of the view of medicine as a commercial enterprise. Mt Sinai J Med. 1993;60:15-19.
27. Fehrsen GS, Henbest RJ. In search of excellence: expanding the patient-centred
clinical method. Fam Pract. 1993;10:49-54.
28. Henbest RJ, Stewart M. Patient-centredness in the consultation, 2: does it really
make a difference? Fam Pract. 1990;7:28-33.
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