On Kleenex

In a late entry, Jaybird asks:

To what extent do you tend to recommend stuff in your day to day interactions (and I don’t mean “you’ve got to go to the new Thai place on 3rd” but “it’s my recommendation that you use Kleenex Facial Tissues when you evacuate your nose” kinda recommendations)?

Almost never.

As the Better Half can tell you, little makes me roll my eyes more predictably than a product that is touted by using a percentage of doctors who recommend it.  I tell you now, in no uncertain terms, that those numbers are wholly meaningless in the vast number of cases.  There are three reasons a medical provider might recommend a specific product, in no particular order:

1)  As shorthand.  Jaybird’s “Kleenex” example is pertinent here, as would be a person who uses “Xerox” to mean photocopiers as a whole.  I will often recommend Tylenol when what I am really recommending is the active ingredient acetaminophen, or Claritin when I mean loratadine.  Etc.  If the name-brand over-the-counter medication has a generic equivalent, I am almost certainly actually recommending the latter.  But you sound like a total tool stipulating the generic name, so it’s the name brand that gets used most of the time.  (For some reason, I can recommend ibuprofen without feeling like a twit in this way.)  I generally try to mention that the generic equivalent is fine when I think of it, but sometimes it slips my mind to do so.  In any case, this may sound like a recommendation for the name brand, but it really isn’t.  And my sense is that most people understand this without needing it spelled out.

2)  An incentive of some kind.  I would love to believe this is not ever the case.  (I would also like a wine cellar and tickets to watch the upcoming men’s swimming events at the Olympics, if I’m going to start listing wishes.)  Now, there are all kinds of incentives we could be talking about, some conscious and some less so.  With the relatively new guidelines for what kinds of bribes gifts that pharmaceutic companies can give doctors, there has (hopefully) been some improvement in this area.  (Gone are the days when Big Pharma would give doctors box seats for baseball games or the theater, alas and alack.)  But they can still sponsor “educational” events, and if that event happens to be at an upscale restaurant then what’s the harm?  And they can still send fetching representatives to talk up their products, and hand out smaller-scale goodies.  And of course they can still pay willing physicians (who, no doubt, sincerely believe in the awesome awesomeness of the drug and would totally be big fans anyway) speaking fees to “educate” other physicians.

As I hope is obvious to discerning readers, I think this kind of recommendation is totally ethically appropriate and have no qualms about it whatsoever.

3)  A genuine belief that the recommended product is better.  In my own practice this is pretty rare.  I will sometimes recommend Dove soap or Cetaphil facial cleanser because I know they won’t be irritating to patients with certain conditions or using other treatments, for example.  But almost all the medications I use or recommend, prescription or not, are available as generics, and that’s just about all I use.

I do not mean to imply that reason #3 does not actually happen with other providers whose specialties and experience differ from mine.  As cynical as I may seem, I think most medical providers make recommendations in good faith.  I think most “recommendations” are actually similar to reason #1, and have no real brand attachment.  And I’m reasonably confident that #3 is much more common than #2.

But those ads that say “More doctors prescribe Panexa than any other panacea”?  They’re no more informative than any other ad.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. ” (Gone are the days when Big Pharma would give doctors box seats for baseball games or the theater, alas and alack.) ”

    Goddammit. I quit.

  2. I’ll have to look into the new regulations. I hope we don’t have to start buying our own pens and refrigerator magnets. We’re used to that steady stream. It does seem to me that it’s been a while since we got a new coffee mug. Man, are we gonna have to start buying those?!

      • chatchke

        You meant maybe chotchkes? (“chazerai”, which comes from “chazer”, i.e. “pig”, connotes “disgusting” more than “worthless”.)

        • Oh, I misunderstood its meaning. I’ve always taken it to mean “worthless trash.” I’ve certainly seen it used in contexts that seemed to imply disgust, but I also feel like I’ve seen it used similarly to how I did. No?

          My grasp of Yiddish is decidedly shaky, at best, so I’m perfectly ready to concede if I’m mistaken.

          • My Yiddish isn’t terrific, so I might be treating my parents’ idiosyncrasies as (you should pardon the expression) gospel. For them, “chazerai” was most commonly anything I wanted to eat that they disapproved of (which might or might not have literally come from a chazer.) But “pig” is a strong epithet, so I’d think it unlikely to apply to a Glaxo coffee mug.

          • My parents used it in the worthless trash sense. Schmatte is to dress as chazzerai is to keepsakes. They have been known to misuse Yiddish, however.

  3. The ad I saw was for the #1 Doctor-recommended Anti-Antiperspirant. It had “clinical strength”.

    I found myself wondering if there was any meaningful information passed along by any of those words at all.

    • The words “clinical strength” trigger in me the same reaction I understand that you have to “organic food.”

      That said, there are doubtless some antiperspirants that are stronger than others, and so there may be some validity to doctors recommended one over another. It’s not an area I’ve researched, frankly. When patients complain of excess sweating after having tried a variety of brands, I generally just go with a prescription.

  4. I had a doctor who explained all about lortadine and Claritin and all tha jazz. For this and other reasons, he was my fave doctor ever (part of the university infirmary staff). He actually took the time to let you know why he was reccomending OTC versus a script and generic versus name brand, which has helped me make informed choices to this day.

  5. Doc-

    Any reliable way to know if we’re getting a legit rec or a product push?

    • If you have seen a recent advertisement for the name-brand prescription you have just received, it is perfectly legitimate to ask if there is a cheaper alternative that is available as a generic, and if not what the basis for the pricier prescription might be.

  6. Don’t underestimate the pens and free food. My residency program didn’t allow the drug reps access to us. We used generic names almost exclusively.sometimes, I find it hard to talk with community pcp’s because all they use are brand names. Not common, but it does happen.

    In medical school we were told of a study where two residency programs in the same city were followed. Program A had no exposure to drug reps. Program B was applies as much exposure as Parma wanted. After residency the docs from B relied on Parma for cme while A went to non Parma sources such as professional societies.

    In the end, I can buy my own pens. Easy for me to say, since the University provides our office supplies

    • For the record, my practice has a very, very limited relationship with drug reps, and we don’t have any of their paraphernalia in our office. I can’t remember the last time I spoke to one.

      • You realize you just shot your chance at a political career.

        “Here’s a direct quote from my opponent: ‘For the record, my practice has […] drug […] paraphernalia in our office.'”

      • I remember the drug rep who regularly visited a preceptor I had in medical school. It was a Urology practice. It was curious how the rep’s blouse buttons were always undone to just above the strap the connected the cups of her bra. Nice cleavage, but I don’t think it changed my preceptor’s prescribing habits at all. Seemed a little sordid and pathetic to me at the time.

  7. I couldn’t even get a doctor to recommend a brand of fish oil. She just kept telling me to look for the Omega3s on the label.

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