Orthopedic companies advertising directly to consumers

Direct-to-consumer advertising is changing the dynamics between patients and their doctors; patients have greater expectations.

Issue: June 2004

Direct-to-consumer advertising may be here to stay in orthopedics. The marketing technique — recently adopted by some orthopedic implant manufacturers and used for years by the pharmaceutical industry — is changing the patient-physician relationship.

Pharmaceutical companies have been advertising directly to consumers since the Food and Drug Administration first allowed the practice in 1997. Stryker Corp. has been active in direct-to-consumer marketing since September 2003 when it announced a new campaign featuring Jack Nicklaus’ endorsement of the company’s ceramic-on-ceramic hip.

Stryker’s decision to use Nicklaus involved an evaluation of the golfer, his lifestyle, and his experiences with the joint replacement as a professional athlete.

“It was an exhaustive, due diligence process on both ends,” said Jeff Ignaszak, director of brand communications for Stryker’s orthopedic division. “We wanted to make sure that it was a good, solid decision and one that was made mutually. He wanted to make sure that he was associating with a company that had the highest degree of ethics, a solid reputation in the industry, and one that is committed to this type of patient education program long-term.”

“Jack was very comfortable with what he saw in Stryker. In his own words, he’s had his hip for five years and has had zero problems. We’re very comfortable with the decision we made,” Ignaszak told Orthopedics Today.

The physician’s view

“Direct-to-consumer advertising informs the public, which I think is essential. The only concern I have is when it’s done in such a way as to directly influence physician choices by the companies,” said Richard Kyle, MD, Hennepin County Medical Center, Minneapolis, and editor of Orthopedics Today’s
Trauma Section on the editorial board.

Kyle has had patients ask about ceramic-on-ceramic hips and specifically about Jack Nicklaus. “If I explain the pros and cons or the risks, benefits and alternative procedures, the patients have been very willing to listen to me. A particular procedure may not be good for all patients and so that discussion is essential, ” Kyle said.

Advertising can influence patients to think that a given procedure or device is the most beneficial, Kyle said. “Am I against consumer information? An informed public is essential for understanding and allows the physicians to interact with a more informed patient. I am against direct advertising to patients to force a physician into a certain treatment mode. Yes, I think that is a problem.”

Alternative sources of information

“Right now, marketing and advertising are very aggressive,” Kyle said. “The public needs to be aware of alternative sources. The American Academy of Orthopaedic Surgeons and some specialty societies have Web sites to inform the public about current practices in orthopedics. We need to make our patients aware of this source of information.” He suggested that orthopedic professional organizations should try to inform patients about procedures and devices, and give them an alternative source of information.

“The consumer is knowledgeable and smart, and if you give them an alternative source they will go to it,” he said. “A patient that has a medical problem is more motivated than anybody in the world to seek information, and they’ll go to any source to seek information. Unfortunately, some sources are valid and some sources aren’t.”

Awareness and information, then, are the key issues. If patients are driven to a Web site by an advertisement, “they need a broader base to make their decision on, other than just a Web site by a particular company,” Kyle said. Access to information on evidence-based information is necessary.

The initial reaction by the orthopedic community to Stryker’s campaign was mixed. “Some people were ecstatic about it because it really invigorated their practices and helped bring people into the loop who before might have been told by a primary care physician that they had to wait as long as they possibly could,” Ignaszak said.

“The response has been positive from both the surgeon community as well as the patient community,” Ignaszak said.

The feeling at Stryker is that the company has established a leadership position in direct-to-consumer advertising. “We have the industry’s only second-generation ceramic-on-ceramic hip design. Nicklaus’ credibility and appeal spans a number of generations and adds a tremendous amount of trust and respect for the entire industry,” Ignaszak said, adding that Nicklaus’ overlying message is “go talk to your doctor.”

Other companies have taken a more cautious approach. “Anyone who approaches this with anything other than mixed feelings is being incognizant. You need to first and foremost recognize that patient care is the province of the orthopedic surgeon, and you need to be careful not to do anything to undermine the relationship between the surgeon and the patient,” said Bill Kolter, vice president of marketing for Biomet Orthopedics Inc.

Kolter said that having uninformed patients question their surgeon’s judgement based on advertising is potentially dangerous. “Another downside is that the surgeon has to spend more time with the patient than he or she otherwise would,” Kolter said.

“More and more [surgeons] are becoming resigned to the fact that direct-to-consumer advertising is going to be the future, and many of them embrace it as a good thing. … If it is viewed as a value-added service for a company’s customer base, then it can help build loyalty among the orthopedic surgeons,” Kolter said.

“If it’s used as a stick to beat doctors into submission, it’s a negative. Our competitors are all run by smart people who know what they’re doing, recognize those risks and are cautious to bring those surgeons into the loop ahead of time,” he said.

Not used by everyone

Ignaszak confirmed that philosophy. Prior to going public with the DTC campaign, Stryker tried to communicate with as many of its surgeon customers as possible, a practice that continues today. “There’s a tremendous amount of work that the entire industry needs to do to make people aware of the new options that are available, not only patients but surgeons as well,” Ignaszak said.

There has not been a multi-company avalanche of direct-to-consumer advertising, however, for a variety of reasons.

Finances must be considered when competing head-to-head against other companies, as well as the likely benefit of going up against companies who are already “dominating the dialogue.” A third consideration would be message formulation.

“It makes absolutely no sense for [companies] to go out there and advertise to patients in a fashion that doesn’t differentiate them,” Kolter said. “You can’t find a better spokesperson than Jack Nicklaus. What [Stryker] has done is exemplary from a marketing standpoint. … Right now, ceramic and Jack Nicklaus are inextricably linked.”

Marketing position

This may be what many companies are struggling with. “Advertisers need to ask themselves ‘Should I come out and talk about minimally invasive hips when Stryker’s been out there doing it already, or is my advertising simply going to reinforce the marketing position that Stryker has already staked out for themselves?’” Kolter said.

In general, the American Academy of Orthopaedic Surgeons (AAOS) has supported direct-to-consumer advertising as long as it conveys health care information that is useful and scientifically accurate, not misleading in any way, and understandable by the layman.

“The AAOS has supported that additional information should be made available to the public, as well as the statement that patients should consult their physician for further information,” said Stuart Hirsch, MD, chair of the American Academy of Orthopaedic Surgeons Council on Communications.

“Clearly, some of the incentive of direct-to-consumer advertising is for [companies] to have some market advantage or to influence sales. That probably would be okay if the public is truly objectively educated. … A more educated and better informed consumer can partner in their care and be able to make wiser decisions.”

“Most of us would like [the advertising] to inform patients, improve and stimulate patient-physician communication and understanding, foster early diagnosis, and possibly even provide improvements in disparity of health care so that maybe we’re reaching some populations that are not regularly reached.”

It may also serve to de-stigmatize a disease. “If we see a celebrity with arthritis who gets treatment, maybe people would say, ‘I shouldn’t just complain about my arthritis, I should do something about it.’ It may improve as the patient is more aware and able to partner in their care, he said.

“Those are very real benefits that we would like to see come out of direct-to-consumer advertising. And that is what industry hopes to get from it while they put their names in front of the public,” Hirsch said.

Ultimately, physicians must remain the source of information for patients. “Rather than complain about it, I think it’s up to [physicians] to make sure that we’re knowledgeable of the procedures and that we thoroughly explain to the patients what the risks, benefits and alternatives are,” Kyle said.

“More than likely, [DTC advertising] is here to stay. It’s a marketing technique and an advertising technique, and whether we like it or not, it seems to be an accepted practice,” he said.

In general, the AAOS has supported direct-to-consumer advertising as long as it conveys health care information that is useful and scientifically accurate, not misleading in any way, and understandable by the layman.