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Over and above

Consider the followingscenario. You are perus-ing your favourite clini-cal journal and flip to anadvertisement for a new

drug. The left frame shows a sadlooking fellow who seems older thanhis years. On the right panel, he looksmuch better and is smiling as he gazes

up at a man wearing a white coat.Th is sec on d mans coat an d hai rcolour match and are equally immac-ulate; he looks younger than his yearsand exudes an aura of good health.You note that, aside from a neatlycoiled stethoscope, his coat pocketsare empty and contain no books, aids,scribbled notes, index cards, oldwhile-U-were-out messages orother paraphernalia. Still, you deducethat he is a physician. You glance atthe text beneath the panels and note

that it seems to be divided into com-partments. You have no trouble read-ing some of it: CARDI-ERECT for all your hypertensive patients.Round-the-clock blood pressure con-trol and NO IMPOTENCE. Theremaining text is too small to makeout, and you lament having left yourreading glasses at the office. A blazingred line, possibly an arrow, arcs acrossthe text from left to right and thencurves upward. It reminds you ofsomething, but you cant put your fin-

ger on it. At this point, do you con-sider switching your hypertensive pa-tients to CARDI-ERECT? Do youconsider putting yourself on CARDI-ERECT? Do you consider washingyour lab coat more often? Or do youconsider dying your hair?

Keeping abreast of the medical lit-erature is a major goal for clinicians.Previously we, and others, describedvarious approaches to reading the

medical literature.14 However, recog-nizing that many clinicians obtain atleast some of their knowledge fromdrug advertisements,5 we felt it wasimportant to extend our recommenda-tions and address the specifics of howto read pharmaceutical ads.

Reading drug ads might save timefor the busy clinician. They take only

a few moments to scan and could con-tain valuable information given thestrict standards of modern advertising.In this article, we offer 6 key guide-lines on how to approach such ads.

1. What to read in the ad?

Songwriter Tom Waits once said,The big print giveth and the smallprint taketh away. He couldnt havecharacterized drug ads any better. Norespectable physician should be

caught dead reading 20-point letter-ing screaming PRESCRIBE GLU-COPLUNGE. And truthfully,the 6-point text is not only illegible,its incomprehensible (No long-term studies with PlaceboNormexist to determine whether its appar-ent inhibition of cytochrome P4502C19 or 3A3 in rhesus monkeys ispersistent or merely reflects the dualkinetic profile of its major metabo-lites 7,7-nordeoxymetaglutamine or5,7-paradeoxymetaglutamine, or

both). We recommend that readersfocus on material printed in a 12-point font (95% confidence interval10 to 14), because thats where themoney is (well actually the money isin multinational corporations basedin Switzerland but you probablyknew that). Material written in boldor italics font is probably not worthreading, yet the temptation to peekmay be hard to resist.

2. Does the practice resembleyours?

Do the patients in the ads look any-thing like patients in your practice?Does the doctor look like a soap operastar? Do the office furnishings resemblea Hollywood mansion? Is the drugnamed Superb-o-tox (for peoplewho really want to spend a lot on look-ing good)? Does the image convey anyof the smells, noises and stresses of areal practice? If not, consider that themedication may work only in the rar-efied atmosphere of idealized settings(perhaps the precise type of settings in

which it was tested in clinical trials).

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Ifthe setting does resemble your practice,please send us a letter indicating if youdbe willing to accept new associates.

3. What references arecited in the ad?

First, find the references. (Goodluck our rule of thumb is that theywill usually be 3/ pages away from the

How to read clinical journals: XII. How you too canprofit from pharmaceutical advertisements

Steven L. Shumak, Donald A. Redelmeier

DOI:10.1

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CMAJ DEC. 7, 2004; 171 (12) 1455

2004 Canadian Medical Association or its licensors

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ad itself, where is the probability thatyouve heard of the drug. For example,if you have only a 10% feeling thatyouve heard of the drug, the citationwill be about 30 pages away, and insome cases you might even need to flip

to next months issue.) If you are read-ing from a PDF on the Internet, youwill likely need to reboot twice duringyour search.

Second, check to see if, and where,the references have been published.We appreciate the difficulty in securingpublication of less-than-earthshakingresults, but remain wary when the ma-jority of references are on file or pub-lished as part of highly specialized pro-ceedings (the first annual SchleswigHolstein symposium of left patellar ef-

fects of Costalot). Likewise, be waryof references to articles in journals thatmay exist expressly for the purpose ofpublishing those results. And, as lin-guistic Philistines, can we be blamedfor harbouring doubts about resultspublished inJornalese por Sjkotea Rurita-nia Occidentalis?

Empirically, we have determined thatthe likelihood of references being in amainstream clinical journal is about /3.Thus, if you have only a 10% feelingthat youve heard of the drug, you have

less than a 4% chance of finding the ci-tation in a mainstream journal. Also, thelikelihood that the search for referenceswill be frustrating approaches 100%(3/ /3). This is known as the High-Sell-Drug Uncertainty Principle (notto be confused with the Folly ExclusionPrinciple, which merely sets a lowerlimit on the degree of frustration).

4. Does the drug namegrab you?

Drug companies spend millions re-searching potential names for drugs. Ifthe name doesnt grab you, the com-pany clearly cant be trusted with morematerial matters. We offer these guide-lines. First, reject any drug whose namehas more than 3 syllables. Thats justtoo pedestrian. So, Uroflow is finebut not Micturmiracle. Second, re-ject any drug whose name conjures un-

pleasant associations. Drugs shouldsoothe the physician as well as the pa-tient. We view Rash-ease favourably,but find Proctopop beyond com-ment. Third, consider trying drugswhose monikers are implicitly candid.

We would prescribe Generopril andlook forward to using Cholecheap.Fourth, exclude drugs whose nameshave, unfortunately, been appropriatedfrom Latin apparently without themanufacturers awareness (Oppro-brium new for depression). Fi-nally, be cautious about drug namesthat seem to have been chosen solelyfor their use in the ad itself (Howmuch should you worry about yourchoice of beta-blocker? Notatol).

5. Is the drug cost stated inthe ad?

Drugs cost a lot of money, and man-ufacturers should highlight rather thanhide this characteristic. Should you re-ally trust your patients life to an antibi-otic that costs only pennies a day? Wedont think so. Indeed, if the advertiseddrug costs 30% more than its nearestcompetitor, wed be tempted to give it atry, especially since the government is

going to pick up the tab anyway. Costconsciousness has never had a place inmedical research or market advertising,so why start now?

6. Is the dosing convenient?

Drugs ultimately need to be orderedby physicians and taken by patients, soconvenience of dosing is a real concern.If Aspirin werent as effective as it is, forexample, we doubt that the 325-mg dosewould be acceptable under contempo-

rary expectations. It would come in 100-mg or 300-mg tablets (in a new easy-to-swallow tabcap). Likewise, donteven look at an ad for a drug that has tobe taken more than once per day. Keepyour eye open for that soon-to-be-de-veloped once a week or once a monthformulation (Infinitum one doseand you need never worry about type 4bporphyrocandidopsis again). Also,avoid drugs whose doses have to be cal-

culated on the basis of body surface area,or adjusted for renal or hepatic insuffi-ciency; these are just mistakes waiting tohappen. (Indeed, many doctors arenteven good at calculating their CMEcredits, with their totals ending up too

high.) We dream of the one-size-fits-allapproach and await the release of Te-dium (never adjust a dose again).

Summary

We have listed 6 guidelines that webelieve will help you when readingdrug ads and deciding whether or notto try a new drug. The guidelinesshould also make reading drug ads lessintimidating and more fun. Alas, wedoubt that the pharmaceutical indus-

try will consider any of these points,because they are already way ahead ofclinicians in sophistication and wayahead of regulators in resourcefulness.

References

1. Redelmeier DA, Shuchman M, Shumak SL.How to read clinical journals: IX. Sounding likeyouve read the literature when you havent reada thing. CMAJ1998;159(12):1488-9.

2. Shumak SL, Redelmeier DA. How to read clini-cal journals: X. How to react when your col-leagues havent read a thing. CMAJ 2000;163(12):1570-2.

3. Redelmeier DA, Shumak SL. How to read clini-

cal journals: XI. Everything you always wantedto know about editorials (but were afraid to ask).CMAJ2003;169(12):1323-5.

4. Haynes RB, McKibbon KA, Fitzgerald D, Guy-att GH, Walker CJ, Sackett DL. How to keepup with the medical literature: II. Decidingwhich journals to read regularly.Ann Intern Med1986;105:309-12.

5. Wilkes MS, Shuchman M. Pitching doctors.NewYork Times Magazine 1989;:88,90,126,128-9.

6. Juurlink DN, Mamdani MM, Lee DS, Kopp A,Austin PC, Laupac is A, et al. Rates of hyper-kalemia after publication of the Randomized Al-dactone Evaluation Study. N En gl J Med2004;351:543-51.

Over and above

1456 JAMC 7 DC. 2004; 171 (12)

Steven Shumak and Donald Redelmeier are with theDivision of General Internal Medicine, Departmentof Medicine, Sunnybrook & Womens CollegeHealth Sciences Centre, University of Toronto,Toronto, Ont.

Acknowledgements: Steve Shumak and Donald Re-delmeier hope to receive support from the MegabucksPharmaceuticals Corporation (We take the sue outof pharmaceuticals). Both authors have also recentlysold short on Angiodrek Inc. (makers of Clotblot Why bust when you can blot!). Earlier drafts of this

article were funnier than the current version, but theygenerated too many haughty complaints from our col-leagues Drs. Ed Etchells and Andreas Laupacis. Wethank Drs. David Naylor, Bill Sibbald and GordonGuyatt for allowing gratuitous acknowledgements.