Have you ever noticed that what your doctor says about a medicine is different from what you hear in advertisements or in the news? The differences may be subtle, perhaps the choice of words, or something more dramatic. In fact, it may seem like one of the sources of information — whether the media or your doctor — must be wrong. When these differences arise, it’s natural to wonder: If one medicine is clearly best in the television ads, why is a different course of treatment being recommended by your doctor? There are several possible explanations, and sorting them out may be helpful to you in understanding what your doctor is saying and how to make better health care choices.
The Facts Seem Simple
For years, I watched advertisements for various remedies and wondered how the claims they made could be true — after all, we’d been taught a very different version of the facts in medical school and in later training. For example, consider pain relievers for “aches and pains” such as muscle soreness or minor injuries. The nonsteroidal anti-inflammatory drugs (NSAIDs, including aspirin, naproxen and ibuprofen) and acetaminophen-containing medicines (such as Tylenol) are the main players for over-the-counter options. Here are some relevant facts about them (at least as we know them now):
- Effectiveness of the over-the-counter NSAIDs (including the many formulations of aspirin, Advil, Motrin IB and Alleve) are considered equivalent; in fact, when comparable doses are taken, even the prescription forms of NSAIDs are about the same in terms of how well they work.
- The NSAIDs provide pain relief in two ways: by reducing inflammation, wherever it may be, and by a direct pain-relieving (analgesic) effect on the brain.
- The side-effect profiles of over-the-counter NSAIDs are also similar to one another, although uncoated aspirin may cause a higher incidence of stomach problems. For the most part, though, they all have the same side-effect profile, with the most common problem being upset stomach and occasional ulcer disease. They may also worsen kidney failure in people with pre-existing kidney disease. Older NSAIDs, including those available over the counter, thin the blood a bit, which may be a problem for people with bleeding problems or easy bruising.
- Acetaminophen (as in Tylenol and many other products) causes far fewer (if any) stomach problems, provides similar pain-relieving effect as NSAIDs for many conditions, but has little or no anti-inflammatory effect. High doses can cause liver problems, however, especially among people with pre-existing liver disease.
- NSAIDs and acetaminophen reduce fever; when a fever is present, some of their benefits are probably related to this effect. However, when the issue is solely fever reduction, acetaminophen is usually the preferred choice because it is considered safer.
- The dosing schedule varies between these drugs:
- Acetaminophen is taken every four to six hours.
- Naproxen (as in Aleve) is taken two to three times a day.
- Ibuprofen (as in Motrin IB or Advil) is taken up to four times a day.
The dosing differences do not imply that one is stronger, more or less effective or more or less risky to take; the differences are simply a consequence of how they are broken down by the body and, therefore, how long they last in the body’s tissues.
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Spinning the Facts
Even if everyone (doctors, patients, drug advertisers, news media, the FDA and agencies that oversee drug manufacturing, promotion and truth-in-advertising) agreed on the above facts, “spin” can alter how these facts are delivered. For example, one or another of the manufacturers could truthfully make the following claims, each suggesting that one medicine is superior to its competitors (even when it isn't):
- “Nothing is proven stronger.” That’s true since they are all about the same in terms of effectiveness.
- “Just one pill provides all the relief you’ll need for the day.” That may be true, but that’s a matter of convenience for the less frequently dosed medicines, not “power” or overall effectiveness.
- “I don’t care about the studies. I just know it works for me.” Testimonials about one or another pain reliever being the best are readily available for each and every one of them, so one should never rely too heavily on them. Remember that the person making these statements is usually being paid by the drug’s maker.
- “When doctors and hospitals choose, more of them prefer this drug." While this may be true, it's important to note why they are choosing the medicine. This important bit of information may be left out of the claim. For example, acetaminophen may be the most commonly prescribed pain reliever in hospitals, but that may be due to its fever-relieving capacity. If you are looking for a pain reliever and you don't have a fever, that claim may mislead you into thinking that acetaminophen is a better pain reliever.
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Consider the Source
A recent analysis of research comparing chiropractic care with traditional approaches (such as exercise and medications) found no difference between the two in terms of effectiveness, and both were better than no treatment. It also demonstrated how spin can alter the message even while sticking to the facts. News articles interviewing chiropractors hailed the study as proof that nothing is more effective than spinal manipulation and that it represents a safe alternative to medications. Other news reports said the study was a disappointment to the advocates of chiropractic manipulation because it did not find that such care was better than other types of care and may cost more. Some predicted that based on this research, insurers would be more likely to cover chiropractic care for back pain; other news articles stated just the opposite.
One finding of the study that was buried in the “spin” was that neither traditional therapies nor chiropractic care were dramatically helpful compared with no treatment! With all of this shifting emphasis depending on the messenger, no wonder the message from your own doctor may differ from that you happen to read or hear in the news.
There are many other examples of this phenomenon. If you ask your doctor about allergy medicines (such as Allegra or Claritin), the newest anti-inflammatory medications (such as Celebrex), or medicines for heartburn (including Nexium or Prilosec), your doctor may suggest a different treatment. A nonprescription medication or an older, generic medicine may work as well at a fraction of the cost. Your doctor may even suggest no medication for your problem, especially if symptoms are mild and avoidable. For example, some allergy sufferers can simply avoid certain plants at particular times of the year and do well without medicines.
A common situation that I encounter in the office is the request for a medication that a friend or family member is taking. It’s a logical question — there seem to be no side effects and it’s working well for them, so why not try it? If your doctor is not enthusiastic about the idea, it may be because your symptoms or illness is quite different from that of your friend, or your other medical problems and medications may make that treatment less attractive. In that situation, what your doctor is saying is this: Each person is different so the risks and benefits of treatment will differ.
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Although the ideal situation might be objective, scientific analysis driving every medical decision, the fact is that there is much we don’t know, we all have our biases and are affected by the bias of others. The undeniable truth is that “reversing spin” is an enormous challenge. Consider the following reasons that operate to manipulate the health care message:
- Bias may not be conscious. Imagine that your doctor was trained by a world expert in infectious disease and urged the use of a particular antibiotic for a common condition. Years later, your doctor may be prescribing that treatment even if better ones have come along, in part because of the impression made by his or her mentor. Similarly, a friend or family member’s experience with a medicine or treatment may powerfully affect your views on it. In both of these examples, the existence of bias may not be obvious.
- Bias may be intentional. Experts in marketing know how to take a fact and emphasize one aspect, downplay another and present it in a way that directly influences opinions, decisions and behaviors. Although you may not always realize it’s going on, advertisers and others with a vested interest in the health care decisions you make may consciously deliver a biased message and that may differ from the one you hear from your own doctor.
- Perspective matters. Your doctor is primarily interested in your health and well-being while your other sources of information may be focusing on other issues (news media want readers or viewers; drug manufacturers want more prescriptions written for the medications they make; health care maintenance organizations want to promote the quality of their members’ care while also controlling costs, and so on). The difference in these perspectives will often explain the difference in the message you read or hear in ads or the news and the one you hear from your doctor.
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When it comes to health care decisions, the facts are important but so is spin. Simply recognizing that spin is at work is not easy. Perhaps the best any of us can do is to stay informed, relying as much as possible on impartial information from sources that are not trying to sell us something. Read medical writers who seem to look at stories from more than one side. But recognize that everyone is biased to some degree and everyone has a perspective that influences his or her outlook. Recognize that there may be a number of good explanations (and some that aren't so good) for why the message of news media and advertisements differs so much from what your doctor is saying. My advice is this: Be skeptical about what you read or hear and, importantly, consider the source.
Establish a relationship with a doctor you trust and ask questions about something you’ve heard or read, especially if you are unsure about the reliability of the source. Ask why your prescription is being changed. Perhaps you would elect to pay a higher price out of pocket to stay on it, or perhaps you’re willing to switch because your insurance company wants you to, but either way, you’ll be better informed if you ask about it. Academic medical centers and government agencies are often good sources of information because they do not have “vested interests” likely to alter the medical message — but that may just be my bias.
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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.